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Epidurals: Do They or Don’t They Increase Cesareans?

January 27th, 2015 by avatar

By Henci Goer

In October, Author Henci Goer wrote an article for Science & Sensibility, Epidural Anesthesia: To Delay or Not To Delay – That is the Question – examining the impact of the timing of an epidural on labor and birth.  Today Henci looks at some new research, Epidural analgesia in labour and risk of caesarean delivery which seeks to determine whether receiving an epidural at all impacts the likelihood of a cesarean delivery.  Lamaze International has a great infographic on epidurals that you also may find very helpful. – Sharon Muza, Community Manager, Science & Sensibility.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Let’s start with a bit of background for those of you who didn’t personally live through the early controversy over whether epidurals increased the cesarean rate. As epidurals began to achieve popularity in the late 1970s and 1980s, one researcher sounded the alarm when he and his group published a study of 714 first-time mothers showing that even after excluding women with big babies and women whose labor pattern was abnormal prior to having an epidural, epidurals remained a potent factor in cesarean rates for delayed progress (Thorp 1989). Everyone pooh-poohed his finding on grounds that observational studies can’t truly determine whether epidurals lead to more cesareans or women experiencing more prolonged, painful labors, and therefore at higher risk for cesarean, were more likely to want epidurals. The “chicken versus egg” question, they argued, couldn’t be resolved without a randomized controlled trial (RCT), and it wasn’t likely that women would agree to be assigned by chance to have an epidural or not. In point of fact, that same year saw publication of a small Danish RCT (107 women, 104 of them first-time mothers) (Philipsen 1989). It reported that having an epidural nearly tripled the cesarean rate (16% vs. 6%) for “cephalopelvic disproportion” despite no clinical evidence of CPD being a requirement for inclusion. The investigators ignored this, however, concluding only that instrumental vaginal delivery rates were similar, and epidurals provided better pain relief. In any case, the anesthetic dose was much higher than was already becoming the norm, so it could be reasonably argued that the trial’s findings wouldn’t apply to modern-day practice.

Thorp, meanwhile, took up the RCT challenge. He and his colleagues carried out an epidural versus no epidural trial in 93 first-time mothers and found that epidurals did, in fact, lead to cesareans (25% vs. 2%), not vice versa (Thorp 1993). That bit of unwelcome news precipitated a stampede to perform more RCTs, and when enough of those had accumulated, to a series of systematic reviews pooling their data (meta-analysis), of which the Cochrane review, Anim-Somuah et al. (2011), is the latest. These reached the more comfortable conclusion that epidurals didn’t increase likelihood of cesarean, and pro-epiduralists breathed a collective sigh of relief and went back, if they had ever stopped, to unreservedly recommending epidurals. (This rather sweeps under the rug the other problems epidurals can cause, but that’s a topic for another day.)

Weaknesses of the “Epidural” vs. “No Epidural” Trials

Epidural

By User:Ravedave (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html)

The finding that epidurals don’t increase cesareans is puzzling because they increase likelihood of factors associated with them (Anim-Somuah 2011). For one thing, they increase use of oxytocin to augment labor, which implies they slow labor. For another, more women run fevers, and it stands to reason that a woman progressing slowly who starts running a fever is a likely candidate for cesarean. For a third, the difference in fetal malposition (occiput posterior) rates at delivery comes close to achieving statistical significance, meaning the difference is unlikely to be due to chance. Persistent OP is strongly associated with cesarean delivery (Cheng 2006; Fitzpatrick 2001; Phipps 2014; Ponkey 2003; Senecal 2005; Sizer 2000). Epidurals even increase cesareans for fetal distress by 40%, although the absolute difference didn’t amount to much (1 more per 100 women). Could a difference exist and meta-analysis of RCTs fail to detect it?

