Alternative Birthing
Alternative Birthing
• System updates
• Medical director video
• https://www.youtube.com/watch?v=KHS6g
VpT1_0&feature=youtu.be
Alternative Birth Movement
• Consumer reaction to medical obstetrical practices
developed in the United States early in this century.
• Settings developed as single labor-delivery rooms in the
hospital or as free standing birth centers
• Physician resistance based on maternal and infant safety
• Physicians fear economic competition and loss of control
over obstetric practices
History
• Until the 1930s childbirth was truly dangerous
• High percentages of women and infants died
during or soon after childbirth
• Organized medicine began to take steps to lower
mortality rate
• New medical specialty was founded called
Obstetrics
• Prenatal care gained recognition for its benefits
in preventing death
History
• Childbirth moved from home to hospital with
promise of more controlled conditions
• Improvements in public health, public sanitation,
and control of chronic illness reduced dangers of
childbirth
• 1940s advances in antibiotics and blood banks
• 1950s routine maternity care became very rigid
in the hospital setting
• 1960s the natural childbirth movement began to
gain momentum
History
• Mothers began to attend childbirth classes
• Involved family members in birth process
• Spent more time caring for their babies in the
hospital setting.
• 1970s saw the reemergence of the midwife as
well as the use of alternative settings for birth
• Hospitals began to offer more flexible family
centered care and more homelike rooms for
birth
History
History
History
History
Current
Providers
• Obstetrician/Gynecologist
• Medical physician (MD/DO) who has completed
residency in OB/GYN
• Certified Nurse Midwife
• Registered nurse who has completed graduate
education/training in midwifery and is an APN
• Direct-Entry/Certified/Professional Midwife
• Non RN who has completed education in midwifery
• Not licensed to practice midwifery in Illinois
Providers
• Doula
• Lay person (nonmedical) who
provides physical
assistance and
emotional support
related to childbirth
Certified Nurse Midwife
• Advanced Practice Nurse
• Registered Nurse
• Average of 2-4 years of nursing experience on
OB/GYN, post partum, or related area
• Graduate education (master’s or doctorate) and
training in nurse midwifery
• Certified by the American College of NurseMidwives Certification Council
• Licensed in Illinois as APN
• Collaborate with OB-GYNs to care for women
Certified Nurse Midwife
• CNMs attend 10% of all spontaneous vaginal
births in the United States
• 7% of total births in United States
• 97% in hospitals
• 1.8% in freestanding birth centers
• 1% at home
• CNMs have been practicing in the United States
since the 1920s
Certified Nurse Midwife
• Scope of practice
• Primary healthcare for women (adolescence to
beyond menopause)
• Gynecologic, family planning services
• Preconception care
• Care during pregnancy, childbirth, and postpartum
• Monitor fetal development
• Manage acute and chronic illnesses of women
• Care of normal newborn during first 28 days of life
• Treatment of male partners for STDs
Certified Nurse Midwife
• Scope of Practice
• Conduct physical examinations
• Prescribe medications
• May admit, manage, discharge patients from the
hospital
• Order, interpret laboratory and diagnostic tests
• Order use of medical devices
• Health promotion, disease prevention, wellness,
education/counseling
Certified Nurse Midwife
• Why nurse midwives?
• Improved infant mortality rate in hospitals, birth
centers for women who are low risk
• Fewer C-section births for low-risk women
• Reduced use of unnecessary procedures
• Reduced healthcare costs
• Increases access to care
• Provides care to underserved,
• Rural areas, as well as urban
Certified Nurse Midwife
• Why nurse midwives?
