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“I Want to Have a Vaginal Birth!” – A Childbirth Educator Meeting the Needs of Her Students.

July 11th, 2013 by avatar

Regular contributor, Jacqueline Levine, shares her experiences teaching Lamaze classes and ponders the responses to the question “Why have you come to this class?” The responses motivate her to continue to teach evidence based information and provide families with the resources they need to have a safe and healthy birth. – Sharon Muza, Science & Sensibility Community Manager.

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© www.momaroo.com

I teach Lamaze classes to the maternity clients at a Planned Parenthood Center.  Planned Parenthood supports women in all facets of their reproductive lives, including supporting a healthy pregnancy and birth.  As part of the informal protocol of the first session, I ask each woman why she’s come to the class.   Most of the time, the answers are pretty predictable;  “My sister (friend, mother, partner) said I should come”, or “How does this baby come OUT?” or sometimes “I want to have a natural birth with no medication.”  There is always a recognizable and comfortable rhythm to these answers.  Sometimes there’s humor, but there’s always the feeling of community; mothers-to-be will meet each other’s glance and smile.  At times, partners roll their eyes ceiling-ward, but the answers I hear do not discomfit, and they do not surprise.  Everyone understands that we are together under the sheltering umbrella of learning about birth, about who we are in this room, at this moment and in this context; we are preparing to learn together. 

I recently heard another reason for coming to class that in years past would have had me shaking my head in disbelief.  ”I’m here because I want to have a vaginal birth.”  I’ve tried to imagine the look on my face when I first heard those words, and I know that the class read my expression; immediately I was knocked from a comfortable and familiar path, and the lighthearted air that normally suffused the room was neutralized in an instant. 

At this writing, five women in four different class series separated from each other by months, were bound together by the fear of having a cesarean. They had each come to class in order to find some sort of powerful knowledge that would stand as a barrier between themselves and cesarean birth.  They were asking me (and  by proxy, Lamaze) to give them an impenetrable defense, some kind of fortress of information.  They were hoping for some special power or status in the world of birth, a talisman or access to some magical knowledge to stay the knife and keep it at bay.  They had come to a childbirth education class for information that, in essence, would teach them how to succeed in challenging the childbirth system.   

What background and history did these women bring, that they came to class with that simple but remarkable request; “I want to have a vaginal birth.” When I inquired further, the answers were all about the same, each a slight variation on “Every one of my friends had a cesarean section, and I saw what happened to them, and I don’t want that to happen to me.”

I was sure that these women were sounding an alpenhorn blast, a call to us who support natural physiologic birth, that we have to give the women we teach an effective and powerful defense. I was handed a very real challenge.

Throughout the life of the Lamaze International, there has always been the vital re-examination and re-articulation of what Lamaze stands for.  Might there be something else we need to do to prepare our clients for the general medicalization of birth. Do we need to do some refinement or expansion of or addition to our syllabi?  Might there be a mini- parallel to the early days of Lamaze and other birth organizations, when there was a grassroots movement of women who wanted to be “awake and aware” during birth. Will more women begin showing up to our classes determined to avoid cesarean sections? 

Inspiration for meeting this challenge from my classes resides in some of the very words on the Lamaze website describing the Healthy Birth Practices, stating that the birth practices area “supported by research studies that examine the benefits and risks of maternity care practices. Therefore, they represent ‘evidence-based care,’ which is the gold standard for maternity care worldwide. Evidence-based care means using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making.”  Keeping up with the latest best-evidence information for our clients is what childbirth educators do; we go to conferences to stay current, we spend our time and our money to make sure that we are ultra-informed.  We feel that we owe it to those we teach.

In my Science & Sensibility post in May 2011 about best-evidence care and childbirth education, I described something I was doing in classes that seemed to give mothers-to-be an extra lift to their confidence. For every facet of birth covered in class, I would hand out one or more best-evidence studies, with the important parts highlighted. No one had to read the whole thing unless they wanted to, but the conclusions were glowing in yellow for all to see and everyone understood what the doctors said as they spoke to each other through the literature.  It was clear that what the doctors were saying to each other was not always what they were saying to the women who were in my class. 

An example; we may teach that continuous fetal monitoring doesn’t change/improve outcomes for babies, but does raise the cesarean section rate.  When we share the actual ACOG practice bulletin to that effect, it just makes sense that the very words in that bulletin confer a new power on our clients. It is doctors telling doctors that continuous EFM isn’t effective and may cause harm. How many doctors tell women outright that CEFM is, at the very least, unnecessary for low risk moms? Authority is speaking and those are the voices that our clients must confront when they are laboring in the hospital.  Now mothers-to-be can know what is said behind the scenes.  They feel supported by the truths the studies tell; this first-time access to those words expands their sense of choice and control. 

Does this approach work?  I’m sure that it does but my proof is only anecdotal. I observe numerous Planned Parenthood Center clients and those in my private practice have births that unfold without interference.  They feel empowered to “request and protest” in whatever measures are appropriate. 