A string of well-conducted observational studies over the years have suggested that they could (Eriksen 2011; Kjaergaard 2008; Lieberman 1996; Nguyen 2010), the most recent of which is a very large, very convincing study published last fall (Bannister-Tyrrell 2014). Its authors point out, as have others before them, the weaknesses of the RCTs, weaknesses serious enough to nullify their results or make them inapplicable to typical community practice (external validity).

To begin with, in most trials, substantial percentages of women allocated to the non-epidural group ended up having epidurals, and some women allocated to the epidural group ended up not having one. Since RCTs analyze results according to group assignment (to do otherwise would negate the point of random assignment, which is to avoid bias), not what actually happened, this diminishes differences between groups. In addition, trials were mostly confined to women with no medical or obstetric complications who were treated according to strict protocols for labor management and indications for cesarean delivery. Neither is the case in most hospitals. To these I would add that many trials lumped together first-time mothers and women with prior births when reporting outcomes. First-time mothers are much more susceptible to factors that impede progress, so including women with prior vaginal births can make it appear that epidurals are less problematic for first-time mothers than they really are. In addition, three of the trials were carried out in a hospital where participants were mostly attended by midwives, and cesarean rates were much lower than is common for women attended by obstetricians.

All of this means that any null results in meta-analyses of the trials can be taken with a grain of salt, any findings of significant differences probably represent a minimal value, and first-time moms may be harder hit than appears. To cite one example, Anim-Somuah (2011) reported that 5 more women per 100 having epidurals had a malpositioned baby at delivery (18% vs. 13%) in the 4 trials reporting this outcome, a difference, as I said, that just missed achieving statistical significance. But when I confined results to the two trials in first-time mothers alone in which 10% or fewer of the women in the “no-epidural” group had an epidural, the gap widened to 9 more per 100 (11% vs. 2%).

Summary of the Bannister-Tyrrell (2014) Analysis

Bannister-Tyrrell and colleagues (2014) drew their population from a database of 210,700 Australian women with no prior cesareans who were laboring at term with a singleton, head-down baby. A strength of the database was that, unlike most, it distinguished epidurals for labor from epidurals for delivery. Using a long list of factors, investigators constructed a propensity score for how likely a woman was to have an epidural, matched women according to their score, and compared results according to whether women with the same score had or didn’t have an epidural. Matched controls were found for 52,600 women who had an epidural and were found across the full range of propensity scores. Women having epidurals were 2.5 times more likely to have a cesarean (20% vs. 8%), or put another way, 12 more women per 100 having epidurals had a cesarean (absolute excess), which amounts to 1 additional cesarean for every 8.5 women having an epidural (number needed to harm). Among first-time mothers, women having epidurals were 2.4 times more likely to have a cesarean. Study authors didn’t provide cesarean rates for this subgroup, but the raw cesarean rates overall were 18% in first-time mothers versus 2% in women with prior births, so the effect on this more vulnerable population could be dire.

But there’s still more. Investigators further adjusted for confounding factors not captured in their database. These included differences in health-care settings (same state but not same city), care provider (women without epidurals are more likely to be attended by midwives), and for confounding interventions more likely with epidurals (continuous fetal monitoring). Relative risk of cesarean with an epidural remained at 2.5. Investigators then adjusted for the association between occiput posterior baby and cesarean by setting estimates of the risk ratio to exceed the strongest associations reported in the literature, and they assumed that the prevalence of severe labor pain was 3 to 4 times higher in women having epidurals. Factoring these into their statistical analysis reduced the risk ratio, but women having epidurals still were 50% more likely to have a cesarean. This means that with a baseline cesarean rate of 8% in women without an epidural, 12% of women with an epidural will have one or 4 more women per 100 or 1 more cesarean for every 25 women.

