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Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 1

June 3rd, 2014 by avatar

Childhood sexual abuse can play a key role as a risk factor for postpartum depression.  Kathy Morelli takes a look at the impact of this horrible childhood event on a woman during her childbearing year.  Today, in Part 1 – we learn how the brain actually undergoes changes as a result of the trauma experienced.  On Thursday, Kathy Morelli will discuss how the woman who has experienced childhood sexual abuse (CSA) and what affect that has on her during the childbearing year,(pregnancy, birth and postpartum)  along with information and tips  for what childbirth educators can do.  Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression – Part 2. – Sharon Muza, Community Manager, Science & Sensibility.

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

© CC Michelle Brea: http://flickr.com/photos/itsallaboutmich/451493421

Woman to Woman Support

As I’ve said in my previous articles about Perinatal Mental Health, Lamaze childbirth professionals are very often the first point of contact for pregnant and new mothers. You’re an important resource in your community about pregnancy and childbirth, so becoming educated about the signs of perinatal mood/anxiety disorders and having an awareness about the prevalence of childhood sexual abuse (12% -20% of women) is an important aspect of your knowledge base. This article is meant to:

  • Increase awareness about the emotional aspects of surviving childhood sexual abuse (CSA)
  • Present a broad overview about the research regarding CSA
  • Present how CSA impacts a woman holistically, over her lifespan
  • Present how CSA impacts a woman specifically during childbearing
  • Discuss the complex recovery process from CSA
  • Generate ideas about whom to add to your community resource and referral list
  • Encourage being effective and supportive while preserving your own personal, certification and/or licensure boundaries

Remember, you may be the first person with whom she feels safe enough to discuss her personal history, even before her healthcare provider and sometimes even before her family. You can help out by being positively aware, being appropriately supportive and providing a list of contacts in the community and online.

Holistic View of a Woman’s Emotional History

Whenever a woman comes into my office for help for feelings of emotional and somatic distress during her pregnancy, childbirth experience and postpartum, I look at her life holistically, across her lifespan. I don’t assume, but I wonder, if she might be in that estimated 12% – 20% of women who have been sexually abused in their lifetime.

Is there a likelihood that past abuse affects how a woman feels about herself during pregnancy and childbirth and can be an underlying causative factor for antenatal depression or anxiety?

The research literature about the link between a woman’s past childhood sexual abuse and distress during pregnancy is scarce, but emergent research does show a connection.

How does a history of childhood sexual abuse (CSA) intersect with postpartum depression? This is a complicated question, but I’ll try to list some influential factors.

The HPA Axis is Modified: Fear and panic of CSA alters internal stress response

In general, research shows us that people who suffered from childhood sexual abuse (CSA) have a higher incidence of emotional, psychological and social distress, in addition to post-traumatic and physical, or somatic, symptoms. Specifically, research shows us that adult survivors of CSA suffer from higher rates of diabetes and cardiovascular symptoms (Plaza et al, 2010).

Women who have suffered past childhood sexual abuse suffer more unexplained gynecological symptoms, such as recurrent pelvic pain and more painful periods and sexual dysfunction than women who don’t have a traumatic sexual history (Lev-Weisel, Daphna- Tekoah, and Hallak, 2009). The stress and fear from childhood abuse manifests later on in adult life on all levels: body, mind and spirit.

What are some of the physical processes underlying this distress on the body and mind levels?

Researchers believe that long-term negative emotions, such as fear, panic and pain, cause an over-activation of the neural pathways in the brain associated with these strong emotions. The internal production of neurotransmitters, which affect mood, is affected. So chronic emotional stress impacts brain health.

The brain communicates with the pituitary and adrenal glands via the feedback loop called the Hypothalamus-Pituitary-Adrenal Cortex Axis (HPA Axis). The pituitary and adrenal glands are responsible for hormone production, which, in turn, affects the brain and our emotional state (Plaza et al, 2010).

During long-term childhood sexual abuse, the HPA Axis is continually activated and, with overactivation, the stress response becomes chronic, persisting throughout a lifetime. Thus, the chronic over-activation of the fear and pain response underlies anxiety disorders and chronic pain syndromes across the lifespan (Plaza et al, 2010).

During pregnancy and postpartum, hormonal changes are very dramatic, so there’s an additional adjustment for the mind and body to cope with. Thus, the hormonal changes during pregnancy also impact brain health via the pituitary and adrenal glands feedback loop.

Brain Development is Modified: Fear and panic of CSA can inhibit encoding of memories

Research shows that chronic fear and stress in childhood can actually inhibit the growth of some brain structures. In fact, some parts of the brain, such as the hippocampus, which is in charge of memory, are smaller in CSA survivors than people who were not abused in childhood. So, recollection of childhood memories is impaired.

