Consensus Statement on Physiologic Birth

SUPPORTING HEALTHY AND NORMAL PHYSIOLOGIC CHILDBIRTH: A CONSENSUS STATEMENT BY ACNM, MANA, AND NACPM*

In 1996, the World Health Organization called for the elimination of unnecessary intervention in childbirth, yet currently there are few resources to assist maternity care providers in achieving this goal . The purpose of this consensus statement is to explicitly identify key benchmarks of safe, healthy, and normal physiologic childbirth. This statement will assist maternity care providers, women, policymakers, and payers to protect, promote, and support human childbearing physiology and to avoid overuse of interventions, thus achieving better care, better health, and lower costs.

This consensus statement represents the work of a task force comprised of representatives from three U.S. midwifery organizations whose members are experts on supporting women’s innate capacities to birth, and was externally reviewed by maternity care organizations and leaders. The specific aims of the consensus statement are to

  • Provide a succinct definition of normal physiologic birth;
  • Identify measurable benchmarks to describe optimal processes and outcomes reflective of normal physiologic birth;
  • Identify factors that facilitate or disrupt normal physiologic birth based on the best available evidence;
  • Create a template for system changes through clinical practice, education, research, and health policy; and
  • Ultimately improve the health of mothers and infants, while avoiding unnecessary and costly interventions.

This statement is placed in the context of the current, widespread application of technological interventions that lack scientific evidence to a primarily healthy birthing population. The use of obstetric interventions in labor and birth has become the norm in the United States. More than half of all pregnant women receive synthetic oxytocin to induce or augment labor, which demands additional interventions to monitor, prevent, or treat side effects. Nationally, one third of women deliver their babies via cesarean, a major abdominal surgery with potential for serious short- and long-term health consequences. For the mothers these consequences include, but are not limited to, postoperative infections, chronic pain, future cesarean births, and placental complications that can lead to hemorrhage, hysterectomy, and rarely, death. Infant risks include respiratory distress, and in subsequent pregnancies maternal risks include increased likelihood of preterm birth and associated morbidity and mortality. Regardless of intervention or outcome, childbearing care perceived by the woman as disrespectful or traumatic is more likely to be associated with maternal psychologic al morbidity and potential for disrupted mother-infant attachment .

Defining the normal physiology of child birth

This statement is grounded in scientific evidence and based on definitions drawn from the 2012 version of the Oxford English Dictionary, in which “normal” refers to typical or usual--a standard, and “physiology” refers to the functional processes of an organism, organ, or system. Thus, normal human physiology provides a framework to understand the optimal functioning of childbirth. For the purposes of this statement, birth includes the three stages of labor, the newborn transition, and the first hour after birth. 

A normal physiologic labor and birth is one that is powered by the innate human capacityof the woman and fetus. This birth is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes. Some women and/or fetuses will develop complications that warrant medical attention to assure safe and healthy outcomes. However, supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for the mother and infant.18-21

Normal physiologic childbirth

  • is characterized by spontaneous onset and progression of labor;
  • includes biological and psychological conditions that promote effective labor;
  • results in the vaginal birth of the infant and placenta;
  • results in physiological blood loss;
  • facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and
  • supports early initiation of breastfeeding.

The following factors disrupt normal physiologic child birth:

  • induction or augmentation of labor;
  • an unsupportive environment; bright lights, cold room; lack of privacy, multiple providers, lack of supportive companions, etc.;
  • time constraints including those driven by institutional policy and/or staffing
  • nutritional deprivation, e.g., food and drink;
  • opiates, regional analgesia, or general anesthesia;
  • episiotomy;
  • operative vaginal (vacuum, forceps) or abdominal (cesarean) birth;
  • immediate cord clamping;
  • separation of mother and infant; and/or
  • any situation in which the mother feels threatened or unsupported.

