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Blog Carnival Round-Up: Stories of Success from the Field

January 28th, 2011 by avatar

It really is a joy and, I believe, imperative to spend time sharing childbirth success stories amongst those of us who dedicate our professional lives to improving childbirth experiences and outcomes for women all around the globe.  This year’s first blog carnival is about just that:  celebrating success while illuminating some ways in which Lamaze’s Six Healthy Birth Practices can and have been implemented in the process of realizing these successes.

Lisa, at Journey Through Lamaze, shared with us a lovely story of one of her recent clients who allowed labor to start on its own, and labored at home long enough before checking into the hospital to find herself fully dilated and ready to begin pushing shortly after admission.  Having begun with Healthy Birth Practice #1, this mama progressed through a non-medicated birth which Lisa describes as, “…the calmest birth I’ve ever been at.”  (Read Lisa’s post to find examples of other Healthy Birth Practices exemplified during this baby’s birth.)

Childbirth Educator, Judith, from Dance While You Cook relates how she incorporates teaching the importance of walking, moving around and changing positions throughout labor (Healthy Birth Practice #2) into her childbirth preparation classes.  Beyond “typical” teaching strategies, Judith shows her students how movement in labor can be effective by demonstration through a labor and birth dramatization. Read her post, and I guarantee you, you will pick up on the renewed energy and empowerment Judith gains each time she conducts this portion of her curriculum.

Many of our carnival contributors wrote about experiencing childbirth from a doula’s point of view.  Wendy from Mom and Little Me wrote about her strong belief in extending Healthy Birth Practice #3 into the prenatal period as much as possible.  It is during the prenatal visits that some of her most effective doula support takes place.  (Follow the link to Wendy’s post to also read about her ambitions for educating “a younger generation on natural childbirth and breastfeeding.”)  Hillary at Infinitely Learning shares with us a lovely anecdote about the birth of one of her doula clients that showed her the importance of holding space and bearing witness to the great journey of another human being, as she describes below:

She was a really independent birther and mostly needed the midwives and me (the doula) there for reassurance during some strong moments, but mostly I just stood Witness. A couple of times I doubted that I was even needed and became self-conscious that I wasn’t doing enough, but when I checked in internally to be guided I heard, “Witness”.

Kate, at Two Bee Birth Services shared the story, as written by the mother, of a successful, un-medicated VBAC.  With a history of multiple medical interventions during previous birth experiences plus some other recent pregnancy-related complications, this mama pursued a vaginal birth in the safest way possible, considering a present and extenuating medical circumstance.  In order to do this, she dedicated herself to avoiding interventions that were not medically necessary (Healthy Birth Practice #4) and succeeded in achieving the VBAC she hoped for.

Providing a fantastic success story that illustrated all six Healthy Birth Practices, in the setting of one birth, “Anthro Doula” Emily at Doula Ambitions simply and beautifully describes the end of one of her first birth experiences as a doula:

Once in the labor and delivery room she crawled up onto the bed on all fours, following her instinct and her urges to push on her own. She changed positions to a squat, leaning against the back of the raised bed, so that she would be able to catch her own baby. (Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push!)

This is my favorite part of the story, and my favorite part of any birth so far…
While the baby’s head was crowning, she reached down and felt his head, and she looked up with a face full of wonderment and said, “His head is coming out and then going back in a little!” She was so calm and intrigued, fully experiencing the birth of her first child. Then she pushed out her baby and pulled him up onto her stomach, all the while calm and grinning like mad!

The husband had tears streaming down his face, and the new mother was immensely pleased with herself. Mama and baby stayed together, skin-to-skin, and began to initiate breastfeeding, for the whole first hour.
(Healthy Birth Practice 6: Keep mother and baby together – It’s best for mother, baby and breastfeeding)

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Thank you to all blog carnival contributors for your thoughtful words and illustrative stories which collectively remind us that safe, healthy, fulfilling birth experiences are not an anomaly, but an achievable reality!
**Don’t forget to swing on over to Giving Birth With Confidence to read additional results of this blog carnival!

Posted By:  Kimmelin Hull, PA, LCCE

Blog Carnivals, Doula Care, Healthy Care Practices, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

“Except When Medically Necessary” : Making informed choices about induction of labor

January 27th, 2011 by avatar

It’s not hard for women to find advice and recommendations to avoid induction of labor “except when medically necessary.”  But what do those words mean and who decides when an induction is medically necessary?

