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A Nurse-Midwife’s Perspective
on
Vaginal Birth
Heather Bradford, CNM, ARNP, FACNM
EvergreenHealth Midwifery Care
Interpreting the alphabet soup
3 types of Cesarean section rates examined:
• Total cesarean sections (total CS/total births)
• Primary cesarean sections (1st CS/total births)
• Nulliparous Term Singleton Vertex (NTSV) CS rate
A quick look at U.S. childbirth statistics…
How do we stack up?
Total CS Rates Holding Steady…
• After 13 years of consecutive increases, the
total U.S. cesarean delivery rate reached a
high of 32.9% in 2009
• Most recent low was 20.7% in 1996
• The rate declined to 32.8% and held steady in
2011 and 2012
U.S. Primary CS Rates
• Declined slightly from 22.1% in 2009 to 21.5%
in 2012
• Varies greatly by region
• Some states show slight decline
• Some states remain unchanged
2012 U.S. Primary CS Rates = 21.5%
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Florida = 26.9%
Washington = 19.5%
Utah = 12.5%
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Primary CS in WA, 2000-2010
Why is the CS Rate So High?
Myth
Truth
Maternal request for CS with 1% of all pregnant women
no medical indication
Changes in childbearing
population
Fear of malpractice suit
Rates are up for ALL groups regardless of age, number of
babies, health problems, and
race/ethnicity
The role of liability pressure is
modest at best and can
account for just a fraction of
the steep recent rise
http://childbirthconnection.org/article.asp?ck=10456&ClickedLink=274&area=27
Possible Clues to Why
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Low priority of enhancing women's abilities to give birth
Side effects of common labor interventions
Refusal to offer informed choice of vaginal birth
Bar lowered for classic C/S indications: dystocia, scarred
uterus, non-reassuring FHTS, breech
Casual attitudes about surgery
Variation in professional practice style
Limited awareness of harms that are more likely with
cesarean section, short and long term
Disincentives for vaginal birth
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Time and money!
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*Follow the
$$:
CS w/no comp
>$15,799
Vaginal w/comp
>$9,617
WA Medicaid Quality Incentive Program
In August 2009, WA state legislature mandated 
Medicaid reimbursement to hospitals for uncomplicated
CS
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Pay facilities for CS the same as for complicated vaginal birth
Develop evidence-based tool-kits for providers
Feedback to hospitals re NTSV and VBAC rates
Pay hospitals for in elective deliveries @ 37-39 wks
As of January 2014, EVH OB providers are required to have
a Bishop Score of 8 or more without cervical manipulation
before scheduling elective inductions
Bree Collaborative in WA State
• Goal: Improved quality and outcomes through transparency
and collaboration in WA state
• Created by legislation in 2011
• 1 area of focus is obstetrics
• Key data finding:
CS variation in WA by hospital and region = 10-39%
A Utah Recommendation for a Local Approach
W. Lawrence Warner. “Arriving at the appropriate cesarean delivery rate.”
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The top contributors to the primary cesarean rate are
either subjective or dependent on management style
• Non-reassuring fetal status, arrest of labor, multiple gestation,
preeclampsia, & macrosomia
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Who patient sees for prenatal care & who is on call for
her delivery may determine cesarean or vaginal birth
Look at each component of care & indication
individually and collectively (as departments)
Evaluate if we are following established evidence-based
protocols, policies, and/or checklists
http://www.acog.org/About_ACOG/ACOG_Departments/District_Newsletters/District_VIII/July
_2013/Cesarean_delivery_rate
Midwifery in WA State
Two Types are Licensed to Practice:
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Certified Nurse-Midwife (CNM)
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Licensed Midwife (LM)
WA Certified Nurse-Midwife (CNM)
• Licensed as an Advanced Registered Nurse
Practitioner (ARNP)
• Education: BSN and Master’s
• Certified by American Midwifery Certification Board
• Regulation: DOH, Nursing Care Quality Assurance
Commission (Board of Nursing)
• Prescriptive Authority: Legend Drugs and Schedules
2-5
• Mandated inclusion in health plans since 1996 law,
“Every category of health care provider”
• Vast majority attend in-hospital births
CNM Scope of Practice
• WAC 246-840-300: “Advanced registered nurse
practitioner (ARNP) scope of practice”
• CNM is one type of ARNP
• Independent providers, prepared and qualified to
assume primary responsibility and accountability for
the care of patients
Birth of EvergreenHealth Midwifery Care
October 2012
Who are We?
