Archive for February, 2011

Part 2: Pain, Suffering, and Trauma in Labor and Subsequent Post-Traumatic Stress Disorder: Practical Suggestions to Prevent PTSD After Childbirth

February 28th, 2011 by avatar

[Editor’s note:  This is part two of Ms. Simkin’s post on childbirth-related Post Traumatic Stress Disorder.  The post is long and detailed–every word worth reading.  Set aside ample time to read this article: such that devouring, versus skimming, might be accomplished.  Birthing mothers & their birth partners, doulas, childbirth educators, L&D staff and maternity care providers will ALL benefit from the recommendations provided below.  To read part one of the post, go here.]

With Part 2 of this blog post, I’d like to move toward practical applications of the research findings on variables associated with traumatic birth and PTSD, as described in Part 1. Here is a list of suggestions (much more lengthy that I originally anticipated –Sorry!) for caregivers, doulas and childbirth educators, designed to prevent or minimize traumatic childbirth and subsequent PTSE of PTSD. These include suggestions for before, during and after childbirth.

Checklist for before labor:

Identify the woman’s issues or fears relating to childbirth.

The caregiver should elicit a psychosocial and medical history from the woman, and if there is evidence of previous unresolved trauma, discuss and strategize a course of care that maximizes her feelings of being supported, listened to, and in control of what is done to her, and minimizes the likelihood of loneliness, disrespect, and excessive pain. (1, 2)

The unique non-clinical relationship between doula and client requires that doulas do not ask specific questions regarding the woman’s psychosocial and medical history; rather, an open-ended question such as “Do you have any issues, concerns or fears that you’d like to tell me to help me provide better care for you?” The woman then has the option of whether or not to disclose sensitive issues. Many doulas, however, can recognize strong emotions without knowing specifics. The doula tries to be sensitive and accommodating without discussing her client’s anxiety directly.

Childbirth educators, rather than asking their groups about their issues, may find it more appropriate to discuss the potential effects of anxiety or old trauma on women’s experiences of labor, and to provide resources: books, referrals to support groups or counselors (possibly including the educator herself, if she can provide counseling) that can be helpful. Caution: If offering her services for counseling, the educator may be perceived as having a conflict of interest in raising these issues. To avoid such a conflict, I advise against charging a fee (beyond the class fee) for counseling one’s students, or to avoid mentioning herself as a resource.

The purposes of counseling for a woman with negative feelings about childbirth or maternity care are to help her clarify and address these feelings and strategize ways to 1) reduce their negative impact (at least), or 2) prevent further suffering or retraumatization, and 3) even result in empowerment and healing for the woman. (3) In fact, I feel there’s a great need to increase the numbers of birth counselors – people with a deep knowledge of birth and its accompanying emotions; maternity care practices and local options; excellent communication skills; and an understanding of trauma, PTSD, and other mood disorders relating to childbearing.  Wise childbirth educators and doulas with good communication skills should consider expanding their roles in this direction, along with nurses and midwives who have the time and skills to provide such counseling.

Recommend that the woman/couple learn about labor, maternity care practices, and master coping techniques for labor.

Childbirth classes that emphasize these elements, especially when they assist women and couples in personalizing their preferences and ways of coping with pain and stress, can take many surprises out of labor and empower parents to participate in their care and help themselves deal with pain and stress, whether with or without pain medications or other interventions.(4)

Recommend a Birth Plan:

A birth plan is a document that describes the woman’s personal values, preferences, emotional needs or anxieties regarding her child’s birth and her maternity care. It is most useful if it is the result of collaborative discussion between the woman and her caregiver, and if it is placed in the woman’s medical chart to be accessible for all who are involved in her care. (5) Usually, in hospitals where there is a spirit of cooperation and good will between clients and staff, birth plans are easily accommodated.  Sometimes, as in some cases of previous trauma or other adverse events, a woman will have a greater need for special considerations than other women. If the effort is made with care planning to address those needs, the potential for a safe satisfying birth experience is great, without causing harm or overwork for the staff. For example, simple requests (such as having people knock and identify themselves before entering her room; limiting the number of routine vaginal exams to those that are necessary for a clinical decision; allowing departure from a routine such as forceful breath holding and straining for birth) require flexibility but are not dangerous. A woman is likely to feel respected and understood if the staff gives serious consideration to her requests. The birth plan should include her preferences for the use of pain medications, not only yes or no, but the degree of strength of her preferences (6)

Of course, in her birth plan (or another term instead of “plan” may be used), she should use polite and flexible language (couching her preferences in language such as “as long as the baby is okay,” “if no medical problems are apparent”). She might prepare a Plan A, for a smooth uncomplicated labor, and a Plan B, for unexpected twists that make intervention necessary. A birth plan allows everyone to be on the same page, and ensures that the woman has a voice in her care, even when she is in the throes of labor. Childbirth educators and doulas have a responsibility to guide parents in the language and options included in the birth plan to maximize the likelihood that the plan will be well-received, while still reflecting her needs and wishes. If prenatal discussions indicate the birth is unrealistic or unreasonable, there is opportunity to discuss, clarify, and settle  the problems before labor, when it’s too late.

During labor:

Those caring for laboring women should remind themselves that the birth experience is a long-term memory (7) that can be devastating, negative, depressing, acceptable, positive, empowering, ecstatic, or orgasmic.