The Take-Home

At the very least we cannot assure women with confidence that epidurals don’t increase the likelihood of cesarean. For this reason and because of their numerous other drawbacks and considering that comfort measures and other strategies have been shown to be both effective for most women and free of adverse effects (Declercq 2006; Jones 2012), women may want to make epidurals Plan B rather than Plan A. That being said, whatever their choice, women can minimize their chance of cesarean—with or without an epidural—by choosing a midwife or doctor whose policies and practices promote spontaneous vaginal birth http://www.lamaze.org/HealthyBirthPractices.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev(12), CD000331. doi: 10.1002/14651858.CD000331.pub3 http://www.ncbi.nlm.nih.gov/pubmed/22161362

Bannister-Tyrrell, M., Ford, J. B., Morris, J. M., & Roberts, C. L. (2014). Epidural analgesia in labour and risk of caesarean delivery. Paediatr Perinat Epidemiol, 28(5), 400-411. http://www.ncbi.nlm.nih.gov/pubmed/25040829

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med, 19(9), 563-568. http://www.ncbi.nlm.nih.gov/pubmed/16966125?dopt=Citation

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Eriksen, L. M., Nohr, E. A., & Kjaergaard, H. (2011). Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas. Birth, 38(4), 317-326. http://www.ncbi.nlm.nih.gov/pubmed/22112332

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol, 98(6), 1027-1031. http://www.ncbi.nlm.nih.gov/pubmed/11755548?dopt=Citation

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. http://www.ncbi.nlm.nih.gov/pubmed/22419342

Kjaergaard, H., Olsen, J., Ottesen, B., Nyberg, P., & Dykes, A. K. (2008). Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth, 8, 45. http://www.ncbi.nlm.nih.gov/pubmed/18837972?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Nguyen, U. S., Rothman, K. J., Demissie, S., Jackson, D. J., Lang, J. M., & Ecker, J. L. (2010). Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women. Matern Child Health J, 14(5), 705-712. http://www.ncbi.nlm.nih.gov/pubmed/19760498?dopt=Citation

Philipsen, T., & Jensen, N. H. (1989). Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries. Eur J Obstet Gynecol Reprod Biol, 30(1), 27-33. http://www.ncbi.nlm.nih.gov/pubmed/2924990

Phipps, H., Hyett, J. A., Graham, K., Carseldine, W. J., Tooher, J., & de Vries, B. (2014). Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery? Acta Obstet Gynecol Scand, 93(10), 1018-1024. http://www.ncbi.nlm.nih.gov/pubmed/25060716

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol, 101(5 Pt 1), 915-920. http://www.ncbi.nlm.nih.gov/pubmed/12738150?dopt=Citation

Senecal, J., Xiong, X., Fraser, W. D., & Pushing Early Or Pushing Late with Epidural study, group. (2005). Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol, 105(4), 763-772. http://www.ncbi.nlm.nih.gov/pubmed/15802403

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstet Gynecol, 96(5 Pt 1), 749-752. http://www.ncbi.nlm.nih.gov/pubmed/11042312?dopt=Citation

Thorp, J. A., Hu, D. H., Albin, R. M., McNitt, J., Meyer, B. A., Cohen, G. R., & Yeast, J. D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol, 169(4), 851-858. http://www.ncbi.nlm.nih.gov/pubmed/8238138?dopt=Citation

Thorp, J. A., Parisi, V. M., Boylan, P. C., & Johnston, D. A. (1989). The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women. Am J Obstet Gynecol, 161(3), 670-675. http://www.ncbi.nlm.nih.gov/pubmed/2782350

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

 

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, Healthy Birth Practices, Medical Interventions, New Research, Pain Management, Research , , , , , , ,

“Pathway to a Healthy Birth” – Using Consumer Materials from Hormonal Physiology of Childbearing Report in Your Classes.

January 22nd, 2015 by avatar

Screen Shot 2015-01-21 at 6.01.46 PMLast week, Dr. Sarah Buckley in coordination with Childbirth Connection released a new research report, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care.”  This massive tome gathers in one place, all the current information available on the role of various hormones on pregnancy, labor, birth, breastfeeding and postpartum and provides information on what happens to the processes when interventions are introduced.  Well known childbirth educator Penny Simkin reviewed the report on Science & Sensibility on January 13th and then Michele Ondeck followed up with an exclusive Science & Sensibility interview with Sarah Buckley later in the week.