Lamaze’s Healthy Birth Practice Paper cites ACOG Guidelines that define medical induction of labor as necessary in the following circumstances:

  • your water has broken and labor has not begun.
  • your pregnancy is postterm (more than 42 weeks).
  • you have high blood pressure caused by your pregnancy.
  • you have health problems, such as diabetes, that could affect your baby.
  • you have an infection in the uterus.
  • your baby is growing too slowly.

Yet a systematic review of the highest quality research found evidence only to support the first three. Even in these three cases, differences in important health outcomes were small, study methodologies have been criticized, and some important questions remain unanswered.

For the rest of this list and other so-called “medical” reasons for induction, we simply lack scientific evidence that induction offers any clear health benefits, and for other conditions the available evidence suggests induction is more likely to harm than help.

When trade-offs are uncertain for a proposed course of treatment, that treatment is known as “preference-sensitive care.”  According to the Dartmouth Atlas of Health Care, a leader in studying practice variation, “Decisions about these interventions — whether to have them or not, and which ones to have — should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician.”

As the Dartmouth Atlas has demonstrated for many types of medical and surgical interventions, however, decisions are more likely to reflect local practice patterns and the preferences of individual providers than the preferences of patients themselves. While the Dartmouth Atlas does not track induction rates, a 2004 study in New York State found that risk factors (at least those documented in birth certificate records) explained just 12.6% of the four-fold variation in induction rates across hospitals.

But what of the variation in the use of interventions when clear evidence suggests is harmful? Shouldn’t rates of those interventions be stable at or near 0%?  Take, for example, the rate of elective (non-medically indicated) deliveries before 39 weeks. In a landscape where clinical consensus is hard to come by, all of the major players from ACOG and ACNM to the March of Dimes, the National Quality Forum, and the Joint Commission, have gotten on the no elective deliveries before 39 weeks bandwagon. Yet this week a major hospital watchdog group, The Leapfrog Group, partnering with Childbirth Connection and the March of Dimes, released for the first time hospital rates of elective deliveries before 39 weeks and the results are all over the map (pun intended). Some hospitals are in the low single digits, rates we know are possible when quality improvement efforts are taken seriously, while others report up to half or more of all births between 37 and 39 weeks are electively delivered.

Women need individualized, evidence-based information about the likely benefits and harms when considering induction of labor in the face of complications or significant risk factors. Childbirth Connection has launched a new web resource dedicated to Induction of Labor to help fill this need. But evidence is just one piece of the puzzle. Women also need information about maternity care practice patterns in their communities, since this factor seems to affect their likelihood of induction more than any other. Leapfrog’s voluntary database of elective early delivery rates stands to drive significant quality improvement. Let’s hope it’s just the first step toward full transparency of maternity care quality.

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Antepartum Bedrest: Helpful or Harmful?

January 20th, 2011 by avatar

Each year approximately 750,000 women in the United States are prescribed antepartum bed rest (ABR) for a portion of their pregnancy due to (but not limited to) preterm labor contractions, incompetent cervix, placental issues, multiple gestation, vaginal bleeding, hypertension/pre-eclampsia, gestational diabetes, impaired fetal growth or oligoamnios. The amount of time spent on bed rest can be anywhere from a few days to several months and women are typically confined to bed with activity restricted (AR) to bathroom privileges only. While the indications for ABR vary, the unifying rationale for prescribing ABR and its perceived benefits remain the same—to prevent preterm labor and the delivery of a premature infant. Preterm birth is the leading cause of perinatal infant morbidity and mortality in developed countries. In 2005, 68.5% of all infant deaths <1 year old in the U.S. were in preterm infants.  The rate of preterm birth in 2005 was 12.7% in the US (and continues to climb) compared to 5-7% in European countries. (Go here and here for additional information on these statistics.)

To date, there is no data to support the efficacy of ABR in the prevention of preterm labor and premature birth. Much of the research done on antepartum bed rest actually shows that it does more harm than good (1-5).  Additionally, in-patient ABR has been shown to have worse effects on maternal and infant morbidity and mortality than ABR at home. To further investigate these findings, Judith Maloni, PhD, RN, FAAN performed an integrative literature review on the research to date. Her findings were published in the article, “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth” (Biological Research for Nursing, October 2010,Volume 12 (2) 102-124). Although ABR has been a mainstay of clinical obstetrical practice for the past 30 years in the United States, Maloni found no evidence for its effectiveness. On the contrary, she found that there is increasing evidence that ABR leads to several negative physical and psychological effects to both mothers and babies yet these findings have not lead to a change in clinical practice. Here she presents the evidence for the practice of prescribing ABR and its associated physiologic, psychological, and experiential side effects. She also presents recommendations for additional research on ABR including the evidence that supports prescribing home care with support as a safe, efficacious and cost effective model.