The difference between negative and positive depends not only on a healthy outcome, but a process in which she was respected, nurtured, and aided. In a study that I published years ago, on the long-term impact of a woman’s birth experience, I found that the most influential element in women’s satisfaction (high or low) with their birth experience 15 to 20 years later is how they remember being cared for by their clinical care providers (8), In fact, it was that study that motivated me to do what I could to ensure that women receive the kind of care that will give them lifelong satisfaction with their birth experiences. The answer became the doula.

“How will she remember this?” is a question that everyone who is with a laboring woman should ask him or herself periodically in labor, and then be guided by the answer to say or do things that will contribute to a good memory.

The doula:

The research findings of the benefits of the doula are well-known; in fact, a newly updated Cochrane Review of the benefits of doulas once again demonstrates the unique contribution of continuous support by a doula in improving numerous birth outcomes (See press release at http://www.childbirthconnection.org/pdfs/continuous_support_release_2-11.pdf and the full review with a summary at www.childbirthconnection.org/laborsupportreview/ (9). Besides the benefits reported in the Cochrane Review, I’d like to suggest a benefit that doulas may confer when traumatic birth is occurring: the doula’s care may be instrumental in preventing a traumatic birth from developing into PTSD. Czarnocka and Slade found with their study on normal births, 24% of the women had Post-traumatic Stress Effects (PTSE) and 3% had the full syndrome of PTSD.(10) (See Part 1 of this blog post for an explanation of the difference between PTSD and PTSE). They found that the women with PTSD were more likely to have felt unsupported and out of control than those who had PTSE. PTSE is far less serious that PTSD in terms of duration and spontaneous recovery.

Ironically, doulas are often traumatized by what they witness in birth settings where individualized care and low intervention rates for normal birth are not emphasized or supported. (11) They feel frustrated, demoralized or burned out, especially when their clients who had originally expressed a preference for minimal intervention, seem oblivious to the departure from their stated preferences and even grateful to the doctor who “saved their baby” after unnecessary interventions (which the woman had not wanted in the first place) led to the need for a cesarean. The woman has a traumatic birth, but later seems okay with everything that happened and doesn’t seem to have many serious leftover trauma symptoms (PTSE). I feel certain that in some of these cases of PTSE, the doula, by remaining with the woman, nurturing and helping her endure the physical helplessness, the fear and worry for her baby and herself, may have provided the positive factors identified by Czarnocka and Slade that protected her from PTSD. Prevention of PTSD is a worthy goal for a doula when birth is traumatic. (12)

Code word to prevent suffering:

No one wants a woman to suffer during labor. On the other hand, no supportive person wants a woman to have pain medication that she had hoped to avoid. A previously agreed-upon “code word” provides a safety net for a woman who is highly motivated to have an unmedicated birth. She says her code word only when she feels that she cannot go on without medical pain relief. The code word frees the woman to complain, vocalize, cry, and even to ask for medications, but her support team knows to continue their pep talks and encourage her to continue, and suggest some other coping techniques. However, if she says her code word, her team quits all efforts to help her continue without pain medications and turns to helping her get them. (13)

Why is a code word better than continuing to help her cope without medications when a woman (who had felt strongly about avoiding them) says she can’t go on, or vocalizes her pain loudly? It’s because some women cope better if they can express their pain than to have to act as if it doesn’t hurt. It also guides the team much more clearly than her behavior. As one woman said, “I shouted the pain down!” It’s really important for the nurse to know and understand the purpose of the code word, or she’ll feel the team is being cruel. If a supporter wonders if the woman forgot her code word, he or she can remind the woman, “You have a code word, you know.” One woman, when reminded, asked herself, “Am I suffering?” She decided she wasn’t, and went on to have a natural birth.

Of course, a code word is unnecessary if the woman plans to use an epidural.

Pain Rating Scale and Coping Scale:

All hospitals use a Pain Intensity Scale to measure patients’ (including laboring women’s) pain. See illustration of the Pain Intensity Scale. The goal, of course, is to ensure that no one suffers. The scale doesn’t rate suffering, however, since pain and suffering are not the same. (See Part 1 of this blog post.) Much more important is the woman’s ability to cope. See the illustration of the Pain Coping Scale. If she rates her pain at 8 (very high) and her coping is also rated very high, she’s not suffering. If pain is at 8 and coping is at 2, she could be suffering, and obviously needs attention, assistance, and very likely, pain medication.

Assessing a woman’s coping is done differently than assessing her pain. Rather than asking her to rate her coping on a scale of 10 (coping most easily) to 0 (total inability to cope), the supporter observes her behavior for the 3 Rs: Relaxation (between, if not during, contractions); Rhythm (in movements, breathing, moaning) and Ritual (coping with the same rhythmic activity for many contractions in a row). If she does not maintain the 3 Rs, she might very well suffer and feel traumatized by her labor. (14)


Pain Coping Scale: 10 to 0

A second way to assess coping is to ask the woman, after a contraction, “What was going through your mind during that contraction?” If her answer focuses on positive thoughts, or helpful activities, she is coping. If she focuses on how long or difficult it is, or how tired or discouraged, or how much pain she feels, she is not coping well and may be suffering. (15)

Intensive labor support may help her cope better and keep her from suffering, but pain medication may be the best way to relieve unmanageable pain that causes suffering. Help her obtain effective pain relief, whether it is pharmacological or non-pharmacological, according to her prior wishes and the present circumstances.