In addition, brain imaging shows brain development is hindered in that there are less robust connections between the emotional part of the brain and the upper part of the brain (Plaza et al, 2010).

How do these underlying biological changes affect a person’s emotional health?

Survivors of childhood sexual abuse survivors are known to suffer from post-traumatic stress disorder, which has a constellation of symptoms on many levels: depression, anxiety, panic attacks, somatic pain, flashbacks and dissociative episodes.

Events that occured long ago in a woman’s life can still play a large role in her mental and physical health when she is pregnant, birthing and in the postpartum period. Join us on Thursday for Childhood Sexual Abuse as a Risk Factor for Postpartum Depression- Part 2: The Childbirth Educator’s Role.- SM

References

Beck, C. Driscoll, J., and S. Watson (2013). Traumatic childbirth. New York: Routledge Press.

Lev-Weisel, R., Daphna- Tekoah, S., Hallak, M. (2009). Childhood sexual abuse as a predictor of birth-related posttraumatic stress and postpartum posttraumatic stress. Child Abuse and Neglect, 33, 877-887.
Perez-Fuentes, G., Olfson, M., Villegas, L., Morcillo, C., Wang, S. & Blanco, C., (2013). Prevalence and correlates of child sexual abuse: a national study. Comprehensive Psychiatry, 5(1), 16-27. http://www.ncbi.nlm.nih.gov/pubmed/22854279

Plaza, A., Garcia-Estave, L., Ascaso, C., Navarro, P, et al. (2010). Childhood sex-ual abuse and hypothalamus-pituitary-thyroid axis in postpartum major depression. Journal of Affective Disorders, 122, 159-163.

Sichel, D. & Driscoll, J. (2000).Women’s Moods. New York: Harper Paperbacka.

Yampolsky, L., Lev-Wiesel, R., & Ben-Zion, I. Z. (2010). Child sexual abuse: is it a risk factor for pregnancy?. Journal of Advanced Nursing, 66(9), 2025-2037. doi:10.1111/j.1365-2648.2010.05387.x

Childbirth Education, Depression, Guest Posts, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Uncategorized , , , , , , ,

CDC & ACOG Convene Meeting on Maternal Mortality & Maternal Safety in Chicago

May 23rd, 2014 by avatar
creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

creative commons licensed (BY-NC-SA) flickr photo by Insight Imaging: John A Ryan Photography: http://flickr.com/photos/insightimaging/3709268648

Earlier this week, I shared information on the Safety Action Series kickoff that all were invited to participate in, by the National Partnership for Maternal Safety – focused on reducing the maternal mortality ratio and morbidity ratio for mothers birthing in the U.S.  This partnership is part of the Council on Patient Safety in Women’s Health Care.  Last month Christine Morton, PhD and Robin Weiss, MPH attended a meeting as board members of Lamaze International.  Christine shares meeting notes and topics that were discussed and what maternity professionals, including childbirth educators,  can do to help. – Sharon Muza, Science & Sensibility Community Manager.

Disclosure:  Christine is a member of the Patient/Family Support Workgroup of the National Partnership for Maternal Safety, and a current board member of Lamaze International. 

Since 1986, the American College of Obstetricians and Gynecologists (ACOG) and the Centers for Disease Control and Prevention (CDC) convened interested persons in public health, obstetrics and maternity care to discuss and share information about maternal mortality, including methodologies for pregnancy mortality surveillance at state and national levels, and opportunities to reduce preventable maternal deaths.   Recently, under leadership of Dr. Elliott Main, medical director of California Maternal Quality Care Collaborative (CMQCC), and drawing from the recent experience of California in maternal quality improvement and work by other organizations and collaboratives, the focus of the interest group has shifted from surveillance to quality improvement.  The meeting has evolved from the early years when 12-20 persons sat around tables to discuss the issue, to this year’s meeting which had over 180 persons registered.  Clearly the time has come for a coalition around improving maternity outcomes in the U.S.

The National Partnership for Maternal Safety was proposed in 2013 in New Orleans, and the goal of the April 27, 2014 meeting in Chicago was to formally launch the initiative and report on the progress of each work group. The goal of the National Partnership for Maternal Safety is for every birthing facility in the United States to have the three designated core Patient Safety Bundles (Hemorrhage; Venous Thromboembolus Prevention; and Preeclampsia) implemented within their facility within three years. The bundles will be rolled out consecutively, beginning with obstetric hemorrhage and advancing to the other areas. To support this national effort, publications are underway in peer-reviewed journals. The first article, as an editorial call to action, appears in the October 2013 issue of Obstetrics & Gynecology, the official publication of the American College of Obstetricians and Gynecologists.