When the women in my class who stated they simply wanted vaginal births first announced their aim to me, I was hoping that documentation of the harms of routine intervention, liberal application of the Six Healthy Birth Practices, lots of role-play and comfort-measures practice would provide these women with the tools to confront hospital policies and routine interventions. But cesarean birth is the ultimate intervention at times. 

Happily, there is much energy devoted to the avoidance of unnecessary cesarean sections from organizations like the International Cesarean Awareness Network supporting vaginal birth and bringing powerful voices to this struggle, but it’s still a one-on-one moment for birthing women.  They will meet that moment face-to-face with a health care provider who may push them to choose a cesarean section for any number of reasons.  At the moment a doctor says “You haven’t made much progress for the last two hours, there’s no guarantee that your baby can tolerate labor much longer and I can have your baby out in 20 minutes,” the pressure can become overwhelming for any woman.

What can we give women so that at that moment they can push back against that pressure?  Is it enough to feel confident in your body? Is it enough to know the cons of unnecessary, capricious cesarean section, its dangers and possible sequelae for mother and baby that make life difficult for  both when they go home? All women are entitled to know that ACOG itself does not recommend cesarean unless it is for a medical reason. While a long labor may not be convenient, labor length is not a medical reason for performing a cesarean section. Every woman should know that long labors are not, in and of themselves dangerous. ( Cheng, 2010.) To quote Penny Simkin; “Time is an ally, not an enemy.  With time, many problems in labor progress are resolved.” (Simkin, 2011.)

But finding the ultimate tool to give women so that they may avoid this ultimate intervention is a complicated matter.  Obstetricians admit that concerns about  their own possible  jeopardy takes precedence over the real health status of the mother.  This Medscape Medical News headline proclaims “ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates”. The article about these fears was presented at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting in May 2009. The article casts the doctor as the victim: “So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” concluded Dr. Barnhart. (ACOG 2009)

It’s been widely reported that, according to a CDC finding in 2011, the cesarean section rate dropped for the first time in a dozen years, and it’s been more recently reported that the rate has stabilized; however, it has stabilized at a at a whopping 31%.  One of every three birthing women will have a cesarean surgery. (Osterman, 2013.)

Will the 2010 ACOG guidelines on VBAC have any effect on the cesarean section rate? The rate of cesareans on first-time mothers is still not declining. (Osterman, 2013.)  The effect of new guidelines will be equivocal if not minimal.  It’s guidelines for first-time mothers that has to change, because both the hardened medical atmosphere surrounding normal, physiologic labor, and the ever-accruing protocols that lead to that primary cesarean will not be subject to new guidelines anytime soon. If women who are past their 40th week of gestation, those thought to be having babies bigger than 8lbs, plus all the women who are older than 35 are now thought to be among the acceptable candidates for VBAC, how can OBs still push for primary sections for those self-same criteria on first-time mothers?   

Finding a way to inform each and every woman of the range of choices she has for her birth and supporting those choices is our ongoing mission. A hopeful sign is ACOG’s call “for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives.” (Waldman, 2011) ACOG is “recognizing the importance of options and preferences of women in their healthcare”and the recommendation by ACOG that Obstetricans actively include women in the “planning of health services to reduce risk and improve outcomes” with “shared medical decision-making” (ACOG 2011.)

Yet in the labor room, day-after-day, even the most well-informed, well-prepared, experienced and determined mother may, in the last moment, have her perineum snipped by a health care provider who states “Oh, and I gave you an episiotomy because you were starting to tear…” Or there could be the doctor who shares with a mother, “I was getting nervous about the baby getting too many red blood cells” and clamps the cord a few seconds after birth, despite the parent’s wishes for delayed cord clamping.

I cannot say that I will have an answer for the women who come in the future seeking answers on how to avoid a cesarean birth.  I believe that these women can feel more positive when they read what Dr. Richard N. Waldman, former President of ACOG), said in his August 2010 online letter to his organization:

“…The US maternal mortality ratio has doubled in the past 20 years, reversing years of progress. Increasing cesarean deliveries, obesity, increasing maternal age, and changing population demographics each contribute to the trend. In 2008, the cesarean delivery rate reached another record high—32.3% of all births. There is a community not far from my home in which 45% of the newborns are delivered via an abdominal incision. Let me be very honest. This increase in cesarean delivery rate grieves me because it seems as if we are changing the culture of birth. While it is certainly true that a physician has a contract with an individual patient, our specialty has a covenant with our society…”

As a childbirth educator, I am committed to teaching evidence based information, providing resources and support and helping women to have the best birth possible.  Won’t you join me in that goal?

References:

Cheng, Y. W., Shaffer, B. L., Bryant, A. S., & Caughey, A. B. (2010). Length of the first stage of labor and associated perinatal outcomes in nulliparous women. Obstetrics & Gynecology116(5), 1127-1135.

 Monitoring, I. F. H. R. (2009). nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. American College of Obstetricians and Gynecologists. Obstet Gynecol114, 192-202.