Recognize that if she has an epidural, she still needs emotional support and assistance with measures to enhance labor progress and effective pushing.

The absence of pain, usually accomplished so effectively by the epidural, does not mean absence of suffering. Nurses and caregivers in hospitals with high epidural rates are likely to make comments like, “There’s no need to suffer;” “You don’t have to be a martyr;” “There’s nothing to prove here.” With this assumption that pain and suffering are the same, once the pain is eliminated, the woman’s emotional needs are often neglected. In their classic study of pain, coping and distress in labor, with and without epidurals, Wuitchik and colleagues found, “With epidurals, pain levels were reduced or eliminated. Despite having virtually no pain, these women also engaged in increased distress-related thought during active labor. The balance of coping and distress-related thought for women with epidurals was virtually identical to that of women with no analgesia.” (16)

What are women distressed about when they have no pain? Wuitchik and colleagues named many things (and I have added some that I have witnessed), including: the length of labor; numbness; side effects such as itching and nausea; being left alone by supporters when she was “comfortable;” helplessness; passivity; worries over the baby’s well-being (especially with the sudden and dramatic reactions of staff when the mother’s blood pressure and fetal heart rates dropped); or feeling incompetent (when unable to push effectively despite loud directions to push long and hard).

The point is that women may suffer even if they have no pain, and their needs for continuing companionship, reassurance, kind treatment, assistance with position changes and pushing, attention to their discomforts and their emotional state, remain as important to the woman’s satisfaction and positive long-term memory as they are to the unmedicated woman. (17)

Take note if any variables occur during labor that are associated with traumatic births and PTSE (explained in Part 1 of this blog).

Warning signs of potential PTSE include feeling: angry (blaming others, alone, unsupported, helpless, overwhelmed, or out of control; also panicking, dissociating, giving up, feeling hopeless and as if she can’t go on (“mental defeat”). If she exhibits some of these signs, her caregiver, doula, and others should do as much as possible to prevent the trauma from becoming PTSD later (remaining close to her, reassuring her when possible, helping her keep a rhythm through the tough times, explaining what’s happening and why, holding her, making eye contact and talking to her in a kind firm confident tone of voice). The point is to help her maintain some sense that she is not totally alone, out of control, and overwhelmed.

After the Birth

Seeds of accomplishment

Before leaving the birth, a few specific positive and complimentary words from the “expert,” her doctor midwife or nurse, will remain in her mind, as she ruminates on her traumatic birth. “I was so impressed when you said you wanted to try waling when the labor had stalled for so long;” or “when you said you wanted to push a little longer;” or “when you realized that we had to get the baby out right away, and you said, ‘do what you have to do.’”

Anticipatory guidance for after birth.

When her labor and birth were traumatic, it is wise for the caregiver and her team to

1)      Acknowledge it openly: “You certainly did your part. I just wish it had gone more as you had hoped.”

2)      Anticipate some ways she might feel later, for example, she may find herself thinking a lot about the birth and recalling her feelings at the time.

3)      Give guidance on what to do: she can call her care provider, doula, childbirth educator, a good friend, or a counselor to review and debrief the experience (3, 18, 19, 20, 21). This cannot be rushed and the counselor (caregiver, doula, or other) should be available when the woman is ready to discuss it.

1.      Books (22, 23, 24) articles (surf the web!), and  Internet support groups may be helpful: Check the following:

http://www.birthtraumaassociation.org.uk/; http://solaceformothers.org/mothers-forum.html; http://www.tabs.org.nz/.

4)      Believe the woman when she says her birth was traumatic, and accept her perceptions of the events before clarifying or correcting misinterpretations. Help her reframe the event more positively, if possible, or suggest therapeutic steps to recover from the trauma. If PTSD does result, a referral should be made to a trauma psychotherapist, preferably one with experience with maternal mental health issues.

In conclusion, this is a reminder that traumatic childbirth is all too common, but with personalized sensitive care, much birth trauma can be avoided. If birth is traumatic for the woman, there are steps that can be taken before, during, and after childbirth to help ensure that the trauma does not become Post-Traumatic Stress Disorder. In fact, processing a traumatic birth experience can even provide an opportunity to heal and thrive afterwards.

This blog post series will be featured in the Fall 2011 issue of the Journal of Perinatal Education.  For references, please contact Ms. Simkin directly at: penny@pennysimkin.com or reference the JPE issue:  Summer 2011 Volume 20, Number 3.

Posted by:  Penny Simkin, PT, CCE, CD(DONA)

Doula Care, Patient Advocacy, Perinatal Mood Disorders, Practice Guidelines, PTSD, Research, Science & Sensibility , , , , , , , , , , , , ,

Epidural Analgesia—a delicate dance between its positive role and unwanted side effects (Part Two)

February 25th, 2011 by avatar
This post is the second in a series by Dr. Michael Klein.  You can find the first installment of this series here.

Research into the consequences of epidural use
Whether the benefits of epidural analgesia outweigh the potential risks has been the subject of many controversies over recent decades. In my department we have studied these controversies extensively. On a regular basis we looked at our own performance in caring for laboring women. The Department of Family Practice at British Columbia Women’s Hospital in Canada (familiarly known as ‘BC Women’s)’is made up of over 100 family doctors, who all attend births. BC Women’s is the largest maternity hospital in Canada, with more than 7,000 births per year, and family doctors are responsible for almost half of these births, despite the hospital also being the tertiary care referral centre for the province. This makes us the largest group of family doctors attending births in Canada.

