Archive for July, 2009

Nursing Care and Management of the Second Stage of Labor: AWHONN Webinar on August 4

July 31st, 2009 by avatar

The Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) has been leading the fight for physiologic care in the second stage of labor. Next week AWHONN will host a webinar for nurses, presented by one of the leading second stage care researchers, Joyce Roberts, CNM, PhD, FACNM, FAAN. Here’s the information.

No Directed Pushing - AWHONN

Register now for this 75-minute educational webinar focused on current evidence-based information about the benefits of upright positioning and delayed and non-directed pushing. Strategies for implementation of these techniques, including preparation and education of the mother for the second stage of labor also will be presented.

Webinar: Nursing Care and Management of the Second Stage of Labor

When:  August 4, 2009 1 PM ET

Presented by: AWHONN and Joyce Roberts, CNM, PhD, FACNM, FAAN. Dr. Roberts is a former Professor of Nursing in the School of Medicine, Dept of OB/GYN at the University of Michigan and former President of the American College of Nurse Midwives.

Register Now!
Book a conference room with a computer and Internet connection and invite your registered and advanced practice perinatal nurses, OBs and family practice physicians to enhance their expertise. Pay just one connection fee, regardless of how many attend. One contact hour of CNE will be available to attendees of the live event. A live Q&A will follow the presentation. Handouts will be provided.

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“Being Safe”: Making the Decision to Have a Planned Home Birth

July 31st, 2009 by avatar

[Editor’s Note: I have asked several of Lamaze International’s 2009 Annual Conference speakers to contribute to Science & Sensibility over the next several weeks. Each guest contributor will share a sneak peak of their conference presentation. Some of them have conducted their own research while others have expertise in communicating research findings and evidence-based maternity care to childbearing women. Enjoy these guest posts and we hope to see you October 1-4 in Orlando at the Lamaze International 2009 Annual Conference. – AMR]

Judith Lothian, PhD, RN, LCCE

Judith Lothian, PhD, RN, LCCE

I became interested in home birth about 15 years ago. As birth became more medicalized I became increasingly discouraged with the lack of options that women actually had in a hospital. Routine intravenous, continuous electronic monitoring, and restrictions on movement during labor, and then the escalating epidural rate, and eventually the shocking rise in the cesarean rate became the back-drop for my column in the Journal of Perinatal Education, and more recently writing with Charlotte DeVries The Official Lamaze Guide: Giving Birth with Confidence.  Over those years, I read more about home birth, and discovered an increasing number of research studies that document the safety of planned home birth for healthy women (Leslie and Romano, 2007). I became increasingly convinced that planned home birth offered women a chance to have a safe, healthy birth without the restrictions and the frustration that too often characterized obstetrician managed (and sometimes midwifery managed) hospital birth (Lothian 2006). Although I had never actually been at a home birth, I began writing about planned home birth as a safe option for healthy women who wanted a natural birth. Then, my oldest daughter had her third baby at home and my world changed (Lothian 2002). I was overwhelmed with just how simple birth is meant to be.

Less than 1% of women in the US have planned home births. The reasons for this are complex but I kept thinking “If more women knew what it was like to give birth at home, more women would choose to have a planned home birth”. Although there is research on the experience of home birth in the Netherlands (Devries 2001), the UK (Edwards 2005) and Ireland (O’Connor 1995) there is no research that describes the experience of planned home birth in the US. So, the purpose of my research was to describe the experience of planned home birth for women and their midwives in the US. I will be presenting the findings related to making the decision to have a planned home birth at the 2009 Lamaze Annual Conference in Orlando.

In this qualitative study, I used the ethnographic techniques of informal interview and participant observation to obtain rich descriptions of women’s experience planning (and then having) a home birth. Twenty women representing diverse backgrounds were interviewed and observed in their homes. Interviews were audio-recorded and transcribed. Guidelines to insure trustworthiness and protection of human subjects were followed. The data were analyzed using standard qualitative techniques—developing codes, categories and themes. I’ll share more about the ins and outs of the research methodology in my presentation. (I promise it will be interesting.)

Many of the findings of the research surprised me. Women made their decision to have a planned home birth before becoming pregnant, early in the pregnancy, or sometimes as late as 30 weeks into the pregnancy. I was surprised that all of the women described themselves as “mainstream”. They all wanted a natural birth. All the women came to believe that “intervention intensive” maternity care increased risk for them and their babies. They valued the personal relationship with their midwife and believed that this relationship increased safety. They believed they could manage the work of labor more easily and more safely in their own homes. They all expressed confidence that a hospital and skilled physician care were available if needed. ‘Being Safe’ emerged as the theme that captured the essence of women’s decision to plan a home birth. In stark contrast to the current thinking, that birth is safer in hospitals under the care of an obstetrician, these women believe that giving birth at home is safer for them and their babies.