I think that everyone will acknowledge that this report is a remarkable and valuable piece of work, but at over 400 pages if you take into account all accompanying documents and with a bibliography consisting of over 1100 sources, the typical pregnant woman is hardly going to be keeping a copy on their bedside table for some light reading before drifting off to sleep.  Today on Science & Sensibility, I would like to highlight the resources and tools that Childbirth Connection has thoughtfully provided that are geared specifically for the consumer.  Childbirth educators, doulas and health care providers can access and share these materials with their students, clients and patients.

Pathway to a Healthy Birth – How to Help Your Hormones to Do Their Wonderful Work – consumer booklet

This 17 page colorful consumer booklet is written in easy to comprehend language and illustrated with attractive photographs that show a diverse collection of families.  Families are introduced to the hormones of birth and postpartum; oxytocin, beta-endorphins, catecholamines and endorphins.  Each hormone has a brief description and a short explanation about the role it plays in childbearing.

Families are told that events can interfere with the intended actions of the childbearing hormones.  Birthing women are encourage to think about how activities around them during their labor and birth may interfere with hormones and prevent the hormones from working effectively.

Women learn that hormones prepare her body for an efficient labor and birth.  The booklet addresses how women’s bodies are prepared by some hormones to handle the pain and stress that may accompany labor. They also find out that the hormones help prepare their babies for the newborn transition.  Infant attachment and maternal behaviors are also supported by the role of the hormones.

Follow Angela’s Birth Story

Families are introduced to “Angela” and read about her labor and birth story.  The story shows how the hormones allow the labor and birth to unfold in support of the normal processes and how small things can have a big impact and disrupt the process.  For example, The transition from home to hospital reduces the intensity and frequency of Angela’s contractions as a result of interference with the normal hormonal process.  The story is filled with lots of strategies to encourage and allow the hormonal effects as they are intended to occur.

It is easy to see from Angela’s story, that while labor and birth are hard and do involve pain, with the right support and environment, along with best practices that endorse physiological birth, Angela is able let her body do the work it is designed to do, and have a birth that is very satisfying to her.

“What’s Happening”

Accompanying the story is an easy to read guide that demonstrates exactly what the hormones of childbearing are doing at each particular point in Angela’s story.  Explanations of the role of each hormone as things unfold help families to understand how what happens in their own birth can affect their own birth story and outcome.

What Can You Do

The next portion of the brochure offers steps that families can take to help them identify providers and facilities that support physiologic birth.  Lists of questions to ask, tips for making a hospital room comfortable and private, interview questions for their doctor or midwife, how to pick a childbirth class, find a doula, how to determine if medical procedures are necessary and explore less interventive alternatives and more are all there in an easy to digest format. Included are valuable links in the final section that makes the booklet resource rich.  There are many web links to get more information about all the topics covered above.  This makes the booklet an ideal handout for a childbirth class, doula consultation or meet and greet with potential health care providers.

Infographic

Screen Shot 2015-01-21 at 6.03.49 PMThere is a consumer infographic that can be printed in a size suitable for hanging in a classroom or office, or provided in a smaller format that makes a great accompaniment to the above booklet.  The infographic identifies things that can keep a woman on the “pathway” to a physiological birth and what can steer her away from the pathway.  There is a lot of similarity between the points made in this infographic and the Lamaze Six Healthy Birth Practices.

One teaching idea

After discussing the role of hormones in labor and sharing the infographic as a visual aid, I can easily see how an educator can play a game with her class – making and distributing cards to class members with scenarios on them, and asking families to share if those scenarios and activities are making it easier for the mother to stay on the physiological pathway or what steers her further away and having the students identify which hormones are affected.

We have a responsibility as childbirth educators to share the important role the hormones of childbearing play in supporting healthy mothers, healthy births and healthy babies.  Using the Pathway to a Healthy Birth consumer booklet and accompanying infographic as part of your teaching materials provides a simple to understand but effective tool for conveying this information to the families you interact with.