Methods
Maloni chose to organize her work following the Human Response Model and its concept of physiologic, behavioral and experiential adaptation. 69 publications made up the sample for this study: 26 articles discussed the physiologic, behavioral and experiential side effects of bed rest; 17 articles compared ABR at home vs. the hospital setting; 5 meta-analyses of RCTs assessed the effectiveness of ABR; and 4 articles analyzed physician use of bed rest. Articles ranged in date from 1990 when major interest in the study of bed rest began, to the present time. The articles come from research in nursing, medicine, psychology, social, biological and aerospace sciences. Maloni searched MEDLINE, CINAHL, PubMed/Medline, and the Cochrane Database of Systematic Reviews.

Results
Several conclusions emerged following the literature review, but none of them supported the idea that ABR with activity restriction (AR) is beneficial in preventing preterm labor. What quickly became apparent is that ABR/AR has some very deleterious effects on mothers and babies. Aerospace research showed that prolonged inactivity in the supine position leads to redistribution of body fluids towards the head, causing functional changes in the cardiovascular/cardiopulmonary systems, fluid and electrolytes balances, hormone balances, hematologic systems, neurosensory and vestibular systems. Additionally, the body weight distribution is shifted and the result is muscle atrophy and bone demineralization. These changes persist far into the postpartum period and may have long standing consequences. They also necessitate a longer than usual postpartum recovery due to deconditioning. Women also reported fatigue, back aches, muscle soreness, sleep changes, round ligament pain, nasal congestion, reflux and indigestion which also persisted well beyond 6 weeks postpartum.

Non-pregnant women on bed rest (astronauts) tend to lose weight due to fluid and bone loss, and occasional loss of appetite. Carbohydrate and fat metabolism are also altered during bed rest. Similar to findings with female astronauts, (pregnant) women on bed rest have been noted to either maintain or to lose weight which is dangerous for fetal growth. Three of the studies, including one which focused on multiple gestations showed that women on ABR—both in the hospital and at home—did not gain the anticipated one pound per week as recommended by the Institute of Medicine for adequate (fetal) growth.

The literature also demonstrates that behavioral changes ensue as a result of prolonged bed rest. Women reported feeling imprisoned with a sense of sensory deprivation. They worried  about their lives and their families and felt powerlessness to fix anything. This stress led to altered mood and often pre- and postpartum depression. These symptoms were most pronounced in women on hospital bed rest and remained well beyond 6 weeks postpartum. Family members were stressed as well, most notably partners who assumed the role of caring for the family in addition to their partners on bed rest. It was also noted that infants born to mothers on ABR had higher incidences of allergies, motion sickness and the need to be rocked to sleep than those infants born to mothers who were never on ABR.

Alternative Models For Antepartum High Risk Care
While ABR in the hospital is currently the standard of care in the United States, it has not been shown to reduce perinatal morbidity or mortality. The literature has shown that women on hospital ABR often had the most pronounced adverse effects, both physical and psychological. Despite these findings, ABR (in-patient ABR, in particular) continues to be prescribed.

Physicians in other countries often prescribe ABR but have patients remain at home, providing maternal and fetal monitoring as well as light housekeeping, child care, nutritional counseling, education and psychological counseling. In contrast, very limited home care assistance is available in the United States.  Home care in the U.S. consists mostly of uterine and fetal monitoring and infusions of Magnesium Sulfate or Terbutaline—medication thought to (but not proven to) inhibit contractions. Maloni’s study showed that women who underwent ABR at home with support (assistance with familial responsibilities and emotional support) actually fared better than women who completed their ABR in the hospital. Additionally, infants born to mothers who experienced ABR at home had fewer or shorter NICU admissions. All researchers concluded that, when truly warranted, home care of high risk pregnant women with ABR is as effective, safe and feasible as hospital care.