We knew from the literature that epidural analgesia use early in labour, before the fetus was well down in the pelvis, could cause malpositioning (occiput posterior or transverse) (7) due to extension of the fetal head. If the fetal head is extended, it cannot rotate or descend. We found that physicians who ordered epidurals frequently and early in labour had more patients with malpositioned fetuses.(8) They also had more patients who received greater amounts of synthetic oxytocin augmentation of labour. They had fewer spontaneous births and more cesarean sections than those in the department who used epidurals less often. Also, surprisingly, high epidural rates were associated with increased numbers of newborns with low 5-minute Apgar scores and more babies admitted to the newborn intensive care unit.

We found that physicians with mean epidural rates under 40% for women having their first baby, had cesarean section rates of about 10%. In contrast, those family doctors with mean epidural rates of 71-100% had cesarean section rates of 23.4%, the others having rates between the two extremes. The women cared for by the three groups were similar. Thus it appeared that only physician practice difference could have accounted for such large differences in outcome. Interestingly, the caesarean rates of women who were having their second or more births were unaffected by the way in which their doctors prescribed epidurals.

Our departmental experience was similar to results from an observational study in which we compared outcomes at a nearby community hospital with our tertiary care centre. (9) In the community care setting, mean epidural analgesia rates were 15.4% compared with 67.2% in the tertiary care center, for comparable women. The odds of having a cesarean section were 3.4 times greater at the tertiary care centre than in the community hospital. The increased and earlier use of epidural analgesia in the tertiary care setting almost completely explained this difference. The community hospital setting encouraged the use of other non-epidural pain coping techniques, resulting in later epidural placements compared to those in the tertiary hospital setting. We were also interested to note that those physicians who ordered epidurals less often actually spent more time with their patients, even though on average their patients spent less time in hospital. The time they spent with their patients involved more intimate, hands-on, supportive care.

It is because of these studies that we had trouble accepting the results of the 2004 Cochrane meta-analysis that concluded that epidural analgesia did not raise the cesarean section rate.(10) This conclusion was the same in the most recent Cochrane meta-analysis,(11) this new one deeply flawed by the inclusion of many studies of women who suffered from complex medical conditions, and many studies that randomized women late, particularly since conventional practice is to use epidurals earlier. Clearly, any meta-analysis is only as good as the individual studies included—illustrating the well-known principle: garbage in, garbage out.

Epidural Analgesia has transformed birth:
In fact, it appeared to us that the increasing use of epidural analgesia was transforming birth. This observation was confirmed by a report from the Canadian Institute for Hospital Information, which indicated that 4 in 5 Canadian women received one or more major obstetrical interventions, with epidurals high on the list at rates of 40-50% of births in various Canadian settings. (12)

We decided to look more closely at earlier Cochrane (10) individual studies that made up the meta-analysis addressing the effect of epidural analgesia on c-section rates. These studies revealed that, epidural analgesia increased the length of the first stage of labour by 4.3 hours. Similarly, the second stage of labour was increase by 1.4 hours. Malpositions were found in 15% of cases where epidurals were used but in only 7% of cases where narcotics were used. Synthetic oxytocin augmentation of labour was found in 52% of women with epidurals and in 7% of women who had narcotic analgesia. Instrumentation (forceps and vacuum) was found in 27% of epidural cases compared with a rate of 16% among women not getting an epidural. Maternal fever was dramatically higher in the epidural versus narcotic analgesia groups—24% and 6%, respectively.

Maternal fever is a common side effect of epidural analgesia because it interferes with the sympathetic and parasympathetic nervous system balance, altering the body’s normal methods to eliminate heat. And since it is hard to know if the fever is due to infection or an epidural effect, a septic work-up is usually carried out following birth on both the mother and baby, including blood and possibly cerebral spinal fluid tests, along with frequent placement on prophylactic antibiotics. Additionally, increased maternal temperature can cause a rapid fetal heart rate and, thus, prompt a caesarean section due to concerns for fetal well-being.

Additionally, several studies have shown that perineal trauma increased two-fold in women who had had an epidural, due in part to an increased use of forceps and vacuum, which in and of themselves are associated with more perineal trauma (with or without epidurals).(13, 14)

Given all the other increases in intervention rates, we found it hard to understand why cesarean section rates were not also higher in the Cochrane meta-analysis. In fact, when we separated out the studies that made up the 2004 Cochrane meta-analysis, we found that, in those studies that showed no difference in cesarean section rates, epidurals had been administered after labour was well established (in the active phase at 4-5cm or more of cervical dilation). In the studies where epidurals were given early on in labour, before the active phase (before 4-5cm of cervical dilation)—the cesarean section rate increased more than 2.5 times. (15, 16)

Inadvertently, the Cochrane meta-analysis of epidural analgesia has caused more frequent use of epidurals, resulting in more continuous electronic fetal monitoring, immobility of the labouring woman, increased instrumentation and perineal trauma, and an increase in the cesarean section rate. Because more women will have received a cesarean section, another consequence will be an increase in problems in subsequent pregnancies relating to placentation issues (previa, accrete, percreta, abruption), infertility, and ectopic pregnancy.(17-20) In most maternity care settings, these down-stream consequences (‘collateral damage’) from epidural use are not discussed.

