Science & Sensibility

In my January Science and Sensibility blog post, I answered the question “Can We Prevent Persistent Occiput Posterior?” but because it wasn’t relevant to the study that prompted the post, and the piece was already long, I didn’t look at the role of epidural analgesia. Let me now rectify that.

All five studies examining the relationship between epidural analgesia and persistent occiput posterior (OP) find an association between them. Three studies compared women with an epidural versus no epidural according to whether they had an OP baby at delivery and found that 4 to 10 more women per 100 having an epidural had an OP baby at delivery (Cheng, 2006; Lieberman, 2005; Sizer, 2000). The other two compared women with an OP baby at delivery according to whether they had an epidural and found that 13 and 27 more women per 100 with a persistent OP baby had an epidural (Fitzpatrick, 2001; Ponkey, 2003).

Their results, however, aren’t sufficient to convict epidurals because we can’t tell whether having an epidural led to persistent OP or more painful and prolonged OP labor led to having an epidural. Investigators in one of the five studies argued for OP labor coming first on the grounds that while epidurals were more common in women with an OP baby at delivery than in women with an OA baby at delivery (74% vs. 47%) at their institution, a rise in epidural use from 3% in 1975 to 47% in 1998 had, if anything, decreased the hospital’s overall rate of persistent OP (4% vs. 2%) (Fitzpatrick, 2001). This must mean that as epidurals became more freely available, women having difficult OP labors were more likely to opt for one. Epidurals were the result, not the cause, of persistent OP. On the other hand, we have some corroborating evidence for their guilt. For one thing, back pain is thought to be a major reason why women with OP babies are more likely to want epidurals, but it turns out that back pain isn’t unique to OP. Serial sonograms reveal that virtually identical percentages of women laboring with an OA baby report back pain (Lieberman, 2005). For another, three of the five studies took into account other factors associated with difficult labor such as labor induction, labor augmentation, and birth weight and still found that epidurals were an independent risk factor for persistent OP (Cheng, 2006; Lieberman, 2005; Sizer, 2000).

Nevertheless, evidence from observational studies isn’t strong enough to close the case. As I noted, observational studies can determine association but not causation. In addition, investigators may not be able to identify all the confounding and correlating factors that affect outcomes. For a more definitive answer, we need experimental studies. This brings us to randomized controlled trials (RCTs), in which participants are randomly allocated to one form of treatment or the other, and to meta-analysis of RCTs, in which statistical techniques are used to pool data from more than one trial.

The Cochrane systematic review of epidural versus no epidural in labor pools data from four RCTs (673 women overall) that reported on persistent OP (Anim-Somuah, 2011). Five more women per 100 assigned to the epidural group had a persistent OP baby, but meta-analysis found that the difference just missed achieving statistical significance. The risk ratio was 1.4, meaning a 40% increased risk of persistent OP in women assigned to the epidural group compared with women assigned to the no-epidural group, but the 95% confidence interval ranged from 1.0 to 2.0, meaning a 95% probability that the true value lies between no increase (ratio of 1:1) and double the risk (2.0). However, a problem with the RCTs of epidural versus no epidural is that substantial percentages of women assigned to the no-epidural group actually had epidurals, but, as is prescribed in RCT data analysis, they were kept in their original group. In two of the four trials (204 women), though, 10% or less of women assigned to the no-epidural group had epidurals. If we calculate the excess rate of persistent OP in these two trials, we find that the gap widens to 9 more women per 100 with epidurals having a persistent OP baby. We don’t know whether this difference would achieve statistical significance, but the fact that the excess is in the same range as reported in the observational studies (4 to 10 more per 100) gives confidence in its validity.

We also have two studies that suggest that the timing of the epidural may matter. One, of 320 women, reports that, after controlling for age, induction of labor, and birth weight, initiating an epidural at fetal station less than zero (above the ischial spines) resulted in 16 more women having a persistent OP or occiput transverse (OT) baby compared with initiation at 0 station or greater (at or lower than the ischial spines), an excess that rose to 20 more per 100 in first time mothers (Robinson, 1996). The other study analyzed outcomes in 500 first-time mothers according to whether an epidural was administered early (at or before 5 cm dilation), late (after 5 cm dilation), or not at all (Thorp, 1991). Seventeen more women per 100 in the early group had a persistent OP or OT baby compared with women in the late-epidural group, and 12 more had a persistent OP or OT baby compared with the no-epidural group, but rates were similar in women in the late and no epidural groups.