Discussion
Because of the significant burden ABR puts on a pregnant woman, her fetus, her family and the U.S. health care system, and given the fact that there has been no recent evidence to support its efficacy, experts agree that bed rest should no longer be a standard component of treatment for the prevention of preterm birth. In fact, these same experts agree that the practice should be eliminated (1,,3, 5,6,7). While there may be a need for an emergent period of intense hospitalization following a crisis, experts concur that once a pregnant woman and her baby have been stabilized, they should be discharged home and managed with modified/restricted activity and supportive home care visits that not only monitor maternal and fetal well-being, but also support a women and her family psychosocially.

While some experts argue that neonatal mortality has gone down over the last 20 years, this has been primarily due to improved neonatal care in NICU’s and increased access to such care. The incidence of preterm birth has essentially remained unchanged (6,7,10).  As such, researchers are increasingly skeptical that the current U.S. model of prenatal care, in terms of prescribing bed rest for threatened pre-term birth, can prevent prematurity. While some researchers advocate the addition of steroids, sedation, psychosocial support and nutrition, other researchers note that these methods have yet to prove effective in reducing the incidence of preterm birth (6,7,11). Maloni, in agreement with their research findings, believes that there really needs to be a complete overhaul of the management of prenatal care. Maloni and others  advocate a re-evaluation and reconceptualization of prenatal care as part of a broader approach to optimize all of women’s health.

References

  1. Crowther, C. (2009) “Hospitalization and bed rest for multiple pregnancy.” Cochrane Database of Systematic Reviews, (2), CD000110. Accession number: 00075320-100000000-00712
  2. Elliott, JP, et al (2005) “A randomized multicenter study to determine the efficacy of activity restriction for preterm labor management in patients testing negative for fetal fibronectin.” Journal of Perinatology, 25, 626-630.
  3. Meher,S., Abalos, E., & Carroli, G. (2005) Bedrest with or without hospitalization for hypertension during pregnancy. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003514. DOI: 10.1002/14651858.CD003514.pub2. Last update January 18, 2010.
  4. Say, L., Gulmezoglu, A.M., & Hofmeyer, G.J. (2009) Bed rest in hospital for suspected impaired fetal growth. Cochrane Database of Systematic Reviews, (3), CD000034. Accession number: 00075320-100000000-01075.
  5. Sosa, C., Althabe, F., Belizan, J., & Bergel, E. (2009) “Bed rest in singleton pregnancies for preventing preterm birth.” Cochrane Database of Systematic Reviews, (2), CD003581. Accession Number: 00075320-100000000-02667.
  6. Goldenberg, R.L. (2002) “The management of preterm labor.” Obstetrics and Gynecology, 100. 1020-1037.
  7. Lu, M. C., et al (2003) “Preventing low birth weight: Is prenatal care the answer?” Journal of Maternal-Fetal & Neonatal Medicine, 13, 362-380.
  8. Heaman, M., Sprague, A.E., & Stewart, P.J.A. (2001) Reducing the preterm birth rate: A population health strategy.” Birth (30) 20-29.
  9. Hodnett, E.D., Fredericks, S. (2009) “Support during pregnancy for women at increased risk of low birthweight babies.” Cochrane Database of Systematic Reviews , (2) CD 000198. Accession number: 00075320-100000000-00157.

Posted By: Darline Turner-Lee, MHS, PA-C

Bed Rest, Do No Harm, Practice Guidelines, Pregnancy Complications, Research, Science & Sensibility, Systematic Review , , , , , , , , , , , , , ,

United States Breastfeeding Commitee: Breastfeeding ~ A Vision For the Future

January 18th, 2011 by avatar

Following posts like this one from last week, it’s encouraging to see that breastfeeding initiation rates have continued to rise in recent years.  But, as Science & Sensibility contributor Edith Kernerman, IBCLC, pointed out: the rates of breastfeeding exclusivity at the six-month-postpartum mark (as recommended by the World Health Organization) are still less than impressive (world-wide, not just in the U.S.).  Thankfully, progress is being made to change these rates for the better.  Beyond local activism and individual interactions between lactation support specialists & consultants and the women they support, leadership “from the top down” is emerging.

If you haven’t heard of the United States Breastfeeding Committee (USBC), let me bring you up to speed:  This non-profit organization is made up of forty voting member organizations (Lamaze, being one of them) and evolved out of the 1990 UNICEF Innocenti Declaration which, among other things, calls for:

…every nation to establish a multisectoral national breastfeeding committee comprised of representatives from relevant government departments, non-governmental organizations, and health professional associations to coordinate national breastfeeding initiatives.

