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REVIEW ARTICLES

Practices to stimulate normal childbirth

Flora Maria Barbosa da Silva, Sonia Maria Junqueira Vasconcellos de Oliveira, Lia Mota e Silva^1
1Programa de Pós-Graduação em Enfermagem, Escola de Enfermagem da Universidade de São Paulo (USP), Brazil

Mail delivery: Department of Maternal-Child and Psychiatric Nursing School of Nursing, University of São Paulo, Rua Eneas de Carvalho Aguiar 419, 05422-90 Cerqueira César (São Paulo (SP)) Brazil

Manuscript received by 18.8.2010
Manuscript accepted by 14.10.2010

Index de Enfermería [Index Enferm] 2011; 20(3): 169-173

How to cite this document

Abstract

This article leads to a reflection about the practices of encouraging normal childbirth, with the theoretical foundation for each one of them. The practices included in this study were fasting, enema, shower and immersion baths, walking, pelvic movements and massage. In a context of revaluation of normal birth, providing evidence-based comfort options for women during childbirth can be a way to preserve the physiological course of labour.
Key-words: Natural childbirth/ Obstetrical nursing/ Evidence-based care/ Midwife.

Introduction

     The management of labour, with its several behaviors and practices applicable to the birth process, leads to some questions and thoughts on the subject. The models of care delivery have been transformed throughout history, both in Brazil and in the world. These changes occurred gradually and involved different social actors, values, beliefs, knowledge, institutions and interests, about different aspects that underlie the context of birth.
     One of the strongest indicators of the changes in patterns of care during labour and birth is the rising caesarean rates. The rate of caesarean delivery in Spain presented an increase of 86.76/1,000 live births in 193 to 250.12/1,000 live births in 2005.¹ In Brazil, a survey conducted in 2006 found that the caesarean section correspond to 44% of births in the country, and in the private sector these rates reach almost double (81%) in the previous decade.²
     These rates far exceed the recommendations of World Health Organization (WHO), which recommends a maximum rate of 15% of caesareans in any country. Maternal complications arising from surgical delivery ranging since from minor events, such as fever and blood loss to major complications, such as accidental viscera laceration, puerperal infections and anesthetic complications. Complications related to the neonate are associated with prematurity and respiratory distress syndrome. Besides the inherent risk of the procedure, the uterus may have consequences as late disease of great hemorrhagic potential (placenta praevia and placenta accreta), whose complications often cause the woman death.³
     In this sense, the abuse of interventionist practices presents problems related to two distinct factors and correlated, with a social character and another, of a financial nature. The first issue, changing the course of physiological childbirth, can trigger a cascade of events unnecessary and repeated, increasing the level of complexity and risk of the procedure. Thus, the intervention model has produced questions based on events that show unfavorable results regarding the inappropriate use of technology. The second issue exacerbates the dispensable practice of cesarian section, with respect to undue expense of such practices in the lack of a real demand, burdening the public or private health care systems.^3-5
     In the context of questioning these interventionist practices, the WHO published in 1996 A Practical Guide for the Care Childbirth. It refers to assistance provided to women during labour and delivery, has the discretion to evidence-based practice and seeks a better basis for clinical decision making. Regarding health care models, this document points out that the practices should include respect for the physiological process and the dynamics of every childbirth, in which interventions should be careful, avoiding the excesses and judiciously using available technological resources.⁵
     This assistance model is strongly related to care provided by midwives, whose training is focused on the emotional support and care to women and newborns, without interfering in the physiological process of childbirth, covering a more complete approach to health care.⁵

Practices to stimulate normal childbirth

     The observation of the physiological aspects and the focus on the woman needs are guidances of first choice for labour and delivery. The practice of encouraging normal childbirth can have three main purposes:
     Avoid routine interventions
     Allow the spontaneous course of labour
     To promote comfort and minimize pain
     In this study, we attempted to discuss some practices to stimulate the normal childbirth, looking up the theoretical basis of each one. In order to do so, we used systematic reviews and randomized clinical trials, which are the best available evidence in health care. The obstetrics is the only health area on which all procedures were appraised in systematic reviews.

