Capítulo 3: MOFs con mezcla de metales
4. Metal‐organic frameworks
The competing perspectives and ideologies of the technological obstetric model and holistic midwifery model surround management of labour (see Chp. 1; Section 1.3, p.6 for discussion). This includes assessment of progress during labour.
Measurement of the dilatation of the cervix is a relatively modern phenomenon.
Emmanuel Friedman (1954) initiated this trend with his careful study of thousands of normal and abnormal labours with serial cervical examinations in the 1st stage, and defined the expected rate of progress and patterns that might indicate a labour abnormality. A graphic labour curve, referred to as the Friedman curve, is used to detect these patterns (Farrington and Ward 1999). He achieved his aim of
identifying maternity cases that needed transfer to remote hospital facilities in Africa.
It was adopted in the Western world where the same conditions do not apply.
Measuring progress in labour became measuring dilatation of the cervix as an imperative with the introduction of active management of labour. Prior to this, progress was measured by the behaviour of the mother, the frequency and strength of the contractions and the amount of the baby‟s head palpable abdominally.
(Sookhoo and Biott 2002), argue that one of the ways of avoiding uncertainty is to rely upon conventions and put trust in procedures. Therefore, the use of 3cm dilatation of the cervix is often adopted as an indicator of the commencement of labour. This measure presupposes that every woman‟s cervix reacts in the same way. Where LETZ has been performed, this supposition may not hold.
Chapter 2 LETZ and progress in labour
2.3.1.1 Mechanism of labour
Labour is a normal physiological process that commences with effacement and dilatation of the cervix, uterine contractions of increasing frequency, length and intensity, and proceeds to the birth of a child (Farrington and Ward 1999). A more medical view states –
“Labour, in its simplest terms, is the force of uterine contractions overcoming resistance of the female reproductive tract including
the lower uterine segment, cervix, vagina, and perineum.”
(Dudley 1999, p.438)
At term, biochemical changes occur in the cervix, which make it softer in consistency, sometimes shorter, and in some women open slightly (Read and Wellby 1985). This is known as ripening of the cervix. The precise mechanisms of these changes remains unknown (Osmers, Rath et al. 1992; Leppart 1995; Steer and Flint 1999). Since the 1990‟s it has been accepted that labour not only depends upon adequate uterine contractions of the uterine smooth muscle, but also on changes in the connective tissue of the uterus and, more particularly, the cervix. If these connective tissue changes do not occur , labour does not succeed, no matter how strong the contractions (Read and Wellby 1985). As postulated in the previous section about research studies on the affects of LETZ on labour, LETZ may affect the changes in the connective tissue of the cervix (Leiman, Harrison et al. 1980;
Raio, Ghezzi et al. 1997; Gentry, Baggish et al. 2000; Acharya, Kjeldberg et al.
2005).
2.3.1.2 Three stages
It is considered fundamental that medical students understand the mechanics that culminates in birth, in order to understand progress in labour (Vande-Vusse 1999a).
The conventional divisions of the components of labour are first identified in the medical literature for students. Labour is arbitrarily divided into three stages for descriptive purposes (Read and Wellby 1985). The medical establishment define these stages to help follow progress in labour and identify women who have an abnormal labour, which may be helped by intervention. These stages or divisions are unequal in length. The one concerned with the cervix is the 1st stage, and therefore it is this stage that is affected by LETZ.
Farrington and Ward (1999) state that the usual definition of 1st stage is from the onset of regular uterine contractions until the cervix is fully dilated. It is further
Chapter 2 LETZ and progress in labour
arbitrarily subdivided into three phases; the passive phase, the progressive phase, and the deceleration phase (Read and Wellby 1985; Farrington and Ward 1999).
Part of the fundamental change underlying the process of 1st stage is progressive dilatation of the cervix. This gives rise to the familiar symptoms and signs of labour.
The cervix is richly supplied with nerve endings, and when it starts to dilate, this produces the characteristic pain of labour. The dilatation of the cervix reduces the support for the amniotic membranes around the baby, which bulge through the cervix, and often the rupture of these membranes is the initiating phenomenon of active labour (Steer and Flint 1999).
The passive phase of the 1st stage is characterised by a gradual increase in contractions. Contractions become stronger in intensity, longer in duration, more frequent and better coordinated. It is also characterised by effacement of the cervix, which is progressive shortening of the cervix, this continues in the progressive phase until it no longer protrudes into the vagina and cannot be distinguished from it. There is also minimal dilatation of the cervix (Read and Wellby 1985; Al-Azzawi 1998). The mother's discomfort can be minimal to severe. Steer and Flint (1999) claim this phase during which the cervix dilates only very slowly is often very demoralising for the mother. Farrington and Ward (1999) restate that the passive phase can be intermittent over several days, or it can last only a few hours.
