King & Pinger, Pearls of Midwifery PDF
King & Pinger, Pearls of Midwifery PDF
King & Pinger, Pearls of Midwifery PDF
org
Original Review
Care for women in labor in the United States is in a period of significant transition. Many intrapartum care practices that are standard policies
in hospitals today were instituted in the 20th century without strong evidence for their effect on the laboring woman, labor progress, or newborn
outcomes. Contemporary research has shown that many common practices, such as routine intravenous fluids, electronic fetal monitoring, and
routine episiotomies, do more harm than good. In 2010, the American College of Nurse-Midwives released a PowerPoint presentation titled
Evidence-Based Practice: Pearls of Midwifery. This presentation reviews 13 intrapartum-care strategies that promote normal physiologic vaginal
birth and are associated with a lower cesarean rate. They are also practices long associated with midwifery care. This article reviews the history of
intrapartum practices that are now changing, the evidence that supports these changes, and the practical applications for the 13 Pearls of Midwifery.
J Midwifery Womens Health 2014;59:572585 c 2014 by the American College of Nurse-Midwives.
Keywords: amniotomy, cesarean, delayed cord clamping, delayed pushing, doula care episiotomy, duration of labor, labor support, midwifery,
normal birth, second stage labor, skin-to-skin care
Many practices in health care, especially in maternity care, chapter of ACNM for a grand rounds presentation on how
were developed because of expediency, habit, or logic and to promote physiologic birth with minimal intervention. In
were not subjected to the rigors of good science.1 2009, ACNM purchased and assumed ownership of the pre-
sentation to make it available to a national audience. The cur-
INTRODUCTION rent version is an ongoing project of ACNM, and new con-
tent is added as evidence becomes available. The current 13
Approximately 4 million women give birth in the United
Pearls of Midwifery are listed in Table 1. In addition to the
States each year and 1.5 million of them undergo a cesarean,2
13 Pearls of Midwifery, the PowerPoint presentation reviews
which is a 50% increase in the cesarean rate since 1990.2
2 overarching concepts that underlie adoption of the Pearls of
The current cesarean epidemic has not lowered indices of
Midwifery: 1) offer the use of nonpharmacologic methods of
maternal or perinatal morbidity for low-risk nulliparous
pain relief; and 2) collaborative multi disciplinary care im-
women at term who present in labor with a singleton fetus
proves all health-related outcomes.
in a vertex presentation. In fact, in this low-risk population,
This article reviews the research findings that support
cesarean is associated with greater morbidity than a vaginal
the 13 intrapartum-care practices associated with optimal
birth.3 Therefore, lowering the primary cesarean rate has
birth outcomes that are reviewed in the Evidence-Based Prac-
become a national priority.4,5 Multiple research studies have
tice: Pearls of Midwifery presentation. More importantly, the
been conducted in the last few years that have identified
degree of evidence for each of these practices is reviewed.
intrapartum care practices associated with increased cesarean
Knowledge of the strength of a particular benefit is essen-
rates,68 and professional associations have issued recom-
tial for clinicians to accurately counsel women and appropri-
mendations that address practices such as avoiding elective
ately individualize care. Ideally, the numbers needed to treat
induction to reduce the cesarean rate.4,5 Thus, identification
would be reported, but that information is not always avail-
of care practices that support normal physiologic labor and
able. Therefore, the actual number per 100 or 1000 women for
birth has also become a recent subject of increasing interest
which a care practice is effective has been calculated wherever
to intrapartum care providers.
possible and reported in the accompanying tables.
The Evidence-Based Practice: Pearls of Midwifery is a
PowerPoint presentation that reviews the evidence for intra-
partum care that supports normal physiologic birth and of-
fers practical techniques that clinicians can incorporate into PEARL: ORAL NUTRITION IN LABOR IS SAFE AND
their practices. This presentation is produced by the American OPTIMIZES OUTCOMES
College of Nurse-Midwives (ACNM) and is available for indi- Allow Women to Eat and Drink During Labor
vidual use. The presentation can be accessed on the ACNM
Web site (http://www.midwife.org/Evidence-Based-Practice- In the United States, laboring women are routinely told not to
Pearls-of-Midwifery). The presentation was initially devel- eat or drink during labor. Routine labor admission orders typ-
oped by the second author (W.P.) and the Washington, DC, ically include restricting oral intake (nothing by mouth) and
insertion of an intravenous line. Rationales for this practice
include hydration, a need for intravenous access in the event
Address correspondence to Tekoa L. King, CNM, MPH, 4265 Fruitvale of an emergency, and the prevention of aspiration in the event
Ave, Oakland, CA 94602. E-mail: [email protected] of general anesthesia. Gastric emptying is delayed during
active labor because peristalsis is inhibited during labor.9 Use No Routine Intravenous Fluids
of opioids for pain relief further retards gastric emptying.