Osterman MJK, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996–2011. NCHS data brief, no 124. Hyattsville, MD: National Center for Health Statistics. 2013.

Partnering with patients to improve safety. Committee Opinion No. 490. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1247–9.

Simkin, P., & Ancheta, R. (2011). The labor progress handbook: early interventions to prevent and treat dystocia. John Wiley & Sons.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63.

Waldman, R. N., & Kennedy, H. P. (2011). Collaborative practice between obstetricians and midwives. Obstetrics & Gynecology118(3), 503-504.

ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , ,

Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed Consent and Refusal

November 2nd, 2012 by avatar

Today, S&S contributor Jackie Levine discusses the potential risks of routine cervical checks near term and how to help your clients and students be prepared to have a discussion with their health care provider about the necessity of such exams. – SM

There are some studies that show a link between routine weekly pelvic exams in the last month or so of pregnancy and an increase in rupture of membranes (ROM) that occur well before labor was meant begin, meaning the membranes have ruptured prematurely, (adding a P to ROM, for premature rupture).   The natural onset of labor may be a week or perhaps only days away, but everything is not quite ready, and if effective labor does not begin induction frequently follows.  And when induction fails, as often it will, since the rupture was premature, and the body and the baby are not ready, cesarean is often the outcome.

photo credit: flickr (link below)

Many women find that their health care providers may start doing pelvic exams at about 37 weeks gestation.  Women should consider asking their doctor or midwife whether these exams are necessary to insure the health and safety of herself and her baby, before providing consent for this invasive procedure.  When I discuss these near term cervical exams with my childbirth class students and look at the studies, mothers-to-be have to ask themselves whether the benefits of weekly exams outweigh the other risks; potential PROM, induction and the increased possibility of cesarean section.

“How do I tell my health care provider that I don’t want an exam, and not have those uncomfortable moments when my doctor or midwife thinks I’m defying him or her and not letting them do what they always do?”  That’s the common and sensible worry, that our students may have, but if we provide an opportunity to role-play with our students and clients and also provide the studies, they will feel confident about having this discussion. They will know the facts and are informed health consumers who could consider saying “Oh, I just don’t want that exam today, so can we do it next week?” They might also share that they’ve researched this topic, mention the studies and ask how routine exams week after week will help insure good health.

An older study examining the relationship between late term pelvic exams and the incidence of PROM stated:

 In the 174 patients on whom pelvic examinations were done weekly starting at 37 weeks gestation, the incidence of PROM was 18%,   which was a significant increase (P=.001).  The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean rate when PROM occurred was found to be twice that of the remaining population. The study suggests that routine pelvic examinations may be (sic) a significant contributing factor to the incidence of PROM. Women with uncomplicated pregnancies were randomly assigned to one of two groups. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation or sub-clinical infection to rupture membranes.“  “It would therefore seem prudent to recommend that no pelvic examinations be done routinely in the third trimester unless a valid medical indication [sic] exists to examine the cervix … especially since the information gained from these routine examinations is often of little or no benefit to either the physician or the patient.” (Lenahan, 1984.)

We have all been subtly bullied at one time or another by those in positions of authority, and it’s easy to understand the courage and confidence needed to question a caregiver. It’s a mother’s right and responsibility first to know and then to question, but confidence is the key.  We must make an effort to give real meaning to a women’s right to choose, and to the principle of informed refusal.  The American Congress of Obstetrics and Gynecology (ACOG) has addressed informed refusal several times with its membership since at least 19921, speaking powerfully  about the autonomy of the individual.  Although these writings and bulletins are aimed mainly at assuring legal protection for caregivers, they are a resounding affirmation of the legal and moral right of the patient to decide for herself.

Since the studies assert that routine exams are neither predictive nor probative, the doctor or midwife must be able to say something medically strong to counter the available studies.  When mothers have asked their providers for the reasons to do an exam, they bring a myriad of interesting answers back to class for discussion, but rarely any facts or science.  Remember, ACOG  itself published a study last year examining the basis for its care guidelines and found that “One third of the recommendations put forth by the Congress in its practice bulletins are based on good and consistent scientific evidence” ACOG, 2011) meaning Level A, and that gives us pause to consider the 70% of practices represented by Levels B and C . Care providers will often reconsider when an informed mother-to-be can ask politely and tactfully, about the science that recommends a weekly routine cervical assessment.

Again, women should be able to weigh the risks of routine exams against the possibility of that cascade of interventions that follow on with PROM, interventions that will, at the least, lead to an uncomfortable and harder-to-manage induction, and at worst, put our students and clients on that gurney ride into the operating room.

When a mother is motivated to discuss routine pelvic exams with her caregiver, it may be the first test of the mutual trust and respect she hopes for in that relationship.  Until that point in her pregnancy, she may not have had the opportunity, or the necessity to assert her rights as a maternity patient.  She may have refused to have a routine sonogram or two because her insurance policy would not cover extra routine assessments, but refusing pelvic exams unless there is a valid medical reason will tell her how little or much her HCP is willing to act on best evidence, give her individuated care and show respect for her informed refusal.

