Continuous Support in Labor:
An Underused Evidence-Based
Practice
Liza Goldman Huertas, MD
Obstetrics Rotation
Dept. of Family & Social Medicine
Agenda
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Review some overused harmful practices and
underused beneficial practices in maternity care
in the U.S.
Case related to continuous support in labor
Define continuous support in labor
Review evidence for doula care
Relate doula care to other aspects of evidencebased maternity care
Identify pts most likely to benefit from doula care
Discuss implications for our practice
Room for Improvement:
Maternity Care in the U.S.
 The
U.S. has some of the highest infant
mortality rates among industrialized
countries… and is falling in ranking: 29th
among countries, tied with Poland and
Slovakia (CDC)
 In 2007, CDC reported an increase in
U.S. maternal mortality rates
 Despite highest cost, best technology
Infant Mortality Ranking
Infant and Maternal Mortality
Complex social phenomena with many contributing
factors:
 Overall Socioeconomic wellbeing of society
 Social Status of women and subgroups of O+:
economic opportunities, education, safety
 Nutrition, health status of vulnerable women
 Obesity and Diabetes
 Access to health care: 1°, prenatal, preventive
 Prematurity, LBW, C-section rate, IVF/multiples,
early inductions
Expensive
QuickTime™ and a
decompressor
are needed to see this picture.
Evidence-Based Maternity
Care: The Millbank Report
 High
rates of interventions with risks of
adverse effects (overused practices)
 Highlighted Overused Practices: Labor
Induction, Epidural & Spinal Analgesia, CSection, Continuous EFM, Rupture of
Membranes, Episiotomy, Certain Routine
Prenatal Screening Practices
 Beneficial underused interventions
Induction of Labor
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Theoretical concerns: pitocin may interfere with
physiologic oxyctocin function in PPH, bonding,
breastfeeding; iatrogenic prematurity in infant,
?Effects on brain development in final 1-2 wks of
pregnancy (in-utero vs. ex-utero)
Increased rates of C/S in 1st time mothers
Increased EFM
More epidural analgesia
More assisted delivery
Increases cost
Epidural & Spinal Analgesia
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Maternal effects: immobility, voiding difficulty,
sedation, fever, hypotension, longer 2nd stage,
perineal tears
Increased IVF, BP monitoring, EFM, bladder
cath, pitocin, meds for hypotension, forceps or
vacuum delivery, episiotomy
Under some conditions, likelihood of C/S
Fetal /newborn risks: fetal tachycardia &
bradycardia, hyperbilirubinemia, sepsis workups,
more abx, lower newborn assessment scores
Increased Cost
C-Section
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Life-saving for absolute indications: cord prolapse, previa, abruption, persistant transverse.
 Increases risk of: maternal death, surgical injury,
PPH, emergent hyst, DVT, CVA, infection, prolonged hosp/rehosp, intense & prolonged pain,
bowel obstruction, poor birth experience, poor
mental health & overall functioning, abruption,
previa, accreta, uterine rupture, infertility
 For infants: iatrogenic prematurity, LBW,
stillbirth, respiratory problems, failure to BF
 Increased risk with repeat C/S.
Case Study
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16yo P0 @40 and 6 undergoing IOL. No
prenatal issues. No PMH.
Pt’s mother & older sister present at bedside.
Older sister has scrubs on; bilingual, assertive,
asks questions.
FOB to be present . FOB and pt are not close
but FOB is traveling from Boston to be present.
Nursing staff comes into conflict with family over
policy of 2 family members only.
Nursing staff increasingly annoyed.
Case Study p2
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Initially coping well with contractions, surprising
the nurses. Hoping to avoid epidural analgesia.
 Mother becomes B’s only support. She speaks
only Spanish. Anxious, distrusts staff & quiet
when staff present.
 B is increasingly frustrated. Wants to eat, go to
the bathroom. Uncomfortable lying down. Does
not want FOB present for vaginal exams.
Caregivers express annoyance outside room.
 Frequency/intensity of contractions increase, B
gets desperate and decides to get an epidural.
Case Study p3
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B’s mother upset because she feels B would be
coping better with pain if her sister was present.
(Sister left because security was called earlier).
Anesthesiology delayed in OR.
B yells at mother & providers, demands epidural,
increasingly suffering & terrified.
B eventually gets epidural, comfortable again.
Epidural is dense and B can barely move her
legs. Progress slows. Pitocin is titrated up.
FHR pattern becomes increasingly concerning.
C-section discussed.
Case Study p4
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2nd stage complicated by “poor maternal effort”.
Providers tell pt she isn’t doing her job, needs to
put in real effort. Fear, frustration turns to yelling.
As B pushes her baby out, room goes quiet. The
baby’s head is blueish.Tight nuchal cord x3.
No exclamations of joy as infant resuscitated.
Doctors complete their care of the mother.
Infant improves quickly but pt & mother are not
updated. Anxiety & grief are palpable.
An hour later, when doctors & nurses are
finished taking care of her, B cries inconsolably.
She is not interested in holding her baby.
Selected Underused
Interventions
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Midwives & Family Physicians
Smoking Cessation for Pregnant Women
Prematurity Prevention: Centering Pregnancy
External Version to Turn Breech Babies
Delayed and Spontaneous Pushing
Non-pharmacologic measures to relieve pain,
promote comfort & labor progress
Non-supine positions
More Underused
Interventions
 Early
Skin to Skin Contact
 Breastfeeding & BF Interventions (e.g.
