24h-payday

Archive

Archive for the ‘Uncategorized’ Category

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.

Childbirth Education, Guest Posts, New Research, Research, Uncategorized , , , , , ,

Exciting Webinar Opportunity! Expand Your Childbirth Class Offerings with this Great Training

April 1st, 2014 by avatar

NOTE:  This post was posted as an APRIL FOOLS JOKE ON 4/1/2014.   Please take it in the lighthearted manner in which it was intended.

old preg woman and dogsAre you a childbirth educator looking to add a skill to your childbirth educator repertoire? Lamaze International is pleased to offer a groundbreaking continuing education opportunity that you can take back to your classrooms and offer as a class add-on to your childbirth education students.

Do you recall when you are teaching the coping skills section of your childbirth class, and a woman will often state “If I could only bring my dog to the hospital with me.  I get such comfort out of having my dog around.”  After attending this webinar, you will have the skills you need to help families train their dogs to be “Trained Canine Labor Support.”  After families and pets attend your hands on training, they will be authorized to have their dog in attendance at their birth.  Hospitals and birth centers will welcome the dog to the support team, knowing that the dog and family have successfully completed their customized “Trained Canine Labor Support” program, including receiving a score of 80% or better on the practical skills test portion.

Childbirth educators are uniquely positioned to be able to offer this supplemental class to their students along with their traditional childbirth education classes.

Evidence has shown that women who choose to have their trained Canine Labor Support dogs at their labor, along with an excellent childbirth education class, a supportive partner/family, a trained birth doula and respectful health care providers will experience reduced pain and increased satisfaction. (Golden and Labrador, 2008).  There is documentation of this beneficial support going back several decades.

Since staying hydrated and nourished during labor (Lamaze International’s Healthy Birth Practice #4 – Avoid Routine Interventions) is very important, the trained dog, when outfitted with a specially designed backpack, can keep the mother’s nutritious food and drink close at hand no matter wherever she is laboring – walking the halls, using the tub or resting in bed.

When a mother is feeling particularly stressed, research has shown that the trained dog can carefully lick the laboring woman’s face, reducing her cortisol levels significantly and promoting oxytocin release along with increased endorphin production. (Airedale, 2013)

Some women find that the sensory stimulation of running their fingers through their dog’s fur can be an effective component of the Gate Control Theory of Pain.  A recent randomized control study demonstrated that fur stroking synchronized with long rhythmic breaths decreased muscle tension and pain by approximately 69% in women who had reached the active phase of labor. (Weimaraner, Schnauzer and Basenji, 2010)

As childbirth educators, we teach and encourage women to labor in many different positions based on the research behind Healthy Care Practice #2 – Walk, Move and Change Positions During Labor.  With a Trained Canine Labor Support dog, the woman can more comfortably get into many positions, using the dog for support and stability.  The dog can offer physical support when the mother prefers to kneel, squat or lean over for comfort and to promote continued progress of labor.

Many women find laboring in water to be a great help in reducing pain.  Trained Canine Labor Support dogs have learned skills in testing the water temperature before the woman gets in the labor tub and signaling to the laboring woman and her team when it is appropriate and safe to get in the water.

Creating a home like intimate environment with the Trained Canine Labor Support dog, even in the hospital, has been shown to relax women, reduce their anxiety and promote productive contractions – leading to reduced need for labor augmentation. (Dalmation and Dashchund, 2012)

This free full day live webinar led by a team of experienced Canine Labor Support Educators will include our pilot families and their dogs, in the education studio to demonstrate the following skills you will learn to teach:

  • The dog as a stable platform for labor positions
  • Canine potty breaks in the labor room – utilization of the chux pad
  • Helping the Trained Canine Labor Support animal to be friendly and welcoming to unfamiliar people in the hospital L&D room.
  • Introducing your Trained Canine Labor Support to the newborn
  • Desensitizing the dog to the normal sounds of labor
  • Why cats are not intelligent enough to provide effective animal support ( a question that will frequently come up in your classes)
  • Additional skills that families will use when they plan to bring their Trained Canine Labor Support animal to their labor and birth.

There are a limited number of spaces for this live webinar, scheduled for Friday, April 25th, 2014 9AM-4 PM EST.  This webinar is provided at no cost to any interested educator in part thanks to a financial partnership with Lick Your Chops Dog Chow.  Only those educators who participate in the full day training will be qualified to offer this to families in their classes.  Click here to register now and ensure your spot.

