Return to Focus on Physiologic Birth Introduction


A Focus on Physiologic Birth

What is Physiologic Birth?

A normal physiologic labor and birth are powered by the innate human capacity of the woman and fetus. This birth is more likely to be safe and healthy because no unnecessary interventions disrupt normal physiologic processes.1 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.2-5

Benefits of Supporting and Fostering Physiologic Birth

Physiologic birth has the following identified benefits for women:

  • Reduced peripartum morbidity primarily through avoidance of surgery and related complications;6

  • Possible reduction in chronic disease through improved likelihood of breastfeeding;7

  • Improved birth experience through access to supportive care and involvement in decision making;8 and

  • Reduced out-of-pocket costs for maternity care primarily through reduced rate of cesarean birth.9

Physiologic birth has the following identified benefits for infants:

  • Reduced likelihood of iatrogenic harms related to augmentation, induction of labor, instrumental vaginal birth, neonatal respiratory distress, and neonatal lacerations;4, 10-12

  • Possible reduction in likelihood of chronic disease related to cesarean delivery13 and disrupted or delayed breastfeeding;14 and

  • Improved maternal-infant attachment.15

Physiologic birth has the following expected benefits for nurses:

  • Potential for increased engagement and support of women in labor leading to increased professional satisfaction;

  • Improved performance on measures likely to be linked to payment, including patient experience measures (eg, Hospital Consumer Assessment of Healthcare Providers and Systems [HCAHPS] Survey); and

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims.16

Physiologic birth has the following expected benefits for obstetricians/midwives:

  • Increased professional satisfaction;

  • Improved performance on measures likely to be linked to payment as payment reforms roll out; and

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims.16

Physiologic birth has the following expected benefits for administrators:

  • Improved performance on measures likely to be linked to payment and accreditation as reforms roll out, including
    • nulliparous, term, singleton, vertex cesarean rate
    • elective delivery before 39 weeks gestation
    • episiotomy
    • exclusive breast milk feeding during the hospital stay
    • experience of care measures (eg, HCAHPS survey);

  • Possible reduction in adverse events and related liability claims or payouts due to reduced use of oxytocin, a high-alert medication implicated in half of obstetric claims;16 and

  • Possible reduction in staff turnover as physiologic care may be more rewarding for physicians, midwives, and nurses.

Characteristics of Physiologic Birth

According to American College of Nurse-Midwives, Midwives Alliance of North America, and National Association of Certified Professional Midwives, normal physiologic childbirth is

  • 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 physiological 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.17

The following factors disrupt normal physiologic childbirth:

  • Induction or augmentation of labor;

  • An unsupportive environment, ie, bright lights, cold room, lack of privacy, multiple providers, lack of support persons, etc.;

  • Time constraints, including those driven by institutional policy and/or staffing;

  • Nutritional deprivation;

  • Opiates, regional analgesia, or general anesthesia;

  • Episiotomy;

  • Operative vaginal (vacuum, forceps) or abdominal (cesarean) birth;

  • Immediate cord clamping;

  • Separation of mother and infant; and/or

  • Any situation in which the mother feels threatened or unsupported.

National Efforts to Improve Maternity Care

Increasing access to care that promotes and supports physiologic birth is a major national strategy for achieving high-quality, high-value maternity care. In 2012, the National Priorities Partnership Maternity Action Team, a multi-stakeholder group of leading national organizations and agencies, began the development and implementation of a plan to reduce the rate of elective deliveries prior to 39 weeks gestation to 5% or less and to reduce the rate of cesarean in low-risk women to 15% or less.18 A major focus of this national effort is engaging consumers and professionals in efforts to promote full-term physiologic childbirth.

In concert with these initiatives, the American College of Nurse-Midwives (ACNM), Midwives Alliance of North America, and National Association of Certified Professional Midwives issued a consensus statement that identified practices and policies consistent with supporting physiologic approaches to childbirth.17 In 2014, the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal-Fetal Medicine promoted evidence-based approaches to safely avoid primary cesarean births.19  Additionally, in 2017, ACOG released an ACNM-endorsed committee opinion that outlines suggestions for limiting interventions during labor and birth.24 The approaches outlined in the 2014 the obstetric care consensus statement and subsequent 2017 ACOG committee opinion echo many of the practices and approaches previously identified by midwifery organizations. Overall, maternity care professionals are prioritizing improved, evidence-based approaches to achieving safe, high quality, high value maternity care for women, newborns, and families.

Obstetric Interventions

Obstetric interventions are overused and misused in many maternity care settings, while beneficial practices that promote optimal maternal and newborn health are often underused. National statistics reported in the Listening to Mothers III Survey20 indicate the following:

  • More than half of all pregnant women receive synthetic oxytocin to induce or augment labor, which requires additional interventions to monitor, prevent, or treat side effects.16

  • Fewer than half of women ambulate during labor, despite evidence that movement and promotes labor progress.21

  • More than two-thirds of women give birth in the supine position, despite evidence that this position increases the likelihood of instrumental vaginal delivery and episiotomy.22

  • One third of women give birth via cesarean, a major abdominal surgery with potential for serious short- and long-term health consequences for the woman, her infant, and future pregnancies.19

According to the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine, “The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia.”19 To address the high rate of caesarean birth in the United States, these organizations call for different approaches to each of these areas of care, including a reduction in the performance of inductions of labor. They also recommend a redefinition of dystocia in alignment with supporting physiologic approaches that promote the spontaneous onset of labor at term and the progression of labor according to evidence-based guidelines to reduce the use of interventions during labor.