Avoid routine interventions

     On the birthing women admission, usually are performed routine procedures such as enema and prescription of fasting. Study in Southeast Asian countries - Philippines, Malaysia, Indonesia and Thailand-showed that rates of use of these procedures ranged from 17 to 61%.⁶ In Brazil, public hospitals and covenant of Rio de Janeiro, the use of enema ranged 17% to 38.4% in vaginal deliveries, respectively.⁷
     The use of enema during labour, in general, reflects the preference of the provider of health care. Although evidence indicates against its use, they are still widely used because they are seen as stimulating uterine contractions. However, this practice can cause discomfort for women and increase the cost of the assistance.⁸ Allowing evacuation before birth, which happens spontaneously is beneficial to encourage the natural peristalsis and lower intestinal distress, it can also prevent the evacuation during the second stage of labour.
     A systematic review that included three studies and 1,765 women with the aim of analyzing the effect of enema performed during labour in infection rates of maternal and neonatal mortality, duration of labour, the dehiscence of perineal trauma, perineal pain and evacuation. The meta-analysis did not reveal any statistical difference in rates of infection in mothers or in newborns, after a month of follow up. The only trial that examined the view of women found no significant difference in satisfaction between these groups. It was concluded that the use of enema has no significant effect on rates of maternal or neonatal infection and satisfaction of women. This evidence does not support the routine use of enemas during labour, therefore the use of this practice should be reduced.⁹
     The opinions about oral intake in scientific articles vary widely. The risk of aspiration of gastric contents during general anesthesia (Mendelson's syndrome) continues to support the conduct of total fasting from ingestion of food and water during labour.⁵ Some studies still justify the fasting during labour based on this theory.¹⁰ Furthermore, the use of regional anesthesia in modern obstetrics minimizes the risk of aspiration of the gastric contents.¹¹
     Clinical trial of 2,426 nulliparous women pregnancy at term (37 completed weeks or more), single fetus, cephalic presentation, in labour with cervical dilation less than 6 cm, evaluated the effect of oral intake on the obstetrical and neonatal deaths. It compared the use of light diet with only water intake during labour. The results showed no statistical difference between groups in outcomes: normal birth and caesarean delivery rates, length of labour, Apgar scores and occurrence of vomiting. The authors concluded that consumption of diet soft during labour did not interfere with obstetric or neonatal outcomes of women and did not increase vomiting rates.¹¹
     Systematic review that included 3,130 pregnant women at low risk, with five studies examined the restriction on the intake of food and fluids during the active phase of labour. The authors concluded that many women naturally reduce food intake when contractions become more intense, so women should be free to decide whether or not to continue to eat or drink during labour.¹² There is no justification for this restriction, although some health care providers argue that food can cause vomiting and administration of intravenous glucose solution can be a source of energy. However, the effects of infusion are related to the increasing of maternal glucose and insulin levels, resulting in increased plasmatic glucose levels in the baby, with a decrease of the umbilical artery pH. Prolonged fasting during labour can be unpleasant and may adversely affect women's experience, besides allowing hypoglycemia and dehydration, since giving birth requires great expenditure of energy.⁵

Allow the spontaneous course of labour

     The onset of labour in pregnancy at term means that the fetus is ready for the birth and the mother is physiologically receptive to the process.¹³ The various interventions that seek to accelerate and correct labour aim to bring it to the rhythm hospital. However, as demonstrated by Barros et al.,¹⁴ the interruption of pregnancy, either by caesarean section or induction of labour, caused significant increase in prevalence of preterm births and reduced the birthweight.
     The most commonly used medication for the acceleration of labour is oxytocin in intravenous administration. May be prescribed by the physician or, according to the protocol prescription, by the nurse midwife, to increase the frequency and intensity of uterine contractions.^8,10
     However, though it has become common, the induction of labour has several consequences for both mother and fetus. A systematic review comparing outcomes of deliveries with elective induction with spontaneous deliveries, noted that elective induction increases the need for analgesia, epidural anesthesia, neonatal resuscitation, increases the rates of caesarean sections and may increase the proportion of instrumental deliveries, intrapartum fever, shoulder dystocia, low birthweight and admission to the intensive care unit neonatal.¹⁵
     Another systematic review, the Cochrane Library, included 12 studies with 7,792 women in an analysis of the effects of the early amniotomy and administration of oxytocin. The reviewers found that there was a modest reduction in risk of caesarean delivery and reduction of about one hour in duration of labour, with no significant effects in maternal and neonatal morbidity rates.¹⁶
     Besides the direct effects of oxytocin on uterine activity, intravenous catheterization can restrict the woman mobility labour, by the fear of losing the venous catheterization. This discomfort can diminish the woman's satisfaction with the event of childbirth.