References:

Airedale, P. U. P. (2013). Benefits of canine saliva on maternal cortisol levels. Journal of the National Canine Medical Association, 88(1), 27.

Dalmation, Spot. and Dachshund, Frank. (2012). Labor sensitivity comparison in austere and home-like LDRPs in clinical situations. International Journal of Domesticity, V119 no 4.

Golden, K. and Labrador, M. (2008). Canine Labor Support- a revolutionary model. Journal of American Kennel Club, 19 no 4.

Weimaraner, F., Schnauzer, H.. and Basenji, A. (2010). Introduction of sensory fur stroking during active labor as a measure to reduce analgesic or anesthetic requests of laboring women. American Journal of Domestic Animals, 107(1), p142-149.

 

 

Uncategorized

Why Pediatricians Fear Waterbirth – Barbara Harper Reviews the Research on Waterbirth Safety

March 27th, 2014 by avatar

By Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE

On March 20th, 2014, the American Academy of Pediatrics Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice released a joint clinical report entitled Immersion in Water During Labor and Delivery in the journal Pediatrics.  While not substantially different than previous statements released by the AAP, quite a stir was created.  Today, Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE, of Waterbirth International provides a research summary that supports waterbirth as a safe and reasonable option for mothers and babies.  Barbara Harper has been researching and teaching about safe waterbirth protocols for several decades and is considered an expert on the practice.  I am glad Barbara was able to share her knowledge with Science & Sensibility readers all the way from China, where she just finished another waterbirth workshop for Chinese hospital programs. – Sharon Muza, Community Manager, Science & Sensibility

In a candle lit room in Santa Barbara, California, in October of 1984, my second baby came swimming out of me in a homemade tub at the foot of my bed.  As soon as he was on my chest, I turned to my midwife and exclaimed, “We have got to tell women how easy this is!”

Earlier that month I sat in my obstetrician’s office with my husband discussing our plans, which had changed from an unmedicated hospital birth to a home waterbirth.  The OB shook with anger and accused me of potential child abuse, stating that if I did anything so selfish, stupid and reprehensible he would have no choice but to report me to the Department of Child Welfare.  I never stepped foot in his office again, but I did call his office and share the news of my successful home waterbirth.

Before setting up my homemade 300 gallon tub, I had researched through medical libraries for any published data on waterbirth, but could not find a single article, until a librarian called me and said she was mailing an article that came in from a French medical journal.  The only problem was that it was quite old. It had been published in 1803!  The next article would not come out until 1983, the very year that I was searching.[i]

The objections to waterbirth have always come from pediatricians, some with vehement opinions similar to those expressed by my former obstetrician.  The current opinion of the American Academy of Pediatrics Committee on Fetus and Newborn is nothing new.  It was issued in 2005, restated in November 2012 and it is showing up again now.  There are many obstetricians and pediatricians who are perplexed and angered over the issuing of this statement.  Especially, doctors like Duncan Neilson of the Legacy Health Systems in Portland, Oregon. [ii]  Dr. Neilson is chair of the Perinatology Department and VP of both Women’s Services and Surgical Services at the Legacy Emanuel Hospital in downtown Portland.

In 2006, Dr. Neilson did an independent review of all the literature on waterbirth, including in obstetric, nursing, midwifery and pediatric journals. He concluded, “there is no credible evidence that waterbirth is a potential harm for either mothers or babies.” He reported that the majority of the waterbirth studies have been done and published in Europe with large numbers in retrospective analyses.[iii], [iv], [v], [vi] What has been published in the US is largely anecdotal and has involved very small numbers of case reports from home birth or birth center transfers into NICU. [vii], [viii], [ix] Dr. Neilson even pointed out that Jerold Lucy, M.D., the editor of the American Journal of Pediatrics put the following commentary in a sidebar in a 2002 issue of this respected research journal, “I’ve always considered underwater birth a bad joke, useless and a fad, which was so idiotic that it would go away. It hasn’t! It should!” [x]

The publication of such prejudicial statements makes it difficult for pediatricians to look at the European research without skepticism. Dr. Neilson concluded that American doctors were not getting the complete picture.  After this comprehensive review of waterbirth literature, Dr. Neilson believed that waterbirth is a safe birth option that provides other positive obstetric outcomes. He helped set up a Legacy research committee and the parameters for waterbirth selection were created, using current recommended selection criteria followed by other Portland hospitals offering waterbirth.

