1. Keeping the ‘Normal’ in Normal Birth Interdisciplinary Panel Discussion November 30 th, 2006

2. ‘Normal’ Birth: A Problematic Notion Wide range of normal amongst labouring women Wide range of normal amongst labouring women Notion of normal has different meanings in different contexts Notion of normal has different meanings in different contexts –WHO DefinitionWHO Definition –Obstetric Normality in Active Management of LabourNormality Intervention has become the norm in contemporary culture Intervention has become the norm in contemporary culture norm

3. WHO Definition of Normal Birth: Spontaneous in its onset Spontaneous in its onset low-risk at the start and throughout labour and delivery. low-risk at the start and throughout labour and delivery. Baby is born spontaneously in the vertex position between 37 and 42 gestation Baby is born spontaneously in the vertex position between 37 and 42 gestation Following birth both mother and infant are in good condition. Following birth both mother and infant are in good condition.

4. Normal Progression in Active Management of Labour 1. Strict diagnostic criteria for labour onset 2. Artificial Rupture of the Membranes (ARM) if dilatation not maintained at rate of l cm/ hr 3. Augmentation with synthetic oxytocin if dilatation not increasing at this same rate 4. Charting of labour progress– the partogram. 5. The provision of customized childbirth education & continuous 1 on 1 support*

5. Intervention As Normal: Physiologic Birth: The spontaneous head-first delivery of a single baby without employment of narcotics, entinox or epidurals, synthetic hormones-induction or augmentation of labor, artificial rupture of the membranes or episiotomy. ( Midwifery ) Physiologic Birth: The spontaneous head-first delivery of a single baby without employment of narcotics, entinox or epidurals, synthetic hormones-induction or augmentation of labor, artificial rupture of the membranes or episiotomy. ( Midwifery ) Physiologic birthrate in Nova Scotia: Physiologic birthrate in Nova Scotia: 4 1.75% for first time mothers 1.75% for first time mothers 5% for women having their second or subsequent baby 5% for women having their second or subsequent baby

6. Birth Intervention Menu Continuous Electronic Fetal Monitoring Continuous Electronic Fetal Monitoring IV Drip IV Drip Catheterization Catheterization Epidurals, Narcotics, Entinox Epidurals, Narcotics, Entinox Labour Induction Labour Induction Artificial Rupture of Membranes Artificial Rupture of Membranes Labour Augmentation Labour Augmentation Operative Assisted Delivery Operative Assisted Delivery Caesarean Sections Caesarean Sections

7. Intervention Menu: The Gaps 1 to 1 Continuous caregiver support (Midwife/ Douala/ Other trained birth attendant) 1 to 1 Continuous caregiver support (Midwife/ Douala/ Other trained birth attendant) Consistent Information, Education and Support re Non-pharmacological Pain Relief Methods Consistent Information, Education and Support re Non-pharmacological Pain Relief Methods Nourishment Nourishment

8. Interventions: The Cascade Effect Cascade: Cascade: A succession of things…each of which activates, effects, or determines the next Understanding the Cascade of Interventions Understanding the Cascade of Interventions Cascade of Interventions Cascade of Interventions

9. The Cascade of Intervention The Cascade of Intervention 6 Directional Relationships highlighted in this diagram have all been established in scientific literature. Directional Relationships highlighted in this diagram have all been established in scientific literature. To interpret the diagram begin with an intervention of interest and follow arrows from that point. To interpret the diagram begin with an intervention of interest and follow arrows from that point.

10. Select Birth Indicators (2001) Select Birth Indicators (2001) 7 IndicatorCanadian Nfld * ProvincialRangeNationalRange C/Section22.5%26.6% 24.8 - 31.5% 9.2-31.5% VBAC26.7%12.5% 7.0 - 14.4% 7.0-60.7% Vaginal Assisted 16.2%18.6% 17.1 - 28.2% 2.5-28.2% VaginalUnassisted61.3%54.8% Inductions20%13% Epidurals45.4%34.4%8.3-50.5%3.9-74.6%