Taken all together, we may not have absolute proof of epidural culpability in predisposing to OP, but if I were on the jury, I would vote them “guilty as charged.”

Take home: Even without certainty, the precautionary principle dictates recommending to women desiring an epidural that they use other measures to cope with labor pain until they enter active labor and until it seems clear that positioning and activities are not putting a slow labor on track.

What do you tell your clients, students and patients about the impact on fetal positioning in labor and birth?  Will having this information change what you say?  Let us know in the comments section.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews(12), CD000331.

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. Journal of Maternal Fetal and Neonatal Medicine, 19(9), 563-568.

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstetrics and Gynecology, 98(6), 1027-1031.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics and Gynecology, 105(5 Pt 1), 974-982.

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstetrics and Gynecology, 101(5 Pt 1), 915-920. 

Robinson, C. A., Macones, G. A., Roth, N. W., & Morgan, M. A. (1996). Does station of the fetal head at epidural placement affect the position of the fetal vertex at delivery? American Journal of Obstetrics and Gynecology, 175(4 Pt 1), 991-994.

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstetrics and Gynecology, 96(5 Pt 1), 749-752.

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. American Journal of Perinatology, 8(6), 402-410.

Henci Goer Childbirth Education, Epidural Analgesia, Evidence Based Medicine, Guest Posts, informed Consent, Medical Interventions, Pain Management, Research back labor, epidural, epidural analgesia, epidurals, guest post, Henci Goer, Occiput posterior, OP

I had waited excitedly for the release of Henci Goer and Amy Romano’s new book for a long time and was delighted to receive it after it was published in May 2012. Optimal Care in Childbirth: The Case for a Physiologic Approach was a robust, updated successor to Henci’s previous book; Obstetric Myths Versus Research Realities which was a well used source on my office bookshelf.

Both authors have a long history with Lamaze International. Prior to her current position with Childbirth Connection, directing the Transforming Maternity Care Partnership, Amy launched Science & Sensibility, and provided a keen and critical eye when analyzing, reviewing and sharing research items with readers. Henci Goer has been the long time resident expert on the “Ask Henci” forum hosted by Lamaze International, providing and sharing resources on a wide variety of pregnancy and childbirth topics with consumers and professionals alike, as well as a regular contributor to this blog. Please read the full bios of Amy and Henci on their website, where you can find complete information on their work, background and other works that they have authored.

As the title clearly states, this book is about childbirth, and as such, you will not find information on pregnancy, breastfeeding or newborn topics. Nor is this the type of text that childbirth educators would hand out in class for consumers to use. This book is heavy with sources, study outcomes and insights into current obstetric practices. But, as a guide to best practice, the book becomes a great repository of information that allows consumers and professionals alike to learn and make decisions about care that can help keep birth as physiological as possible. The book focuses on what factors affect, both positively and negatively, birth, so that an optimal outcome can occur.

The authors define optimal outcomes as “the highest probability of spontaneous birth of a healthy baby to a healthy mother, who feels pleased with herself and her caregivers, ready for the challenges of motherhood, attached to her baby, and goes on to breastfeed successfully.”

The chapters are well organized, with the topic of cesareans starting things off. Cesarean rates have never been higher, and many of the topics that Goer and Romano discuss later in the book often have the unintended consequence of contributing to the skyrocketing cesarean rates in this country. I think it is an important topic and one that receives a thorough evaluation by the authors.