Upon Dr. Neilson’s recommendations, the entire Legacy system has adopted waterbirth. The most recent hospital to begin waterbirth was Good Samaritan in Portland, which conducted their first waterbirth in February of 2014.

Women seeking waterbirth and undisturbed birth have usually considered the consequences of interference with the birth process on the development, neurology and epigenetics of the baby.  The goal of the pediatrician and the goal of mothers who choose undisturbed birth is really exactly the same.  The use of warm water immersion aids and assists the mother in feeling calm, relaxed, nurtured, protected, and in control, with the ability to easily move as her body and her baby dictate.  From the mother’s perspective, using water becomes the best way to enhance the natural process without any evidence of increased risk.  A joint statement of the Royal College of Obstetricians, the Royal College of Midwives and the National Childbirth Trust in 2006 agreed.  They sat down together to explore what would increase the normalcy of birth without increasing risk and the very first agreement was that access to water for labor and birth would accomplish that task.[xi]

Framework for Maternity Services Protocol

The UK National Health Service and the National Childbirth Trusts formed a Framework for Maternity Services that includes the following statements:

  • Women have a choice of methods of pain relief during labour, including non pharmacological options.
  • All staff must have up-to-date skills and knowledge to support women who choose to labour without pharmacological intervention, including the use of birthing pools.
  • Wherever possible women should be allowed access to a birthing pool in all facilities, with staff competent in facilitating waterbirths.

There is a concerted effort to educate midwives and physicians in all hospitals in the UK on the proper uses of birthing pools and safe waterbirth practices. [xii]

The baby benefits equally from an unmedicated mother who labors in water and has a full complement of natural brain oxytocin, endorphins and catecholamines flowing through her blood supply. The mother’s relaxed state aids his physiologic imperative to be born.  The descent and birth of the baby is easier when the mother can move into any upright position where she can control her own perineum, ease the baby out and allow the baby to express its primitive reflexes without anyone actually touching the baby’s head.  The birth process is restored to its essential mammalian nature.

The true belief in the safety of waterbirth is a complete understanding of the mechanisms which prevent the baby from initiating respirations while it is still submerged in the water as the head is born and then after the full body has been expelled.  When Paul Johnson, M.D., of Oxford University, explained these mechanisms at the First World Congress on Waterbirth at Wimbledon Hall, in 1995, there was a collective nod of understanding from more than 1100 participants.  With this information, more waterbirth practices were established all over the UK and Europe.  Dr. Johnson went on to publish his explanations in the British Medical Journal in 1996.[xiii]

Johnson’s 1996 review of respiratory physiology suggests that, in a non-stressed fetus, it is unlikely that breathing will commence in the short time that the baby’s head is underwater. Johnson sees no reason to prevent this option being offered to women.

A Cochrane Review[xiv] of women laboring in water or having a waterbirth gives no evidence of increased adverse affects to the fetus, neonate, or woman.

American Academy of Pediatrics’ Misleading Committee Commentary

Despite this review, the 2005 American Academy of Pediatrics committee on Fetus and Newborn commentary raised concerns regarding the safety of hospital waterbirth. The committee commentary was not a study itself, but rather an opinion generated upon the review of research.

A review of the commentary and the sources cited, revealed irregularities. The commentary often paraphrased text from the references, redacted crucial words and sentences from the texts, and sometimes re-interpreted the authors’ conclusions.  Anecdotal case studies were referenced without being part of an empirical study.

Example:

Committee text: “All mothers used water immersion during labor, but only a limited and unspecified number of births occurred under water.” 2 infants required positive pressure support, but little additional data were provided.

From cited reference: 100 births occurred under water. Only 2 infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support. [xv]

Committee text: “Alderdice et al performed a retrospective survey of 4494 underwater deliveries by midwives in England and Wales. They reported 12 stillbirths or neonatal deaths”

From cited reference: “Twelve babies who died after their mothers laboured or gave birth in water, or both, in 1992 and 1993 were reported. None of these cases was reported to be directly related to labour or birth in water.”[xvi]

Committee text: “In a subsequent survey of 4032 underwater births in England and Wales, the perinatal mortality rate was 1.2 per 1000 live births (95% confidence interval: 0.4–2.9) and the rate of admission to a special care nursery was 8.4 per 1000 live births (95% CI: 5.8–11.8) The author of this survey suggested that these rates may be higher than expected for a term, low-risk, vaginally delivered population.”