Highlights from this year’s meeting included two presentations from CDC researchers William Callaghan, MD, MPH and Andreea Creanga, MD, PhD, on work being done to better identify cases of severe maternal morbidity (SMM) and drivers of racial/ethnic disparities.  One of the goals of creating a working definition of SMM is to help facilities track and review cases in order to identify systems issues and address them through quality improvement efforts.

Next, representatives from selected work groups (Hemorrhage; Venous Thromboembolus Prevention; Patient/Family Support) shared their updates.    It has become very clear from ongoing work within large hospital systems, state-based quality collaboratives and other countries such as the UK, that standardized protocols for recognition and response to preventable causes of mortality and morbidity are effective.  Unfortunately, there is no national requirement for all birthing facilities (hospitals and birth centers) to have updated policies and protocols on these preventable causes of maternal complications.

The good news is that there is a groundswell of support for a coordinated effort to realize the goals of the Initiative.  From state quality collaboratives in California, New York, Ohio and Florida to Hospital Engagement Networks, there are many hospitals already implementing some maternal quality improvement toolkits.  The Joint Commission plays a key role in helping hospitals work on patient safety issues and identified maternal mortality as a sentinel event in 2010 and is now proposing that any intrapartum (related to the birth process) maternal death or severe maternal morbidity should be reviewed.  As the nation’s largest accreditation body for hospitals, the Joint Commission is in a position to provide oversight as well as guidance to hospitals as they develop system-level reviews of these outcomes.

More states are being supported by federal and nonprofit agencies to develop and conduct maternal mortality reviews, and the role of Title V, the only federal program that focuses solely on improving the health of mothers and children, is critical.  Title V is administered by each state to support programs enhancing the well being of mothers and their children.

The last topics of the day were how to address the most common cause of maternal mortality – cardiovascular disease in pregnancy – but not as preventable as the three causes featured in the Initiative.

Suggested topics for future meetings including looking at maternal mortalities due to suicide, helping states with small populations aggregate their data, and addressing the issue of prescription (and other) drug abuse among pregnant women.  Eleni Tsigas from the Preeclampsia Foundation stressed the importance of including women’s perspectives and the emotional, social and ongoing physical sequelae of living after a severely complicated childbirth experience.

How is this information relevant for childbirth educators, doulas and other maternity professionals?  First, the rising rates of maternal mortality and morbidity are in the news.  While deaths are rare, severe complications are more common.  CBEs and doulas can reassure pregnant women in their classes that the likelihood of a severe morbidity is low, and can provide resources to share with women and help them learn which hospitals in their communities have begun the work of maternal quality improvement.  CBEs can share this information with key nursing and medical leaders at hospitals where they teach, and offer to help with the Quality Improvment (QI) efforts.

Childbirth educators and others can help ensure the focus not become too one sided – while it is important for every hospital to be ready for typical obstetric emergencies, it is also important for every hospital to be prepared to support women through normal physiologic birth by trained staff and supportive physicians. AWHONN launched its campaign, “Go the full 40” in January 2012 to help everyone remember that while we don’t want to ELECTIVELY deliver babies prior to 39 completed weeks gestation, we also want to support labor starting on its own.  And most recently, ACNM unveiled its BirthTOOLs site, which includes resources, tools and improvement stories on supporting physiologic, vaginal births.  CBEs and doulas can be strong advocates in supporting facility and maternity clinician preparedness for the ‘worst case’ and ‘best case’ scenarios in childbirth.

For more info about National Partnership for Maternal Safety or the CDC/ACOG Maternal Mortality Interest Group, please contact:  Jeanne Mahoney, jmahoney@acog.org

Past and future webinars about the initiative are available to the public here: http://www.safehealthcareforeverywoman.org/safety-action-series.html

Archived presentations from past CDC/ACOG maternal mortality interest group meetings

2014:  http://bit.ly/1sXkaGw

2012: http://bit.ly/1pfay9S

 

Childbirth Education, Guest Posts, Lamaze International, Maternal Mortality, Maternal Mortality Rate, Maternal Quality Improvement, Pregnancy Complications, Uncategorized , , , , ,

Evidence Supports Celebrating the Doula! Happy International Doula Month!