In a powerful way, the findings suggest that we need to look closely at the meaning of safety for women, and whether women and their babies are indeed safe in the current system.

At the conference I will share the women stories, in their own words. You will follow in their footsteps as they struggled to make sense of their options, resolved doubts and ultimately made the decision to have a planned home birth.

Judith Lothian, PhD, RN, LCCE, is a nurse and childbirth educator. She is an Associate Professor of Nursing at Seton Hall University and the Associate Editor of the Journal of Perinatal Education. She writes a regular column for the JPE and is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Judith lives in Brooklyn, NY and has five grown children and eight grandchildren.

Lamaze International Annual Conference

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The New GBS Cochrane Review: A Hot Mess!

July 30th, 2009 by avatar

The Cochrane CollaborationAdvocates for evidence based care feel our ears perk up when we hear about a new Cochrane systematic review. Cochrane Review = Evidence! Right? Indeed, systematic reviews represent the top of the “evidence pyramid” and Cochrane systematic reviews are the gold standard for their rigor and transparency. A Cochrane review can even conclusively settle important clinical controversies.

But sometimes Cochrane reviews leave us with more questions than answers.

Last week, the Cochrane Library released a systematic review evaluating the effectiveness of intrapartum antibiotics for known maternal group B streptococcal (GBS) colonization. And it’s a hot mess.

The four included trials that compared IV antibiotics with no treatment in labor collectively had only 500 participants, which we automatically know is far too small to find statistically significant differences in a condition that affects 1 in 2000 newborns, and results in death or long-term complications even less frequently. But small sample sizes were the least of the problems here. The reviewers noted several other problems with the trials:

  • In one study, researchers tracked their findings and halted the trial as soon as a significant difference was found (favoring treatment with antibiotics). This is a blatant form of bias – it is like flipping a penny until you get heads 5% more often than you got tails. If you keep flipping long enough (or stop flipping soon enough) you’ll be able to find that 5% difference simply by chance.
  • In the same study, researchers changed to a different statistical test that allowed them to achieve statistical significance with their data, when the originally planned (and more appropriate) test would have produced a nonsignificant finding.
  • None of the studies used placebos, so women, care providers, and hospital staff knew which women received antibiotics and which did not. This may have altered treatment of the women or the babies, possibly in ways that would make no antibiotics appear safer (for instance, avoiding or delaying membrane rupture in a woman who is GBS+ but not getting antibiotics).
  • One study excluded women who developed fevers in labor. GBS colonization can cause maternal fever and newborn sepsis, so excluding these cases makes no sense.
  • Some women included in the studies were likely GBS negative because methods used to determine GBS status were inadequate
  • Outcomes were poorly defined.
  • Data on a substantial proportion of women and babies were missing.
  • Groups were mysteriously differently sized.
  • Need I go on?

The Cochrane reviewers, in my opinion, did a respectable job with what they had, but what they had was garbage and as the saying goes, “Garbage in, garbage out.” You can’t make reliable conclusions out of a bunch of bad research, even if you’re a Cochrane reviewer.

So what were the findings?

Three trials, which were around 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics.

More, better research is needed, but the Cochrane reviewers are not optimistic:

Ideally the effectiveness of intrapartum antibiotics to GBS colonized women to reduce neonatal GBS infections should be studied in adequately sized double blind controlled trials. The opportunities to conduct such trials have likely been lost as practice guidelines have been introduced in many jurisdictions. (p. 11)

Source: Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm

Source: Centers for Disease Control and Prevention. http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5111a1.htm

In the meantime, women should be aware that other evidence, albeit not from randomized controlled trials, suggests that antibiotic treatment reduces deaths from early onset GBS disease in newborns. According to the Centers for Disease Control and Prevention, a steady decline in GBS disease has been seen in individual institutions, in the whole U.S. population, and in other countries as antibiotic use has risen. But these population-level data cannot tell us whether antibiotics or some other factor  caused the decline.

What other advice can we share with women?