Since the 1970s, intravenous hydration for women in labor
Thus, laboring women have an increased risk for aspiration
has been routine in most US hospitals. Two of the reasons
if they undergo general anesthesia.
put forth for routine intravenous fluids are to counteract
A 1946 article by Mendelson first focused attention on the
ketosis and prevent dehydration in women who are restricted
risks of pulmonary aspiration during labor. In Mendelsons
from oral consumption of food and fluids. Labor is a de-
review of 44,016 pregnant women, 66 of the women experi-
manding metabolic event, and laboring women are at risk
enced pulmonary aspiration during labor. Two of the women
for dehydration. In turn, dehydration may adversely affect
died secondary to asphyxiation with solid particles and a gas-
myometrial contractility and can decrease blood volume,
tric pH that was very low.10 After the Mendelson article was
resulting in decreased uterine blood flow.14 Laboring women
published, the policy of prohibiting women from eating or
produce ketones more rapidly than nonpregnant women,
drinking during labor became the norm in the United States
and ketones may lead to ketoacidosis, which in turn is
in order to prevent aspiration pneumonia.
associated with prolonged labor and an increased need for
Today, the anesthesia-related maternal mortality has de-
augmentation. However, clinically significant adverse effects
creased dramatically to approximately 1.2 per one million
of ketosis have not been documented.15 Using the Cochrane
live births.11 Aspiration is related solely to general anesthesia,
meta-analysis methodology, Toohill et al found no studies
which is rarely used. The major causes of death in women who
that demonstrated either benefit or adverse effects of treating
do receive general anesthesia are related to intubation failure
ketosis during labor.15
and induction problems.11 Thus, aspiration during labor or
The amount of oral intake needed to prevent dehydration
birth is almost nonexistent.
in labor is unknown and subject to extensive individual varia-
In addition, the original rationale for limiting oral in-
tion. The standard policy of intravenous fluids of 125 mL per
take during labor was not well founded in the physiology of
hour for women who are restricted from oral intake is asso-
gastric emptying during labor. Gastric emptying times vary
ciated with an extended duration of labor when compared to
considerably between individuals, and fasting does not guar-
women who are administered 250 mL per hour of intravenous
antee that an empty stomach will ensue within a defined pe-
fluids.16 Thus, it appears that current practices of limiting oral
riod of time. Secretion of gastric juices continues despite the
intake and using intravenous fluids of 125 mL per hour as re-
presence or absence of food. Therefore, it is possible that gas-
placement therapy provides too little fluid and may be iatro-
tric pH may actually be lower in women who are fasting,
genically contributing to longer labors.
putting them at increased risk for pneumonitis if they do as-
There are no published studies that have directly
pirate. The studies that have evaluated maternal and neonatal
compared labor outcomes in women who were administered
outcomes in women who eat versus those who do not eat have
intravenous fluids versus women who had unrestricted oral
not identified any clinically relevant differences between the 2
intake only. That said, studies of labor outcomes in low-risk
groups; however, given its rarity in occurrence, these studies
women who give birth in settings where intravenous fluids are
have had too few numbers to assess the incidence of aspiration
not routinely administered have been shown to be as good as
pneumonitis.12
or better than outcomes of comparable populations of women
who give birth in settings that routinely administer intra-
Practical Application venous fluids.17
When women are allowed freedom to eat and drink during la-
bor, most choose small meals of semisolids during early labor, Practical Application
and few chose to eat at all during the active phase. Given the
lack of evidence that oral intake is harmful, women who are at Do not routinely administer intravenous fluids. A policy that
low risk for needing a cesarean should be offered the choice to allows women to self-select their oral intake has benefits and
eat or drink during labor.13 Discuss aspiration risk related to no adverse effects; therefore, it is best to encourage women
general anesthesia with women prior to labor onset. Limit oral to maintain hydration via oral intake of fluids.13 Use a saline
solids or fluids if the patient is at increased risk for cesarean. lock when intermittent intravenous access is desired. Periodic
Source: American College of Nurse-Midwives. Evidence Based Practice: Pearls of Midwifery. http://www.midwife.org/Evidence-Based-Practice-Pearls-of-Midwifery.