May 15th, 2014 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

May is International Doula Month and I am delighted to recognize and celebrate this important member of the birth team today on Science & Sensibility.  A birth doula is a trained person (both men and women can be and are doulas) who supports a birthing person and their family during labor and birth with information, physical and emotional support and assistance in women finding their voice and making choices for their maternity care. A postpartum doula is a trained professional who supports the family during the “fourth trimester” with emotional support, breastfeeding assistance, newborn care and information along with light household tasks as postpartum families make adjustments to caring for a newborn in the house.  Birthing families  traditionally have received support from family and community going back hundreds of generations.  In the early to mid 20th century, as birthed moved from home to hospital, the birthing woman was removed from her support. In 1989, the first doula organization, PALS Doulas was established in Seattle, WA, and then in 1992, DONA International was founded by by leaders in the childbirth and maternal infant health field.  Since then, many other training and professional doula organizations have been created around the world and the number of doulas trained and available to serve birthing and postpartum families has grown substantially.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Doulas and childbirth educators have similar goals and objectives – to help birthing families to feel supported, informed , strong and ready to push for the best care for themselves and their babies.  Some childbirth educators have trained as doulas as well, and may work in both capacities.  It can be a wonderful partnership of mutual trust and collaboration.  In fact, Lamaze International, the premier childbirth education organization and DONA International, the gold standard of doula organizations have joined together to offer a confluence (conference) jointly hosted by both organizations in Kansas City, MO in September, 2014. An exciting time for networking, continuing education, learning and fun with members of both organizations.

© Sarah Sweetmans

© Sarah Sweetmans

While the profession has grown considerably since those early days, the most recent Listening to Mothers III survey published in 2013, indicates that only 6 percent of birthing families had a trained labor support person/doula in attendance at their birth. (Declercq, 2013)  The most recent systematic review on the impact of doulas on a woman’s birth experience found that birthing women supported by a doula were:

  • more likely to have spontaneous vaginal births
  • less likely to have intrapartum analgesia or regional analgesia
  • less likely to report dissatisfaction
  • more likely to have shorter labors
  • less likely to have a cesarean
  • less likely to have an instrumental vaginal birth
  • less likely to have a baby with a low five minute Apgar score

There were no adverse effects reported. (Hodnett, 2013)

When the American College of Obstetricians and Gynecologists (ACOG) and the Society for Maternal- Fetal Medicine (SMFM) released their groundbreaking “Safe Prevention of the Primary Cesarean Delivery” Obstetric Care Consensus Statement in February 2014, one of their key recommendations to reduce the primary cesarean rate in the USA was the continuous presence of a doula at a birth. (Caughey, 2014)

Continuous Labor and Delivery Support

Published data indicate that one of the most effective tools to improve labor and delivery outcomes is the continuous presence of support personnel, such as a doula. A Cochrane meta-analysis of 12 trials and more than 15,000 women demonstrated that the presence of continuous one-on-one support during labor and delivery was associated with improved patient satisfaction and a statistically significant reduction in the rate of cesarean delivery. Given that there are no associated measurable harms, this resource is probably underutilized. – ACOG/SMFM

dianne hamre doula

© Dianne Hamre by Kristen Self Photography

Doulas do a great job of supporting mothers, partners and families during the childbearing year and helping to improve outcomes for mothers and babies. The research shows it, the experiences of families confirms it and now ACOG recognizes the important role that a trained doula has in reducing the cesarean rate in the United States.  Childbirth educators can share this with students and maybe the next time birthing families are surveyed, the number of families choosing to birth with a doula with have risen significantly!

Doulas, thank you for all you do to support families!  You are providing a much needed service and improving the birth experience for families around the world.  We salute you!

How do you discuss doulas with the families you teach and work with?  Do any educators have doulas come in to help during class time?  Please share your experiences and let us know how it works out for you and your students and clients.

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology, 210(3), 179-193.

Declercq, E. R., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, A. (2013). Listening to Mothers III: Pregnancy and Birth; Report of the Third National US Survey of Women’s Childbearing Experiences. New York, NY: Childbirth Connection.

Dekker, Rebecca. “The Evidence for Doulas.” Evidence Based Birth. N.p., 27 Mar. 2013. Web. 14 May 2-14.

Hodnett ED, Gates S, Hofmeyr GJ, Sakala C. Continuous support for women during childbirth. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub5.

 

 

 

2014 Confluence, Childbirth Education, Confluence 2014, Doula Care, Healthy Birth Practices, Lamaze International, Maternity Care, Newborns, Push for Your Baby, Research, Uncategorized , , , , , , , , ,

Finding Common Ground: The Home Birth Consensus Summit

April 15th, 2014 by avatar
© HBCS

© HBCS

While home birth has a proven safety record in countries outside the U.S., some attribute that to the fact that, in other countries, home birth takes place in the context of an integrated health care system. It is critical that all of the stakeholders in the maternal health care system are working together to ensure safe birth options in the U.S. as well.