From cited reference: “4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (THEY LEFT OUT THE 2ND CI 5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water….”

The reference also provides that the UK perinatal mortality and special care admission rates for conventional birth ranged from 0.8 to 4.6/1000 for perinatal mortality, and 9.2 to 64/1000 for special care admission—significantly higher than those utilizing waterbirth.

Nowhere in the cited reference can the statement be found that “these rates may be higher than expected for a term, low-risk, vaginally delivered population.” In fact, the study results reflect no effect on fetal outcomes and certainly not an increase in fetal mortality and special-care admissions.[xvii]

Finally, the committee commentary acknowledges the findings of the Geissbühler study[xviii]:

“A prospective observational study compared underwater birth with births using Maia-birthing stools and beds. Although underwater birth was associated with a decreased need for episiotomies and pain medication as well as higher APGAR scores and less cord blood acidosis in newborns, the birthing method was determined by maternal preference, and potential confounding variables were not analyzed.”

The committee does not elaborate on which confounding variables they feel are of concern. It appears this supportive study was automatically discredited without a reason.

While the American Academy of Pediatrics is committed to patient safety and evidence-based medicine, this commentary’s conclusions that hospital waterbirths are of greater risk than other hospital birth options for low risk and carefully screened patients are completely unfounded.

Waterbirth Studies

In 1998, I copied all the medical journal articles about waterbirth that had been published to date and sent the labeled and categorized studies to the Practice Committee of ACOG.  In the cover letter accompanying the rather weighty binders, I asked the Committee if they would review the literature and issue an opinion about actual birth in water.  The letter that arrived a few months later from Stanley Zinberg, MD, then head of the Practice Committee, stated, “until there are randomized controlled trials of large numbers of women undergoing birth in water, published in peer reviewed journals in the US, the committee is not able to issue an opinion.”

Randomized studies of waterbirth are difficult to design and implement for one major reason: women want to choose their own method of delivery and should be able to change their mind at any point of labor. Because of this, it is difficult to design a randomized controlled study without crossover between control and study group. A 2005 randomized trial which was set up in a Shanghai, China hospital was abandoned because the hospital director realized after only 45 births that the study was unethical.  The original goal was to study 500 births, but the results of those first 45 were so good they abandoned the research project, yet continued their commitment to offering waterbirth to any woman who wanted one.  The latest communication from the Changning Hospital in Shanghai indicates that they have facilitated well over 5000 waterbirths since then.

Randomized controlled trials may be few, however, many retrospective and prospective case-controlled studies have been performed, primarily in European countries with a long history of waterbirth. In reviewing published studies, a comparison of the safety of waterbirth to conventional births among low-risk patients can be made. The evidence reveals the option of waterbirth is safe and, looking at certain parameters, has superior outcomes.

European Research

Highlights of the literature:

  • APGAR scores were found to be unaffected by water birth.[xix] One study found a decrease in 1-minute APGAR scores exclusively in a subgroup of women who were in water after membranes were ruptured longer than 24 hours.[xx]
  • A consensus of researchers found that waterbirth had either no effect or reduced cesarean section and operative delivery rates.[xxi]
  • No studies have found an effect on rates of maternal or fetal infection.[xxii]
  • Statistically, waterbirth leads to increased relaxation and maternal satisfaction, decreased perineal trauma, decreased pain and use of pharmaceuticals, and decreased labor time.[xxiii]

Cochrane Collaboration Findings

A Cochrane Collaboration review of waterbirth in three randomized controlled studies (RCTs) show no research that demonstrates adverse effects to the fetus or neonate.[xxiv] Other studies that were not RCTs were included in the conclusion:

“There is no evidence of increased adverse affects to the fetus or neonate or woman from laboring in water or waterbirth. However, the studies are variable and considerable heterogeneity was detected for some outcomes. Further research is needed.”

Conclusion

Waterbirth is an option for birth all over the world. World-renowned hospitals, as well as small hospitals and birthing centers, offer waterbirth as an option to low risk patients. Though some members of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists feel otherwise, the Cochrane Review and many other studies find no data that supports safety concerns over waterbirth.

Women increasingly are seeking settings for birth and providers that honor their ability to birth without intervention. Waterbirth increases their chances of attaining the goal of a calm intervention free birth.