• Low risk pregnancies account for 60-80% of all
pregnancies
• CNMs consult with and refer to obstetricians,
perinatologists and other healthcare professionals
when patient is not low risk
• 20-40% could have potential complications
• Complicated pregnancies are referred to
obstetricians or co-managed by physicians and
CNMs in hospitals
Certified Nurse Midwife
• Referral from home to hospital
• 7-18% antepartum for OB reasons
• Placenta previa, pregnancy-induced hypertension,
pre-term, intrauterine growth restriction
• 8-12% intrapartum referrals
• Failure to progress, prolonged rupture of
membranes, meconium staining, fetal distress,
bleeding, hypertension
Certified Nurse Midwife
• 1-2% post-partum maternal referrals
• Retained placenta, post partum hemorrhage,
laceration repair
• 1-2% neonatal referrals
• Inability to establish normal respiration,
congenital abnormality, low birth weight, low
APGAR score, birth trauma, sepsis
• Urgent transfer 1/1000
Certified Nurse Midwife
• What to expect for EMS
• Report
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Vital signs
Description of reason for the call
Description of current patient condition
Description of all actions taken to stabilize patient
History
Last menstrual period
Estimated due date/mother’s medical history
Gravida and para
Certified Nurse Midwife
• What to expect for EMS
• CNM is an expert resource that can be utilized by
EMS to assist with patient care
• CNM cannot ask EMS to administer medication
outside of their SOPs
• CNM cannot ask EMS to perform any procedure
outside of their scope of practice
• Usually will accompany patient to the hospital to
continue care
• Also trained to provide newborn care
Certified Nurse Midwife
• Ensure that provider is a certified nurse midwife
• Non-licensed individuals may refer to themselves
as “midwives”
• If the situation is questionable, contact Medical
Control immediately
Doulas
• A doula, also known as a birth companion and
post-birth supporter, is a non medical person
who assists a woman before, during, and/or
after childbirth, as well as her spouse and/or
family, by providing physical assistance and
emotional support
Doulas
Doulas
DO
• Assist and coach
prior to, during, and
after labor
• Provide emotional
support
• Physical support and
massage
• Assist with non-labor
related needs
DO NOT
• Physically aid in
delivering baby
• Provide medical
advice
• Examine, diagnosis,
or treat medically
Doulas
• Formal education not required
• Can participate in a training program
• May also learn through an apprenticeship or
mentorship
• Certification highly recommended (Certified
Labor Doula (CLD))
Doulas
• CAPPA is an international certification
organization for doulas
• The labor doula works with families during
pregnancy, during labor, in the birth process and
in the immediate post partum phase
• They can be found working in the community, in
private practice, in cooperatives, as part of
groups or agencies, as well as serving in various
community programs
Childbirth
• Childbirth has not changed but many things
associated with childbirth have
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Women’s expectations
Pain management options
Economics of childbirth
Healthcare system
Technology used during pregnancy and birth
Birthing Methods
• Birth practices have changed in the past 100
years
• The Cesarean section rate is approaching 30% in
the United States
• Labor induction is becoming more common. An
estimate of 40% of all women are induced
Birthing Methods
• Vaginal birth
• Most common method
• Can be done with/without pain medication
• Cesarean section
• Surgical method requiring incision in abdomen
and uterus
• Longer recovery
• Best for women at risk for complications, birth
defects, multiple fetuses, or women with certain
health conditions
Birthing Methods
• Home birth
• Allows for birth in familiar surroundings
• Home birth not suitable for women with high
blood pressure, heart problems, or diabetes
• Should be prepared for possible transfer to a
hospital should complications occur
Water Birth
• Process of giving birth in a tub of warm water
• 25 U.S. hospitals and 70% of all birth centers
support water birth
• Water birth said to reduce anxiety, relax muscles,
and speed up labor, more holistic experience
• Reduces tearing of delicate tissues
• Emerged as widespread practice in Europe in
1980s and 1990s
Water Birth
• Water immersion in labor
• Water birth mother remains in the water during
the pushing phase and actual birth of baby
• Risk of infection concern of physicians
• Not recommended for breech births, twins or
pregnancies with risks of complications
• In 2014 the American College of Obstetricians
and Gynecologists and the AAP released a
statement rejecting water births
Water Birth
• Breathing reflex in
healthy newborn
babies does not kick
in until the baby’s
face, nose and mouth
have been stimulated
by exposure to air
Hypnobirth
Hypnobirthing
• Self hypnosis in childbirth has been around for
centuries
• Birthing women and their support partners are
taught non pharmacological strategies
Hypnobirth
• Hypnosis and self hypnosis during childbirth lead
to:
• Decreased average length of labor
• Lower cesarean section rates
• Decreased use of pain relief medication such as
epidurals
• Increased ease and comfort of labor and birth
• Babies born under hypnosis tend to be calmer,
more alert and better sleepers and eaters
Acupuncture
• Acupuncture and acupressure alternatives to
medical intervention during labor
• Recommended to begin in the 36th or 37th week
of pregnancy leading up to birth
• Treatments help prepare uterus, pelvis, cervix for
birth encouraging efficient labor
• Pre-birth acupuncture found women 35% less
likely to be induced and 31% less likely to have
epidural
Acupuncture
Acupuncture
• Acupuncture can be used in labor as well
• Helps to increase and sustain contractions
• Stimulates cervical dilation
• Increases endorphin release (body’s natural
coping mechanism for pain)
• Acupressure can also be used to achieve similar
results during labor
• Also utilized post partum to promote healing,
can decrease need for pain medication postpartum
Birth Centers
• Home like facility, existing within a healthcare
system with a program of care designed in a
wellness model of pregnancy and birth.