  1. Be aware that antibiotics are not harmless. Severe allergic reactions are possible, and antibiotic use in labor can result in thrush (candida infection) which causes painful breastfeeding and sometimes early weaning. We do not know other possible harmful effects because they have never been studied adequately or at all.
  2. No study confirms the effect of labor practices on GBS infection in newborns, but here we can use our common sense. Care providers should avoid or minimize sweeping/stripping membranes before labor, breaking the bag of waters, vaginal exams, and other internal procedures, especially those that break the baby’s skin and can be a route for infection. These include internal fetal scalp electrodes for fetal heart rate monitoring and fetal blood sampling.
  3. Keep mothers and babies skin-to-skin after birth. This exposes the baby to beneficial bacteria on the mother’s skin, facilitates early breastfeeding, and lowers the likelihood that the baby will exhibit signs or symptoms that mimic infection, such as low temperature or low blood sugar, which could cause the need for blood tests or spinal taps to rule out infection.

Citation: Ohlsson A, & Shah VS (2009). Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane database of systematic reviews (Online) (3) PMID: 19588432

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When Push Comes to Shove

July 27th, 2009 by avatar

According to Listening to Mothers II, a survey of U.S. women giving birth in 2005, 17% of women having vaginal birth reported a “health professional pressing down on her belly to help push the baby out” (Declercq 2006, p. 35). This is called fundal pressure, and 17% is fairly common, so I decided to look at its safety and effectiveness in the chapter I’m working on now for the new edition of Obstetric Myths Versus Research Realities. Here’s what I found out:

Fundal pressure can harm mothers. Three studies concluded that fundal pressure increased likelihood of anal sphincter injury. A small study comparing 34 women who had fundal pressure with 34 similar women who didn’t found that fundal pressure was a disaster for the anal sphincter when combined with midline episiotomy. Ten of 16 women—a whopping 63%—who had fundal pressure and episiotomy had an anal sphincter tear compared with only 1 woman of the 16—6%—who had episiotomy and no fundal pressure. A larger study of 845 women reported that fundal pressure increased the risk of anal sphincter injury 4.6-fold after adjusting for correlating factors. Rates in the overall population were 6% while rates with no fundal pressure were 3%, and rates with fundal pressure were 21%. A very large study of 238,500 women having spontaneous vaginal birth and 46,300 women having instrumental vaginal delivery found much smaller differences, but the addition of fundal pressure increased risk of anal sphincter injury with spontaneous birth (2.1% vs. 1.7%) and forceps delivery (5.2% vs. 4.7%), although, not, oddly enough, with vacuum extraction. Finally, a study looked at factors associated with painful intercourse 12 to 18 months after delivery. Investigators excluded women who had had anal sphincter tears. Even so, fundal pressure popped up as a problem. Among women experiencing painful intercourse, 35% had had fundal pressure compared with 13% of women not experiencing painful intercourse.

But we’re not done. Fundal pressure can harm babies too. A study of 13,700 vacuum extractions reported more brachial plexus injuries (a cluster of nerves serving the shoulder and arm) in babies when fundal pressure was used—2% versus 1%. Study authors theorized that fundal pressure may jam (the word they used was “impact”) the baby’s shoulder behind the pubic bone. So much for safety.

Still, every intervention has potential harms. The question is: “Does fundal pressure do sufficient good to counterbalance those harms?” Despite its fairly common use, until this year, we had no evidence that it did. Now we do, and it doesn’t. In a randomized controlled trial (women assigned by chance to one form of treatment or the other), investigators allocated healthy women with full-term, head-down babies and no epidural analgesia or oxytocin (Pitocin or “Pit”) infusion to have fundal pressure or not when they reached full dilation and felt an urge to push. (RCTs produce the strongest evidence because random assignment eliminates many sources of bias.) Second-stage duration rates were similar in the group overall as well as among first-time mothers and among women with prior births. Ominously, umbilical cord oxygen levels at birth were lower in the fundal pressure group and carbon dioxide levels were higher. All newborns were in good condition at birth, but these were healthy pregnancies, and the same might not be true for babies already having some difficulty. So much for efficacy.

I could speculate on why the practice has persisted and continues to persist in the absence of any evidence to support it—in fact, I will in the book—but the take-home pay here is if progress is slow in second stage, women would be much better off trying an upright position, or better yet, preventing the slow progress by staying off her back in the first place and choosing a provider who practices patience rather than imposing time limits on second stage. Most women can get upright even with an epidural and confined to bed. Modern epidurals can relieve pain while still leaving sufficient feeling and muscle strength in the legs, for example, to rest on hands and knees between contractions and push back onto heels during contractions, or to kneel upright using a stack of pillows or a stability ball (A.K.A. “birth ball”) for support, or to sit between contractions and use the help of labor companions or a squatting bar to pull into a squat during contractions. Women with weak contractions would also be better off using breast stimulation or having I.V. oxytocin to bring strength up to par before resorting to more aggressive means of getting the baby born. And if push does come to pull, instrumental vaginal delivery isn’t entirely harmless, but at least it’s effective. Fundal pressure is neither. The wise woman whose care provider wants to press on the top of her belly either alone or in conjunction with instrumental delivery, will, in the words of a famous campaign, “just say, ‘No.’”’