Each chapter starts off with “contradicting” quotes from researchers working in the field of obstetrics, and I have to say, that reading these at the beginning of each chapter was something I looked forward to, a nice added bonus and really made me pause and consider the different viewpoints and how they influence practice today. The lead in for chapter 12 on epidurals and spinals contains one of my favorites:

“There is no other circumstance in which it is considered acceptable for a person to experience untreated severe pain, amenable to safe interventions, while under a physician’s care.” ACOG 2006

“Epidural anaesthesia remains one of childbirth’s best exemplars of iatrogenesis. It is a wonderful intervention for managing labour complications, especially as an alternative to general anaesthetic for caesarean sections, but has significant side effects that constantly need weighing alongside benefits. Though its rising popularity almost grants it the status of normative practice on some [U.K.] maternity unites, it remains incompatable with physiological labour.” Walsh 2007

Each chapter begins with a wonderful perspective on each topic, sharing history and cultural practices so the reader can understand how standard protocols found in most birthing facilities have come to be, even when not backed up by research. I think it is critical to include this information, for if there is to be a shift to more evidence based care in the field of obstetrics, we need to be aware and acknowledge that some practices may have evolved for legal, cultural, social or policy reasons having nothing to do with sound research.

The authors ask and answer the very questions that I find myself asking out loud, helping the reader to understand why we continually observe care that is known to not improve outcomes. For example, when discussing electronic fetal monitoring, the question “Why does use of continuous EFM persist?” in normal low risk labors is asked (and thoroughly answered) with supporting references for further information.

Each chapter contains a brief summary of action steps that women can take to receive optimal care, along with the supporting research that backs up these steps. These lists are great talking points both for educators to integrate in their classrooms, but also for consumers to discuss with their health care providers and understand why their care might deviate from that supported by research.

The conclusion of each chapter has what the authors call a “mini-review” and neatly summarizes the important topic statements and provides (and references) outcomes of studies so that the reader can evaluate for himself or herself the validity of the research. Though these sections are called reviews, I found them to be a very helpful component of the book, when looking for solid sources.

At the end of each chapter, all of the sources referenced in that chapter are listed.

I was very appreciative throughout the book, for the definitions that the authors provided when discussing a topic. It is important (and helpful) to know how terms are defined, so that the reader can best understand the discussion. For example, in one of the cesarean chapters, one can find a list of “rate” terms, so when “primaparous cesarean rate” is discussed, this term has already been explained.

Several places throughout the book, in various callout boxes, Goer and Romano discussed the selective language that health care providers use when talking about childbirth and presenting information to families. I found these small detours fascinating, as I am very interested in the language that HCPs use to discuss risk, procedures and events with their patients.

The last chapters of the book take a look at choice of birth location, what the ideal maternity care system might include and includes information on maternal mental health. The appendices speak to common “less than optimal” situations, such as the OP fetus in labor, meconium staining and other circumstances that frequently cause concern and labor interventions. Again, the authors include information on optimal care in these cases that can help.

It is clear from some of the phrasing, chapter titles and choice of words in some of the discussions, that the authors have a bias towards a childbirth process that unfolds in a natural and physiological manner. This language, while potentially off-putting to those who firmly believe in the medical model, is effective in causing the reader to consider standard practices that make no logical “sense”, and certainly, references are provided for further research should the reader wish to investigate further.

I must say that I very much enjoyed this book, and I will find it very useful in my doula and Lamaze childbirth education practice. It is the type of book that one thumbs through frequently, when asked a question by a student or client, or when helping a client to prepare to speak to their health care provider about best practices and birth preferences. I think that any birth professional would do well to have this book on their shelf and be able to refer to it when necessary. This book represents a significant amount of research and I find great comfort in knowing that all the resources and references supporting the statements made in the book are available for me to source myself.

I look forward to the release of the e-book version of this title, expected this fall, for the Kindle, iPad and other tablets, so that I could have easy access from wherever I am. I would be delighted if the references and sources could be routinely updated as new research is released and published, so that I can use this guide for many years to come, confident that it reflects the newest and most valid research. I know that is a formidable task, but I would gladly pay a small subscription fee to have an updated version as often as necessary.

This book is available for purchase from both Amazon.com and the Optimal Care in Childbirth website. The book is on the expensive side, costing approximately $50.00, but very well may become the go-to source for evidenced based research on your office shelf, so worth the investment. If you choose to purchase from the book’s site, there are bulk and wholesale discounts available.  For purchases made from the book’s website, the authors are providing a 15% discount for our Science & Sensibility blog readers and conference attendees. Enter code UXJXI52F at checkout to receive the discount.

I hope that you are planning to attend the upcoming Lamaze International Innovative Learning Forum next week, where both Amy Romano and Henci Goer have been invited to speak. You will have an opportunity to meet these authors, ask them questions, purchase this book and hear their powerful presentations. As a General Session Speaker, Amy’s session will be available as part of the “Virtual Conference” option for those unable to attend the conference in person.