The first time she refuses the exam may not be an accurate opportunity for her to judge; many caregivers will let refusal ride that once, but as pregnancy nears term, most docs begin to be insistent about cervical assessment, even without medical indication. A mother-to-be can begin to learn her caregiver’s view of best-evidence care and his or her willingness to listen to her so that she will have an idea, going forward, of how best to assert her rights, with knowledge and confidence in herself, and can get support she may need in our classes.

In a Science & Sensibility post in May 2011, I talked about the importance of giving mothers the same studies that caregivers have access to.  What I said then about giving our classes the actual studies, along with discussion, still applies:

“…perhaps we need to give women a different kind of “evidence”, by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas….Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice. “  

Refusing to have routine pelvic exams in those last weeks of pregnancy is a real opportunity for our students and clients to learn how to ask for, even insist on, best-evidence care for themselves and their babies.  It’s certainly worth a try, and we can support them in the last weeks in a positive way with lots of opportunity for role-play and discussion as they report back to class and share their experiences with informed refusal.

How do you bring up the topic of regular cervical exams for women who are not in labor?  Do you talk about this with your clients and students?  What are your favorite resources for presenting this and facilitating discussions?  Have your students shared stories about their experiences.?  Are you a health care provider?  What are your feelings on routine pelvic exams at the end of pregnancy?  Share your thoughts in our comment section. – SM

References:

ACOG: Ethical dimensions of informed consent: a compendium of selected publications, ACOG Committee Opinion 108. Washington DC, 1992.

ACOG Committee opinion. Informed refusal. Number 166, December 1995. Committee on Professional Liability. American College of Obstetricians and Gynecologists. et al. Int J Gynaecol Obstet. (1996).

ACOG Committee Opinion No. 306. Informed refusal. ACOG Committee on Professional Liability, Obstet Gynecol. 2004 Dec;104(6):1465-6.

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Levine, J. (May 31, 2011) A Lamaze Story. Retrieved from http://www.scienceandsensibility.org/?p=2954

Vayssière, C. Contre le toucher vaginal systématique en obstétrique Gynécologie Obstétrique & Fertilité, 2005, Volume 33, Issue 1, Pages 69-74.

Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ, Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins, Obstet Gynecol. 2011 Sep;118(3):505-12.

photo credit: www.flickr.com/photos/nathansnostalgia/498100786/

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , , , , ,

The New World of the Newborn – Part Two

December 15th, 2011 by avatar

[Editor's note: This is Part Two of Jackie Levine's essay on The New World of the Newborn in which she explores the frequent dichotomy between up-to-date evidence and common obstetrical practice.  To read Part One of this post, go here.]

 

In the third class of each of my Lamaze education series, I start to disseminate studies about what happens during the first moments in the life of the new baby and the new mother. One of the articles I give out is a copy of a blog post I read in 2009: Dr. Nick Fogelson’s essay on his blog site, the Academic OBGYN. It gives the mothers in my classes a real hard look at obstetric philosophy, politics and practice.  It helps them to have a really good look at what docs say to each other and rarely to their patients, and supports parents’ abilities to make informed decisions about acceptance or refusal of care…to demand best-evidence practices for themselves and their babies.

I had really mixed feelings about the article.  Fogelson exhorts his colleagues to change the practice of immediate cord clamping and presents a wealth of evidence, yet stays away from a real condemnation of the current practice with language that has a veiled politeness, but he declares that he’s doing due diligence by “blogging” about it.  The title of his blog post is “Delayed Cord Clamping Should Be Standard Practice in Obstetrics.”  That seems really unequivocal to me…a title that calls out for a total change of the current practice of immediate clamping and cutting of the umbilical cord.  In my last post on this subject, I quoted extensively from his article and some of his words are chilling.  To recap just two items from his post: “We ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut ‘em off,”  and,  “I wonder at times why delayed cord clamping has not become standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors but midwives and sometimes we are influenced by prejudice.”  (My emphases.)

Nowhere in Dr. Fogelson’s post does he say, “Let’s stop now!  All of us!  Stop now!  Let’s stop harming babies, let’s change the textbooks, let’s put out new practice bulletins immediately!” In his defense, since the writing of that blog post, Dr. Fogelson has delivered a couple of Grand Rounds lectures on the subject, and he continues to be an advocate for DCC, (delayed cord clamping) but his original words seem to make obeisance to the establishment, to ask politely for them to heed best-evidence care.

Dr. G.M. Morley, a Fellow of the American College of Obstetrics and Gynecology says on his website:

 

The normal healthy newborn with millions of years of experience in its genetic code, clamps its own cord, usually between two to four minutes of birth. After natural closure, the doctor’s cord clamp may be safely applied.”
(morley@cordclamping.com)

 

This advice, when followed, surely cannot harm any doc if he/she heeds it, but can help many newborns.