The Home Birth Consensus Summit (HBCS) is a unique collaboration of all of the stakeholders currently involved in home birth in the United States. First held in 2011, the Home Birth Consensus Summit offers physicians, midwives, consumers, administrators and policy makers; (a varied group of representatives who do not often share common ground,) a chance to take a 360 degree look at the current maternal health care system and tease out the areas of conflict and common ground in order to increase safety in all birth settings.

Today on Science & Sensibility, our readers learn about the Home Birth Consensus Summit; its participants, purpose and process. Thursday, we will have the opportunity to review one of the groundbreaking products from the past two summits, when the HBCS releases the “Best Practice Guidelines: Transfer from Home Birth to Hospital” for consideration and adoption by maternal health organizations. Learn more about the HBCS from Summit Delegate Jeanette McCulloch as she interviews Saraswathi Vedam, RM FACNM MSN Sci D(hc), Home Birth Consensus Summit convener and chair. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: What was the motivation behind launching the Home Birth Consensus Summit?

Saraswathi Vedam: Women want – and deserve – respectful, high quality maternity care regardless of their planned place of birth. Women and their families are not served by the interprofessional conflict and confusion that occurs in many regions in the US around place of birth.

While there may be points of disagreement, I know from numerous conversations with consumers, midwives, physicians, administrators, and policy makers that there are many more areas in maternity care where we all share a common set of principles and goals. Everyone is committed to working towards improved quality and safety for women and infants.

In 2011, a very intentionally selected group of stakeholders came together for the first Summit at the Airlie Center, in Warrenton, VA. These individuals represented all key leaders of the maternity care team, researchers, policy makers, payors, consumers, and consumer advocates. They came to the Summit with a wide variety of perspectives – including those for and against planned home birth. At the Summit, these delegates engaged in a unique process designed to help those with opposing viewpoints untangle complex issues. This process, called Future Search, guided the group through a complete exploration of every aspect of the maternal health care system. There were frank, challenging, and productive conversations, often among stakeholders who rarely, if ever, had been at the same table before. Once we were able to discover common ground, we were able to create a realistic and achievable strategic action plan together.

JM: Tell us about what common ground the Home Birth Consensus Summit has found so far.

SV:  As the delegates discussed their shared responsibilities and vision for providing the best possible care, we realized that the vision applied to all birth settings. The nine common ground statements describe a maternity care environment that respects the woman’s autonomy, ensuring she has safe access to qualified providers in all settings, and that the whole team that may care for her are well prepared with the clinical skills and knowledge that best applies to her specific situation. This will require attention to equity, cross-professional education, and research that includes the woman in defining the elements of “safety” and accurately describes the effects of birth place, or different models of care, on outcomes. The delegates shared a goal of increasing knowledge and access to physiologic birth, access to professional education and systems for quality monitoring for all types of midwives, from all communities; and reduction in barriers like cost and liability. Coming to this place of understanding and agreement, though, was only the beginning. Each of those action statements had to be turned into a concrete action plan that all of the stakeholders collaborated on developing.

© HBCS

© HBCS

JM: What is happening with the common ground statements now?

SV: Multi-disciplinary work groups have formed around each common ground statement. In 2013, the work groups came together for the second summit, again at the Airlie Center, to discuss progress made so far and tackle challenges.

Coming to this place of understanding and agreement, though, was only the beginning. The common ground statements are also encouraging a dialogue outside of our action groups that we could have never predicted. For example, the statements were read into the congressional record by Congresswoman Roybal-Allard, who said that the publication of the Home Birth Consensus document was “of critical importance to all current and future childbearing families in this country.” In the following year, several of the Summit delegates were invited panelists and presenters at an Institute of Medicine Workshop on Research Issues in the Assessment of Birth Settings.

JM: What are some of the top outcomes of the work groups?

SV: One exciting outcome – a set of Best Practice Guidelines to provide optimal care for mothers and families transferring from home to hospital – will be released by the Home Birth Consensus Summit later this week. This project represents what the Summits are all about: bringing together stakeholders to look at every facet of an issue, and work together on concrete initiatives to improve outcomes. These guidelines are based on the best available research on effective interprofessional collaboration. Delegates who are leading midwives, physicians, nurses, policy makers and consumers from across the U.S. formed the Collaboration Task Force. They met regularly over eight months on weekends and after hours to research and carefully design a concrete evidence-based tool to improve quality and safety for women and increase respectful communication among providers. Easing the friction that can sometimes occur when families arrive at the hospital can not only increase safety for families, but also build trust and collaboration between providers.