Have you read Optimal Care in Childbirth?  Are you using it already in your practice?  Please share your thoughts and comments in our comment section here on the blog.  I look forward to hearing your views. – SM

References

ACOG committee opinion. No. 339: Analgesia and cesarean delivery rates. Obstet Gynecol 206;107(6):1487-8.

Walsh D. Evidenced Based Care for Normal Labor and Birth. London: Routledge; 2007.

Sharon Muza Book Reviews, Cesarean Birth, Childbirth Education, Epidural Analgesia, Fetal Monitoring, Healthcare Reform, informed Consent, Lamaze 2012 Annual Conference, Maternal Mental Health, Medical Interventions, New Research, Pain Management, Practice Guidelines, Research, Systematic Review, Transforming Maternity Care Amy Romano, Ask Henci, book review, Henci Goer, Lamaze 2012 Annual Conference, Lamaze Innovative Learning Forum, Lamaze International, Optimal Care in Childbirth, Research about pregnancy and birth, Sharon Muza

In May of this year, three leading midwifery organizations, American College of Nurse Midwives (ACNM), Midwives Alliance of North America (MANA) and National Association of Certified Professional Midwives (NACPM) jointly released a statement titled “Supporting Healthy and Normal Physiologic Childbirth; A Consensus Statement by ACNM, MANA and NACPM,“ intended for health care professionals and policymakers.  This strongly worded statement supports healthy and normal physiologic childbirth for for U.S. women. It is logical that the three main U.S. midwifery organizations coordinated in preparing this statement, as midwives are the gatekeepers of normal birth for low risk women.   The purpose of the consensus statement, which was developed by a joint task force appointed from members of the three midwifery organizations was to:

• Provide a succinct definition of normal physiologic birth;
• Identify measurable benchmarks to describe optimal processes and outcomes reflective of normal physiologic birth;
• Identify factors that facilitate or disrupt normal physiologic birth based on the best available evidence;
• Create a template for system changes through clinical practice, education, research, and health policy; and
• Ultimately improve the health of mothers and infants, while avoiding unnecessary and costly interventions.

A normal physiologic labor and birth is one that is powered by the innate human capacity of the woman and fetus. This birth is more likely to be safe and healthy because there is no unnecessary intervention that disrupts normal physiologic processes.  Some women and/or fetuses will develop complications that warrante medical attention to assure safe and healthy outcomes.  However, supporting the normal physiologic processes of labor and birth, even in the presence of such complications, has the potential to enhance best outcomes for mother and infant.

These three organizations recognize the current state of U.S. maternity care and acknowledge how technology and interventions are being commonly used despite the lack of scientific evidence supporting routine applications. (Sakala, 2008.)  Some of the interventions cited including pitocin being used to induce or augment more than half of all pregnant women’s labors. (Declercq, Sakala, 2006.)  The cesarean rate in the United States is more than 33%. (Martin,Hamilton, Ventura 2011.) This cesarean rate is not without risks for both mothers and babies with the original cesarean birth but also recognizes the complications to subsequent pregnancies and birth.  The organizations also commented that women who have perceived their birth or the care they received as traumatic or disrespectful are more likely to develop postpartum mood disorders and potentially difficulty in establishing healthy mother-infant attachment. (Beck, 2004), (Beck, Watson, 2008), (Beck, 2006).

The consensus statement goes on to state the characteristics of normal physiologic birth;

• is characterized by spontaneous onset and progression of labor;
• includes biological and psychological conditions that promote effective labor;
• results in the vaginal birth of of the infant and placenta;
• results in physiological blood loss,
• facilitates optimal newborn transition through skin-to-skin contact and keeping the mother and infant together during the postpartum period; and
• supports early initiation of breastfeeding. (World Health Organization 1996).

When I was reading the above list, as outlined by the World Health Organization and cited in the consensus statement,  I was stuck by how these statements are in sync with Lamaze International’s Healthy Birth Practices.  I was also a bit discouraged that these statements, published by WHO in 1996 sometimes still seem a distant goal.