• Birth centers are guided by principles of
prevention, sensitivity, safety, appropriate
medical intervention and cost effectiveness
• They provide family centered care for healthy
women before, during and after normal
pregnancy
Birth Centers
• Offers gynecologic and maternity care in safe,
comfortable environment
• Designed for healthy low risk mothers and
healthy babies
• Involves the entire family in the pregnancy and
birth
• Relaxed atmosphere
• Offers privacy
Birth Centers
• Women are encouraged to drink instead of
routine IVs
• Mothers are not tied to electronic fetal
monitoring
• Baby’s heartbeats are checked with handheld
dopplers at regular intervals
Birth Centers
• Nurse midwife is with mother throughout labor
• Mother choses most comfortable position to
give birth
• Birth centers promote breastfeeding
• No separation of mother and baby
• All infant care done in front of family
Birth Centers
• Birth center is part of a medical care system
• If mother or baby develops a problem patient is
transported to the closest appropriate hospital
• Nurse midwife may accompany mother to the
hospital
• EMS should follow appropriate SOP’s
Birth Centers
• Low overall intrapartum and neonatal
mortality rate
• Focus on creating healthy pregnancies and
minimizing interventions during labor
• No maternal mortality
• Neonatal mortality of 1.3/1000 births
• C-section rate averages 4.4% compared to
national hospital average of 26%
OBSTETRICAL COMPLICATIONS
BLS/ALS
1. Initial Medical Care SOP, p. 4
2. HIGH FiO2 or VENTILATION
 ALS: If altered mental status or signs of hypoperfusion, IV FLUID BOLUS IN
200 mL increments titrated to patient response.
 Palpate abdomen to determine uterine tone and presence of contractions.
 Place mother on left side or raise right side of backboard 20-30°. Insert second
IV line if no response to initial fluids.
BLEEDING IN PREGNANCY
2. Note type, color and amount of bleeding and/or vaginal discharge. If tissue passes,
collect and bring to the hospital with the patient.
TOXEMIA IN PREGNANCY OR PREGNANCY INDUCED HYPERTENSION
2. HANDLE PATIENT GENTLY. Minimize CNS stimulation (avoid lights and siren).
DO NOT check pupil response. Seizure precautions.
3. ALS: If seizure occurs:
Administer VERSED (midazolam) 2 mg increments IV q 2 minutes up to 10 mg
total as necessary, titrated to control seizures.
Labor and Delivery
Complications
• Premature rupture of membranes (PROM)
• Membranes rupture too early in pregnancy
• Exposes baby to high risk of infection
• Umbilical cord prolapse
• Cord can slip thru cervix after water breaks
preceding baby thru birth canal
• Blood flow becomes blocked
• Or stopped
Labor and Delivery
Complications
• Cord stretches and is
compressed during
labor
• Leads to decrease in
blood flow
• Can cause sudden
drops in fetal heart
rate
• Occurs 1 in 10
deliveries
Labor and Delivery
Complications
• Amniotic fluid embolism
• Most serious complication of labor and delivery
• Small amount of amniotic fluid enters mothers
blood stream
• Usually occurs during difficult labor or C-section
• Fluid travels to lungs and causes arteries in lungs
to constrict
• Widespread blood clotting a common
complication
EMERGENCY CHILDBIRTH
BLS/ALS
PHASE I: UNCOMPLICATED LABOR
1. Obtain history and determine if there is adequate time to transport
a. Gravida (number of pregnancies) and Para (number of live births).
b. Number of miscarriages, stillbirths, and multiple births.
c. Due date (expected date of confinement, “EDC”) or date of LMP (last menstrual
period).
d. Onset, duration, and frequency of contractions (time from beginning of one
contraction to beginning of the next).
e. Length of previous labors in hours.
f. Status of membranes, intact or ruptured. If ruptured, inspect for prolapsed cord
or evidence of meconium.
g. HIGH RISK CONCERNS:
o maternal drug abuse
o teenage pregnancy
o history of diabetes/hypertension/cardiovascular disease/other pre-existing
diseases that may compromise mother and/or fetus
o preterm labor (< 37 weeks)
o previous breech or C-section.