How do you see yourself using these consumer products in your childbirth classes?  With your doula clients?  Please share your ideas for teaching, discussing and using this material and covering these topics with the families you work with.  I would love to hear your thoughts.

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns, Research, Transforming Maternity Care , , , , , ,

You Are Invited to Submit an Abstract for the 2015 Lamaze & ICEA Joint Conference

January 20th, 2015 by avatar

Screen Shot 2015-01-19 at 4.24.40 PM

You are invited to submit an abstract for the 2015 Lamaze International – ICEA Joint Conference: Raising the Stakes for Evidence Based Practices & Education in Childbirth.  This fantastic conference is scheduled for September 17 – 20, 2015 at the Planet Hollywood Resort in Las Vegas, NV.  Share your knowledge and expertise with maternal health care professionals from around the globe.

Lamaze International and the International Childbirth Education Association are two of the oldest and most respected childbirth education organizations.  These two childbirth education leaders last came together in 2010 for a groundbreaking mega-conference in Milwaukee, WI. and was attended by many hundreds of educators and other birth professionals.abstract 2015

Here we are five years later, and it is happening again, but will certainly be bigger and better than before.  At this time the joint conference committee is soliciting abstracts to be considered for this year’s conference program. Abstracts are wanted for both concurrent sessions and morning exercise sessions.

This year’s conference objectives are to:

  • Analyze the evidence base for childbearing and breastfeeding practices, education and support.

  • Implement strategies that use technology and innovation to reach and support childbearing and breastfeeding women.

  • Describe new and emerging research that supports normal pregnancy, birth and breastfeeding practices.
  • Address professional challenges in providing support for childbearing families and breastfeeding women.

Abstracts are being solicited that speak to one or more of the following areas:

Evidence-Based Teaching and Practice
Childbearing families face key choices when selecting providers and birth facilities, as well as options during pregnancy, labor, birth, and breastfeeding. By providing evidence-based information, childbearing professionals can empower women to make informed decisions about their care. For this track, we seek presenters who will clarify how to identify the evidence for practices that can improve safety and satisfaction for childbearing.

Using Technology and Innovation to Reach Childbearing and Breastfeeding Women
Pinterest, Instagram, Facebook, Tumblr, FaceTime, Skype, Google Hangouts, Flipped Classrooms, Vine, apps, and blogs. Millennial women are highly connected to social media and widely receive information about childbirth, postpartum, breastfeeding and parenting through social media platforms. How can childbirth professionals connect electronically with new or potential clients and integrate technology into education, support and advocacy? For this track we seek presenters who will present case studies, technology tool demos and best practices, or marketing tips for the independent provider, educator and doula.

New and Emerging Research in the Field of Childbearing and Breastfeeding
For this track we seek presenters who will share new research, practice guidelines and collaborative efforts (published in the last three to five years) that are relevant to childbearing and breastfeeding families and those who serve those families. Topics may range from holistic approaches to perinatal care, nutritional recommendations, effects of stress and toxic environmental exposures on pregnancy, the life course approach to healthy birth, breastfeeding, epigenetics and the intrauterine environment, approaches for women with pregnancy complications, preconception health, VBAC, and other subjects.

Challenges of the Maternal Child Professional
For this track, we seek presentations on professional issues and practice challenges. Topics may range from meeting the needs of a diverse classroom, ethical issues, healthcare reform, insurance reimbursement, meeting cultural needs and more. Presenters will share innovative techniques for supporting and sharing information with pregnant and parenting families and for advocating for the needs of childbearing women in the classroom and in the community.

The deadline for abstract submission is Sunday, February 1, 2015 and I am confident that many of you have expertise, knowledge and skills that will be well received at this gathering of professionals. What a great opportunity for you to present on your passion and for all the birth professionals; childbirth educators, doulas, lactation consultants, midwives, physicians, l&d nurses, counselors, authors and more to learn from YOU! Receive a generous honorarium and conference discount if your abstract is accepted. You will be contacted by March 6th, 2015 about the status of your submission.