© HBCS

© HBCS

Another group is collaborating to develop a Best Practice Regulation and Licensure Toolkit – a resource for state policy makers that will provide a best practice model of midwifery regulation to be used as a template to enact or improve licensure in a particular state.

Another important outcome is a study of midwives and mothers of color to better understand social and health care inequities that lead to higher incidence of prematurity and low birth weight.

JM: What comes next for the Summit?

SV: The action groups are continuing their work on initiatives in each of the common ground areas. At Summit III, scheduled for Fall 2014 in Seattle, WA, each action work group will share the products of their collaborations, and address some remaining priorities. These include research and data collection, ethics, and access to equitable care during pregnancy. We plan to expand the participants to include more leaders from policy and practice to disseminate the documents and engage more in this exciting work.

I have been working towards ensuring equitable birth options for women and their families for nearly 30 years. My goal for the Summits is to increase the probability that my four daughters – and everyone’s daughters, wives, and sisters – will experience high quality, respectful maternity care.

What are your thoughts on the Home Birth Consensus Summits and this collaborative model?  How do you see this further maternal infant health and safety.  What would you like to see discussed by the stakeholders at Summit III in Seattle this fall?  Let us know in the comments and join us on Thursday to learn more about the details of the soon to be released “Best Practice Guidelines: Transfer from Home Birth to Hospital.”

Bios:

© Saraswathi Vedam

© Saraswathi Vedam

Saraswathi Vedam, RM FACNM MSN Sci D(hc), is the convener and chair of the Home Birth Consensus Summit. She has been active in setting national and international policy on home birth and midwifery education and regulation, providing expert consultations in Mexico, Hungary, Chile, China, Canada, and the United States. She serves as Senior Advisor to the MANA Division of Research, Chair of the ACNM Transfer Task Force, and Executive Board Member, Canadian Association of Midwifery Educators. Over the past 28 years she has cared for families in all birth settings. Professor Vedam’s scholarly work includes critical appraisal of the literature on planned home birth, and development of the first US registry of home birth perinatal data. Contact Saraswathi Vedam.

© Jeanette McCulloch

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell an organization improving infant and maternal health by changing the way we talk about birth and breastfeeding. She has been using strategic communications and messaging to change policy, spread new ideas, and build thriving businesses for more than 20 years. Jeanette is honored to be working with local, national, and international birth and breastfeeding organizations (including the Home Birth Consensus Summit) and advocates ensuring that women have access to high-quality care and information.

Babies, Healthcare Reform, Home Birth, Legal Issues, Maternal Quality Improvement, Maternity Care, Newborns, Practice Guidelines, Uncategorized , , , , ,

Peanut Balls for Labor – A Valuable Tool for Promoting Progress?

April 8th, 2014 by avatar

 Today, Andrea Lythgoe, LCCE and doula, takes a look at the peanut ball as a tool for promoting labor progress for women resting in bed or with an epidural.  Many more facilities are making this new tool available to laboring women. Childbirth educators will benefit by understanding how to teach peanut ball use to families in the classroom and those professionals who attend births will want to know about the benefits and proper usage as well. Andrea shares the research that is available along with the personal perspectives of those who have used them firsthand. – Sharon Muza, Science & Sensibility Community Manager.

PeanutBall-measure

Most experienced peanut ball users recommend either the 45 cm or 55 cm sized peanut ball. The size is measured from the floor to the tallest point on one of the larger ends. Because it will be used between the legs to open up the pelvic outlet, you don’t want it to be as large as the balls that are used for sitting and swaying. As I learned about the peanut ball, I found that many moms who did not like the peanut ball in labor felt it was too big. For this reason, I chose to purchase and use the 45 cm sized ball, which is the size used in the photos that accompany this article.

The peanut ball is most commonly used when mom needs to remain in the bed, whether because of epidural use, complications, or simply because mom is exhausted. There are two main ways in which peanut balls are used, with plenty of room for variation. The first is with mom in a semi reclined position, one leg over the ball, one leg to the side of the ball. The ball is pushed as close to mom’s hips as is comfortable. As the ball can have a tendency to slide away from the mom, a rolled up towel can be used to hold it in place. This position seems to be most commonly used to promote dilation and descent with a well-positioned baby.

The second common use is with mom in a side-lying or semi-prone position, with the peanut ball being used to lift the upper leg and open the pelvic outlet. The ball can be angled so that the leg hooks around the narrower part, or aligned with both mom’s knee and ankle resting on the ball. Mom’s comfort level is key to knowing the right placement. Most women who used this position used it to help rotate a posterior baby to a more favorable position for delivery.