There are factors that interfere with the normal physiologic process, including many that you may be very familiar with; induction or augmentation of labor, lack of a supportive environment, time limits on labor, denial of food and drink, pain medications, episiotomies, vacuum or forceps assisted deliveries, cesareans, immediate cord clamping, separation of the new mother from her newborn and finally, a situation that may feel threatening or unsupportive to the mother.

The consensus statement recognizes the numerous short-term and long-term health implications of normal birth to the mother-baby dyad.  Allowing labor and birth to unfold without interference permits labor and birth hormones to work effectively, thereby reducing the need for the familiar “cascade of interventions.”

For most women, the short-term benefits of normal physiologic birth include emerging from childbirth feeling physically and emotionally healthy and powerful as mothers…A focus on these aspects of normal physiologic birth will help to change the current discourse on childbirth as an illness state where authority resides external to the woman to one of wellness in which women and clinicians share decisions and accountability. (Kennedy, Nardini, McLeod-Waldo, 2009).

When women enter motherhood from a position of strength and confidence, babies benefit, families benefit and society benefits.  Multiple factors for the woman, the clinician and the birthing environment help to promote women birthing without intervention.  All three sides of an important triad need to share equal responsibility in meeting this goal.

The consensus statement indicates that education plays a role in helping women obtain a normal physiologic birth.  The role of the childbirth educator cannot be underestimated.  Sharing the values of Lamaze and the Lamaze Healthy Birth Practices is right in line with the midwifery statement.

ACNM, MANA and NACPM go on to encourage hospital policies to be set that support normal birth, the recognition that care practices need to be evidenced based.  Midwifery care is a “key strategy” in that direction.  Education of clinicians on care practices that promote physiologic birth and furthering research on the effects of normal birth, among other things.

This consensus statement is clear and powerful in demonstrating that our mothers and babies deserve, depend on and require the opportunity to birth without interventions and that everyone will benefit as a result, in the absence of medical complications or medical need.  I look forward to policy changes, increased accessibility of mothers to midwives and the midwifery model of care and collaboration of all health care providers, both doctors and midwives, to promote practices that result in an increase in normal physiologic birth.

Take a moment to read the entire consensus statement and let me know what you think?  A step in the right direction?  What comes next?  Do you think it is exciting that these three organizations have worked together to come out with this bold challenge to make change? What do you do in your childbirth classes or with the women you work with to promote these values represented by the consensus statement.  Would you add anything else?   I welcome your discussion in our comments section. – SM

 Sources

Beck CT. Birth trauma: in the eye of the beholder. Nurs Res. 2004; 53(1):28-35.

Beck CT, Watson S. The impact of birth trauma on breastfeeding: a tale of two pathways. Nurs Res. 2008; 57(4):228-236.

Beck CT. The anniversary of birth trauma: failure to rescue. Nurs Res. 2006; 55(6): 381-390.

Beck CT.Post-traumatic stress disorder due to childbirth:the aftermath.NursRes, 2004; 53(4):216-224.

Declercq ER, Sakala C, Corry MP, et al. Listening to mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection; 2006.

Kennedy HP, Nardini K, McLeod-Waldo R, et al. Top-selling childbirth advice books: a discourse analysis. Birth. 2009;36(4):318-324.

Martin JA, Hamilton BE, Ventura SJ, et al. Births: preliminary data for 2010. Natl Vital Stat Rep. 2011; 60(2):1-25.

Sakala C, Corry MP. Evidence-based maternity care: what it is and what it can achieve. New York, NY: Milbank Memorial Fund; 2008.

World Health Organization. Care in Normal Birth: A Practical Guide. World Health Organization; 1996.

Sharon Muza Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Epidural Analgesia, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, Home Birth, Infant Attachment, informed Consent, Maternal Mental Health, Maternal Mortality, Maternal Quality Improvement, Medical Interventions, Midwifery, Newborns, Pain Management, Push for Your Baby, Transforming Maternity Care ACNM, birth trauma, Healthy Birth Practices, Healthy Care Practices, infants, interventions, Lamaze International, MANA, Midwifery Care, midwives, NACPM, newborns, Sharon Muza, traumatic birth, WHO, World Health Organization

This is a guest post by Trish DeTura, RN, CNM, MS, MAMA President

Pregnancy is such an exciting time in a woman’s life filled with the great wonder of what is to be. However, it may also be a time of great stress as a woman’s body goes through a great metamorphosis. Some of the common discomforts of pregnancy are round ligament pain, indigestion, aching back and pelvic pressure, just to name a few.