assessments to detect dehydration are warranted, and intra- recent meta-analyses that assessed the effect of upright mater-
venous fluids may be beneficial for women who are at high nal positions in labor found that upright positions shorten the
risk for complications or who are unable to maintain adequate duration of the first stage of labor by approximately one hour
oral intake. (mean difference [MD], 0.99; 95% confidence interval [CI],
1.60 to 0.39).21 Gupta et al found that upright positions
PEARL: AMBULATION AND FREEDOM OF shorten the second stage and decrease the incidence of oper-
MOVEMENT IN LABOR ARE SAFE, MORE ative vaginal births.22 Most observational studies of maternal
SATISFYING FOR WOMEN, AND FACILITATE THE position during labor have found that women spontaneously
PROGRESS OF LABOR assume many different positions during the course of labor,
Lying in bed during labor is a relatively new practice that de- often preferring upright positions in earlier labor and chang-
veloped in parallel with the use of technologies such as labor ing to side-lying later in labor.21
analgesia and continuous, electronic fetal heart rate monitor- In summary, supine positioning during labor has clear ad-
ing (EFM). The disadvantages of lying in bed throughout la- verse effects on labor progress, whereas ambulation and free-
bor are well known. The supine position reduces blood flow dom of motion during labor have beneficial effects on labor
to the uterus; is associated with maternal hypotension, variant progress and maternal satisfaction. In addition, Sims position
fetal heart rate patterns, and lowered fetal oxygenation; and or hands and knees positioning may facilitate rotation from
may decrease the effectiveness of uterine contractions. Yet, occiput posterior to occiput anterior, although the data for us-
only 2 of 5 women who give birth in hospitals today report ing positions to rotate a fetus is not conclusive. Because the
being able to walk during their labors.18 ability to choose a position that is most comfortable enhances
Ambulation and upright positions during labor are asso- feelings of control and decreases pain, freedom to assume any
ciated with many advantages such as improved maternal sat- position of comfort should be encouraged.
isfaction and reports of less pain, less use of analgesia, shorter
duration of the first stage, increased strength and effective- Practical Application
ness of uterine contractions, and a lower incidence of fetal
Encourage upright positions during labor and allow women
heart rate decelerations.19 Older studies that conducted radio-
to labor and birth in any position that feels comfortable and
graphic measurements of pelvic diameters of laboring women
natural. Encourage ambulation and frequent position changes
in upright versus supine positions found that upright posi-
during labor to enhance maternal comfort and optimal fetal
tions increased room in the midpelvis and created approxi-
positioning.
mately 20% more space in the pelvic outlet.20
The use of the reclining position is reserved for periods of
Despite the plethora of studies that have documented pos-
rest or to help the fetus to rotate by placing the women in a
itive effects of upright positions, it is difficult to study and iso-
side-lying position.
late the independent effect of position on labor outcomes in
a formal research study. Women do not stay in one position
during the course of a study and cannot ethically be required PEARL: HYDROTHERAPY IS SAFE AND EFFECTIVE
IN DECREASING PAIN DURING ACTIVE LABOR
to maintain one position. In addition, many practices such as
epidural analgesia independently affect the duration of labor Immersion in water during active labor has been consistently
and may have a stronger independent effect than does mater- associated with relaxation, decreased reported pain, less use of
nal position. Despite these methodologic problems, the most analgesics, and a shorter duration of the first stage of labor.23
574 Volume 59, No. 6, November/December 2014
Immersion in water does not affect the second stage of labor, presence of a support person improves several maternal and
mode of birth, perineal outcomes, or neonatal outcomes; and labor outcomes, albeit these are modest improvements in the
there is no increase in maternal or neonatal infection associ- aggregate27 (Table 2). The positive effects of having a contin-
ated with water immersion. uous support person are more robust when that individual is
Water immersion has physiologic effects that could slow a layperson previously unknown the woman. Women who do
labor or speed labor. Water immersion induces a central blood not have extensive support also have better health outcomes
volume bolus that may dilute plasma oxytocin levels and when they have continuous support throughout labor.