PeanutBallCollage

© Maternal Focus

The Research

There is not much research out there on the use of the peanut ball. In my search, I found one study, presented as a poster presentation at the 2011 AWHONN Convention. Tussey and Botsois (2011) randomized 200 women (uncomplicated labor with an epidural) into two groups. One group used the peanut ball in either the semi Fowler’s position (bottom photos) or the sidelying position (top photos), switching sides every 1-2 hours. The sample size was small, but the results were very promising. The first stage of labor was shorter by an average of 90 minutes, and second stage was roughly half as long (43.5 min in the control group, 21.3 min in the peanut ball group). The use of vacuum and forceps was also lower in the peanut ball group. There were no serious adverse events reported in the study. This looks very promising, and I will be watching for more studies on the peanut ball in future years.

Many have speculated that the more upright semi Fowler’s position might also be helpful in preventing the increase in operative deliveries seen with epidurals (Anim-Somuah (2011), but a recent Cochrane Review found insufficient evidence to demonstrate a clear effect. (Kemp, 2013) A similar review looking at the benefits of upright positions in moms without an epidural did show some benefit. (Gupta, 2012)

Since it is known that babies in an Occiput Posterior (OP) position can increase the length of second stage and the rate of operative delivery (Lieberman, 2013; Caseldine, 2013) the reports of posterior babies turning when the peanut ball is used may be a big reason for its effectiveness.

The Mother’s Experience

Jennifer Padilla, a mom who used the peanut ball in labor, described to me her experience with using the ball to rotate her posterior baby after 20 hours of labor. She had an epidural that did not take as well as she would have liked, and still found the peanut ball in the side lying position to be comfortable enough to take short naps. She said it took 1-2 hours with the peanut ball to rotate her baby, but that once the baby rotated to an anterior position, she was ready to push.

In preparing for this article, I read through over 30 online birth stories that included the peanut ball and noticed a few common themes:

Maternal Preferences and Positioning

Moms who were unmedicated preferred upright positions to the peanut ball nearly every time. Even when they used it and felt it was beneficial, the comments were not very positive. For example, one mom described it like this:

Being positioned on the peanut ball was excruciating, I couldn’t see straight and was howling in agony. I wanted to push it away and jump up but I could feel it working.

Moms with an epidural liked the peanut ball almost universally, except for a few instances where moms complained it “made their butt go numb” when using it in the semi-Fowler’s position. Some commented that it was difficult to sleep when needing to switch the ball from side to side. Most moms described switching every 1-2 hours, some as frequently as every 20 minutes. (Women with epidurals usually switch side to side with the same frequency, even without the epidural.) One mom felt that using it semi-prone made her feel “undignified” and she wished her nurse had kept her covered with a sheet while lying in the position.
Some birth stories described moms leaning over the peanut ball, straddling the peanut ball, or using it in the shower in some capacity, but the vast majority used the ball in a side lying or semi prone position, with the reclined semi Fowlers a distant second.

Epidural Experiences

None of the moms who had an epidural reported any troubles with the epidurals losing effectiveness on one side while using the peanut ball, though several nurses I spoke with expressed concern that this would be a problem. More than a few moms who had an epidural said that they asked to stop using the peanut ball because of pressure in their back that turned out to be complete dilation.

Effect on Labor Progress

A few moms reported some pretty dramatic results:

A Doula’s Perspective

I spoke with Heidi Thaden-Pierce, a doula and CBE in Denton, Texas. She has been using the peanut ball with her doula clients for a while now, and she says women are very receptive to the idea. Many of them have already discovered that sleeping on their sides with a stack of pillows between their knees is very comfortable. The peanut ball replicates this and doesn’t slip and slide around as much as a stack of pillows can.

In her experience, most unmedicated moms will get up and get active in other positions over using the peanut ball, but “if a mom is needing some rest then we’ll tuck her into bed with the peanut ball because it’s comfortable and helps keep things in good alignment.” She also will occasionally use it while mom is on the bed on all fours as a place to rest mom’s upper body that is not as high as a regular birth ball. This can be nice if mom is more comfortable with her hips slightly higher than her shoulders.

Whenever I bring the ball to a hospital birth, I do explain what it is to the nurse and ask if there is any reason we should not use it. If a mom needs to labor in a certain position or there are concerns with the baby then I want to make sure that the peanut ball isn’t going to be in the way. I think it’s important that the mom’s care team be aware of and comfortable with the use of the peanut ball, so I make sure we talk about it before we try it at the birth.