Dr. Klein’s final post next week will take a look at the realities of how epidural analgesia has “transformed birth.” All references for this series of posts can be found here: References _ michael klein post 





Posted by:  Michael C. Klein, MD, CCFP, FAAP(Neonatal-Perinatal),FCFP, ABFP
Emeritus Professor of Family Practice and Pediatrics
University of British Columbia
Senior Scientist Emeritus
Centre Developmental Neuroscience and Child Health
Child and Family Research Institute
4500 Oak Street
Vancouver, V6H 3N1
Tel: 604-875-2000 ext 5078
Fax: 604-875-3569

[MK1]Mixing issues here


Lamaze Healthy Birth Practice #3: Bring a Loved One, Friend, or Doula for Continuous Support

February 22nd, 2011 by avatar

Science & Sensibility welcomes new contributor,  Jackie Levine, as she shares with us her thoughts and compilation of the latest industry research about doula care.

Why is Labor Support So Important?

Ordinary intuition informs us, without reference to any study, that human touch and supportive contact, caring and calming behavior, and the sharing of the profound experience of birth with a loved one or close friend can all have powerful and positive effects on a woman in labor.

It turns out, our intuition is correct about the salutary effects of labor support; there is a bulging library of good research that clearly measures and identifies the benefits to mother and baby.

One comprehensive study published in Clinical Obstetrics and Gynecology (Kayne, Greulich, Albers, 2001) presents a thorough history of the doula and of continuous labor support in the US. The study highlights the social and medical rationales for doula care, including a meta-analysis of the research on labor support.  This observation in the study rings particularly true: “Perhaps the greatest lesson to be learned from these studies is that the laboring woman, not hospital policy, should decide who should be present for labor support”.  That thinking harmonizes nicely with the statement of “The Rights of Childbearing Women,” enumerated by Childbirth Connection and quoted in The Official Lamaze Guide: “#15- Every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver trained in labor support”.

Maternity care policies vary from institution to institution and from caregiver to caregiver. This is old news.  In spite of considerable resources spent and the good intent of those caregivers, we know that some models of maternity care involve the overuse of harmful or ineffective but expensive protocols, and the underuse of ones that confer benefit; current care practices do not always reflect the host of systematic reviews that support best-evidence protocols.  The Milbank report, as posted on Childbirth Connection, tells us that, in an analysis of practice bulletins issued by ACOG between 1998 and 2004, only 23% of those practice recommendations were based on Level A evidence (consistent science), 35% were assessed as Level B (inconsistent or limited evidence) and 42% were Level C (based on consensus or the opinions of experts). (Sakala C, Corry M, 2008.)  Those numbers are reflected in the dismal ratings that the WHO gives the US:  we are 49th in maternal mortality and 29th in infant mortality of 141 developed countries (WHO 2006). Clearly, we’re not doing everything right and we all hope to see the day when evidence-based maternity care becomes the standard, replacing the existing welter of practices. But continuous labor support is Level A.

In the recent past, through the 1960s, when “twilight sleep” for hospital birth was the paradigm, women did labor alone, and would awake from their anesthetized slumber the next day, perhaps, and ask “Did I have a boy or a girl?”  There are some women, of course who just don’t want any “company,” who find the intermittent visits from staff and caregivers to be enough interruption of concentration and purpose. These women typically invite their partner or other family members back into the room just for pushing and birth. I have known a very few who labor this way. But for most women, whether first-time mothers or not, continuous support and “company” is a must. The arsenal of data showing improved obstetric outcomes with continuous labor support gives potent ammunition to every mother desiring it. I believe that at this juncture, very few caregivers will deny labor support to the mother.  But that is not enough.  The most effective labor support for mother and family is shown to be provided by the “paraprofessional the doula ”(Lantz,Low,Varkey, Watson, 2005).

Paying a doula fee is out of the reach of many, but several recent developments will make doula care increasingly accessible. Hospital-based programs that supply doulas to laboring women are few and far-between, but some insurance companies will now reimburse part of a doula’s fee. And it’s heartening, that the need for “paraprofessional” labor support is now understood by those in government to be a vital part of good maternity care, evidenced by President Obama having signed an Omnibus bill in December which included 1.5 million dollars that The Health Resources and Services Administration (HRSA) will distribute to support community-based doula training programs on a grant basis.  The Kayne study asserts that even in active management of labor “continuous professional support is considered the most effective in reducing operative deliveries” (Kayne, Greulich, Albers, 2001). The rationale for doula care for all is further bolstered by the latest (2011) review from the Cochrane Database: Continuous Support for Women during Childbirth (Hodnett, Greulich, Albers, 2011).  There is no question that doula support results in healthier mothers and babies, and safer labors and births.

How can we, educators, doulas, friends and family of birthing women, encourage, convince and facilitate this Healthy Birth Practice?  In 2005, the Journal of Perinatal Education published a study on community-based doulas, advising childbirth educators in sum to act as advocates, and “catalysts in their community to initiate highly personal support services” (Breedlove, 2005). In June 2010, Melinda Gates, of the Gates Foundation spoke at a Women Deliver Conference. Gates discussed a world where “women are given the knowledge to make better decisions about their health and their children’s health.” We can give birthing women the facts about support in labor, teach that our bodies are marvels and perfect for the job of birth, and that best evidence-care proves that to be so. The studies that refute interference with normal birth are mounting, and more and more the OB profession realizes, sometimes in a very self-congratulatory way, that things can and must change. (As example, see “Changes in Episiotomy Practice: Evidence-based Medicine in Action, Lapin & Gossett, 2010.)