• Practice opened September 2012
• 5 nurse-midwives providing full-scope care
• Attend births at EvergreenHealth’s Family
Maternity Center
• EvergreenHealth Women’s Care as OB
consultants (Drs. Cook, Hyde, Morrell, Russell,
& Stemmerman)
• Collaborate, consult, co-manage, refer as
needed
Our Data
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Attend 30-35 births/month
50% epidural rate
11% NTSV CS rate
Other data points (consistent with national
CNM data):
• Low rates of induction of labor, episiotomies,
3rd & 4th degree tears, and NICU admissions
• High rates of breastfeeding
#500 and Counting…
Comparing Apples to Apples…
Limits on patients eligible for midwifery care:
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Pre-existing diabetes or HTN requiring meds
Multiples
Blood clotting disorders
GDM requiring medication
Our Philosophy of Care
• Midwife means “with woman”
• We are specialists and the guardians of
normal birth
• Listening to women is a hallmark of our
care
• Midwifery: The Art of Doing “Nothing”
Well
• Holly Powell-Kennedy, CNM, PhD, FACNM, FAAN
Midwifery: The Art of Doing
“Nothing” Well
• Supporting the normalcy of pregnancy and birth,
vigilance and attention to detail, and respecting the
uniqueness of the woman
• Intervening and using technology only when the
individual situation required
• The ultimate outcome is healthy mom/baby and a
birth experience that is both respectful and
empowering
Translation to How We Care
for Women in Pregnancy
• The midwife and patient relationship is based
on partnership and advocacy
• Our patients have extensive access to us via:
• Phone calls
• Triage
• Meet all the midwives prior to the birth
• Extensive (45 minute) 36 week birth plan visit
• Postdate IOL at 42 weeks
• NST/AFI at 41 weeks, NST at 41 ½ weeks
Translation to How We Care
for Women in Labor
Early labor:
• Phone call directly with patient in early labor
• Our patients stay at home
• Admit only if 4cm and in active labor (GBS
positive and ruptured)
Translation to How We Care
for Women in Labor
Active labor:
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Intermittent monitoring after reactive NST
No IV unless indicated
No time constraints
Doulas welcome
Intention to be present from hospital
admission until breastfeeding initiation
• We evaluate cervixes (with minimal
frequency) and fetal lie ourselves
Translation to How We Care
for Women in Labor
2nd stage:
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We honor the “lull phase” (between 10cm and urge
to push)
Change positions every 20 minutes
We labor down with epidurals
Warm compresses to perineum and no
episiotomies
Delayed cord clamping is routine
Skin to skin contact for minimum of 1 hour (no
weighing the baby!), goal for skin to skin after
cesarean section too
We
the EvergreenHealth
Family Maternity Center Staff!
EVH Nurse-led Intentional Labor Management
Project to decrease CS rates
• Implemented June 2013
• Areas with the most potential impact
• Failure to progress (1st stage)
• Fetal intolerance to labor
• Failure to descend (2nd stage)
• Nurses became more invested in caring for
laboring patients
Six Elements of Project
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Redefinition of the length of labor
New strategies for managing early labor
Importance of fetal lie and maternal
positioning
Ongoing adjustment of Pitocin (when needed)
Shared understanding of fetal monitoring
language
Laboring down if possible, then active
maternal positioning in 2nd stage
EvergreenHealth C/S Data
2012 Data:
• NTSV CS Rate: 35%
2013 Data:
• NTSV CS Rate: 29%
(June 2013 NTSV rate was 24.8%)
Conclusions about the Project
• Formal project ended 10/31/13
• Nurse evaluation of the project revealed:
• Excitement about improved collaborative care
• Standard practice of Leopold's
• Understanding of maternal positioning and
importance in facilitating labor progress.
• Improved understanding of fetal well-being
allowing more patience in the laboring process.
Other beacons of light…
Definitions from Spong:
Labor Progress
Bree Recommendations @ State Level
• Strong leadership and commitment to quality improvement
• Evidence-based or tested clinical guidelines & protocols, e.g.
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If no fetal or maternal compromise, admit @>/=4 cm
1st stage labor arrest only in active phase
Sufficient time and interventions in 2nd stage for dx arrest
No elective deliveries before 39 weeks
• Transparency of data on selected OB procedures, by
facility
• Patient education
• Realignment of financial and non-financial incentives
ACOG and SMFM issue new consensus
statement - March 2014
Safe Prevention of the Primary Cesarean Delivery
Recommendations:
1. Allowing prolonged latent (early) phase labor.
2. Considering cervical dilation of 6 cm (instead of 4 cm) as
the start of active phase labor.
3. Allowing more time for labor to progress in active phase.
4. Allowing women to push for at least two hours if they
have delivered before, three hours if it’s their first
delivery, and even longer with an epidural.
5. Using techniques to assist with vaginal delivery if
needed, such as forceps or vacuum extraction.
6. Encouraging patients to avoid excessive weight gain
during pregnancy.
Are We Finally At A Tipping Point???