cause a decrease in uterine contraction frequency.24 Con-
versely, high levels of anxiety and pain induce a release of cate-
Practical Application
cholamines that can slow uterine contractility. In this instance,
reduction of anxiety associated with bathing may improve Continuous one-to-one support during labor should be the
uterine contractility. However, Eriksson et al compared out- standard of care for all women. Continuous nonmedical sup-
comes of women who bathed early in labor (before 5-cm di- port during labor has positive effects for the woman, her la-
latation) versus those who bathed in active labor. The women bor course, and the initial postpartum adjustment of both the
in the early bath group had longer labors and were more likely woman and her newborn.
to need oxytocin augmentation and use epidural analgesia.25
Cluett et al evaluated the use of water immersion in PEARL: INTERMITTENT AUSCULTATION SHOULD
nulliparous women who had been diagnosed with dystocia BE THE STANDARD OF CARE FOR LOW-RISK
( 1 cm/hr dilation) and who would have been offered am- WOMEN
niotomy and/or oxytocin augmentation in usual care. The
Continuous EFM was introduced into clinical practice in the
participants were randomized to water immersion for up to
1960s in the United States under the assumption that EFM
4 hours (n = 49) or amniotomy followed by oxytocin aug-
would allow the detection of fetuses at risk for asphyxia.
mentation (n = 50). Thirty-five (71%) of the women in the
Several large RCTs comparing intermittent auscultation (IA)
water immersion group subsequently required oxytocin aug-
to EFM were conducted in the 1980s and early 1990s. The
mentation. Water immersion did not prolong the ultimate du-
Cochrane meta-analysis of these trials (N = approximately
ration of labor.23 The results of this trial suggest that water
37,000 women) found that the use of EFM is associated with
immersion may help a significant number of women avoid la-
more cesareans and more vaginal operative births without im-
bor augmentation; however, there were 6 newborns in the wa-
provement in neonatal outcomes28 (Table 3). Newborns of
ter immersion group who required admission to the neonatal
women in the EFM groups had approximately half the inci-
intensive care unit (NICU) compared to no newborns in the
dence of neonatal seizures, but long-term follow-up of these
augmentation group. The reasons for NICU admission varied,
children found that the newborn seizures were not associated
and only 2 were potentially associated with water immersion.
with permanent neurodevelopmental abnormalities.29
Assessment of fetal well-being can also be obtained via IA
Practical Application
with a Doppler (or Pinard) fetoscope. IA allows for freedom
of movement and upright positions. In addition, the technique
Hydrotherapy and water immersion are nonpharmacologic for using IA effectively requires one-to-one continuous care,
pain-relief methods that should be made available to all low- which has an independent positive effect on childbirth out-
risk laboring women. Prolonged immersion, especially during comes. Maternal and neonatal outcomes of women who give
the latent phase, may slow labor. The use of water immersion birth in settings for which IA is the standard of care are better
as a treatment for dystocia probably has no adverse effects; al- than the outcomes of women with similar characteristics who
though it requires more investigation. give birth in hospitals.17
thereby increasing the strength and effectiveness of uterine both the risk of cord prolapse and emergency cesarean. Selec-
contractions. tive amniotomy for resolving dystocia needs more study.