We know that continuous labor support does make for better outcomes, although research-wise, the exact reason that happens is not established.  The Kayne study mentioned above says this: “Whether it is the role of the support person as comforter or protector that leads to better obstetric outcomes is still unanswered.” The most recent Cochrane review theorizes that the stresses of hospital birth are dis-empowering, raising stress levels that impede both the dynamic and subtle mechanisms of normal labor.  Research aside, we understand intuitively that continuous support in labor both protects and comforts; it acknowledges the vulnerability of a woman in labor and can provide, both through advocacy and unconditional acceptance of everything she does, an antidote to fear, and the path to a safe birth that will be remembered with joy.


1-Breedlove, G., Perceptions of Social Support from Pregnant and Parenting Teens Using Community-Based Doulas, J. Perinatal Educ 2005 Summer; 14(3): 15-22

2-Gates, Melinda. Full speech available at: http:/www.livestream.com/womendeliver/video?clipId=pla_7e848eb5-43eb-41e4-a5d3-e6de7cab31bc&utm­_source=1slibrary&utm_medium=ui-thumb.

3- Hodnett, E.D., Gales, S., Hofmeyr, G.J., Sakala, C., Weston, J. 2011, Continuous Support for Women during Childbirth, Cochrane Review

4-Kayne, M.A., Greulich, M.B., Albers, L. Doulas: An Alternative Yet Complementary Addition to Care During Childbirth, 2001, Clinical Obstetrics and Gynecology, 2001; .44(4):692-703

5-Doulas as Childbirth Paraprofessionals: Results from a National Survey, Lantz, P.M., Low L. K., Varkey, S., Watson R.L. Women’s Health Issues, 2005,15:109-116.

6-Lappen, J.R., Gossett, D.R., Changes in Episiotomy Practice: Evidence-based Medicine in Action, Expert Rev of Obstet Gynecol. 2010;5(3):301-309

7- Lothian, Devries: The Official Lamaze Guide (New York: Meadowbrook Press, Simon & Schuster Publising, 2005, 2010), Appendix C, p 261.

8- Sakala, C., Corry, M. 2008, Evidence-based Maternity Care: What it is and What it Can Achieve. (Milbank Report

Posted by:  Jackie Levine, LCCE,FACCE,CD, CLC

Doula Care, Healthy Birth Practices, Healthy Care Practices, Science & Sensibility, Uncategorized , , , , , , , , , , , , , , , , ,

Straight Talk on Epidurals for Labor

February 21st, 2011 by avatar

Recently, we’ve seen some buzz on the internet about a new book, Epidural Without Guilt. Childbirth Without Pain by Gilbert Grant, an anesthesiologist. At least one other blogger has disputed his logic, so I thought I’d weigh in on the evidence basis for his claims.

Dr. Grant says that according to his analysis of the medical studies, epidurals:

  • Can speed up labor
    This may be true for some women but not in general. Meta-analysis, a technique for pooling data from multiple trials, finds that epidurals slow labor and increase the need for strengthening contractions with oxytocin.
  • Don’t increase the need for cesarean
    True, but this is because other factors outweigh epidurals. In a nutshell, if a woman has a care provider who tries to minimize use of cesarean, she is at low risk of surgical delivery regardless of whether she has an epidural, and if her care provider resorts to cesareans liberally, she is at high risk, again, regardless of whether she has an epidural.
  • May reduce the likelihood of postpartum depression
    Studies of what makes for a satisfying birth experience consistently find that quality of supportive care is the key factor, and pain management only enters the picture when the woman’s pain relief expectations are not met.
  • Can help with breastfeeding
    Epidurals are associated with breastfeeding difficulties, although these can be overcome with good support. Dr. Grant, though, is actually proposing epidural anesthesia after the birth, to relieve postpartum discomforts that he believes interfere with breastfeeding. Few women, however, would need anything more than an ice pack and maybe some over-the-counter medication for cramps after vaginal birth especially if they have not had instrumental delivery or an episiotomy.  As for post-surgical women, I would think that impairing mobility would increase risk of deep venous clots and that conventional pain relief methods are deemed adequate for every other type of surgery.

Dr. Grant’s blurb says his book offsets the focus on epidural risk. I disagree that the problem is, in fact, overemphasis on the risks of epidurals. The American Society of Anesthesiologists consumer pamphlet, which should set the standard for informed consent, mentions only hypotension, which can sometimes cause slowing of the fetal heart, post dural puncture headache, dizziness or seizure if the drug enters a vein, and difficulty breathing if the drug enters the spinal fluid. On the contrary, I think women are given far too little information about potential harms, which is why I wrote the article reprinted below for Choices in Childbirth’s “Guide to a Healthy Birth” booklet which summarizes my own analysis of the literature. The piece is based on the epidural chapter for the new edition of Obstetric Myths Versus Research Realities, now nearing completion for University of Michigan Press (Amy Romano, co-author).

I append the chapter’s mini-reviews reference list and include as well some studies from the labor support chapter relevant to my critique of Dr. Grant’s findings. I should add that the book is not a narrative review, that is, authors cherry pick studies and data from studies that support their thesis. Amy and I preset inclusion and exclusion criteria, tried to find all studies that fit those criteria on our topics, and give reasons for excluding studies that otherwise fit our criteria.