In an article posted in 2010 by Expert Reviews Ltd., on changing practices in episiotomy, the authors ask in bold subhead: Why Don’t Physicians Follow Clinical Practice Guidelines?1 They answer: The challenges of obtaining high-quality data to direct evidence-based care have been greater in obstetrics than in many other medical disciplines” and “since obstetrics generally has lagged behind other disciplines in its efforts to have standardized, outcomes-based practices, there may be greater cultural barriers among obstetricians to changing practices based on new data.”

More from the same study:

 

In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice. Concerning comments from this survey included, ‘obstetrics requires manual dexterity more than science’…’evidence-based medicine ignores clinical experience,’ and that following guidelines could result in ‘erosion of physician autonomy.’”

These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education. The following year, Cabana and colleagues published a review of reasons that physicians fail to change their practices in the face of new evidence or published clinical guidelines. They found multiple types of barriers to practice change, including lack of awareness or familiarity with current recommendations, lack of agreement with the recommendations, lack of self-efficacy to make practice changes, inertia and external barriers to practice change. Of those physicians who did not agree with the practice recommendations, a variety of reasons were cited. Some physicians felt the evidence did not support the guidelines, some felt the recommendations were like a ‘cookbook’ or reduced physician autonomy, or did not apply to their patient population. Finally, some physicians had a ‘lack of outcome expectancy,’ or did not believe that making the recommended practice changes would improve clinical outcomes.”

These reasons are not acceptable, they smack of nonsense, and yet they guide practice. It makes me ask, when I read the words that evidence-based practice is not “very applicable to obstetric practice,” why is practicing good medicine on a birthing mother different from practicing good medicine on anyone else? And why will using good science “erode physician autonomy”?

John Maynard Keynes famously said “When the facts change, I change my mind. What do you do (sir)?”  What should docs do?  Seems simple, doesn’t it?  Change practices to reflect best evidence.  Do it now. No mother will object, I’m certain.  But no one yet has offered an effective way to change these attitudes or overcome the barriers that negate best-evidence care

A study that came out this year entitled, “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins”2 the conclusion of which was stated in its abstract, proudly announced:  “One third of the recommendations put forth by the College in its practice bulletins are based on good and consistent scientific evidence.” How about the other 70%?  I cannot imagine another medical discipline that would succeed when only a third of its practices were evidence-based.

The fastest part of birth should probably be slowed considerably.  Out comes baby, whoosh, and a mad rush of procedures begin. These first moments are when the fetus becomes a baby, and a huge amount of respect should be paid to the process by which the newborn acclimates to life outside the womb. The immediate, routine, aggressive suctioning of the newborn would likely disturb and irritate the sensitive tissues of even the adult nose and mouth. We have all seen the distressing images of the relentless blue bulb attacks on those delicate newborn passages. How can we imagine what the newborn perceives the world to be like if those actions are the first he experiences? In a World Health Organization Handbook3 written for health care providers, the section entitled Care of the Newborn at Birth says: 

 

Most babies do not need any resuscitation at birth. Mouth suction, face mask oxygen, and vigorous stimulation in order to provoke a first gasp or cry are all pointless rituals that lack any clinical justification.

“Even in a baby born covered in meconium there is no evidence that carefully cleaning of the nose and mouth reduces the risk of meconium being drawn down into the lung.”

In at least one hospital in Vancouver BC, the latest neonatal resuscitation program has been updated to reflect a resuscitation  manual which recommends that babies are not routinely suctioned at delivery.  As a result of their changes in procedure, they no longer have suction available to the obstetrician at the foot of the bed and on the rescusitaire.  As always, practices differ from place-to-place and we can only hope for this best-evidence care to spread like a blessing from birth venue to birth venue.

The practice of an immediate bath in the nursery is also anathema to the newborn’s efforts to adjust and stabilize itself in the first hours of life.  The bath, given far away from the mother’s warm body, can be harmful and dangerous, and is usually for the convenience of the nursery staff. The WHO talks about preventing heat loss with this caveat:

 “Babies very easily get cold immediately after birth, and using water or oil to clean the skin within four hours of birth before body temperature has stabilised can make the baby dangerously hypothermic (a problem that may well be missed if a low reading thermometer is not used). Nothing is a more effective source of warmth than the mother’s own body as long as the baby is first gently dried to minimize evaporative heat loss and mother and baby are then both protected from draught.”4

There’s a fine video out there about thermal protection of the newborn that should be shown to every caregiver of the motherbaby.

I must reiterate: the studies on delayed cord clamping (DCC) are unequivocal; they all say that it is best for the baby, and that it causes no harm, but that immediate clamping is harmful.  Penny Simkin has also done a wonderful video illustrating the reasons for DCC that every educator, doula and mother-to-be should see. Mothers must be aware that their babies need the stores of iron, the stem cells, the hormones, the sheer volume of the blood pulsing out of the placenta.