Progress in the passive phase is assessed with the Bishops Score (see Appendix A, p.262), a score based on not only dilatation of the cervix but thinning and softening of the cervix, position of the cervix and position of the presenting part of the baby .
When the cervix is approximately 3cm dilated, or when the Bishops Score is equal to 11, is the indication in use in the medical model for the onset of the progressive, or active, phase of labour (Steer and Flint 1999). The contractions become much stronger and very regular. The rate of cervical dilatation increases markedly, and the presenting part descends well into the pelvis. By the end of the 1st stage, with most women, the contractions occur every two to three minutes and last 40 seconds or more. As the contractions become stronger, they also become more intense. Dudley (2008) agrees with Vahratian, Hoffman, Troendle and Zhang (2006) that the 1st stage is of variable duration and is longer in women having their first baby. This phase of labour is predictably associated with increased discomfort for the mother (Read and Wellby 1985).
Chapter 2 LETZ and progress in labour
Various definitions are given for the average rate of normal labour. Steer and Flint (1999) claim that the Bishop Score changes by 1 point per hour for the first birth and 1.6 points per hour for future births. Read and Wellby (1985) state that the average rate of cervical dilatation in women in their first birth is 1cm per hour, and for future births 1.6cm per hour, while Dudley (2008) and Farrington and Ward (1999) claim all women normally have cervical dilatation in excess of 1cm per hour. Steer and Flint claim a reasonable time from 3cm to 10cm dilated (or full dilatation) varies from 8-12 hours for first births and 3-8 hours for other births, while Farrington and Ward claim up to 5 hours for first births and 2 hours for other births. These are the timescales against which „slow‟ or protracted labours are judged. A prolonged progressive phase is attributed to be the result of inadequate uterine contractility. This is often despite the timing, and strength of uterine contractions appearing to be normal, and the cervix continuing to change slowly, with or without oxytocin infusion. Dudley (2008) confirms that oxytocin therapy is often not successful in accelerating labour.
These changes in the cervix may well be influenced by LETZ and it may be that this needs to be taken into account when defining „normal‟ progress.
The deceleration phase goes unnoticed in many labours. It occurs at the end of the progressive phase and simply represents the observed relative slowing of dilatation when the cervix is close to being fully dilated (Farrington and Ward 1999). Some authorities do not recognize the deceleration phase and claim that prolonged time in achieving complete dilation from 8cm is an ominous sign (Dudley 2008).
The 2nd stage of labour occupies the time from full dilatation of the cervix until the baby is born. The 3rd stage of labour involves the separation and expulsion of the placenta and membranes. The management of these stages is another thesis in itself. As the section of birth that involves the cervix is the 1st stage, these other stages are not discussed in the study.
2.3.1.3 Vaginal examination
The purpose of obstetric Vaginal Examination (VE) is primarily to determine dilatation of the cervix. Lai and Levy (2002) assert that the VE is an invasive examination, which often causes women distress and discomfort or pain. As in this quote from one woman -
Chapter 2 LETZ and progress in labour
“I had vaginal examination twice. It is very uncomfortable for a woman to be in that situation, it bothers you psychologically more
than physically. The doctor is used to performing these kinds of medical examinations but you can never expect a woman to get
used to that”
(Kabakian-Khasholian, Campbell et al. 2000,p.106-107 )
VE is usually performed to assess progress in dilatation of the cervix, but also provides other information, such as presentation of the baby and level of presenting part. Good practice suggests that VE includes assessment of the following; the softness or firmness of the cervix, degree of effacement (thinning), dilation of the cervix, location of the cervix with respect to the axis of the birth canal (vagina) noted as anterior or posterior, and the level of the presenting part (Farrington and Ward 1999). The origins of VE as a method of labour assessment are uncertain. Historical documents suggest it was routine practice in the 19th century, when it was
recommended that the examination be carried out at least three times: at the onset of labour, when the membranes ruptured and when contractions gained strength (Stewart 2005). Repeated measurements of dilatation of the cervix are a relatively new phenomenon, the trend started after Friedman‟s work, mentioned previously, for identification of women needing transfer to remote hospital facilities in Africa..
The number and frequency of VE varies from hospital to hospital and from labour to labour. In an audit of hospital policy in the UK, Tindall (1995) suggests that maternity units have a policy of three to four hourly VE. However, Stewart (2005) in her study claims the actual number performed exceeds this figure in 71% of cases. Although the guidelines in the study hospital state 4 hourly VE, in the study women have 2-9 VE, with on average only 2 hours 40 minutes between examinations. This finding replicates those in the study by Stewart. Frequent VE increases a woman's expectations for progress in labour that may not be realistic; in addition, such examinations are uncomfortable and increase the risk of infections (Farrington and Ward 1999).