2. Inspect for bulging perineum, crowning, or whether patient is involuntarily pushing
with contractions. If contractions are two minutes apart with crowning or any of the
above are present, prepare for delivery. If delivery is not imminent, transport on left
side. DO NOT ATTEMPT TO RESTRAIN OR DELAY DELIVERY UNLESS
PROLAPSED CORD IS NOTED.
IF DELIVERY IS IMMINENT:
3. Initial Medical Care SOP, p. 4
a. If patient is hyperventilating, coach her to take slow deep breaths
b. ALS: If patient becomes hypotensive or lightheaded at any time:
 IV FLUID BOLUS in 200 mL increments
 HIGH FiO2 or VENTILATION
4. Position patient supine on a flat surface, if possible. Use standard precautions.
5. Open OB pack. Place drapes over the patient’s abdomen and beneath perineum.
EMERGENCY CHILDBIRTH (Continued)
PHASE II: DELIVERY
4. Control rate of delivery by placing palm of one hand over occiput. Protect perineum
with pressure from other hand.
5. If amniotic sac is still intact, gently twist or tear the membrane. Note presence or
absence of meconium.
6. Once the head is delivered, allow it to passively turn to one side.
7. Feel around the neck for the umbilical cord (nuchal cord). If present, attempt to gently
lift it over the head. If unsuccessful, double clamp and cut the cord between the
clamps.
8. To facilitate delivery of the upper shoulder, gently guide to head downward. Once the
upper shoulder is delivered, support and lift the head and neck slightly to deliver the
lower shoulder. Allow head to deliver passively.
9. The rest of the newborn should deliver quickly with one contraction. Firmly grasp the
newborn as it emerges. Newborn will be wet and slippery.
10. Keep newborn level with vagina until cord stops pulsating and is double clamped.
PHASE III: CARE OF THE NEWBORN
NOTE: The majority of newborns require no resuscitation beyond maintenance of temperature,
mild stimulation, and suctioning of the airway. Transport is indicated as soon as the airway is
secured and resuscitative interventions, if needed, are initiated. If the APGAR score is < 6 at 1
minute or meconium is present, begin resuscitation.
BLS / ALS
1. Pediatric Initial Medical Care SOP, p. 74
2. Deliver head and body
3. Clamp and cut cord
4. Assess neonatal risk factors:
 Term gestation?
 Clear amniotic fluid?
 Breathing or crying?
 Good muscle tone?
5. Provide basic care:
 Provide warmth
 Position; clear airway as needed with bulb syringe or large bore suction catheter
 Dry the newborn, stimulate and reposition as needed
6. Check respirations:
 If apneic and meconium present, clear airway and provide deep suctioning of the
oropharynx. Begin positive pressure ventilation at rate of 40-60 per minute using
neonatal BVM.
 If apneic without signs of meconium, begin positive pressure ventilation at rate of 4060 per minute using neonatal BVM.
7. Check heart rate:
 If heart rate > 100 BPM, check color
 If heart rate 60-100 BPM, continue ventilations for 1-2 minutes, reassess heart rate.
 If heart rate < 60 BPM, administer chest compressions for 30 seconds at a ratio of
3:1 with ventilations, reassess heart rate.
 If heart rate remains < 60 BPM, continue CPR.