Physicians and midwives are skilled providers who are being trained in waterbirth techniques, safety concerns, the ability to handle complications and infection control procedures.

Carefully managed, waterbirth is both an attractive and low-risk birth option that can provide healthy patients with non-pharmacological options in hospital facilities while not compromising their safety.

In contrast to Dr. Lucy’s statement, waterbirth is not a fad and it is not going away, especially when it is mandated as an available option for all women in the UK and practiced worldwide in over ninety countries. The first hospital that began a waterbirth practice in 1991, Monadnock Community Hospital in Peterborough, New Hampshire, is still offering this service to low risk women 23 years later.  They have been joined since then by just under 10% of all US hospitals including large teaching universities and the majority of all free standing birth centers.  Hospitals have invested in equipment, staff training and are collating data to present to the medical community.  Dr. Duncan Neilson in Portland, Oregon is working on a summary of the data on over 800 waterbirths at only one hospital in the Legacy Health System.

I have dedicated my entire life to changing the way we welcome babies into the world since that October night in 1984, when I told my midwife that we have to tell women about the wonders of waterbirth. Since that night, I have traversed the planet to 55 countries and helped hundreds of hospitals start waterbirth practices.  Birth in water is safe, economical, effective and is here to stay, despite the AAP’s recent statement.

References


[i] Odent, M.,1983. The Lancet, December 24/31, p 1476

[ii] Medical Plaza Bldg. 300 N. Graham St., Suite 100 Portland, OR 97227, (503) 413-3622 dneilson@lhs.org

[iii] Alderdice, F., R., Mary, Marchant, S., Ashiurst, H., Hughes, P., Gerridge, G., and Garcia, J. (April 1995). Labour and birth in water in England and Wales. British Journal of Medicine, 310: 837.

[iv] Geissbuehler, V., Stein, S., & Eberhard, J. (2004). Waterbirths compared with landbirths: An observational study of nine years. Journal of Perinatal Medicine, 32, 308-314

[v] Gilbert, Ruth E., Tookey, Pat A. (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal ;319:483-487 (21 August)

[vi] Zanetti-Dallenback, R., Lapaire, O., Maertens, A., Frei, F., Holzgreve, W., & Hoslit, I. (2006). Waterbirth:, more than a trendy alternative: A prospective, observational study. Archives of Gynecology and Obstetrics, 274, 355-365

[vii] Bowden, K., Kessler, D., Pinette, M., Wilson, D Underwater Birth: Missing the Evidence or Missing the Point? Pediatrics, Oct 2003; 112: 972 – 973.

[viii] Nguyen S, Kuschel C, Reele R, Spooner C. Water birth—a near –drowning experience. Pediatrics. 2002; 110:411-413

[ix] Schroeter, K., (2004). Waterbirths: A naked emperor (commentary) American Journal of Pediatrics, 114 (3) Sept, 855-858

[x] Neilson, Duncan  Presentation at the Gentle Birth World Congress, Portland, Oregon, Setpember 27, 2007

[xi] RCOG/The Royal College of Midwives (2006) Joint Statement no 1: Immersion in Water During Labour and Birth. London: RCOG

[xii] Johnson P (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology 103(3): 202-8

[xiii] ibid

[xiv] Cluett, E.R., Burns, E. Water in Labor and Birth(review) Cochrane Database of Systematic Reviews 2012, Issue 2 Art. No.: CD000111.DOI: 10:1002/14651858.CD000111.pub3

[xv] Odent, M.,1983. The Lancet, December 24/31, p 1476

[xvi] Alderdice, F. et.al.1995. British Journal of Midwifery 3(7), 375-382

[xvii] ibid

[xviii] Geissbühler V, Eberhard J, 2000

[xix] Aird, et al, 1997; Cammu, et al, 1994; Eriksson, et al, 1996; Lenstrup et al, 1987; Ohlsson et al, 2001, Otigbah et al, 2000; Rush, et al, 1996, Waldenstrom & Nilsson, 1992.

[xx] Waldenstrom & Nillson, 1992

[xxi] Aird, Luckas, Buckett, & Bousfield, 1997; Cammu et al, 1994; Cluett, Pickering, Getliffe, & St. George, 2004; Eckert, Turnbull, & MacLennon, 2001; Lenstrup, et al, 1987, Ohlsson, et al, 2001, Rush, et al, 1996)

[xxii] Cammu, Clasen, Wettere, & Derde, 1994; Eriksson, Lafors, Mattson, & Fall, 1996; Eldering, 2005; Lenstrup, Schantz, Feder, Rosene, & Hertel, 1987; Geissbuhler & Eberhard, 2000; Rush, et al, 1996; Schorn, McAllister, & Blanco, 1993, Thöni A, Mussner K, Ploner F, 2010; Waldenstrom & Nilsson, 1992.