Findings on a VE differ depending on the parity of a woman (how many births she has previously). In a woman having her first baby, labour usually starts with effacement of the cervix, with or without contractions, followed by dilatation of the cervix. Conversely, in other births, labour often starts with cervical dilatation followed by effacement. The amniotic membranes may be intact or not (Read and Wellby
Chapter 2 LETZ and progress in labour
1985; Al-Azzawi 1998). Women having their first baby and women having other births behave fundamentally differently in labour. Indeed, the Friedman curve reflects two different curves or labour patterns for women having their first baby or others (Farrington and Ward 1999). Buchmann and Libhaber (2007) conclude in their study that findings on a VE also vary between practitioners who perform the VE, be that midwives, obstetric staff or consultant obstetricians, often by 1-2cm but that is enough to change the definition of a labour from „normal‟ to „dystocia‟. The study postulates that LETZ affects the dilatation of the cervix. The study shows this medical reliance on dilatation results from VE is not appropriate for these women.
2.3.1.4 Pharmacological pain relief
The increased availability of pharmacological methods of pain relief, further affects the labours of women. Opiates based pain relief, such as Diamorphine and
Pethidine, affect the cooperation of the woman in the birth process, restrict her movements and dull her senses. Epidural pain relief means she has to labour on a bed, and is continuously attached to an Electronic Foetal Monitor (EFM) that continuously records the foetal (baby) heart rate and the contractions. Epidural interferes with the release of the natural Beta-endorphins and interferes with the woman‟s full participation in the birth process. Epidurals increase malpositions of the baby‟s head by slowing rotation (Illuzzi, Magriples et al. 2003), which increases Instrumental births (Cunningham, Levenko et al. 2001; Illuzzi, Magriples et al. 2003) and increases the use of oxytocin (Cunningham, Levenko et al. 2001). Epidurals are also implicated in maternal temperature rises, with concomitant rise in baby‟s heart rate that increases CS (Fusi, Steer et al. 1989; Goetzl 2008; Steer 2009). Use of EFM means that the woman is exposed to the very heavy false positive indications of that particular monitoring, resulting in more interventions and an increase in CS (Walsh 2008).
2.3.1.5 Prolonged labour (Dystocia)
Progress in labour is difficult to predict. The likely strength and frequency of uterine contractions are unknown, the ease with which the cervix softens and dilates and the extent of moulding of the baby‟s head are also unpredictable elements. Equally, the complex rotation of the baby necessary for an efficient labour to take place properly, can only be anticipated not calculated (Steer and Flint 1999). Various definitions are used for normal labour throughout the UK and the world. Dudley (1999) claims normal labour progresses in a predictable fashion after the diagnosis
Chapter 2 LETZ and progress in labour
of labour is made. Alternatively, Oakley and Houd (1990) state that normal labour progresses at a rate that is normal for each individual woman.
Dystocia, literally translated, means „difficult childbirth‟ and includes all labour abnormalities that occur in women during childbirth (Pearsall 2001). As the above discussion of time frames in the section on the 1st stage of labour illustrates, there is no real consensus on the time frame for normal labour. The precise incidence of dystocia is difficult to determine and varies with different maternity units, based on local practice patterns. In 1990, 30% of the CS in USA were for dystocia and 36%
for previous CS (Dudley 1999).
One medical opinion of the increase in dystocia is –
“...results from environmental changes that are developing more rapidly than Darwinian natural selection. Humans are poorly adapted to the affluence of our modern diet, and the result is
dystocia.”
(Cunningham, Levenko et al. 2001, p.496)
No evidence is given for this supposition. Other medical opinion believes that tighter control of the definition of progressive 1st stage of labour will be the answer to the continued rise in CS rates. Stewart (2005) and Dudley (2008) feel that incorrect diagnosis of progressive labour puts more women in the definition of „dystocia‟ than is necessary. NICE (2007) obviously agrees, as the definition of the start of the progressive phase of the 1st stage of labour was recently changed from 3cm to 4cm cervical dilatation. It has apparently not occurred to the policy makers at NICE that perhaps they need to look at the definition of time scales for normal. Lavender, Alfirevic and Walkinshaw (1998) question the time scales and their research concludes that the CS rate is decreased markedly, if women‟s labours are allowed to deviate from the „normal‟ time parameters by up to 4 hours before any
interventions. Publication of that data has not changed medical practice. Given the likelihood that, following LETZ, women‟s labours may not be conventional, the study is further justified.
Chapter 2 LETZ and progress in labour