In case you are still on the fence about submitting, here are my top ten reasons to speak at the 2015 Lamaze/ICEA conference:

  1. Help fund your way – (honorarium and registration discount)
  2. Build up your resume or CV
  3. Share something interesting or innovative with others
  4. Have fun with a peer by submitting a joint presentation
  5. Provide information about new research that others need to know
  6. Grow your international presence by presenting to a global audience
  7. Contribute to a successful conference
  8. Guarantee your commitment to attend this year’s conference
  9. Meet new people
  10. Have a ton of fun

Please consider sharing your wisdom!  Start working on your conference abstract now.  The Online Abstract Submission Portal is thorough but easy to use. You can find more information on submitting an abstract and access to the the online abstract submission tool here.  See you in Las Vegas, where we all will be “Raising the Stakes for Evidence Based Practices & Education in Childbirth!”  Let us know in the comments section if you are planning to submit!  I look forward to all of your great ideas!

2015 Conference, 2015 Lamaze & ICEA Joint Conference, Childbirth Education, Continuing Education , , ,

An Interview with Sarah Buckley: Discussing Her New Report – “Hormonal Physiology of Childbearing”

January 15th, 2015 by avatar

By Michele Ondeck,RN, MEd, IBCLC, LCCE

© Sarah Buckley

© Sarah Buckley

Sarah Buckley is a family doctor, mother of four, and author of the bestselling book Gentle Birth, Gentle Mothering. She has been writing and lecturing about the hormones of birth, among other topics, since 2001. Mothering Magazine published her article “Ecstatic Birth, Nature’s Hormonal Blueprint of Labor” in 2002.  She lives with her family near Brisbane, Australia.  On Tuesday, January 13th, 2015, Dr, Buckley released a comprehensive report entitled “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” in cooperation with Childbirth Connection.  Two days ago, Penny Simkin reviewed the report and shared valuable information on how birth professionals will be able to use this report in their classes or practices.  Today, Lamaze International Past President, Michele Ondeck, shares her recent interview with Dr. Buckley.  In this interview, they discuss Sarah’s thoughts on what this report means for both families and professionals. Sarah speaks to how it we are just beginning to recognize the downstream effects of disturbing the normal hormonal process that occurs during labor, birth and postpartum and what this disturbance might mean for future generations. – Sharon Muza, Community Manager, Science & Sensibility.

Michele Ondeck: Sarah, thank you for the in-depth review of the hormones of labor in the Hormonal Physiology of Childbearing (HPOC) report. I am thankful for the support you received for this project from the Childbirth Connection programs with the National Partnership for Women & Families. As a board member of Lamaze International, I am proud that we were able to also provide some support to make this report possible. How are you celebrating the report’s release?

Sarah Buckley: Finishing the report has been a big milestone, not just for me but also for my family who have been very involved and supportive. We’ll be celebrating with champagne and, as its summer down here, with an Aussie barbeque.

MO: Sarah, I have been sharing orchestration of the hormones of birth: oxytocin, beta endorphins, epinephrine and nor-epinephrine and prolactin from Ecstatic Birth with parents and professionals since its publication. You have expanded, clarified, and synthesized that basic information in your report. I know that you have been working on this report since 2011. What was your inspiration to keep at it? How did you find time to review more than 1,100 publications?

SB: Yes, it’s been a long gestation! What has kept me engaged is the practical relevance of the material for mothers, babies, fathers, and families, and my own lived experiences. For me, its much more than an academic body of knowledge, it’s a paradigm that recognizes the superb design of our female bodies, and describes the smoothest, safest, easiest, and most pleasurable path to parenting. I am also lucky to receive much support and positive feedback about this material, both from maternity care providers, who gain a scientific understanding of what they are seeing every day in the birth room, and from women themselves, who realize that there are positive ways to support their hormones and increase safety, ease, and pleasure for themselves and their babies.