[xxiii] Mackey,2001; Benfield et al, 2001

[xxiv] Cluett, E.R., Burns, E. 2012

About Barbara Harper

© Barbara Harper

© Barbara Harper

Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE,  loves babies and has been a childbirth reform activist since her first day at nursing school over 42 years ago. She is an internationally recognized expert on waterbirth, a published author and she founded Waterbirth International in 1988, with one goal in mind – to insure that waterbirth is an available option for all women. During the past four decades, Barbara has worked as a pediatric nurse, a childbirth educator, home birth midwife, midwifery and doula instructor and has used her vast experience to develop unique seminars which she teaches within hospitals, nursing schools, midwifery and medical schools and community groups worldwide. She was recognized in 2002 by Lamaze International for her contributions in promoting normal birth on an international level. Her best selling book and DVD, ‘Gentle Birth Choices’ book has been translated into 9 languages so far. Her next book ‘Birth, Bath & Beyond: A Practical Guide for Parents and Providers,’ will be ready for publication at the end of 2014. Barbara has dedicated her life to changing the way we welcome babies into the world. She considers her greatest achievement, though, her three adult children, two of whom were born at home in water. She lives in Boca Raton, Florida, where she is active in her Jewish community as a volunteer and as a local midwifery and doula mentor and teacher. Barbara can be reached through her website, Waterbirth International.

ACOG, American Academy of Pediatrics, Babies, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Midwifery, New Research, Newborns, Research, Second Stage, Uncategorized , , , , , , , ,

Book Review: “Lamaze: An International History” – Breath Control: The Rise and Decline of Psychoprophylaxis

March 7th, 2014 by avatar

Lamaze: An International History is  newly published book by Paula A. Michaels that takes a look at the historical concept of pain-free childbirth through breath control and other relaxation techniques.  Regular contributor, Deena Blumenfeld reviews this book and shares her thoughts on how accurate the book is, what the book does well and where the book falls short.  Read Deena’s review and if you also have read this perspective on the history of Lamaze, please share your thoughts in our comment section. – Sharon Muza, Science & Sensibility Community Manager.

lamaze history book cover

When we look back at the past, we often see it through the filter of our modern sensibilities, values and sociopolitical beliefs. However, the past is best understood within the context of the social, political and ethical values of the time period. “Lamaze, An International History” by Paula A. Michaels should be read and understood within its appropriate historical context.

 Most of us know the Cliff’s Notes version of the origins and history of Lamaze. What we may not know are the details of the development of psychoprophylaxis and its journey from Russia to France and then to the United States. We may also not know of its decline in use and the reasons behind the decline.

Psychoprophylaxis is the technique developed by Dr. Vel’vovskii, a psychologist, and his colleagues, in the 1920s. The technique included multiple weeks of childbirth education classes taught by the woman’s physician, patterned breathing (“hee, hee, hoo, hoo”) and relaxation techniques. This was a training method designed to help women have painless childbirth. The belief was that fear caused pain and through education and training, fear could be eliminated. This follows directly from the belief that women’s gynecological health issues were all in their heads. Victorian physicians espoused this idea and the emerging field of psychology latched on to it and perpetuated it.

Michaels seeks to elucidate the social, economic and political influences behind psychoprophylaxis and its relative importance with regards to women’s expectations for childbirth; the prevailing opinions on pain during labor; roles of the father and the doctor during birth and the overall social implications regarding feminism and paternalism. She explores not only psychoprophylaxis, but its creators, its rise in popularity and its decline in use. Michaels looks at the medical environment of the day, as well as the social, economic and political influences on women and childbirth at the time (1930s – 1980.)

Only in the final chapter does Michaels address the Lamaze of today. She alludes to the Six Healthy Birth Practices and modern teachings. She appropriately refers to modern Lamaze as more of a “philosophy” rather than a “method.”