Looking Ahead
Newest Healthy People (2020) Objectives include:
• Reduce NTSV CS rates:
• From the 2007 baseline of 26.5% to a target rate of 23.9%
• 2010 goal was 15%
• Prior cesareans: increase the percent of
vaginal births among women with a prior
cesarean (increase VBACs)
• Raise the 2007 baseline VBAC rate of 8.2% to target of
18.3%
Evidence-Based Practice: Top 10
Pearls to Achieve a Vaginal Birth
10. Education and preparation
are key
• Healthy diet, normal weight gain and lots of exercise
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PROTEIN!! (60 gms a day)
Multips need to be just as careful with weight gain to
avoid vacuum/forceps delivery if LGA babies
• A true understanding of “normal” lengths of labor
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Admit only if 4cm and in active labor
• Education about going post dates
• A tour of the unit helps the woman acclimate faster
• Who is in the room (and waiting outside) can affect
her ability to progress.
• There is a time and a place for epidurals and Vitamin P
9. Hydration and nutrition
far outweigh IVs
• Oral nutrition in labor is a proven underused
intervention which can promote normal
birth
• A sip of water/clear liquid after every
contraction
• Keep the support team hydrated and fed as
well
8. Continuous labor support goes a
long way
• This includes emotional support, comfort
measures, information, and advocacy
• Research has shown that continuous labor is
associated with high rates of vaginal births,
shorter labor, less use of pain medication, and
higher satisfaction
• Women who have support in labor are more
likely to give birth spontaneously without the
need for Pitocin
Why Give Supportive Care?
Maternal anxiety leads to catecholamine release
Catecholamine release leads to maternal shunting of blood
to vital organs
Less oxygenation of the uterus causes ineffective uterine
activity
Less oxygenation of the uterus leads to less oxygenation to
the fetus
Can avoid failure to progress and fetal intolerance of labor
by giving supportive care
7. Non-pharmacologic pain relief measures
are helpful in all stages of labor
• Change positions every 20 minutes (even in 2nd
stage) and sing low
• Its time to change position if the three R’s are
missing: relaxation, rhythm, and ritual (thank
you Penny Simkin)
• Tennis balls (acupressure) and cold washcloths
• Heat (warm blanket) increases circulation and
reduces the “flight or fight” response
• Save the tub for transition
6. Supine in bed is the
worst place to labor
• Initial NST upon admission does not need to
occur in bed
• Favorite positions:
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Bed as table, double hip squeeze
Beanbag hug
7th grade slow dance
The Princess throne
Exaggerated Sims
Toilet, tub, and birthing stool
5. Optimal fetal positioning
cannot be overstated
• Applies to pre-labor and early labor too
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Avoid bucket seats and recliners
Hands and knees at home
• Penny Simkin’s Roadmap of Labor
• Penny Simkin’s Safe Positions for a Mother with an
Epidural
• Exaggerated Sims for Spinning OT/OP babies
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Peanut balls and tray tables
Rocking of the hips
• Hands and knees for anterior lip, back pain, OP lie
4. Affirmations and hands on the
momma go a long way
• Physiologic affirmations
• Trust and confidence in the birth process and
our bodies
• My favorite personal affirmations:
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You and your baby are safe
Your body knows what to do
Go back to your rhythm: just breath
We are here for you
Everything you are feeling is normal
3. PROM and no labor…no rush…
• Confirm without digital exam (pooling,
ferning, pH)
• Therapeutic rest, review optimal fetal
positioning
• After reactive NST, can wait 24 hours for
labor (if GBS negative)
• There is a time and a place for Vitamin P
2. Breast pump stimulation does work
• 2 hour trial
• 20 minutes on, 40 minutes off
• Remove pump during a contraction
• Ambulate when pump off
• Continuous monitoring when using breast
pump
1. Trust in Birth
• The Friedman Curve has been replaced by
the Spong Guidelines
• There are rarely absolute time constraints
• All women can have a vaginal birth until
proven otherwise
• Birth is a normal physiologic phenomenon
for the vast majority of women
“What works is not flashy, not expensive, but its
human intensive.”
Dr. Heidi Rinehart,
Amnesty International
“Take heart, even though the trail is hard in the
blazing…”
Mary Breckenridge
Questions/Comments
Heather Bradford, CNM, ARNP, FACNM
[email protected]
www.evergreenhealth.com/midwife
References
Association of Women’s health, Obstetric , & Neonatal Nursing. (2009). Fetal
Heart Monitoring: Principles and Practices (4th ed.). Washington,
DC:AWHONN.
Declerq et al. 2006. Listening to Mothers II. Childbirth Connection
Hatem, Sandall, Devane, Soltani, & Gates. 2008. Midwife-led versus other
modesl of care for childbearing women. Cochrane Database of Systematic
Reviews.
Main EK, Morton CH, Hopkins D, Giuliani G, Melsop K and Gould JB. (2011).
Cesarean Deliveries, Outcomes, and Opportunities for Change in California:
Toward a Public Agenda for Maternity Care Safety and Quality. Palo Alto, CA:
CMQCC. (Available at www.cmqcc.org)
Sakala & Corry.2008. Evidence-Based Maternity Care. Milbank Memorial.
Spong, C. S., Berghella, V., Wenstrom, K. D., Mercer, B. M., & Saade, G. R.
(2012). Preventing the first cesarean delivery. Obstetrics & Gynecology,
120(5), 1181-93

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