The L&D Nurse’s Perspective

Carly Trythall, a nurse at the University of Utah Hospital in Salt Lake City, has worked with the peanut ball for labor in two different hospitals in her career as a nurse. She has mostly used the ball in the side lying position for helping to shorten labor. She said that most of her patients have been “accepting and eager” to try the ball and find it very comfortable. She finds that the ball is “most beneficial for moms who are not able to change positions frequently and utilize gravity (i.e. women with epidurals).”

The peanut balls are new to University Hospital; Carly was integral to introducing their use there, and she continues to work to educate patients and nurses about the balls and their use. Some providers have expressed a little resistance to their use, thinking it wouldn’t be beneficial for moms, but as they have gained experience, that is changing.

The Childbirth Educator’s Perspective – Teaching With The Peanut Ball

Because the effects of the peanut ball seem to be most pronounced in moms who use epidural anesthesia, teaching it in conjunction with epidural use seems the most logical. I teach techniques and support for moms with epidurals just after we learn the mechanics of an epidural and the benefits and risks of an epidural. This is where I recently integrated teaching about the peanut ball into my classes. Because I have a limited number of balls to work with (one peanut ball and one elliptical shaped ball of similar proportions) I can’t have all the moms practicing with the ball at the same time. I break up the group into smaller groups of 2-3 moms and partners, and have the other groups working on other epidural support activities while each group has a chance to practice with the peanut. We allow enough time for every mom who wants to experience the 2 main positions with the peanut to try them. I warn them the week before to be sure they wear comfortable loose clothing that they will be able to freely move around in as we practice.
We practice with mom trying out both of the main uses of the ball:

  1. Semi-sitting position (Semi Fowler’s) with one leg over the birth ball and one leg open to the side. In the absence of a hospital bed in the classroom, I use a traditional birth ball or mom’s partner sitting against the wall for moms to recline against as we practice this position.
  2. Side lying or semi prone with the peanut ball between the legs. We experiment with different positions to find a variation that is comfortable, reminding the parents that what they like now may not be the one they like in labor.

We also brainstorm possible ways to do these positions in the event there is not a peanut ball available.

Carly Trythall said that, as a nurse, she wished that women were learning more about the peanut ball in their classes: “I would like for moms to be taught the benefits of using a peanut ball during labor such as assisting with fetal rotation and descent by widening and opening the pelvis (great for OP babies), shortening the active phase of labor (because baby is in a more optimal position) and shortening the pushing phase of labor.

Conclusion

While there remains much to be learned about the efficacy and circumstances in which the peanut ball might be most useful, the peanut ball appears to be a promising technique for laboring women, in particular those who have a posterior baby and/or need to remain in bed. Teaching this technique in your childbirth class can help women go back to their care providers and birth places informed about another option that is becoming more and more widely available.

Are you teaching about peanut balls in your childbirth classes?  Are you seeing the balls in use in your communities?  Have you had personal experiences either as a birthing mother or a professional with the peanut balls?  Please share your experiences and information in the comments below so we can all learn about this new labor tool to help promote vaginal birth.- SM

To learn more about peanut balls:

http://betterbirthdoula.org/peanut-ball-and-epidurals-tips-for-doulas/

http://www.cappa.net/documents/Articles/Peanut%20Ball.pdf

My thanks to the University of Utah Labor and Delivery unit for the use of their room for the photos included in this article.

References

Anim-Somuah M, Smyth RMD, Jones L. (2011) Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD000331. DOI: 10.1002/14651858.CD000331.pub3

Carseldine, W. J., Phipps, H., Zawada, S. F., Campbell, N. T., Ludlow, J. P., Krishnan, S. Y. and De Vries, B. S. (2013), Does occiput posterior position in the second stage of labour increase the operative delivery rate?. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53: 265–270. doi: 10.1111/ajo.12041

Gupta JK, Hofmeyr GJ, Shehmar M. (2012) Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub3

Kemp E, Kingswood CJ, Kibuka M, Thornton JG. (2013) Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD008070. DOI: 10.1002/14651858.CD008070.pub2.

Lawrence A, Lewis L, Hofmeyr GJ, Styles C. (2013) Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub4.

Lieberman, E, Davidson, K, Lee-Parritz, A, Shearer, E (2005) Changes in Fetal Position During Labor and Their Association With Epidural Analgesia. Obstetrics & Gynecology. 105(5, Part 1):974-982.

Overcoming the Challenges: Maternal Movement and Positioning to Facilitate Labor Progress.
Zwelling, Elaine PHD, RN, LCCE, FACCE
[Article] MCN, American Journal of Maternal Child Nursing. 35(2):72-78, March/April 2010.

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