Being that her intention is to address the origins of Lamaze, more specifically psychoprophylaxis, there is little need for her to discuss how classes are taught currently or about present day birthing culture. The reader should not impress the image of historical childbirth class, or the childbirth class of another culture, onto current day classes. Michaels does say that:

“The international history of psychoprophylaxis speaks to how we arrived at today’s status quo, but perhaps more significantly it also reminds us that the values and meanings that we attribute to certain obstetric interventions, like the use of anesthesia, are not constant, but provisional. Practices are historical products of specific technological, economic, social and political conditions. What constituted a desirable birth experience changed with the times, as issues of safety, dignity, control and power each came to be reconfigured under both national and international influence.”

There was a review of this book published on The New Republic recently. The review fell into this trap of imposing historical Lamaze and the practice of psychoprophylaxis onto modern Lamaze, thus presenting a false impression of the purpose and intention of current Lamaze childbirth classes and broader Lamaze International organizational work to improve maternity care for all women. It also misrepresented the intention of the book which is, as best I can tell, an historical perspective, set in the context of the prevailing beliefs at the time with regards to women’s place in society, proper behavior and issues of power and control.

Power and Control

The proponents of early childbirth education, including Dick-Read, Vel’vovskii (creator of psychoprophylaxis), Lamaze, Bradley and others sought to help women control their pain through education, managing expectations, breath control, and relaxation including very specific techniques for pain management. Their initial intentions fell within the scope of prevalent societal beliefs surrounding women’s role in society, religious beliefs, proper behavior, and origins of pain, patriarchy and the political climate of their respective countries.

The author posits that the Russian doctors used psychoprophylaxis as a method to control women during labor, such that they were calm, quiet and obedient. The technique relied on the doctor, nurse, or later, the woman’s husband, to assist the laboring mother in maintaining the breathing and relaxation such that she remained in a passive state. So we can see, how taken out of proper historical context, this is offensive to modern sensibilities.

When the Lamaze method, psychoprophylaxis, made its transatlantic trip to the United States the intention behind the technique changed. However, this shift was a transition, not an immediate change. It took a decade or so to adapt to the prevailing beliefs regarding women’s autonomy and desire for more control over their bodies. Once the method began to take root, it became more about the feminist movement and women’s empowerment as we moved into the latter 1960s and 1970s.

Final Thoughts on the Book and a Look Forward 

Being that I don’t have a TARDIS to go back in time and observe for myself the successes or failures of psychoprophylaxis; I will have to take into account history’s record and Michael’s analysis thereof.

“Lamaze, an International History” should have been more appropriately titled “Psychoprophylaxis, an International History,” although “Lamaze” is a more well understood title and has the potential to garner more readers. In the book, Michaels paints a paternalistic, often misogynistic, view of how birthing women were treated in mid-century Russia and the rest of the Western world. She describes how psychoprophylaxis, and the proponents of the Lamaze method, strived to reinforce the paternalism and pronatalism of the day, while offering women a non-pharmacological form of pain management during labor, childbirth education and support by bringing husbands into the delivery room.

Psychoprophylaxis and the early days of Lamaze should be viewed in their proper historical context and not through the lens of modern feminism, ethics or social mores. I find Michaels’ book to be an eye-opening perspective regarding a piece of the history of my profession. Her book, however, ends rather abruptly at about 1980, with a small concluding chapter of her own perspective on a more modern Lamaze and what her thoughts are as to what women need or want during birth. I would have liked to have seen her take the history of Lamaze through the 1980s, 1990s and into the 2000s.

There’s been a large paradigm shift in how we as Lamaze educators approach childbirth education since the decline of the use of psychoprophylaxis. The move from being a one method technique to a comprehensive, evidence-based, hands-on, multi-modal form of childbirth education has brought Lamaze effectively into the 21st century to reach mothers and families in the classroom, online and via social media. Our advocacy for women’s health is far reaching, and is not addressed in Michaels’ book. I do not find this to be a flaw in her book as her book is a look into our origins and early history. I do find that I want more from her. I want the rest of the story of Lamaze’s history. I’d love to see her write another 140 pages of well researched analysis of the social, economic and political influences on Lamaze in the past three plus decades.

A peek back into history can often help us determine why we do what we do today and how to make more appropriate changes for the future. My question to you, blog readers: “Where do you see Lamaze in 10 years? 15 years? 20 years? What social, economic and political factors will influence how we are educating and supporting women in the future?

Additional suggested readings

Childbirth Education, Guest Posts, Lamaze International, Uncategorized , , , , , ,