Screen Shot 2015-01-13 at 6.38.16 PMMO: Now with the publication of the Hormonal Physiology of Childbearing, there is the potential to educate so many more professionals in the maternity and newborn care community. How does the timing of the report fit with the changes that you see happening today that can influence professionals?

SB: I have been writing and lecturing about the hormonal physiology for more than 10 years and I have seen a significant shift in receptiveness to this perspective, especially in the last 2 to 3 years. I think we are maturing as birth professionals and beginning to think more widely about the perinatal period. The microbiome paradigm, for example, which looks at the effects of birth on the transfer of healthy bacteria from mother to newborn, is giving us solid evidence that what happens at birth can have long-term consequences.

It is also a very exciting time to launch the report because this material is very much aligned with other initiatives, including ACNM’s Physiologic Birth Initiative and the ACOG/SMFM Safe Prevention of the Primary Cesarean Delivery statement. It’s also a pleasure to me that the Hormonal Physiology of Childbearing supports and extends other current models including the Lamaze Healthy Birth Practices.

MO: You refer to the growing recognition of the significance of the Developmental Origins of Health and Disease (DOHaD) in the report. Midwives, childbirth educators and doulas among others have long discussed the unintended consequences of interventions in childbirth. Now with more recognition of the importance of the perinatal period as a sensitive period that potentially affects long term health, how do you simply explain this fascinating concept and others like epigenetic programming for childbearing families?

SB: The perspective of Hormonal Physiology is very much aligned with these big-picture models including DOHaD, epigenetics, and Lifecourse Health Development, which is a multi-system model looking at the potential for early events to change the trajectory of long-term health and development.

Epigenetics refers to the biochemical processes that switch genes on or off, which helps organisms to adapt to their environment and circumstances. We know that epigenetic changes give critical adaptations (“programming”) in early life that increase the chance of survival in the environment they have come into.

In relation to DOHaD, it is now scientifically established, and widely accepted — e.g., you read this research in the media and online — that the baby’s exposures in the womb can have long-term health effects. We also know from animal studies (with a growing interest in human research also) that early life events can have long-term programming effects, and we have even identified the associated epigenetic changes in some animal studies.

What the HPOC perspective adds to these models is the possibility that these long-term programming effects may occur not only before and after birth but also during birth, and it provides possible mechanisms for such effects. In other words, changing the hormonal experiences around the time of birth could have far-reaching effects.

In fact, we would expect very significant epigenetic effects at this time, as part of the enormous shifts involved with adapting to life outside the womb and, for the mother, optimally adapting her to the essential tasks of nurturing and nourishing her young. We have substantial animal research showing long-term effects from perinatal hormone exposures, including exposure to high doses of synthetic oxytocin.

MO: When you were doing this in-depth research on the hormones of labor. What finding(s) were most meaningful to you as a mother?

SB: As we describe in the report, this is a “consistent and coherent mosaic coming into view,” so we don’t have all the gaps filled in. However, what strikes me as a mother, and in relation to my own experiences of birth and mothering, is evidence that the hormonal processes of labor and birth, including mother-newborn contact in the first hour after birth, might switch on maternal reward systems in the brain at this powerful time, so that the new mother finds her offspring rewarding into the future. This is a critical mechanism for species survival, and ensures that mammalian mothers give the dedicated care that their newborns need- without going to a prenatal class! And after birth, these systems are reinforced for the mother by rewarding hormones including oxytocin and beta-endorphins released with breastfeeding and also with close infant contact.

© Sarah Buckley

© Sarah Buckley

I wonder if some of the problems we have with parenting in our culture, that it seems like hard work, that we can find caring for our young children boring, are because we can miss all of these sources of rewarding hormones.

MO: The forward to the report was written by leaders in medicine, midwifery, nursing, obstetrics, and pediatrics urging maternity care to support physiologic birth in order to uphold the Precautionary Principle of “do no harm.” What do you want to say to us on where to start in changing the current environment?

