During the 1980's, a new concept of obstetrics called "birthing" was evolving, having originated with midwives, parents and advocates of natural childbirth rather than the hospital-based obstetric community. The term birthing generally denotes a more natural, physiologic process in which the childbearing couple or woman would actively participate in giving birth.[1-3]

Slowly, thoughtful obstetric providers began to recognize the need for low-intervention care[2-5]. Procedures such as shaving the perineum, intravenous infusions, routine enemas, continuous electronic fetal monitoring and episiotomies were no longer part of the routine, and directives such as bed rest, no food or drink by mouth and limitations on the number of family members in the room were used only when necessary. Women were also able to get out of bed to walk, bathe and socialize during labor, and were able to choose their own most comfortable position for labor and for giving birth.[1,3-7]

Women, in general, prefer physicians who are skilled in considering both the medical and nonmedical issues in birthing care and in communicating this information in a respectful, informative, understandable and nonpaternalistic way. Women are increasingly selecting physicians who are willing to empower them in the process of birthing.[2,3,7-9]

How did family practice initially adapt to the concept of birthing? For the most part, family physicians attempted to follow the course set by their obstetric colleagues, mastering the newest technology and using it in their care of patients.[2,3,6,10,11] Studies showed that family physicians had outcomes identical to or better than their obstetric colleagues; however, these studies also showed that family physicians had been successful in shaping their obstetric practices to resemble those of obstetricians in the sense of being "high-tech and low-touch."[10,12-16]

Nevertheless, some family physicians became increasingly dissatisfied with the technologic approach to obstetrics, [2,10,17-19] Fortunately, the specialty of family practice acknowledged that attempts to form the family physician/obstetrician from the same technologic mold as the obstetrician/gynecologist had failed. A different paradigm was needed, and that paradigm became the movement now called "family-centered birthing."[2,10,16,20]

Family-centered birthing summarizes the philosophy and the practice that emphasizes birth as a natural process, not an incipient disease.[10,16,19] This movement de-emphasizes the use of medical interventions, unless required.[1,3,10,16,19]

Family physicians, however, often find themselves trying to practice family-centered birthing in hospital settings brimming with technocrats.[1,2,11]. To smooth the way to family-centered birthing, leaders in family practice and obstetrics need to develop obstetric protocol that recognize that most pregnancies require no specific medical intervention.[3,7,9,10,19] Such protocols must be assembled, not from case law, but from critical review and study of the different obstetric approaches and traditions applied to low-risk settings with low-risk patients - studies such as those attempted by the North American Primary Care Research Group.[3,7,10,16] In addition, family physicians have the opportunity to provide a vital counterbalance to the relentless increase in the "technologization" of obstetrics.[1,2,8,16,20]

Individual providers of obstetric care who advocate family-centered birthing must critically assess the effects of each medical practice or procedure on the child-bearing family's comfort, sense of mastery and safety,[2,3,7] Approaches to labor and delivery care for which safety benefits are small or unproven should remain subject to the choices and preferences of the child-bearing couple and not the physician providing care.[2-5,7]

Family physicians and obstetricians who were trained as "maximum strategy" physicians but adopt this new birthing philosophy must alter their way of "treating" women in labor.[2,20] There seems to be a continuum of change along which a physician must travel. Only when a physician begins to feel comfortable with a certain level of nonintervention can progression to a higher level of nonintervention be made. These philosophic and practice changes involve altering one's maximum-strategy concepts and role in the process of labor and birth. It requires new skills (which must be learned in the presence of nurses, patients and labor supporters) and the conscious effort to switch from a rapid to a slow gear. Family-centered birthing is not for every patient, nor is it for every physician, but it is a philosophy that is ideal for family physicians and family medicine.[2,6,16]

This philosophy is simple and satisfying, and can fairly simply be put into practice.[4,18] For example, the simplicity of having a female support person (called a doula) in the labor room to provide continuous emotional support to the woman in labor has been shown to have dramatic effects.[21] In one prospective study, healthy, low-risk, nulliparous women in labor who received the continuous support of a duola had significantly better outcomes when compared with women who were not supported by a doula. The rate of cesarean delivery was 8 percent in the group of women who received support from a doula, compared with a rate of 18 percent in the group without a doula; their epidural anesthesia rate was 7.8 percent, versus 55.3 percent. Rates of oxytocin use, duration of labor, prolonged infant hospitalization, neonatal morbidity and maternal fever followed patterns similar to the rates of cesarean delivery and epidural anesthesia.[21] The obstetric practice that follows the philosophy of fostering maximum involvement of patients in decisions about their care and maximum involvement of their support structure in the labor process appears to be a practice that leads to safer, shorter and more satisfying birthing experiences.[1-4,6,10,12,16,20,21]

Family physicians can, in conjunction with their midwife and obstetrician colleagues who understand and practice family-centered birthing, define a defensible standard of practice for providing thoughtful and rational obstetric care to low-risk women.[3,5,6,10,16,22] Family physicians can and should be able to establish a style of obstetric practice that is safe, enjoyable and less subject to the vagaries of professional liability trends. To do otherwise will mean that family physicians will continue to abandon obstetrics, which will have dire effects on the access to prenatal and maternity care.[18,23,25]

Family physicians play a valuable role in the provision of obstetric care.[3,4,16,18,26] They have the unique capacity to provide inter-generational continuity and care for the mother and infant in the context of the family, a role that no other practitioner can fill.[2,6,10,16,18,19,23,27]

It may be time for family medicine educators to recognize that many obstetrician-gynecologist specialists are ill-equipped to teach family-centered birthing to family practice residents and medical students.[4,19,27] Based on family medicine's historic and philosophic roots, family-centered birthing may best be taught by family physicians.

