Parturition and the perinatal period: can mode of delivery impact on the future health of the neonate?

Caesarean section and instrumental delivery rates are increasing in many parts of the world for a range of cultural and medical reasons, with limited consideration as to how 'mode of delivery' may impact on childhood and long-term health. However, babies born particularly by pre-labour caesarean section appear to have a subtly different physiology from those born by normal vaginal delivery, with both acute and chronic complications such as respiratory and cardio-metabolic morbidities being apparent. It has been hypothesized that inherent mechanisms within the process of labour and vaginal delivery, far from being a passive mechanical process by which the fetus and placenta are expelled from the birth canal, may trigger certain protective developmental processes permissive for normal immunological and physiological development of the fetus postnatally. Traditionally the primary candidate mechanism has been the hormonal surges or stress response associated with labour and vaginal delivery, but there is increasing awareness that transfer of the maternal microbiome to the infant during parturition. Transgenerational transmission of disease traits through epigenetics are also likely to be important. Interventions such as probiotics, neonatal gut seeding and different approaches to clinical care have potential to influence parturition physiology and improve outcomes for infants.

Childbirth and consequent atopic disease: emerging evidence on epigenetic effects based on the hygiene and EPIIC hypotheses.

BACKGROUND: In most high and middle income countries across the world, at least 1:4 women give birth by cesarean section. Rates of labour induction and augmentation are rising steeply; and in some countries up to 50% of laboring women and newborns are given antibiotics. Governments and international agencies are increasingly concerned about the clinical, economic and psychosocial effects of these interventions. DISCUSSION: There is emerging evidence that certain intrapartum and early neonatal interventions might affect the neonatal immune response in the longer term, and perhaps trans-generationally. Two theories lead the debate in this area. Those aligned with the hygiene (or 'Old Friends') hypothesis have examined the effect of gut microbiome colonization secondary to mode of birth and intrapartum/neonatal pharmacological interventions on immune response and epigenetic phenomena. Those working with the EPIIC (Epigenetic Impact of Childbirth) hypothesis are concerned with the effects of eustress and dys-stress on the epigenome, secondary to mode of birth and labour interventions. This paper examines the current and emerging findings relating to childbirth and atopic/autoimmune disease from the perspective of both theories, and proposes an alliance of research effort. This is likely to accelerate the discovery of important findings arising from both approaches, and to maximize the timely understanding of the longer-term consequences of childbirth practices.

The EPIIC hypothesis: intrapartum effects on the neonatal epigenome and consequent health outcomes.

There are many published studies about the epigenetic effects of the prenatal and infant periods on health outcomes. However, there is very little knowledge regarding the effects of the intrapartum period (labor and birth) on health and epigenetic remodeling. Although the intrapartum period is relatively short compared to the complete perinatal period, there is emerging evidence that this time frame may be a critical formative phase for the human genome. Given the debates from the National Institutes of Health and World Health Organization regarding routine childbirth procedures, it is essential to establish the state of the science concerning normal intrapartum epigenetic physiology. EPIIC (Epigenetic Impact of Childbirth) is an international, interdisciplinary research collaboration with expertise in the fields of genetics, physiology, developmental biology, epidemiology, medicine, midwifery, and nursing. We hypothesize that events during the intrapartum period - specifically the use of synthetic oxytocin, antibiotics, and cesarean section - affect the epigenetic remodeling processes and subsequent health of the mother and offspring. The rationale for this hypothesis is based on recent evidence and current best practice.

Fostering evidence-based care in clinical teaching.

Understanding scientific research evidence and applying it to clinical practice is a focus in today's health care arena. Fostering evidence-based care (EBC) in clinical teaching is an effective way to help students learn to think critically, search for, evaluate, and incorporate the best research evidence into their clinical practice. For example, helping a student plan care for a woman creates a "teaching moment" for the application of scientific evidence to clinical practice. Essentially, EBC is a learned skill for both the student and the clinical teacher. It requires intellectual curiosity and a willingness to explore beyond "the way it has always been done." This article presents a review of the goals of clinical teaching, strategies to foster EBC, and tools to assess the readiness of the teacher, the student, and the clinical setting for EBC. By aligning the goals of clinical teaching with evidence-based strategies, both the educator and student strive together to provide midwifery care that is supported by available research.

Science and midwifery: paradigms and paradoxes.

The everyday world of clinical practice is filled with paradigms and paradoxes that stem from the issues of who defines knowledge, how it is generated, and how the individual midwife applies it when providing care for women and families. Research useful for clinical practice should provide evidence to support scientific approaches (models) or strategies (interventions) in caring for women. In a clinical discipline, the answers to research questions should eventually inform clinical decision-making by providing practical clinical knowledge. This article presents an application of Stevenson's research steps for the development of clinically applicable knowledge that the midwife can use to analyze and evaluate research findings as a basis for practice decisions. Specific examples of midwifery research are used to illustrate each stage in the process and the circular nature of knowledge development. The challenge is to prepare midwives who can apply research findings skillfully using the best evidence to support clinical practice, as well as to groom midwife researchers who will develop systematic programs of relevant research about midwifery practice and outcomes.

A model of exemplary midwifery practice: results of a Delphi study.

What is unique and exemplary about the midwifery model of care? Does exemplary midwifery care result in improved outcomes for the recipient(s) of that care? These are the questions that the profession of midwifery grapples with today within the context of a changing health care arena. Exemplary midwives, and women who had received their care, came to consensus about these issues in a Delphi study. A model of exemplary midwifery care is presented based on the identification of essential elements aligned within three dimensions: therapeutics, caring, and the profession of midwifery. Supporting the normalcy of pregnancy and birth, vigilance and attention to detail, and respecting the uniqueness of the woman, were several of many processes of care identified. The critical difference that emerged was the art of doing "nothing" well. By ensuring that normalcy continued through vigilant and attentive care, the midwives were content to foster the normal processes of labor and birth, intervening and using technology only when the individual situation required. Health care, whether in the gynecologic setting or during pregnancy, was geared to help the woman achieve a level of control of the process and outcome. The ultimate outcomes were optimal health in the given situation, and the experience of health care that is both respectful and empowering. The model provides structure for future research on the unique aspects of midwifery care to support its correlation with excellent outcomes and value in health care economics.

Enabling conception and pregnancy. Midwifery care of women experiencing infertility.

This article provides a comprehensive and thoughtful overview of primary midwifery care of the woman experiencing infertility. Midwifery assessment and management strategies that can assist women and their partners experiencing infertility to achieve a successful pregnancy are reviewed. In addition to physiologic considerations, the article addresses psychosocial, spiritual, legal, and financial issues essential to understanding the ramifications of infertility care. The authors frame their approach in a feminist perspective that enables the woman to achieve control of fertility and self-determination of care.

The essence of nurse-midwifery care. The woman's story.

The purpose of this qualitative research study was to discover the experience of the woman cared for by a nurse-midwife. Six variously situated and ethnically diverse women were interviewed about their experience with nurse-midwifery care. Using Colaizzi's phenomenological method, the data were analyzed extracting 151 significant statements that were clustered into nine themes. A picture of the essential structure of the women's experience of nurse-midwifery care unfolded and was returned to them for their comments and confirmation. Women talked about a relationship built on respect, trust, and alliance. It was the nurse-midwife herself, her qualities and behaviors, her concern and caring, and her respect for women that laid the foundation for how the women in this study perceived the experience. Repeatedly, women articulated the respect for their time, their families, their fears, and their need for information. Ultimately, it was this respect from the nurse-midwife that empowered the women to determine and direct their care.