Drug of the Month
• The FDA has established five categories to indicate the
potential of a drug to cause birth defects if used during
pregnancy
• Category A: failed to demonstrate a risk to the fetus in first
trimester (levothyroxine, folic acid, magnesium sulfate)
• Category B: Animal studies have failed to demonstrate risk to
fetus or pregnant woman (metformin, hydrochlorothiazide,
cyclobenzaprine, amoxicillin)
• Category C: Studies have shown adverse effects on fetus but
potential benefits may warrant use of drug in pregnant
women despite risks (tramadol, gabapentin, prednisone)
Drug of the Month
• Category D: Studies have shown fetal abnormalities and
positive evidence of human fetal risk, risks outweigh benefits
of use in pregnant women ( lisinopril, alprazolam, lorazepam
and losartan and most chemotherapy drugs)
• Category X: Studies demonstrated fetal abnormalities/fetal
risks and use of drug in pregnancy outweighs potential
benefits (atorvastatin, simvastatin, warfarin, methotrexate)
• Antibiotics: Drugs in the penicillin category are safe to take
during pregnancy. Also most types of erythromycin and
antibiotics in the cephalosporin category
Drug of the Month
• Asthma medication: Pregnancy is an additional physiological
challenge that can impact severity of disease. Although
uncontrolled asthma is rarely fatal, complications to the
mother include high blood pressure, toxemia, and premature
delivery
• Antidepressants: Excellent safety record in second and third
trimesters
Cardiac
• Arrhythmias in pregnancy are common
• Majority that occur are benign
• Cardiovascular system undergoes significant
change
• Increased heart rate
• Increased cardiac output
• Reduced systemic vascular resistance
Cardiac
• The decision to treat a pregnant woman’s
arrhythmia depends upon:
• Frequency
• Duration
• Tolerability of the arrhythmia
• Balance between benefit of arrhythmia
reduction and maternal/fetal side effects of any
drug treatment
• Palpitations most common symptom in
pregnancy
Cardiac
• Potential factors that can promote arrhythmias
in pregnancy and during labor and delivery
include:
1. Electrophysiologic effects of hormones
2. Changes in autonomic tone
3. Hypokalemia in pregnancy
4. Underlying heart disease
Torsades de pointes
• Torsades is a distinctive polymorphic ventricular
tachycardia
• QRS amplitude varies
• QRS complexes appear to twist around baseline
• Associated with prolonged QT interval
• May be congenital or acquired risk can increase
with pregnancy
Torsades de pointes
Cardiac
• Cardiac arrest during childbirth rare
• Factors that can cause cardiac arrest include
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Preeclampsia
Excessive bleeding (45%)
Heart failure (13%)
Heart attack
Blood infection (11%)
Amniotic fluid embolism (13%)
Cardiac
• Researchers found that CPR was often successful
in cases of cardiac arrest during childbirth and
that survival rates rose from 52% in 1998 to 60%
in 2011.
• Those who had cardiac arrests were older or had
limited health care prior to or during their
pregnancy.
State of Illinois
Abandoned Newborn
Infant Protection Act
Background
• Safe Haven Laws
• Statutes in the United States that decriminalize the leaving of
unharmed infants with statutorily designated private persons
so that the child becomes the ward of the state
• Also known in some states as:
• Baby Moses Law
• Safe Place
• Safe Surrender
Background
• Texas was first state to enact a “Baby Moses Law” in 1999
• Safe place originates in Mobile, Alabama
• By 2008, all 50 states had a form of safe haven law
• As of 2013, no one has used the law in the state of Alaska
Summary of Act
• The Abandoned Newborn Infant Protection Act allows the
parent or parents of unwanted infants, 30 days old or less to
relinquish the newborn to a Safe Haven
• Regardless of the age of the child, If there are signs of abuse
or neglect, proceed as if the child were abused or neglected
with appropriate care and transport to a medical facility at
which time a DCFS report must be filed
• If the child is obviously older than the 30 day-age covered in
the Act, proceed as if the child is abused or neglected and
proceed in accordance with the Act including filling a report
with DCFS
Definitions
• Newborn
• 30-days old or less
• Safe Haven
• Any fire station, police station, hospital and emergency
medical care facility that is staffed 24-hours a day where the
relinquishing parent may take an unwanted newborn
• This excludes free standing medical facilities
• If a designated Safe Haven is not staffed 24-hours a day, the sign
must read “Only When Staff Are Present”
Immunity
• Receiving personnel are immune from criminal
or civil liability for acting in good faith in
accordance with this Act
Presumptions Allowed by the Act
• It is presumed that the relinquishing parent
consents to the termination of his or her
parental rights
• It is presumed that the relinquishing parent is
the newborn infant’s biological parent
Consent and Treatment
• Consent for Medical Treatment of the Newborn
• The act of relinquishing the newborn infant serves as
implied consent for medical treatment if necessary
• Treatment and Transport of the Newborn
• Medical treatment will be provided as necessary
• Any abandoned newborn or infant will be transported
to the hospital by ambulance
Relinquishing Parents’ Rights
• The relinquishing parent has the right to anonymity
providing there is no evidence of abuse or neglect
• If abuse or neglect is suspected at the time of relinquishment
notify law enforcement
• The relinquishing parent may return to the Safe Haven
within 72 hours of relinquishment to reclaim the infant
• Upon request by relinquishing parent, the name and location of
the hospital that the newborn was transferred to must be
provided
• The relinquishing parent may petition the State within 60-days of the
relinquishment to reclaim the infant
• As a designated Safe Haven, all employees
are required to accept relinquished infants
and newborns