Click on the extended post to see the references.

Read more…

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Denis Walsh, mommy wars, and coming together On Common Ground

July 19th, 2009 by avatar

Last week, I was thrilled and humbled to be asked to contribute to the On Common Ground collection at RH Reality Check. My assignment was to write a piece from the maternity care perspective that represents common ground for people on opposing sides of the abortion debate.On Common Ground

I was asked to help readers who cannot agree even on the basic precepts of an issue discover concerns and beliefs held in common. I hope I succeeded. But I may have stepped from one divisive debate right into another. In my article, Improving Maternity Care: A Mother and Child Reunion, I discuss how what happens in birth can affect a woman’s transition to motherhood, and even her biological bond with her baby. Sound familiar? This is a bit like what midwife and researcher Denis Walsh is reported to have said in a recent article. The article, published in the Daily Mail’s Online Edition, ignited a storm of attacks against Dr. Walsh, who is a man, for allegedly saying that epidurals can complicate maternal-infant attachment and breastfeeding. A look at the hundreds of comments on the feminist site Jezebel will give you a sense of how unpopular his remarks are.

Whether Denis Walsh said what was reported or not (there’s a good chance he didn’t), this isn’t the first time any of us have heard the claim – and even the science behind the claim – that epidurals disrupt the biological processes of maternal-infant attachment and breastfeeding. These claims are made about cesareans, too. But clearly, even the most eloquent and informed among us (for example, Denis Walsh) are unable to talk about these effects in language that resonates with the majority of women.

Is there a better way we can talk about the impact of maternity care practices on mother-infant attachment? I think so.

In my article at On Common Ground, I discuss the beneficial effects on maternal-infant attachment of two practices: continuous support in labor and skin-to-skin contact between mothers and newborns after birth. I give an example from a randomized controlled trial comparing women who had continuous support from friends or family members trained as “lay doulas” with other women who labored without such support. I also discussed the findings of a Cochrane systematic review of studies of skin-to-skin contact. In both cases, beneficial effects included easier transitions to motherhood and improved maternal-infant attachment.

These are practices we can offer women whether or not they have epidurals, and regardless of how they give birth. More importantly, they improve mother-infant attachment whether or not women have epidurals and regardless of how they give birth.

In the doula study, postpartum effects were profound. Women who had continuous support were more likely to describe their babies as “very easy” and to believe that their babies cried less often than other babies. They were more likely to pick up their babies when they cried and to report that they were able to sense their babies’ needs “very well.” Regarding their own postpartum experience, they were more likely to say that the transition to motherhood had been “very easy” and to report that they had received support from others in the previous week. Women assigned to the doula  group also scored more favorably on measures of self-worth including sense of self as a woman, sense of their bodies’ physical strength, and ability to be a good mother. Do you want to know what did not differ? The rates of epidural use (85% doula group vs. 88% no doula group) and cesarean surgery (19% doula group vs. 18% no doula group).

The systematic review of skin-to-skin contact included mostly studies of vaginal births in women without epidurals, but one study included in the review looked only at women who had scheduled repeat cesareans under spinal anesthesia. This study in fact yielded some of the most impressive differences in maternal-infant attachment behaviors of all of the studies included in the review. Some of the differences in maternal attachment behaviors persisted an entire month after giving birth.

I believe that mothers and babies experience physiological and emotional benefits when the woman has an unmedicated vaginal birth. But in our culture, women are not given a fair shake to achieve unmedicated vaginal births, and are fed messages that they shouldn’t care how they give birth as long as there’s a healthy baby. Even when care is top-notch, some women will still need epidurals or cesareans. Do we really want to tell these women that they might not be able to parent effectively?

The Healthy Birth Practices that Lamaze International has been championing for years allow us to have our cake and eat it too. Taken together as a package of care, they decrease the need for cesarean surgery and pharmacologic pain management. As we have seen in the two examples here (which represent two of the six Healthy Birth Practices), they may also mitigate or even overcome the effects of epidurals and cesareans on maternal-infant attachment. How’s that for a win-win?

We need to find common ground with women when it comes to talking about birth and bonding. Focusing on outcomes, which can result from choices, circumstances, or system effects, dooms us to alienate some women and ultimately fail to reach them with information that matters. Let’s instead advocate for better, safer care in labor – The Healthy Birth Practices – and fight to make sure no woman is denied access.

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