Mothers-to-be should be strongly encouraged to discuss procedures on their newborns at the moment of birth with their caregivers from the position of informed consent/ refusal.  We must encourage them to ask about the benefits and harms accruing to those procedures and demand that their newborns be treated with best-evidence care, and if they know what that care should be, they will be better able to demand it for their newborns.  I remember writing about a study in which ACOG recommended “partnering with patients to improve safety.”5 In my experience, most parents-to-be will gladly welcome information  that invites them to share in the responsibility for the safety of their babies by demanding best-evidence care from their health care providers.

Posted by:  Jackie Levine, LCCE, FACCE, CD(DONA) CLC

References:

1-Changes in Episiotomy Practice: Evidence-based Medicine in Action, Justin R Lappen; Dana R Gossett Posted: 05/12/2010; Expert Rev of Obstet Gynecol. 2010;5(3):301-309. © 2010 Expert Reviews Ltd.

2Obstetrics & Gynecology: September 2011 – Volume 118 – Issue 3 – p 505–512 doi: 10.1097/AOG.0b013e3182267f4373- Integrated Management of Pregnancy and Childbirth. Managing Newborn Problems: a guide for doctors nurses and midwives. WHO 2003 ISBN 92 4 154622 0 ESS-EMCH SECTION 11 Neonatal Emergencies Last updated 27/4/2009 215

4 Ib id

5-ACOG Recommends Partnering With Patients to Improve Safety, Obstet Gynecol. 2011;117:1247-1249

 

 

 

 

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The New World of the Newborn – Part One

December 13th, 2011 by avatar

[Editor's Note:  This is Part One of Jackie Levine's essay on the New World of the Newborn in which she discusses the third and fourth stages of birth.  Stay tuned for Part Two.]

 

The fetus makes an amazing change from life as the denizen of a water-world to life as an air-breathing baby who must adjust quickly to her new environment.  Do the routine procedures prevalent in hospital birth properly support the efforts of the newborn to adjust to its new life outside?

In our “industry,” which encompasses the many facets of normal birth advocacy and childbirth education, we generally spend our time promoting best-evidence maternity care, always hoping to improve outcomes for “motherbaby”…that fine word-meld that CIMS has started us all using.  We tackle the every-day realities of the problems for birthing women and their babies from a thousand angles, with the energy of a hundred suns, from within a myriad of organizations or flying solo.  And, as this year gathers towards a close many of us are talking about another  aspect of the unproven practices that at worst can cause harm, or at best are useless and costly, the current and longstanding practices in the third and fourth stages of labor.

Textbook definitions of the 3rd stage refer to the time immediately after the birth, to when the placenta is delivered, and the 4th stage refers to the stabilization of the mother’s body and the beginning of its return to the pre-pregnant state.

Sometimes, in a field of inquiry, several people will be working independently on the selfsame premise or problem, unaware that others are concurrently pursuing the same issues.  There are times when ideas are out there in the air for many to breathe; ideas that have naturally evolved, and are synthesized from the fertile field of the discipline; ideas that bubble up from all the work and thinking that has gone before, or from compelling current circumstances.

That duplication of independent thinking used to happen every few years during the time I spent in the apparel industry in New York, working as a designer and artist.  All of a sudden a new technique or “treatment” would appear at the same time in several places around the industry.  One year, several unconnected apparel companies showed garments sewn with the seam stitching showing on the outside of the garment. Until then, seams were normally sewn on the inside, the private side. The use of this public-side stitching gave the garment a totally new look. This embellishment is now common and arose because of  a moment of confluence  in the possibilities that already existed.   It happens often: the accumulation of experience, tools and techniques leads to the synthesis of new things, and we can expect that more than one human brain responds.  And this is what seems to be happening where the third and fourth stages of labor are concerned.  There was no huge meeting where we all, in our many thousands and in the many areas where we concern ourselves with optimal maternity care, agreed that this was the subject we now wanted to study and address; there’s just an organic, growing push to try to influence immediate post-birth care, and to support evidence-based, humane treatment of motherbaby.

The medicalization of birth in this country led to the separation of mothers and babies from the moment of birth, and to a rash of procedures on the newborn that lacked scientific justification. And then came the march of studies debunking the safety and/or efficacy of those procedures, demonstrating just how urgently babies need their mothers and mothers their babies.  As I pointed out in my June post on the 6th Healthy Care Practice, evidence has been accumulating for at least 30 years, showing the benefits of keeping mother and babe together, evidence documenting the stark harms of immediate cord-clamping, routine aggressive suctioning,  and the  isolation of tightly swaddled  babies far from their mothers in a nursery.  This past July, at the annual DONA conference in Boston, in a stirring lecture on 3rd and 4th stages of birth, Penny Simkin said “If we’re here for a revolution this is where it’s at folks. There are more things wrong with the management of third and fourth stage…”  Penny has made a wonderful and monumentally important video illustrating the need for delayed cord clamping.  I also referred to the new videos-cum-research of Brimdyr, Svensson and Widstrom1 on the first hour after birth in that same post, to find later that it was to be a subject of discussion at the Lamaze conference in September. Yes, it’s all in the air.