From the Guide to a Healthy Birth booklet:

No doubt about it. Epidurals are aptly named the “Cadillac of analgesia.” Epidurals allow women to be awake and aware yet free from pain during labor and birth. They permit an exhausted woman to rest or sleep. And while their usual effect is to slow labor, the profound relaxation they offer can sometimes put a stalled labor back on track. Despite these benefits, you would do well to look under the hood before you decide to drive this “Cadillac” off the lot. Like all medical interventions, epidurals have potential harms. The wise woman will want to weigh them against her other options. Unfortunately, many care providers don’t supply complete information. To give you a more balanced picture, here are the disadvantages of epidurals according to the research:

  • A minimum of 5 more women per 100 will have a vacuum extraction or forceps delivery: Consequences of these types of delivery include increased probability of a tear into the anal sphincter muscle and injury to the baby.
  • Seventeen more women per 100 will experience a drop in blood pressure, which may pose a risk to the baby.
  • The narcotics included in epidurals greatly increase likelihood of nausea and can cause itching.
  • Epidurals interfere with establishing breastfeeding. Studies specifically link fentanyl, a common narcotic component, to early problems and higher probability of switching to bottle feeding. Associated interventions such as instrumental vaginal delivery may also affect early breastfeeding.
  • Somewhere between 1 in 1,400 and 1 in 4,400 women will experience a life-threatening complication.
  • Combined spinal-epidurals, sometimes called “walking epidurals,” increase complications. Compared with standard epidurals, more women will experience itching, some will have breathing problems or difficulty swallowing, and some babies will experience a prolonged episode of abnormally slow fetal heart rate.

Epidural side effects can also have negative psychological consequences. Fetal heart rate disturbances, a drop in blood pressure, or difficulty breathing or swallowing may cause intense alarm and distress. Itching or nausea can make a woman miserable.

While complete pain relief may make for a more positive labor experience, epidurals interfere with the natural interplay of hormones, which has its downside. During un-medicated labor, beta-endorphin levels rise in response to pain, producing a “high” that enables women to transcend labor pain and experience that “top of the world” feeling after giving birth. An adrenalin surge in late labor dispels exhaustion, gives a woman extra oomph to push out the baby, and ensures that she is excited and alert to greet her baby. Oxytocin is the hormone of love, not just contractions, and un-medicated women have higher levels after childbirth than any other time in their lives.

Still, labor is unpredictable. You don’t want to cross an epidural off your dance card. Just be sure that you make your decision freely, not because you feel pressure or lack an alternative. Here are some ways to do that as well as minimize potential harms:

  • Choose a care provider with a cesarean surgery rate of 15% or less. Studies show that in the hands of care providers with low rates, epidurals do not increase cesarean odds Practitioners who have vaginal birth as a goal will have more patience and manage labor and epidurals differently than others.
  • Choose a mother-friendly birth environment. In most hospitals, confinement to bed, continuous fetal monitoring, and restricting labor support companions such as doulas, along with lack of amenities such as showers, deep tubs, and birth balls make it difficult to cope with labor without an epidural. Where epidurals are the norm, nurses may not know how to support a laboring woman without one, and staff may actively promote their use.
  • Delay an epidural until active, progressive labor. This will help prevent two problems: running a fever, which becomes more likely the longer the epidural is in place, and the baby persisting in the occiput posterior position (head down, facing the mother’s belly). These complications increase the likelihood of cesarean or instrumental vaginal delivery. And because epidural-related fever cannot be distinguished from fevers caused by infection, babies are more likely to be kept in the nursery for observation, undergo blood tests and possibly a spinal tap, and be given precautionary I.V. antibiotics.
  • Choose a standard epidural of the lightest intensity that keeps you reasonably comfortable over a spinal or “walking” epidural.

Finally, whether an epidural is Plan A or B, take classes that prepare you for coping with labor without one and consider hiring a doula. You will want a variety of comfort measures and coping strategies at your fingertips. For one thing, you may need them if you are delaying an epidural until active labor. For another, the anesthesiologist may not be available when you want your epidural, or you may be among the 1 in 10 women for whom it does not work. It is also possible that labor will turn out to be easier than you thought and you decide you don’t need one after all.

For references, go here:references_hencigoer_epiduralwoguilt

Posted by:  Henci Goer

Epidural Analgesia, Evidence Based Medicine, Practice Guidelines, Uncategorized , , , , , , , , ,

Healthy Birth Practice #2: Walk, move around and change positions throughout labor

February 18th, 2011 by avatar

Last month, Lamaze published a press release entitled, Why Choosing “Free Range” Labor May Make Birth Easier.  As we continue re-visiting the Six Healthy Birth Practices on Science and Sensibility, today I invite you to think about Healthy Birth Practice #2: Walk, move around and change positions throughout labor.  To read the research behind this recommendation, follow the above link, and check out the list of references at the bottom of the page: the written evidence is abundant, and speaks for itself.Today, however, I’d like to offer a different sort of evidence:  the words of a woman who has recently undergone two different birthing experiences.

One year ago, my best friend and Physician Assistant colleague Liz, gave birth to her second child.  Less than two years prior, she and her husband welcomed their first child into the world.  Liz’s birth experiences occurred in two different states with two different providers.  Her first pregnancy and birth were anything but normal—as she explains in her reference to a “highly medically managed” pregnancy, which continued into birth.  Her second birth was quite different and yet, she created the opportunity for herself to employ “free range labor” during both labor and birth experiences.