In the last few years, the USBC has accomplished numerous impressive feats–including communications and collaborations with federal law makers, White House staff members, CDC entities, FDA departments, popular media outlets and more.  Go here to see the complete overview.   Most importantly, go here to view USBC’s Breastfeeding Vision for the Future in which barriers to breastfeeding success are addressed and goals for improved support of mother-baby breastfeeding dyads are delineated.   To show your support for the work USBC is doing on behalf of ALL nursing mothers–current and yet to come–sign the petition which seeks support from all sectors of U.S. society for improving each and every factor that influences a woman’s ability to breastfeed her child(ren) for the duration that is mutually beneficial for mom and baby.

***Our government is taking note:  keep your eyes and ears pealed for an important announcement from the Surgeon General on this very same topic…this coming Thursday, January 20! ***

UPDATE: Go here tomorrow (Thursday) at 10:00EST to see the live webcast of the Surgeon General’s call to action to support breastfeeding!

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Dorsal Lithotomy Position vs. Non-supine Positions During 2nd Stage of Labor: Quadriped

January 18th, 2011 by avatar

Please welcome new Science & Sensibility contributor, Amanda Blaz, DPT.  Amanda is a Physical Therapist in south central Montana and has recently completed her Certificate of Achievement in Pregnancy and Postpartum Physical Therapy (CAPP-OB) from the Section on Women’s Health of the American Physical Therapy Association, one of 28 physical therapists in the country to do so.  She will now be working toward that same certification in the area of pelvic floor rehabilitation.  Amanda is also a DONA-certified birth doula.  This is the first of a four-part series.

How Supine Positioning Became Commonplace
If you ask anyone in the United States to describe the appearance of a woman giving birth, a majority would likely describe the dorsal lithotomy position in which the mother is semi-recumbent with knees and hips flexed, all the while screaming and sweating.  This is the most popularly portrayed childbirth image in television and movies, and the most common pushing position in the American labor and delivery world (65.9% of women deliver in this position) (Shorten ‘02).  So it poses the question, if dorsal lithotomy is the most well-known and widely used position during second stage  labor, is it the best? 

Over the course of a four-part series I will look at the literature regarding the topic of second stage positioning, and offer a comparison of the dorsal lithotomy position vs. other non-supine positions, starting with the hands-and-knees position.  In the next three posts, lateral lying, squatting and other alternate positions will also be discussed.  While there are many differences in birth outcomes when comparing dorsal lithotomy to other second stage positions I will focus specifically on those related to the anatomy of the pelvis, pelvic floor musculature, orthopedic issues, and nerves of the pelvic and sacral areas.

Convenience vs. functionality
The position of the pelvis when in dorsal lithotomy places the birth canal at an angle that actually makes the baby travel upward.  There are many texts and articles that cite this position as the “gold standard,” suggesting that it is the most widely used and, therefore, the most satisfactory position for second stage.  However, the reason dorsal lithotomy has long-been considered “most satisfactory” is never delineated.  In fact, many well-known books, such as Human Labor and Birthby Dr. Harry Oxorn, suggest that second stage dorsal lithotomy positioning is the favored position because it is easier for the attendant to access the birth canal and perineum, and take care of any complications that may arise.  This doesn’t necessarily prove the position as the most satisfactory for maternal outcomes.

Anatomical Concerns
When in the dorsal lithotomy position, a woman is putting direct pressure on her sacrum (tailbone), forcing it into a flexed position and making the pelvic outlet smaller.  Also, as stated above, when in this position, the birth canal curve has an “uphill” orientation, forcing the mother to have to push the baby against gravity through an increasingly narrowed space (flexed sacrum pushing into pelvic outlet space).  Furthermore, it has been shown that the femoral nerve can be compressed at the inguinal ligament during delivery by thigh flexion, lateral hip rotation, and abduction (dorsal lithotomy position) (Sax 2006 ).  Femoral nerve injuries can lead to quadriceps weakness and/or sensory loss to the front/middle part of the thigh.  Weakness of the quadriceps can cause the knee to feel as though it is going to “buckle”—increasing the woman’s risk of an orthopedic injury.  Functionally, quadriceps weakness can make it difficult for the mother to go up and down stairs or get in and out of a squat position—a position that is used frequently to care for or play with a young child.  Lastly, dorsal lithotomy is a position to avoid when the following orthopedic issues are present during the pregnancy: sacroiliac joint dysfunction (common cause of low back pain in pregnancy), pelvic girdle pain, pubic symphysis dysfunction, coccydynia(painful tailbone), hip joint dysfunction, knee joint dysfunction.  When these issues are present, the dorsal lithotomy position places a large amount of stress on these joints and can increase pain, discomfort, or may even further injure the affected area. 