I am afraid however, that many OBs and neonatologists are not responding to the evidence, and are betraying mothers and their newborns by again neglecting best-evidence care.  As Penny Simkin said in her lecture at the most recent DONA conference, “I am troubled.” “I want a revolution right now.”  So it’s not for lack of evidence or lack of effort in our studying, as we keep abreast of the literature or for any lack of enthusiasm in our teaching.  We are grateful for the best-evidence care that many docs give and the life-saving procedures available to the newborn. But it’s the confounding fact that is disturbing and disquieting; the question to which we all want an answer. Why will many OBs not change practices that are provably harmful?

I admit to being fascinated by this question. I come back again and again, shaking my head, looking for yet another study that may hold the reasons.

I got a fleeting look at a partial answer when I came across a blog post by Nick Fogelson, MD. It allows a rare look at attitudes and politics that shape practice.  It was written in 2009 to his professional colleagues about delayed cord clamping.  There had already been a multitude of studies on the subject (and many more since).  The title of his post?  “Delayed Cord Clamping Should Be Standard Practice in Obstetrics.” There are mighty powerful words in that title, but I’m going to quote some equally powerful ones at random from the body of his post in no particular order, but his words can be chilling.

 

After some research I found that there is some pretty compelling evidence that indeed, early clamping is harmful for the baby.”… “We ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut ‘em off.”… “This evidence is compelling enough that I feel like a real effort should be made in this regard.  So to do my part in this, I am blogging about it.”… “If the burden of proof is on us to prove that immediate clamping is good, that burden is clearly not met.” …“I wonder at times why delayed cord clamping has not become standard already; why by and large we have not heeded the literature.  It is sad to say that I believe it is because the champions of this practice have not been doctors but midwives and sometimes we are influenced by prejudice.”… “We champion evidence-based medicine, but tend to ignore evidence when it comes from the wrong source which is unfair.” “…midwives have done the world a favor by scientifically addressing this issue and their data deserves serious consideration.”…“In the end, the data is the data.”

(emphases, mine).
All these quotes just serve to point out the real necessity that every mother-to-be must be informed  about delayed cord clamping,  and that she will have to be vigilant about demanding it as best-evidence care for her newborn.

 

[Editor’s note:  For another recent appearance of this topic in the lay media, check out this article published in the New York Times.  In Part Two (available Thursday, 12/15/11), Jackie explores research that attempts to explain where and why the discrepancy lies between best evidence and the actual practice of maternity care--especially as it pertains to the third and fourth stages of birth. ]

 

 

Posted by:  Jackie Levine, LCCE, FACCE, CD(DONA), CLC

 

References

1-the Magical Hour: Holding Your Baby for the first Hour After Birth. DVD produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom. www.healthychildren.cc

 

Evidence Based Medicine, Third Stage , , ,

Sex and Pregnancy: Teaching our Students …What’s Important to Know

August 11th, 2011 by avatar

Childbirth educators should be able to discuss sex during pregnancy and sex in the postpartum period with sensitive, evidence-based counseling, so that women need not rely on anecdotal information, old-wives tales or unreliable sources.

The following quote stands as introduction to the chapter on “Sexuality in the Prenatal Period” in Childbirth Education: Practice, Research and Theory:

Childbirth educators, in their evolving role to meet the needs of twenty-first century prenatal couples, must perceive themselves as more than educators.  They must judiciously add counseling skills to their repertoire of classroom strategies.”1

 

They should “approach pregnancy as a time of  heightened feelings in which physical contact and affectionate behaviors are particularly important for the pregnant  couple”2,  teaching from a strong “knowledge base”3  but those recommendations may be difficult to implement  when discussing  sex during  and  after pregnancy.  Clinicians have reported that sexuality is a difficult subject to discuss and some even question the appropriateness of any discussion of sex with their clients4.  Therefore, guidance, advice and the counseling of pregnant women by childbirth educators about sex is bound to be a tricky task.

I’ve brought up this aspect of our teaching with several CB educators, and have heard the opinion that discussing sex during pregnancy should not be in our purview, that it did seem integral to touch briefly on sex and contraception after birth, but in the main, they felt that the subject of sex was of small importance in our teaching, what with all the other information for which we are responsible.  The Official Lamaze Guide  devotes a mere half-page to information  about sex during pregnancy and only a short paragraph more  about postpartum sex.  In the 2010 edition of the Debby Amis and Jeanne Green Prepared Childbirth, the Family Way, there are two sentences about having sex before birth, confined to a chart on the progression of a pregnancy, and a few sentences about sex postpartum; both books give virtually no importance to the subject.

For those of us who do allocate class time for this subject, there is some very good advice and counsel in Midwifery: Community-Based Care during the Childbirth Year.  Most of us will find the advice properly helpful, sensitive and conservative: obtain permission to discuss the subject, offer concise, simple and basic facts when introducing the subject, make specific suggestions, illustrate with good visuals, and invite women to share experiences with a question like,

 

Some women have told me that their sex life changes a lot when they are pregnant…what has it been like for you?”