During both of Liz’s pregnancies, I was honored to help this couple prepare for the births of their children through knowledge sharing, informal childbirth ed. discussions during a visit to them leading up to their first birth experience and telephone labor support during Liz’s second labor.  (I will never forget secreting away into the quiet guestroom of our house during the late-night hours while the rest of my family slept, verbally supporting Liz via telephone, as she worked through the transitional contractions that hit during their drive to the hospital.)

Liz graciously accepted my request to an interview in which she and I discussed and compared her two birth experiences, with a focus on the topic of movement during labor.  Here are her insights:

Can you describe the differences between your two labor and birth experiences?

In many ways the two labor experiences were the same and in many ways different. With both pregnancies, I carried the babies until 39 weeks gestation.  With both, I labored down from 4 cm-8 cm in one hour.  With both I remained active and moving—until 8 cm with the first, and until birth with the second.  With both, I had my husband present for support. With both, the physician did not arrive in time for the birth of my child.

With the first, I had a highly “medically” managed pregnancy, and I believe that alone contributed to my fear of having a natural childbirth. I had an IV, monitor, and my water was broken by nursing staff at 4 cm. I was not, however, in active labor pain. As above, I labored quickly, but found it difficult to maneuver in a hospital room with IV attached. I opted for an epidural at 8cm.

The second delivery was easier as I was home when labor started and was able to move through my own familiar surroundings, my own clothes, my own bed, etc. When I did arrive at the hospital I was fully dilated. I found recovery to be enormously easier with the second delivery.

What factors do you think influenced the difference in your two babies’ births?

For the first birth, the biggest factor which made labor difficult for me was being hooked to an IV. I am GBS positive, and was admitted to the hospital at 4 cm dilated without painful contractions, to have IV antibiotic prophylaxis and have my water broken (basically augmenting labor!). When I finally went into labor I found it difficult to move with IV and monitor attached.

For the second birth, I went into labor on my own; no induction or augmentation. The biggest factor which made labor easier for me was the ability to move within my home and surroundings before going to the hospital.

I will add for both deliveries I was fortunate to have tremendous support from nursing staff to help facilitate my need to move during labor.

Last but not least, my husband and I were better prepared emotionally in meditation, reading, and undying support from a dear friend who is a childbirth educator to have a NATURAL delivery the second time around. Even though I had this same support during my first pregnancy, EXPERIENCE of already having a vaginal delivery helped to ease the fear the second time.

Considering the speed and intensity of your second baby’s birth, what labor-coping techniques helped you through your labor?  Why do you feel these things helped?

Liz: MOVING!  Hindsight reminds me my contractions were erratic with intensity and timing, so I had no idea when the next would start or end. Unfortunately, I didn’t have the chance to “think” about which strategy I would use for the next contraction.  However, my body naturally WANTED to move through each contraction: I found myself getting on all fours; I had my husband push very hard on my sacrum as I bent forward on the counter; [I benefited from] receiving a giant bear hug from anyone willing while I stood; all of these techniques just came naturally to me to find comfort, as my body just KNEW what to do.

Within Lamaze’s Six Healthy Care Practices comes the advice to “walk, move around and change positions throughout labor.”  Did you find yourself doing these things during one or both of your labors and, if so, what was your experience with movement during labor?

During both labor experiences, I did feel that changing positions not only helped my body physically, but mentally challenged me to focus on what position I would try during the next contraction. As the pain grew stronger, my body took over and I found myself naturally moving into the most comfortable position for that contraction without thinking about it.

Looking back on the births of your children, do you feel your physical behavior during labor and birth influenced your emotional experience?  If so, in what way(s)?

Yes, I was able to move more during my second labor and birth and I feel as though this reduced my stress and anxiety level, as opposed to the first labor and delivery where I wasn’t able to move as much.  Looking back I now realize having to lay still, hooked to IV and monitor, had caused more anxiety for me and my husband.

What thoughts and/or advice (if any) would you offer health care providers and/or the partners of laboring women in terms of providing assistance for walking/moving/changing positions in labor?

To anyone in the presence of a laboring woman, they need to know that ANY position she can get comfortable in is acceptable. (I still remember the look of shock on my sister’s face when I was on all fours on the hospital bed). This goes for health care providers as well. If the laboring woman cannot lay supine during a contraction for the monitor to be strapped on, please TRUST in her body the baby is OK for those few minutes and wait for the contraction to pass.
Specifically to health care providers—respect the wishes of the mother’s/partner’s birth plan and do everything in your power to facilitate a safe and comfortable environment for the laboring woman. Petition for a birthing bar, balance balls, bath tubs in your maternity ward and practice medicine going ‘back to the basics’ of allowing free movement during labor. After all, having a baby is the most powerful and natural act the human body can endure. Pain serves a purpose and doesn’t always need to be treated.

Elizabeth Posoli-Futch is a Physician Assistant practicing urgent care medicine at a community hospital in the Northern suburbs of Philadelphia.  My deepest thanks go out to Liz and her family for sharing these insights surrounding the births of their beautiful daughters.  Happy first birthday, baby M!

Epidural Analgesia, Healthy Birth Practices, Healthy Care Practices, Practice Guidelines, Science & Sensibility , , , , , , , ,

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