However, routine amniotomy is controversial. Some au-
thors suggest that the bag of waters protects the fetus dur-
ing labor and that amniotomy is associated with variable fetal PEARL: SECOND-STAGE MANAGEMENT SHOULD
heart rate decelerations, an increased risk of chorioamnioni- BE INDIVIDUALIZED AND SUPPORT AN INITIAL
tis, and umbilical cord prolapse.31,32 Others have found am- PERIOD OF PASSIVE DESCENT AND
SELF-DIRECTED OPEN-GLOTTIS PUSHING
niotomy is an effective means of accelerating labor that, when
combined with oxytocin augmentation, results in a small de- Offering nulliparous women who have epidural analgesia an
crease in the number of cesareans performed.33 initial period of rest after the cervix is 10-cm dilated is based
The most recent meta-analysis of RCTs that compared on the theory that a short rest period will allow the fetus to
amniotomy to no amniotomy in women who were in spon- passively descend and rotate while conserving the womans
taneous labor at term found that routine amniotomy does energy for expulsive efforts.35 This practice has variously been
not shorten the duration of labor (MD, 20.43 min; 95% CI, termed delayed pushing, laboring down, and passive de-
95.93-55.06). There is a trend toward an increased risk for scent. Several RCTs of delayed pushing have found that this
cesarean (relative risk [RR], 1.27; 95% CI, 0.99-1.63) and a practice increases the incidence of spontaneous vaginal birth;
trend toward more fetal heart rate decelerations (RR, 1.09; reduces the risk of instrument-assisted birth; decreases active
95% CI, 0.97-1.23) in women who experience amniotomy.34 pushing time; and has no effect on the cesarean rate, genital
This meta-analysis did not find a difference in duration of la- tract lacerations, or episiotomies.35,36 Both meta-analyses of
bor if the amniotomy was performed early or later in labor, these trials found that approximately 10% more vaginal births
nor did amniotomy accelerate labor for either multiparous or occur when maternal pushing is delayed and the period of ac-
primiparous women.34 tive pushing is shortened by a mean of approximately 12 to 20
minutes. However, the Tuuli analysis found that the increase
in vaginal birth rates was not statistically significant when
only high-quality studies were included (RR, 1.07; 95% CI,
Practical Application
0.98-1.16).36 Table 4 presents a comparison of these 2 meta-
Routine amniotomy should be abandoned. An intact bag of analyses.
waters prevents fetal heart rate decelerations due to cord com- The largest RCT on delayed pushing found a lower rate
pression, prevents chorioamnionitis, and allows for fetal ro- of umbilical artery cord pH values lower than 7.10 in the de-
tation. Allowing the bag of waters to remain intact decreases layed pushing group (RR, 2.45; 95% CI, 1.35-4.43). However,
Abbreviations: CI, confidence interval; EFM, electronic fetal monitoring; IA, intermittent auscultation; RR, relative risk.
a
The relative risk is slightly different than the difference between percentages of events in each group secondary to weighting of the studies.
Adapted from Alfirevic et al.28
it found no difference in the rate of umbilical artery cord pH Studies of spontaneous bearing-down efforts in women
values lower than 7.0 between the groups and no difference who do not have epidural analgesia have found that women
in other clinical newborn outcomes such as Apgar scores or exhibit a pattern of intermittent open-glottis efforts that begin
NICU admission.37 after the contraction starts. When spontaneous bearing down
No studies have evaluated long-term effects of delayed efforts begin, the woman usually pushes 2 or 3 times during
pushing such as pelvic floor integrity, urinary incontinence, each contraction. Some contractions may pass without push-
or fecal incontinence. In addition, although there are no na- ing, and the pushing efforts become more frequent and longer
tionally recommended contraindications to delayed pushing, in duration while the second stage progresses. Women may
it is not recommended when chorioamnionitis or recurrent spontaneously bear down without a contraction while the fe-
fetal heart rate decelerations are present. tus is crowning.38
Journal of Midwifery & Womens Health r www.jmwh.org 577
In contrast, use of the Valsalva maneuver, during which siotomy is an independent risk for anal sphincter lacerations
the woman holds her breath (closed glottis) while bearing (odds ratio [OR], 8.9; 95% CI, 6.1-13.0).42
down, has been standard practice for many years. Studies of Many RCTs ensued, followed by a systematic review43
repeated Valsalva maneuvers have documented adverse phys- and a Cochrane meta-analysis of routine versus selective
iologic effects such as decreased cardiac output, increased in- episiotomy.44 The results of this body of work are robust and
cidence of fetal heart decelerations, and lower umbilical-cord consistent in showing that routine episiotomy has adverse
blood pH values.39 When compared to spontaneous bearing- effects without concomitant benefits (Table 5). Routine
down efforts, Valsalva pushing is also associated with more episiotomy is not recommended by the American College of
maternal fatigue and damage to the maternal pelvic floor.38,40 Obstetricians and Gynecologists (ACOG) or ACNM, and the
A meta-analysis of 4 RCTs found no difference in neona- incidence has been steadily declining in recent years.45,46
tal indices or rates of operative birth when Valsalva pushing Aggressive perineal massage results in trauma to the per-
