Historical Perspectives: Lamaze Healthy Birth Practice 2 and 4

"Walk, Move Around and Change Positions throughout Labor" and "Avoid Interventions that Are not Medically Necessary"

This month in our Historical Perspectives series, we're focusing on Healthy Birth Practices 2 and 4. Encouraging mothers to use movement throughout labor (#2) goes hand in hand with avoiding routine medical interventions (#4) that interfere with the mother's ability to get out of bed, so we'll consider them together.Why is movement so important for labor? Labor is movement the baby is descending and rotating her way through the birth canal, the uterus is contracting, the cervix is dilating. When mothers add their own movement to the baby's, they can effectively work together to help labor progress. As Lamaze Healthy Birth Practice 2 notes, movement and upright positioning is the best way for you to use gravity to help your baby come down and to increase the size and shape of your pelvis. It allows you to respond to pain in an active way, and it may speed up the labor process.[1]Movement is a natural response to physical discomfort. If you're carrying something and it hurts your arms, you shift its position. We don't just take it we move! So why, so often, are women prevented from having freedom of movement during labor?Healthy Birth Practice 4 gives us part of the answer. Many times, routine interventions like IVs, continuous External Fetal Monitoring (EFM), and continuous blood pressure monitoring make it difficult for mothers to labor out of bed. Some nurses are more accepting than others of a mother laboring on a ball or in a rocking chair while continuous monitoring is taking place, but walking any distance would be impossible.The other part of the answer can be found by taking a look at our birth culture. When did these kinds of interventions become routine? And when did labor move into the labor bed? Let's take a look back and see what we find.Where We've BeenIf you didn't watch the video presentation of the history of birth last month, I highly recommend visiting the Mothers' Advocate channel on YouTube and watching the video clips Images of European Childbirth from the 1500s and Changes in Birth Practices.[2] Even before the 20^th century, the differences between midwife-attended births and physician-attended births are clear. While midwife-attended births happen with the mother upright and out of bed, those with physicians feature the mother lying in bed.Once birth moved to the hospital at the turn of the 20^th century and twilight sleep for labor and birth became the all the rage, there was no other labor position for mothers than strapped (literally, in most cases) to their labor beds.The use of twilight sleep was eventually phased out, but the medical management of birth continued, and new interventions in the birth process became common. In 1958, Dr. Edward Hon reported the first uses of external fetal monitoring, and medical colleagues from around the world soon began using the technology to detect fetal distress in high-risk pregnancies. However, [b]y 1978, it was estimated that fetal monitoring was in routine use in over half of labors.[3] Once EFM became the norm, the mother's ability to move was restricted.Problematically, EFM became routine without being proven to be helpful or safe.[4] In fact, the technology rapidly became used more and more for low-risk mothers: the percentage of low-risk mothers monitored in 1988 was 76.3%, compared to just 62.2% of high-risk mothers.[5] According to the Listening to Mothers II Survey, completed in 2006, 76% of mothers were montitored continuously during labor and 80% reported having an IV.[6] So, interventions originally intended for high-risk women only are now routine, without any benefit to mothers or babies.When considering freedom of movement during labor, it's important also to mention the development of the epidural. Dr. John Bonica, who worked with pain management for wounded soldiers, developed the epidural block technique in the 1940s. His wife Emma, who nearly died from complications from ether anesthesia during the birth of their first child, was the first to receive an epidural during their second child's birth.[7] The popularity of the epidural has surged in recent years, and it is now the most frequently used form of pharmacological pain relief.Women using epidurals can't put weight on their feet, and because epidurals require continuous EFM, an IV, a urinary catheter, and maternal blood pressure and heart rate monitoring, their freedom of movement is severely restricted. In order to preserve the position changes that help labor for the mother using an epidural, Penny Simkin developed a series of rotations called the Rollover.[8] So, epidural use, while it does restrict freedom of movement, shouldn't mean that the mother doesn't move at all.Where Do We Go from Here?In 2009, ACOG revised its guidelines on continuous EFM. George A. Macones, MD, who headed the revision, points out that

[a]lthough EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.[9]

Lamaze's Healthy Birth Practice 4 is aimed at reducing the number of women who undergo unnecessary interventions in the birth process, which often lead to complications that require further intervention.According to the Listening to Mothers II Survey, epidurals are used by 76% of mothers (or higher, depending on the hospital).[10] As women continue to use pharmacological pain relief options (like the epidural), they need to know what techniques they can use to help their labor progress. Lamaze's Healthy Birth Practice 2 encourages women to understand how freedom of movement helps the progress of birth, which can then be applied to their unique birth experiences.

[1] Healthy Birth Practice #2. Reference to P. Simkin & R. Ancheta, The Labor Progress Handbook (2^nd ed.). Malden,MA: Blackwell Science, 2005.

[2] Mother's Advocate YouTube Channel: http://www.youtube.com/user/MothersAdvocate.

[3] Freeman, Roger K., Thomas J. Garite, Michael P. Nageotte. Fetal Heart Rate Monitoring. 3^rd ed. Philadelphia: Lippincott Williams & Wilkins, 2003. Available on Google Books.

[4] Ibid.

[5] Ward, Joyce. The Evolution of External Fetal Monitoring from Use in High-Risk Women to Routine Practice: A Critical Historical Perspective. 1999. Available at http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/1e5626880167e040852569fc00610cf3?OpenDocument

[6] Listening to Mothers II Survey. Available at www.childbirthconnection.com.

[7] http://painresearch.utah.edu/crc/CRCpage/Bonica.html

[8] Simkin, Penny. The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions. 3^rd Edition. Harvard: The Harvard Common Press, 2008. 284.

[9] http://www.acog.org/from_home/publications/press_releases/nr06-22-09-2.cfm

[10] Available at www.childbirthconnection.com.