SB: I think one of the most powerful things we can do is to share the information in this report, including the knowledge gaps, with professionals and with expectant parents, so that we can shift our cultural understanding towards appreciating how superbly designed women’s bodies are for childbearing, how these hormonal systems can be disrupted, and that we actually don’t know the long-term effects for our children, so we should be applying precaution.

I especially want to reach high-technology settings, so that we can begin to recognize the gap between physiology and current practice and work to bridge it. In situations where interventions are genuinely needed, I want care providers to be asking “How can we safely add more hormonal physiology?” and take actions. This could be as simple as supporting skin-to-skin after cesarean, or promoting doula care for women with pregnancy complications.

I also want this report to get the attention of policy makers and funders. Physiologic childbearing is a low-technology approach that is generally inexpensive compared to our current high-technology models of care. The hormonal physiology perspective also suggests significant longer-term and public health benefits, for example through support for breastfeeding. This could give even greater benefits and cost-effectiveness in the longer-term, making it an excellent investment of health-care funds

About Michele Ondeck

michele ondeck head shot 2015Michele Ondeck,RN, MEd, IBCLC, LCCE serves the Lamaze International Board of Directors as its immediate past president. She was employed by Magee-Womens Hospital of University of Pittsburgh Medical Center for more than thirty years in a number of positions including education and research in the pursuit of improving women’s health and maternity care. She is the mother and grandmother of four. Currently, she is a director of a Lamaze International Accredited Childbirth Educator Program and self-employed as a perinatal education consultant.

 

 

 

 

 

 

 

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Sarah Buckley’s “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” – A Review for Birth Educators and Doulas

January 13th, 2015 by avatar

by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth.  Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley’s latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth.  In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report.  On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview,  S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. – Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

© Childbirth Connection

Introduction

For many of us who work in the maternity field, Sarah Buckley’s fine work is well-known. Her book, “Gentle Birth, Gentle Mothering” (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, “Ecstatic Birth,” (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,” (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley’s overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The “theory” that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

“According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.”

The Precautionary Principle, to which she refers, has been stated as follows:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.” (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it – the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

© Sarah Buckley

What’s new in this document and how might you use it and apply it in your classroom or practice?

This document represents the “State of the Science” regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, “How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?” should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth – induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention –major and minor — and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you’re a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it’s all here. If you’re a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you’re a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you’re a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you’re an expectant parent who wants to make choices that maintain or improve the pregnant person and infant’s well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 — “Oxytocin;” 4 —“Beta-Endorphins;” 5 —“Epinephrine-Norepinephrine and Related Stress Hormones;” ; and 6 —“Prolactin”) follow the same outline of topics and subtopics.

Using Chapter 6 (“Prolactin”) as an example, here is the outline:

  • 6.1 Normal physiology of prolactin
    • 6.1.1 Introduction: Prolactin
    • 6.1.2 Prolactin in pregnancy
    • 6.1.3 Prolactin in labor and birth
    • 6.1.4 Prolactin after birth
  • 6.2 Maternity care practices that may impact the physiology of prolactin
    • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
    • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
    • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
    • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
    • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
    • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
    • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
  • 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. “’Physiological childbearing’ refers to childbearing conforming to healthy biological processes,” (Buckley, 2015, page 11) as opposed to what many might refer to as “medicalized childbearing,” in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person’s anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic – Physiologic Onset of Labor, which is Lamaze International’s First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , “Physiologic Onset of Labor and Scheduled Birth,” details the ‘highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.” (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother’s body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don’t convey the physiology on which the benefits and risks are based. It’s all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, “The Events of Late Pregnancy” (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.© Penny Simkin

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn’t disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

“Hormonal Physiology of Childbearing” is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly “State of the Science” on Hormonal Physiology of Childbearing.

Conclusion

Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley’s discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley’s “Hormonal Physiology of Childbearing” is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.

References 

American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693–711.

Buckley S. Ecstatic Birth. Nature’s Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

 

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