Take pubic symphysis separation for example:

                       

If the mother already has a pregnancy-induced pubic symphysis separation (even a partial separation), placing her in the dorsal lithotomy position is going to further distract the joint because of the excessive hip abduction and external rotation required.  Not only can this lead to excessive immediate postpartum pain, but prolonged supra-pubic pain and tenderness with radiation to the back or legs, difficulty walking, and occasionally, bladder dysfunction (Snow, 1997).

The Benefits of All-Fours
When a woman in is the quadruped (hands-and-knees) position, she has many advantages on her side:  For one, the birth canal curve is in a downward orientation, allowing gravity to aid in descent of the baby—promoting a gentler passage rather than a forced upward journey that involves significantly greater pressures and level of effort for the mother.  Secondly, the woman is able to sway side to side as well as flex and extend her spine to aid in pain/discomfort during and between contractions.  Similarly, quadriped is a favorable position when sacroiliac joint dysfunction, pubic symphysis dysfunction, coccydynia, spondylolisthesis, discogenic pain, or spinal stenosis is present.  This is due to the fact that joints are not placed in a position that places a large amount of compression or stress on them and can be easily adjusted by the mother to increase her comfort level.  Also, when in this position, a woman is more amenable to manual prompting by birth attendants to contract abdominal musculature and relax/contract the pelvic floor to aid with pushing.  Lastly, Soong (2002) showed that when giving birth in the quadruped position, a woman may have less need for perineal suturing when compared to the dorsal lithotomy position.  With a sample size of 3,756 women who had a spontaneous vaginal delivery, 61% of those giving birth in the hands and knees position had intact perineums.

Although there are many advantages to delivering in the hands and knees position, there are also times when it is not advantageous.  Obviously, it becomes a less likely option when an epidural has been placed (depending on analgesic used and flow rate). Secondly, some women may not be able to maintain this position because of decreased mobility, decreased core strength, increased fatigue, or other factors.  Lastly, this position is not favorable if the woman has any knee joint dysfunction as it requires weight bearing on the joint and at least 90° of knee flexion.

Current literature  supports the fact that non-supine positions are most often favorable when compared to the dorsal lithotomy position.  It has been found in many articles that women who delivered in a non-supine position tended to experience easier pushing, less pain with pushing, less back pain, and fewer perineal tears which leads to reduced need for suturing  (Gardosi, 1989, Liddell 1985).  I feel that because of these favorable outcomes, it should be at the forefront of our pregnancy and inter-partum community to educate women on the options they have as far as positioning during the second stage is concerned. Maybe one day we will see a baby delivered in a movie while the woman is on her hands and knees.

 _________________________________________________________________________________________

References:

 Gardosi, J., Sylvester, S. and B-Lynch, C. (1989), Alternative positions in the second stage of labour: a randomized controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 96: 1290–1296.

 Liddell, H. S. and Fisher, P. R. (1985), The Birthing Chair in the Second Stage of Labour. Australian and New Zealand Journal of Obstetrics and Gynaecology, 25: 65–68

 Sax TW, Rosenbaum RB.  Neuromuscular disorders in pregnancy.  Muscle Nerve.  2006 Nov; 34(5):559-71

 Shorten, A., Donsante, J. and Shorten, B. (2002), Birth Position, Accoucheur, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth. Birth, 29: 18–27.

 Snow, R., Neubert, A. Peripartum Pubic Symphysis Separation:  A Case Series and Review of the Literature.  Obstetrical & Gynecological Survey: July 1997 – Volume 52 – Issue 7 – pp 438-443

 Soong B, Barnes M.  Maternal position at midwife-attended birth and perineal trauma: is there an association?  Birth.  2002;32(3):164-169.

Harry Oxorn, MD Human Labor and Birth (University of Ottawa, Ontario, Canada,McGraw-Hill Professional Publishing)1986

Posted by:  Amanda K. Blaz, PT, DPT


Doula Care, Practice Guidelines, Research, Science & Sensibility, Uncategorized , , , , , , , , , , , , , , ,

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