Baby Friendly Hospitals)
 Psychosocial Interventions for Postpartum Depression
 Continuous Support in Labor
What is Continuous Support
in Labor
 Continuous
presence
 Emotional support
 Advice regarding comfort measures and
coping
 Patient education
 Advocacy on behalf of the laboring woman
Doulas in the United States
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Non-medical providers of labor support
Ancient Greek meaning woman of service
Provide emotional support, physical comfort,
objective view, support informed decisionmaking, facilitate communication, advocacy
Provide support to partners and family
May also be interpreters & cultural brokers
Several accreditation organizations
Postpartum doulas, end of life doulas.
Why Would Doula Care Help?
Theories
 May
mediate effect of birth environment:
Buffers to unfamiliar, stressful
environments.
 Enhancing maternal feelings of confidence
& control, reducing reliance on medical
interventions.
 Potential to limit “cascade of interventions”
by enhancing labor physiology
Why Would Doula Care Help?
Labor Physiology
 Intervene
on stress response--> increased
epi--> can effect FHR pattern, catecholamines decrease uterine contractility,
prolong labors--> lower APGARs
 Enhanced
feto-pelvic relationships
(mobility, gravity, preferred positions)
Why Would Doula Care Help?
Possible Longterm Impact
 Adjustment
to parenthood, self-image,
feelings of competence & confidence
 Mother-infant Bonding
 Breastfeeding
 Postpartum depression
 Role modeling: nurturing mother, infant,
and family.
 Encouraging healthy family relationships
Cochrane Intervention
Review: Use this practice!
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First Do No Harm: No evidence of harm from
continuous support in labor has been reported.
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Major Outcomes: increased chance of NSVD
(decreased C/S, forceps and vacuum), less
likely to use pain medications, greater
satisfaction with the childbirth experience,
slightly shorter labors.
Cochrane Intervention Review
(Meta-Analysis) 2007
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16 trials, 11 countries, 13,000 women
 Controlled trials: support person could be
certified professional or trained family member
 Outcomes included: pitocin, EFM,
pharmacologic analgesia, severe pain, labor
length, SVD, C/S, episiotomy, perineal trauma,
low APGARS, low cord pH, NICU, anxiety during
labor, perception of low control, longer term
maternal outcomes
 Subgroup Analysis: effects of childbirth
environment, provider of care, timing of care
Cochrane:
What doulas can do
 Increase
NSVDs (double in some cases)
 Decrease regional analgesia, any
analgesia
 Decrease vacuum, forceps, C sections
 Fewer negative childbirth experiences
 Slightly shorter labor length, less than 1 hr
difference (effect diluted by trials involving
staff doulas)
Subgroup Analysis: Care
most effective
 When
provided by person who was not a
member of the hospital staff
 In settings where epidural analgesia was
not routinely used
 When started early in labor--> Evidence of
dose-response phenomenon
Insufficient Data
(Cochrane could not assess)
 Mother’s
and infants wellbeing postpartum
 Perineal trauma
 Relationship between woman and partner
 Urinary and fecal incontinence
Conclusions from Authors of
Cochrane Review
 Continuous
support should be the norm
not exception!
 Birth
environments should afford privacy,
be empowering and non-stressful
 Birth environments should not be
characterized by routine interventions that
add risk without clear benefit
Evidence of Longterm Benefit
in Smaller Trials
 Higher
rates of breastfeeding at 6 weeks
 Improved mother-infant bonding
 Decreased rates of postpartum depression
 Increased confidence in & perception of
ease of parenting
 Positive maternal self-image and positive
perception of body
 Needs more study to corroborate.
May have particular benefit
for certain groups
 Young
women, especially teens
 Low income women
 Women of color, Black women & Latinas
 Doula programs for Spanish-, Vietnamese, and Somali-speaking immigrant women
 Incarcerated women
 Women laboring alone
Implications for Family
Physicians?
References
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Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during
childbirth. Cochrane Database of Systematic Reviews 2007, Issue 3. Art. No.:
CD003766.
Stuebe, A. Continuous intrapartum support. In: UpToDate, Basow, DS (Ed),
UpToDate, Waltham, MA, 2009.
Sakala, C and Corry, MP. Evidence-Based Maternity Care: What It Is and What It Can
Achieve. 2008.
Newton KN, Chaudhuri J, Grossman X, Merewood A. Factors associated with
exclusive breastfeeding among Latina women giving birth at an inner-city babyfriendly hospital. J Hum Lact. 2009 Feb;25(1):28-33.
Dundek LH. Establishment of a Somali doula program at a large metropolitan
hospital. J Perinat Neonatal Nurs. 2006 Apr-Jun;20(2):128-37.
Schroeder C, Bell J. Doula birth support for incarcerated pregnant women. Public
Health Nurs. 2005 Jan-Feb;22(1):53-8.
Lantz PM, Low LK, Varkey S, Watson RL. Doulas as childbirth paraprofessionals:
results from a national survey. Womens Health Issues. 2005 May-Jun;15(3):109-16.
Stein MT, Kennell JH, Fulcher A. Benefits of a doula present at the birth of a child. J
Dev Behav Pediatr. 2003 Jun;24(3):195-8.
www.dona.org, www.childbirthconnection.org