is compared to open-glottis pushing. The authors concluded ineal tissue and does not prevent or decrease the incidence
that closed-glottis pushing is associated with a shorter second of perineal lacerations.47 Practices that help reduce the inci-
stage41 (MD, 18.59 min; 95% CI, 0.46-36.73 min). However dence of perineal lacerations include antenatal perineal mas-
the wide confidence interval that crossed one suggests that sage, the application of warm compresses just prior to birth,
this finding is not significant. In contrast, Valsalva pushing giving birth in the lateral position, and controlling extension
adversely impacted maternal urodynamic parameters such as of the head slowly between contractions.47
decreased bladder capacity and urodynamic stress inconti-
nence at 3 months postpartum in one well-designed RCT
(16% [11/67] in Valsalva group vs 12% [7/61] in noncoached Practical Application
group).40
Teach interested women antenatal perineal massage to pre-
vent lacerations. There is no evidence to support routine epi-
siotomy or aggressive perineal massage during the second
Practical Application
stage. Wait for and support spontaneous bearing-down ef-
The Valsalva maneuver should be excluded from second-stage forts; discourage Valsalva maneuvers; apply warm heat and/or
care practices. In women laboring without epidural analgesia, oil for comfort; and maintain a quiet, low-light environment.
wait for and support the spontaneous bearing-down efforts. Perform episiotomies only when indicated for fetal or mater-
For the woman with epidural analgesia who does not have a nal conditions.
contraindication to delayed pushing, place her in a side-lying
position with liberal use of pillows for comfort. Placing her
so that the fetal back is up may encourage the rotation and PEARL: DELAYED CORD CLAMPING IMPROVES
descent of the fetal vertex. The period of time that delayed NEONATAL OUTCOMES
pushing should last is undetermined, but most studies used Delayed cord clamping (DCC) has been variously defined in
1 to 2 hours or until the woman has a rectal urge. Once push- the literature. Most commonly practiced, the cord is clamped
ing, discourage prolonged breath holding and Valsalva ma- 60 seconds or more and up to 5 minutes after birth or when the
neuvers. Individual practices that adopt a policy of routine de- cord stops pulsating. In contrast, early cord clamping (ECC)
layed pushing for women who have epidural analgesia should occurs when the cord is clamped at less than 60 seconds after
also develop a list of contraindications to this practice. the birth, which in practice usually occurs within the first 15
seconds.48
DCC allows for a placental transfusion of up to 30% of the
PEARL: THERE IS NO EVIDENCE TO SUPPORT total fetalplacental blood volume. This transfusion includes
ROUTINE EPISIOTOMY OR AGGRESSIVE PERINEAL many types of pluripotent stem cells that may have signifi-
MASSAGE AT BIRTH
cant long-term value for the child. More directly, this trans-
Routine episiotomy became the norm in the United States in fusion supplies approximately 60% more red cells and about
the 1920s and has remained a routine practice until it was re- 81 mL (range 50 to 163 mL) of whole blood.49 The placental
visited in the 1990s. It was initially believed that an episiotomy transfusion that occurs with DCC supplies approximately 30
had multiple benefits, including reduction in the incidence of to 35 mg of iron, which is sufficient to sustain the newborn
third- and fourth-degree perineal lacerations; provision of a for 3 to 4 months longer than if the cord was clamped im-
cleaner incision for repair, which would enhance wound heal- mediately after birth.50 When DCC occurs at 2 minutes after
ing; decrease in postpartum pain; and reduction in the risk of the birth or later, benefits include a 47% reduction in the risk
fecal or urinary incontinence via shortening the duration of of iron-deficiency anemia (RR, 0.53; 95% CI, 0.40-0.70) and
the second stage. a 33% reduction in the risk of having deficient iron stores at
In 1989, Green et al published the results of an observa- 2 to 3 months of age (RR, 0.67; 95% CI, 0.47-0.96).48 Older
tional study of perineal outcomes in women who had an epi- physiologic studies of human newborns substantiated ani-
siotomy versus those who did not have an episiotomy.42 In this mal studies that showed the newborn responds with a pro-
cohort of 3065 women who had spontaneous vaginal births, found bradycardia if ECC occurs before the first breath is
anal sphincter injury occurred in 2.2% of those who did not taken.51 Similar well-conducted observational studies in hu-
have an episiotomy and 28.4% of those who did have an epi- mans found that DCC is associated with improved cardiopul-
siotomy (P .00001). Logistic regression confirmed that epi- monary adaptation after birth, better cutaneous perfusion and
higher skin temperature, increased renal blood flow and more Practical Application
urine output, and increased blood flow to the brain and gut.50
DCC should be the standard of care. DCC improves both the
The possible adverse effects of DCC are hyperbilirubine-
short-term and long-term hematologic status for the newborn
mia and polycythemia secondary to overperfusion. Protec-
and does not have clinically significant adverse effects. The
tion against these 2 newborn disorders has been the primary
optimal duration of DCC appears to be up to 3 minutes, un-
reason that ECC has been recommended in obstetric texts.