Yet, not every delivery will be a birthing experience, for medical complications can and do completely change the orientation of labor and delivery from birthing to medical management. For these situations, family physicians must depend on their colleagues who are best trained to handle these high-risk patients. However, family physicians can be ideal providers of most maternity care, either as the primary provider for low-risk patients or as a trusted source of support when an obstetric consultant is called in.

Family physicians who practice family-centered birthing may be more satisfied with medicine in general and family practice in particular. They are well paid financially and psychologically and have practice demographics that are nearly ideal. They may suffer from less family stress than their colleagues, they work no more hours than their colleagues who do not practice obstetrics and they feel less hassle by third-party regulations, probably because of reduced numbers of Medicare patients.[6,18,24,28-30]

Family-centered birthing may result in increased practice diversity, increased practice income and increased practice satisfaction. Family physicians who do not practice obstetrics may develop practice styles that are more like those of general internists in demographics, dissatisfaction and income.[18,28,30] Child-bearing patients, the specialty of family practice and the country need family physicians to deliver infants more than ever before. Birthing is just too darn important to be left to technologists.

REFERENCES

[1.] Fenwick L. Birthing. Perinatol Nurs 1984;3: 51-62. [2.] Larimore WL. Family-centered birthing: a niche for family physicians [Editorial]. Am Fam Physician 1993;47:1365-6. [3.] Rooks JP. Low-intervention maternity care. J Fam Pract 1990;31:125-7. [4.] Scherger JE, Levitt C, Acheson LS. Nesbitt TS, Johnson CA, Reilly KE, et al. Teaching family-centered perinatal care in family medicine, Part 1. Fam Med 1992;24:288-98. [5.] Smith MA, Ruffin MT, Green LA. The rational management of labor. Am Fam Physician 1993;47:1471-81. [6.] Scherger JE. Family-centered childbirth. A philosophy well suited to family practice. Fam Pract Recert 1989;11(1):23-6. [7.] Smith MA, Acheson LS, Byrd JE, Curtis P, Day TW, Frank SH, et al. A critical review of labor and birth care. Obstetrical Interest Group of the North American Primary Care Research Group. J Fam Pract 1991;33:281-92. [8.] King CR. Where is the woman in obstetrics and gynecology? Pharos 1989;52(3):8-11. [9.] Stolte K, Myers ST. Nurses' responses to changes in maternity care, Part 1. Family-centered changes in short hospitalization. Birth 1987;14:82-6. [10.] Rosenblatt RA. The future of obstetrics in family practice: time for a new direction. J Fam Pract 1988;26:127-9. [11.] Geyman JP. Toward a middle ground in the technological debate in obstetric care. J Fam Pract 1981;12:971-2. [12.] Chaska BW, Mellstrom MS, Grambsch PM, Nesse RE. Influence of site of obstetric care and delivery on pregnancy management and outcome. J Am Board Fam Pract 1988;1(3): 152-63. [13.] Klein M. Zander L. The role of the family practitioner in maternity care. In: Chalmers I, Enkin M, Keirse MJNC, eds Effective care in pregnancy and childbirth. Vol. 1 New York: Oxford University Press, 1989. [14.] Mengel MB, Phillips WR. The quality of obstetric care in family practice: are family physicians as safe as obstetricians? J Fam Pract 1987;24:159-64. [15.] Franks P, Eisinger S. Adverse perinatal outcomes: is physician specialty a risk factor? J Fam Pract 1987;24:152-6. [16.] Klein M. "Obstetrics is too important to be left to the obstetricians" [Editorial]. Fam Med 1987;19:167-9. [17.] Wood AP. Survey reveals growing disenchantment among FPs. Fam Pract News 1991 Sept. 15;21:1. [18.] Larimore WL. Assessing the risks and benefits of including obstetrics in family practice [Editorial]. Fam Pract Recert 1991;13(11):18-29. [19.] Reynolds JL. Who should be doing obstetrics in the 1990s? Can Fam Physician 1988;34: 1937-40. [20.] Brody H, Thompson JR. The maximum strategy in modern obstetrics. J Fam Pract 1981; 12:977-86. [21.] Kennel J, Klaus M, McGrath S, Robertson S, Hinkley C, et al. Continuous emotional support during labor in a U.S. hospital. A randomized controlled trial. JAMA 1991;265: 2197-201. [22.] Chalmers I, Lawson JG, Turnbull AC. Evaluation of different approaches to obstetric care: Part 1. Br J Obstet Gynecol 1976;83: 921-9. [23.] Scherger JE. The family physician delivering babies: an endangered species. Fam Med 1987;19:95-6. [24.] Larimore WL. FPs who do obstetrics may be more satisfied. Fam Pract News 1992 Nov 15;22:17. [25.] Robertson WO. Access to obstetric care: a growing crisis [Editorial]. J Fam Pract 1988; 27:361-2. [26.] Driscoll CE. Obstetrics: the intensivist's domain? Fem Patient 1990;15:11-2. [27.] Rodney WM. Obstetric enhanced family practice: an endangered species worth saving! [Editorial]. Fla Fam Physician 1993;43:8-9. [28.] Larimore WL. Family practice maternity care in central Florida: increased income, satisfaction, and practice diversity. Fla Fam Physician 1993;43:25-7. [29.] Nesbitt TS, Kahn NB, Tanji JL, Scherger JE. Factors influencing family physicians to continue providing obstetric care. West J Med 1992;157:44-7. [30.] Bredfeldt RC, Sutherland JE, Wesley RM. Obstetrics in family medicine: effects on physician work load, income, and age of practice population. Fam Med 1989;21:279-82.

Record Number: A14282681

SOURCE:

Walter L. Larimore. American Family Physician.  Oct 1993 v48 n5 p725(4).

Full Text: COPYRIGHT 1993 American Academy of Family Physicians