The mechanisms and outcomes of physiologic child birth

Normal physiologic labor and birth has positive short- and long-term health implications for the mother and infant. Optimal physiologic function of the neuroendocrine system enhances the release of endogenous oxytocin and beneficial catecholamines in response to stress. These hormones promote effective labor patterns and protective physiologic responses, including enhanced endorphin levels, facilitation of cardio-respiratory transition and thermoregulation of the newborn, successful lactation, and enhanced bonding behavior between the mother and infant. When there is optimal physiologic functioning, women are less likely to require interventions to artificially augment labor, which can potentially interfere with their ability to cope with pain. When labor progresses spontaneously there is a reduced likelihood of fetal compromise or need for instrumental/surgical intervention.

For most women, the short-term benefits of normal physiologic birth include emerging from childbirth feeling physically and emotionally healthy and powerful as mothers. Their infants will benefit from the ability of their mothers to respond to their needs and from the lack of exposure to medications that can affect neurological behavior. Long-term outcomes include beneficial effects for the woman’s physical and mental health and capacity to mother, enhanced infant growth and development, and potentially diminished incidence of chronic disease. Together, these outcomes are beneficial to the family and society through enhanced family functioning and cost effective care. Importantly, a focus on these aspects of normal physiologic birth will help to change the current discourse on childbirth as an illness state where authority resides external to the woman to one of wellness in which women and clinicians share decisions and accountability.

Factors that influence normal physiologic child birth

There are multiple factors that influence the ability of a woman to give birth without intervention. These include the following:

For the woman:

  • Her individual health status and physical fitness;
  • Autonomy and self-determination in childbirth;
  • Personal knowledge and confidence about birth, including cultural beliefs, norms, and practices and education about the value of normal physiologic birth;
  • Fully informed, shared decision-making; and
  • Access to health care systems, settings, and providers supportive of and skilled in normal physiologic birth.

For the clinician:

  • Education, knowledge, competence, skill, and confidence in supporting physiologic labor and birth, including helping women cope with pain;
  • Commitment to working with women through education to enhance their confidence in birth and diminish their fear of the process;
  • Commitment to shared decision making; and
  • Working within an infrastructure supportive of normal physiologic birth.

For the birth setting and environment:

  • Access to midwifery care for each woman;
  • Adequate time for shared decision making with freedom from coercion;
  • No inductions or augmentations of labor without an evidence-based clinical indication;
  • Encouragement of nourishment (food and drink) during labor as the woman desires;
  • Freedom of movement in labor and the woman’s choice of birth position;
  • Intermittent auscultation of heart tones during labor unless continuous electronic monitoring is clinically indicated;
  • Maternity care providers skilled in non-pharmacologic methods for coping with labor pain for all women;
  • Care that supports each woman’s comfort, dignity, and privacy; and
  • Respect for each woman’s cultural needs.

Recommendations for policy, education, and research to promote normal physiologic childbirth include, but are not limited to, the following:

  • Introduction of policies into hospital settings to support normal physiologic birth;
  • Comprehensive examination and dissemination of the evidence and care practices supportive of normal physiologic birth;
  • Midwifery care as a key strategy to support normal physiologic birth
  • Increasing the midwife workforce and enhancing regulations and funding strategies to support their practice;
  • Competency-based, inter-disciplinary education programming for maternity health care clinicians and students on the application of care that promotes normal physiologic birth; and (see the Normal Birth Summit Statement)
  • Development of a future research agenda on short and long-term effects of normal physiologic birth.

* Note. ACNM=American College of Nurse-Midwives, http://www.midwife.org/;
  MANA=Midwives Alliance of North America, http://mana.org/;
  NACPM=National Association of Certified Professional Midwives, http://www.nacpm.org/.
  This document is intended for health care professionals and policymakers. Please download the full color PDF companion document for consumers here

Approved by the Boards of Directors of ACNM, MANA and NACPM, April 2012 Released May 14, 2012

 

To view the full footnoted version with resources download the attached file.

 

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