less the cord stops pulsing sooner. Healthy newborns should
A systematic review of DCC versus ECC did not find that
be placed on the mothers chest to encourage skin-to-skin con-
DCC is associated with hyperbilirubinemia (RR, 1.16; 95% CI,
tact while waiting to cut the cord. If there is a need to move
0.85-1.58).48 Although there does appear to be an increase in
the newborn for resuscitation, one can hold the newborn be-
asymptomatic polycythemia (RR, 3.82; 95% CI, 1.11-13.21)
low the introitus and/or milk the cord to increase the amount
that was no longer statistically significant when only high-
of transfusion in a short time.
quality studies were included in the analysis (RR, 3.91; 95% CI,
1.00-15.36), none of the newborns with asymptomatic poly-
cythemia required treatment.48 PEARL: IMMEDIATE SKIN-TO-SKIN CONTACT
The amount of placental transfusion is affected by the du- AFTER BIRTH PROMOTES THERMOREGULATION,
ration of DCC, height that the newborn is held, milking the IMPROVES INITIAL BREASTFEEDING, AND
FACILITATES EARLY MATERNALINFANT
cord, and possibly uterotonic medications. Approximately 80
BONDING
mL is transferred after 60 seconds and reaches approximately
100 mL after 3 minutes.49 Lowering the newborn at least 10 Historically, newborns were placed skin-to-skin on their
cm below the vaginal introitus speeds the time needed for mothers chest to protect against heat loss and facilitate
placental transfusion to complete. Lowering the newborn 40 breastfeeding. This practice, also referred to as kangaroo
cm or more led to complete transfusion in the one study that care, is recommended by the World Health Organization for
specifically evaluated the height of the newborn after birth.49 all newborns regardless of birth weight or clinical condition.53
The effect of uterotonic medications depends on the med- Common practice in the United States has been to hand the
ication used and the route of administration. Uterine contrac- newborn to a second health care provider immediately after
tions definitely facilitate placental transfusion, but the effect of the umbilical cord has been cut so that the newborn can be
oxytocin (Pitocin) given after birth is likely minimal because dried, wrapped in a warm blanket, and examined.
it takes 3 to 5 minutes to generate uterine contractions after Several RCTs and one meta-analysis54 have shown that
the drug is administered. In addition, intravenous fluids may placing the newborn skin-to-skin on the mothers chest, with
dilute plasma levels of endogenous oxytocin and slow contrac- the newborns head covered with a dry cap and the back cov-
tion activity. ered with a blanket, improves several newborn physiologic in-
Milking or stripping the blood in the cord from the pla- dices (eg, cardiorespiratory stability, glucose levels), reduces
centa toward the newborn has been proposed as an alternative newborn crying, and increases the rate of breastfeeding initi-
to DCC. Although milking the cord significantly increases ation and breastfeeding continuation at one to 4 months after
iron stores and does not appear to have adverse effects in term birth.54
or preterm newborns, study protocols have varied and it is not
clear how many times one should milk the cord or how long
the cord should be to transfuse an adequate supply of blood Practical Application
to the fetus.51,52 Replacing DCC with cord milking appears to Placing healthy newborns skin-to-skin on the mothers ab-
be a reasonable option if it is necessary to move the newborn domen immediately after birth should be the standard of care.
quickly. This practice has substantial positive benefits and no adverse
Continued
Abbreviations: BMI, body mass index; NA, not applicable; NR, not reported; SD, standard deviation.
a
First stage of labor as defined by patient history.
b
90th percentile.