Hospital Accreditation

Hospital accreditation will be tied to reporting of maternity care performance, and physiologic birth practices can effectively improve performance. Beginning in January 2014, accredited hospitals with at least 1100 births per year will be required to report to the Joint Commission on perinatal core measures.23 Measures that are amenable to improvement by implementing physiologic care in labor and birth include

  • nulliparous, term, singleton, vertex cesarean rate

  • elective delivery before 39 weeks gestation

  • episiotomy

  • exclusive breast milk feeding during the hospital stay

In summary, promotion of physiologic approaches to care of the women during childbirth have the potential to increase safety, improve quality and promote optimal health outcomes for childbearing women and their families.



Resources

Supporting Healthy and Normal Physiologic Childbirth Joint Statement
This document was developed by the national midwifery organizations (ACNM, MANA, NACPM) as a policy statement regarding opportunities to improve maternity care through the promotion of normal physiologic childbirth. This statement is the foundation for the BirthTOOLS Web site.

Normal Healthy Childbirth for Women & Families: What You Need to Know
Links to the web page featuring the consumer-oriented normal physiologic birth document developed by ACNM for Our Moment of Truth (OMOT). Copies of this document are available as a free PDF download from this site.

Obstetric Care Consensus Statement
This document is a joint statement by the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal Fetal Medicine (SMFM) addressing approaches to reduce the risk of cesarean births.

Click to view additional resources available in the Focus on Physiologic Birth Resource Toolbox, or search our resource library by clicking here.


References

  1. Romano AM, Lothian JA. Promoting, protecting, and supporting normal birth: a look at the evidence. J Obstet Gynecol Neonatal Nurs. 2008;37:94-105.

  2. Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database Syst Rev. 2008;(4):CD004667.

  3. Low LK, Seng JS, Miller JM. Use of the Optimality Index-United States in perinatal clinical research: a validation study. J Midwifery Womens Health. 2008;53:302-309.

  4. Cragin L, Kennedy HP. Linking obstetric and midwifery practice with optimal outcomes. J Obstet Gynecol Neonatal Nurs. 2006;35:779-785.

  5. Murphy PA, Fullerton JT. Development of the Optimality Index as a new approach to evaluating outcomes of maternity care. J Obstet Gynecol Neonatal Nurs. 2006;35:770-778.

  6. Goer H, Romano A, Sakala C. Vaginal or Cesarean Birth: What is at Stake for Women and Babies? A Best Evidence Review. New York: Childbirth Connection; 2012.

  7. Schwartz E. Infant feeding: seeing the whole picture. Paper presented at: First Food Forum; Atlanta; GA, 2013.

  8. Hodnett ED. Pain and women's satisfaction with the experience of childbirth: a systematic review. Am J Obstet Gynecol. 2002;186:S160-S172.

  9. Truven Health Analytics. The Cost of Having a Baby in the United States. Ann Arbor, MI: Truven Health Analytics; 2013.

  10. Johantgen M, Fountain L, Zangaro G, Newhouse R, Stanik-Hutt J, White K. Comparison of labor and delivery care provided by certified nurse-midwives and physicians: a systematic review, 1990 to 2008. Womens Health Issues. 2012;22:e73-e81.

  11. Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database Syst Rev. 2012;10:CD003766.

  12. Gregory KD, Jackson S, Korst L, Fridman M. Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol. 2012;29:7-18.

  13. Hyde MJ, Mostyn A, Modi N, Kemp PR. The health implications of birth by caesarean section. Biol Rev Camb Philos Soc. 2012;87:229-243.

  14. Newburg DS, Walker WA. Protection of the neonate by the innate immune system of developing gut and of human milk. Pediatr Res. 2007;61:2-8.

  15. Moore ER, Anderson GC, Bergman N, Dowswell T. Early skin-to-skin contact for mothers and their healthy newborn infants. Cochrane Database Syst Rev. 2012;5:CD003519.

  16. Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009;200:35.e1-35.e6.

  17. American College of Nurse-Midwives, Midwives Alliance of North America, National Association of Certified Professional Midwives. Supporting healthy and normal physiologic childbirth: a consensus statement by ACNM, MANA, and NACPM. http://mana.org/pdfs/Physiological-Birth-Consensus-Statement.pdf. Published May 14, 2012. Accessed March 2, 2014.

  18. National Quality Forum. Patient safety collaboration. http://www.qualityforum.org/Setting_Priorities/NPP/NPP_Action_Teams.aspx. Accessed March 2, 2014.

  19. American College of Obstetricians and Gynecologists, Society for Maternal-Fetal Medicine. Obstetric care consensus: safe prevention of the primary cesarean delivery. http://www.acog.org/Resources_And_Publications/Obstetric_Care_Consensus_Series/Safe_Prevention_of_the_Primary_Cesarean_Delivery. Published March, 2014. Retrieved March 2, 2014.

  20. Declercq ER, Sakala C, Corry MP, Applebaum S, Herrlich A. Listening to Mothers III: Pregnancy and Birth. New York: Childbirth Connection; 2013.

  21. Lawrence A, Lewis L, Hofmeyr GJ, Dowswell T, Styles C. Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev. 2009;(2):CD003934.

  22. Gupta JK, Hofmeyr GJ, Shehmar M. Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database Syst Rev. 2012;5:CD002006.

  23. Zhani EE. The Joint Commission expands performance measurement requirements. http://www.jointcommission.org/the_joint_commission_expands_performance_measurement_requirements/. Published November 30, 2012. Accessed March 2, 2014.

  24. American College of Obstetricians and Gynecologists. Committee Opinion Number 687: Approaches to limit intervention during labor and birth. https://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-Obstetric-Practice/Approaches-to-Limit-Intervention-During-Labor-and-Birth. Published February, 2017. Retrieved June 28, 2017. 


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