 

The text also recommends that clinicians, and I suggest, childbirth educators, become knowledgeable about lesbian pregnancy-and-parenting as well.   While there seems to be little research specific to lesbian pregnancy and that family dynamic, it is a contemporary issue, and I submit that it deserves further thought and discussion as we pursue parity and equity for women. This forum might indeed be a good place to start the conversation.

A woman’s feelings about sex may, of course, change during pregnancy for a multitude of reasons, some physical, some emotional and some spiritual. Her partner’s feelings are subject to change as well, even though sexual intercourse during pregnancy is generally fine for healthy women with healthy pregnancies and will not harm the baby.  Nonetheless, women/couples may experience changes in physical and emotional comfort and desire as the pregnancy progresses.

As for the bare physiological facts surrounding sex during pregnancy, there is general consensus in the medical profession about what sexual behaviors are safe and which ones may be harmful, with agreement to be found across the range of medical organizations and prestigious journals.   As example of the continuing and prevailing view, there is a “new, evidence-based primer to assist physicians in counseling patients regarding sexual activity during pregnancy.”  It was published online, on January 31, 2011 in the Canadian Medical Association Journal.6 The primer joins all the other expert opinions that have been telling women essentially the same thing for the last twenty years… that sex during pregnancy is safe in most instances. However, intercourse should be avoided where the following apply: history of miscarriage, history of preterm labor/birth, unexplained vaginal bleeding or discharge of fluids, low-lying placenta or placenta previa, incompetent or dilated cervix, and multiples in utero. Women should avoid having sex when a partner has a sexually transmissible infection in all circumstances. Oral sex is ok as long as a partner does not blow air into the vagina because of the risk of air embolism.

The conventional opinions, ranging from that in the pregnancy book published by the Mayo clinic, to the “cool” website AskMen.com, are all in accord about the facts of sex during pregnancy, mixing what the aforementioned childbirth education text calls  “the unmixable”…  that of mother and lover7.  The AskMen site says with good humor,  “Luckily you can have lots and lots of sex as long as she’s game and doesn’t have any special medical complications.”8

Most women don’t really think in advance about the first couple of months after the birth of their babies with any awareness of the huge physical and emotional changes that birth brings.  There will be new physical stressors like the genuine exhaustion that comes from being the 24/7 caregiver of a newborn, and other demands of parenthood.  This is where childbirth educators may give some anticipatory guidance with a discussion of postpartum contraception, information about the behavior of the newborn in the first weeks after birth, and extend the invitation to discuss facts about resuming sex.  It is common for most women to be told by their caregivers that they can resume having sex about six weeks after the birth, depending of course, on whether their bodies have healed and whether they want do so. The six-week time line usually coincides with a woman’s first postpartum check-up after a vaginal birth, so she can base her decision about resuming sex at least in part on a physical evaluation.  This time-frame may be too stringent for the woman who has had an uneventful birth, with little or no trauma to her birthing body, and the one-size-fits-all prescription to wait six weeks can be set aside; she should be encouraged to resume having sex whenever she feels ready.  Ideally, we hope that a woman will be able to make decisions about her intimate relationship during and after her pregnancy with a loving partner, based on accurate and supportive information.

As promoters and supporters of breastfeeding, Lamaze educators must make themselves knowledgeable about contraceptive methods that don’t have a negative impact on breastfeeding.  The natural infertility conferred by lactation can be very brief, between three and six months or less, and depends upon total and exclusive breastfeeding with nursing frequency at least six times in 24 hours. Depending solely on exclusive breastfeeding for contraception is known as LAM, the Lactation Menorrhea Method. To be sure to prevent unwanted pregnancy, contraception should commence when women resume having sex. The hierarchy of contraceptive methods for nursing mothers begins with barrier methods as first choice…condoms, diaphragms (for which women need to be refitted after the birth of their babies), and spermicides and other non-hormonal methods.  Hormonal contraceptives should be progestin-only, but are considered to be a second choice. We hope that women will get evidence-based advice from their caregivers about contraception, but  we should, nonetheless, be prepared to discuss the topic. As in every other phase of women’s’ reproductive lives, informed choice based on accurate information is the ideal.

Posted by: Jackie Levine, LCCE, FACCE, CD(DONA), CLC

 

References:

1-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p49, 2nd edition, WB Saunders, 2000

2-Ibid p.64

3-Ibid p.62

4-Warner PH, Rowe T, Whipple B: Shedding light on the sexual history, American Journal of Nursing 99(6):34-40, 1999.       

5-Midwifery: Community-Based Care during the Childbirth Year, Linda V Walsh, p180 WB Saunders Company, 2001.

6- http://www.medscape.org/viewarticle/736791

7-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p62 2nd edition, WB Saunders, 2000

8-www.askmen.com/dating/love_tip_250/259b_love_tip.html

 

Science & Sensibility, Uncategorized , , , , ,