Adapted from King TL.69
previous cesarean (TOLAC).75 Because the US cesarean rate ing modifications of food and fluid intake and fetal monitor-
is now 32.8%,73 all strategies that could lower the overall rate ing guidelines.
need to be implemented. Increasing the number of women
who undergo TOLAC is one of the most important.68
CONCLUSION
TOLAC carries an overall risk of uterine rupture of less
than 1%.76 TOLAC is recognized to be the safest option for The practices reviewed in this article are as old as midwifery,
women who have had one prior cesarean and no concurrent and many of them predate the advent of hospital birth. As
conditions that increase the risk for uterine rupture (eg, a this review has demonstrated, modern research techniques
pregnancy condition that precludes vaginal birth such as pre- have affirmed the value of midwifery strategies in optimizing
vious classical incision or uterine surgery). The overall suc- normal vaginal birth. Epidemiologic and observational stud-
cess rate of TOLAC is 74% but varies between 54% and 94%, ies have long documented that midwifery care is associated
depending on clinical factors in the womans history, current with improved perinatal outcomes,8386 yet the concern
pregnancy, and labor status.76 about selection bias has haunted this work. Does midwifery
Since 2010, the National Institutes of Health and ACOG care improve outcomes, or are women who chose midwives
have recommended that women who are candidates for TO- inherently more likely to have better outcomes? Analysis
LAC be offered this option.76,77 It was hoped that more hospi- of the research that supports the Pearls of Midwifery care
tals would offer TOLAC after these guidelines were released, practices, which are midwifery practices, sheds some light on
but thus far they do not appear to have made a significant this question. Although each of the Pearls of Midwifery has
impact.78 Strategies that increase the TOLAC rate include in- a modest independent contribution to improving childbirth
terventions at all levels from health policy to individual pa- outcomes, the combined effects contribute to and may be
tient counseling. Tort reform that relieves physicians from the largely responsible for exemplary midwifery outcomes.
worry about medicallegal risks will have to play a role.76 The Pearls of Midwifery clearly improve maternal and
Several studies have found that decision aids and prenatal neonatal outcomes, facilitate normal physiologic birth, and
counseling for women who have had a previous cesarean assist prevent cesareans. They should resume their place as a stan-
women in making an informed decision that is reflective of dard of care for women in labor. Midwives are the health care
their core values.7981 Prenatal counseling in a culturally sen- providers most responsible for ensuring that these practices
sitive manner that accommodates patient values and encour- again become the norm in maternity care for women and their
ages shared decision making is essential and has promise as a newborns. Rooted in evidence, the Pearls of Midwifery can
strategy that will aid women while they learn about the bene- and should be generalized to every practice setting, popu-
fits and risks of TOLAC versus elective repeat cesarean.80 lation, and provider. By following the recommendations for
practical applications outlined for each of the Pearls of Mid-
wifery, all maternity care providers can improve childbirth
outcomes for women and their families.
Practical Application
Both TOLAC and VBAC rates are higher in institutions where AUTHORS
midwives care for laboring women.82 Counsel all women pre-
Tekoa L. King, CNM, MPH, FACNM, is Deputy Editor of the
natally about the risks and benefits of TOLAC. Encourage
Journal of Midwifery & Womens Health and Health Sci-
TOLAC as the safest option for women who are appropriate
ences Clinical Professor at the School of Nursing at the Uni-
candidates. Follow the Pearls of Midwifery to optimize each
versity of California, San Francisco.
womans chance of a normal vaginal birth, including women
attempting TOLAC. Institute modifications to the Pearls of Whitney Pinger, CNM, MSN, FACNM, is Director of Mid-
Midwifery for women attempting TOLAC as needed, includ- wifery Services and Associate Clinical Professor at the George