To promote comfort and minimize pain

     Many practices used during the active phase of labour seek to promote comfort and minimize pain inherent to the process of parturition. Among the advantages of non-pharmacological methods is the lower incidence of side effects, since methods such as anesthesia or analgesia during labour may result in decreased maternal awareness and vitality of the newborn or the woman's loss of control over the delivery process. These methods can also hinder the cooperation of the mother in the case of some emergencies, such as shoulder dystocia. The non-pharmacological methods are less expensive and can delay the use of pharmacological methods, which reduces the exposure of the mother and baby to their adverse effects. It is known that factors such as fear, stress, tension, fatigue, cold, hunger, loneliness, helplessness, social and emotional aspects and ignore what is happening may intensify the sensation of pain of childbirth, while relaxation, confidence, receive correct information, support continuum of family and friends and the fact of feeling active and quiet in a comfortable environment can reduce the pain perception.¹⁷
     The shower bath is a very common practice during labour by not requiring special equipment, promote hygiene and keep the mother in comfortable temperature in tropical countries. Some research highlights the possibility of the shower bath to stimulate uterine contractions and give the feeling of comfort during childbirth. They also argue that the shower bath revitalizes, stimulates blood circulation, reduces back pain and promotes relaxation which promotes cervical dilation.⁸ The shower bath is often associated with other non-pharmacological practices, such as the Swiss ball and massage. There were found no clinical trials with methodological rigor to demonstrate the effect of the shower bath in the contractions, pain and duration of the labour.
     The influence of immersion baths at labour was evaluated in several studies. Among the effects caused by immersion baths during labour are: increased production of endorphins, resulting muscle relaxation and stress reduction, improves blood flow and fetal oxygenation, increased excretion of urine and decrease blood pressure.^10,17
     A randomized clinical trial with 108 pregnant women investigated the effects of immersion baths in pain during the first stage of labour, for 60 minutes. The women were divided into two groups, an experimental group on which women immersed in water when they reached 6 to 7 cm of cervical dilation and a control group which did not receive the bath therapy. It was found that the pain in the control group was higher than the experimental group. According to the study, the immersion bath is a successful alternative for pain relief.¹⁸
     Systematic review with 11 studies and 3,146 women evaluated the effects of immersion baths during labour and birth outcomes on maternal, fetal, neonatal and on providers of care. The results indicated a significant decrease in the use of epidural analgesia. There were no statistical differences regarding duration of labour, rate of operative deliveries and adverse effects on the newborn. No adverse effects were observed in this practice.¹⁹
     However, it seems wise to recommend that at immersion bath the water temperature must be chosen by the birthing woman, it shall not be offered during latent phase of labour and the woman should be accompanied during the bath. The therapy may cause vasodilatation from the heat, which can induce to hypotension. In this situation, it is needed to provide cooling water into the bath or to remove the birthing woman out of the tub. The relaxation brought by the immersion bath can facilitate childbirth so the delivery can occur during immersion, which requires extra care with the newborn and the placental expulsion. The perineal assessment to verify the need for repair should preferably be done outside the tub.
     Walking promotes an upright position and has been highlighted in delivery care by professionals. Among the advantages that this position offers are the action of gravity on the fetal descent, no compression of maternal large vessels, increasing in the diameters of pelvic inlet and docking angle and an improved ventilation and basic acid balance. This effects therefore act improving the efficiency of uterine contractions and shortening the labour.^8,10,20
     The movement is related to pelvic muscle relaxation of the pelvic region and improvement of local circulation. Favors the permanence of the mother in a vertical position and can shorten the active phase of labour and encourage maternal mobility.^{8, 20} The use of Swiss ball can facilitate pelvic movement during labour and promote comfort and decreased pain by stimulation of pelvic joint mechanoreceptors.²¹
     Restricting women to bed can be convenient the hospital staff in order to facilitate the control of the labour process. However, it is recommended mobility and upright positions to the labouring woman. It can provide greater comfort and relaxation to the birthing woman, and allows her a sense of control over the delivery process.²² When at home, women seem to instinctively seek the most favorable position to the progress of labour.¹³ Protocols and policy statement in maternity care differs about the maternal position issue, however the supine position should be avoided by bringing harm to mother and fetus, as the uterine contractions gets weaker and the placenta´s blood flow is reduced.¹⁰
     A systematic review of the Cochrane Library on position and maternal mobility during the first stage of labour, compared to an upright position (walking, sitting, standing, kneeling) and recumbent position (supine, semi-recumbent and lateral). It included 21 studies and 3,706 women. One of the main results is that dilation period was one hour shorter in women who adopted the upright position compared to recumbent position. Women in upright position were less likely to receive analgesia. No differences between groups regarding the duration of the expulsion period, type of delivery, or other related to the welfare of mothers and babies. It concluded that women should be encouraged to take whatever position they feel most comfortable in the first stage of labour,²³ as many prefer to walk, especially during the early phase.²⁴
     Massage is also associated with positive experiences for women throughout this process by providing a sense of caution and being assisted.¹⁰ According to some research, massage in the dorsal region decreases pain perception through the release of endorphins, promoting muscle relaxation and the participation of the companion during labour.
     Systematic review²⁵ on alternative and complementary therapies on the management of pain during labour and delivery clinical trial included a massage with 60 women divided into two groups. The massage group received three sessions of 30 minutes, during labour (3-4cm, 5-7cm and 8-10cm of cervical dilation). The control group received standard nursing care, and 30 minutes of conversation with the researchers. Pain and anxiety were measured after the three sessions, and in the massage group significant results were: anxiety reduction only on the first application and a reduction in pain after three applications. The authors conclude that the massage technique is a simple, noninvasive and can positively influence the experience of labour.²⁶
     According to the authors Zwelling, Johnson and Allen,²¹ massage stimulates circulation and enhances tissues oxygenation, facilitates toxins excretion through lymphatic system and can also be applied to the hands, arms, legs, feet or back.

Conclusion

     Technological advances in health care brought a marked improvement of obstetric care. However, the abuse of the interventions resulted in poor obstetric and perinatal outcomes and ruled out the central role of women in childbirth. It is possible that today, with careful review of the evidence about the practices and behavior in obstetrics and the possibility the woman´s choice, to find a balance between technology and natural.
     While application of these practices can be easier if assistance occur in an environment outside the hospital - as a freestanding birth center or at home - it can encourage normal birth and preserve their physiology at a hospital environment. Providing women care practices based on evidence, which are comfort options and helps to bring childbirth to an emotional and familiar scenery, must be one of the primary goals of nursing care.

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