11. NL Intervention Rates By Region (2005) NL Intervention Rates By Region (2005) 8 IndicatorEasternCentralWesternLabradorGrenfellProvinceChange(01-05) C/Section31.1%29.4%26.5%26.5%29.8%+3.3% C/S – 1 st time moms 31.6%30.6%25.0%30.7%30.5%N/A Vaginal Assisted 12.4%12.4%11.6%5.6%11.7% - 6.9% VaginalUnassisted56.5%58.3%61.9%67.8%58.5%+3.7% Induced26.3%28.8%17.8%19.7%25.0%+12% Epidurals39.7%7.9%43.7%5.9%32.9%-1.5%

12. Why Should We Be Concerned? Birth Intervention Trends Impact Health Outcomes (women and baby) Carry Significant Financial Implications Contravene Best Practice Guidelines

13. CaesareanSections Infant Risks: Breathing Problems Breathing Problems Low Apgar Scores Low Apgar Scores Fetal Injury Fetal Injury Increased Neonatal Deaths & NICU Admissions Increased Neonatal Deaths & NICU Admissions Premature Birth Premature Birth Lower Breastfeeding Initiation Lower Breastfeeding Initiation Increased Asthma Incidence Increased Asthma Incidence Higher Stillbirth Rate amongst women with previous C/S Higher Stillbirth Rate amongst women with previous C/S Maternal Risks: Operative & Post-Op complications: e.g. bleeding, clots, infections, transfusions Operative & Post-Op complications: e.g. bleeding, clots, infections, transfusions Increased pain, length of recovery, hospital stay and re-admission Increased pain, length of recovery, hospital stay and re-admission Respiratory complications Respiratory complications Secondary infertility Secondary infertility Ectopic pregnancy Ectopic pregnancy Placental abruption/ adherence problems Placental abruption/ adherence problems uterine rupture before and during labor uterine rupture before and during labor Need for further surgeries (e.g. Hysterectomy, bladder repairs) Need for further surgeries (e.g. Hysterectomy, bladder repairs)

14. Caesarean Sections: The Financial Costs The Financial Costs 9 Average Cost of Vaginal Delivery Without Complications in 2002/2003: Average Cost of Vaginal Delivery Without Complications in 2002/2003: $2700 $2700 Average Cost of Caesarean Delivery Without Complications in 2002/2003: Average Cost of Caesarean Delivery Without Complications in 2002/2003: $4600 $4600

15. Best Practice Guidelines The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent. The World Health Organization (WHO) states that no region in the world is justified in having a cesarean rate greater than 10 to 15 percent. 10

16. Explaining The Trend Maternally Derived Factors Socio- Cultural Factors Caregiver Derived Factors

17. References 1. Kaufman KJ, Effective control or effective care, (roundtable debate: active management part 2) Birth, 1993; 20(3): 150-61 2. World Health Organisation (1996). Care in Normal Birth: A practical guide. www.who.int/reproductive- health/publications/MSM_96_24/MSM_96_24_Chapter1.en.html www.who.int/reproductive- health/publications/MSM_96_24/MSM_96_24_Chapter1.en.html www.who.int/reproductive- health/publications/MSM_96_24/MSM_96_24_Chapter1.en.html 3. Thornton, J.G (1996). Active management of labour. BMJ, 313: 378. http://www.bmj.com/cgi/content/full /313/7054/378 http://www.bmj.com/cgi/content/full /313/7054/378 http://www.bmj.com/cgi/content/full /313/7054/378 4. Source: The Reproductive Care Program of NS 5. The second national U.S. Listening to Mothers® survey (2006). http://www.marketwire.com/mw/release_html_b1?release_id=175714 6. Cascade of Intervention: http://www.acegraphics.com.au/parents/obstetric/diagram.html 7. Canadian Institute for Health Information (2004) Giving Birth In Canada: A Regional Profile. http://secure.cihi.ca/cihiweb/products/GBC2004_regional_e.pdf http://secure.cihi.ca/cihiweb/products/GBC2004_regional_e.pdf 8. Prepared By the NL Centre for health Information, November 8 th, 2006 9. Canadian Institute For Health Information (2006) Giving Birth in Canada: The Costs. http://secure.cihi.ca/cihiweb/products/Costs_Report_06_Eng.pdf http://secure.cihi.ca/cihiweb/products/Costs_Report_06_Eng.pdf 10. WHO Guidelines for Caesarean Sections - http://www.childbirth.org/section/CSFact.html http://www.childbirth.org/section/CSFact.html