Add to this list the mental/emotional challenges a woman experiences in pregnancy surrounding the uncertainty around motherhood, sadness and depression.

One wonders as a practitioner, what can I offer this woman that will benefit her and her unborn baby?

While attending the Art of Birthing Conference in the New York Academy of Medicine in 2000, I found a wonderful complementary technique.

Complementary techniques are popularly used by many women for the relief of aches and pains during pregnancy and birthing (Jones et al, 2012). Leanna Jones and her colleagues (2012) found complementary methods were most often offered and used in midwife-led births. Relaxation, acupressure/acupuncture, massage and immersion in water were found to provide pain relief and positive maternal outcome without invasive side effects. Also, regarding acupuncture/acupressure, a decrease in the use of forceps, ventouse and cesarean section was noted (Jones et al; 2012).

I learned about Maya Abdominal Massage from Rosita Arvigo and Ms. Hortense Robinson. Rosita is a naprapath, herbalist and teacher of Maya medicine. She who apprenticed with Don Elijio Pante, a traditional Maya healer, in Belize, Central America. Ms. Robinson is a midwife.

They shared how the Arvigo Technique of Maya Abdominal Therapy (ATMAT), restores the body to its natural balance by correcting the positions of organs that have shifted and restrict the flow of lymph, blood, nerve and qi energy. Thus, ATMAT promotes homeostasis.

As a result of ATMAT, the pregnant woman experiences an increase of arterial blood carrying oxygen, nutrients and minerals to the mother and her unborn along with removal of any waste via the venous system and lymph. In addition, the mom experiences a removal of any congestion or blockages enhancing better hormonal, nerve flow and flow of chi.

I thought this all made good physiologic and common sense. I was hooked! Onward to learning this technique to support women with all kinds of challenges then onward to learning the pregnancy aspect of this method.

This gentle, non-invasive approach of this abdominal massage begins at 20 weeks of gestation continuing up to when the woman delivers. ATMAT eases the common discomforts of pregnancy.

I find it to be a lovely complement to a midwifery practice, the mom gets to focus on her baby and her developing baby intimately, thus preparing her to open psychologically and physically to her pregnancy and birth.

Tiffany Field, Ph.D. at the Touch Research Institute in Miami, has collected extensive data on the profound healing effects of touch, which is what ATMAT is- healing and nurturing touch- for both the mother and her unborn.

In the Journal of Psychosomatic Obstetrics and Gynecology, Field (2010) published a study demonstrating that regular massage during pregnancy results in: decreased anxiety, improved mood, reduced back pain, improved sleep patterns, reduced stress hormone levels, fewer complications during labor and fewer complications for infants following birth.

Further, Field (2010) reports women who have received massage therapy experienced significantly less pain and their labors were on the average three hours shorter.

The data collected by the midwives providing ATMAT to their pregnant clients supports these findings. In addition to the shortening of labors, mothers who receive ATMAT bond with their unborn baby leading to less postpartum depression. This has been substantiated by Dr. Tiffany Field and her colleagues in a 2009 study revealing that postpartum depression was lessened as a result of prenatal massage.

It is my hope that one day the Arvigo Technique of Maya Abdominal Therapy will be recognized as an essential and vital aspect of maternity care. To learn more about this great modality please go to: www.Arvigotherapy.com

References:

Field, T. (2010). Pregnancy and labor massage therapy. Expert Review of Obstetrics and Gynecology, 5, 177-181.

Field, T., Diego, M., Hernandez-Reif, M., Deeds, O., & Figueiredo, B. (2009). Pregnancy massage reduces prematurity, low birthweight and postpartum depression. Infant Behavior & Development, 32, 454-460.

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP.Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Trish DeTura, RN, CNM, MS specializes in the Arvigo Technique of Maya Abdominal Massage, a non-invasive and natural technique of restoring health to the reproductive organs. She is in private practice in Hoboken, NJ. Contact her at trishdetura@gmailcom

Kathy Morelli Cesarean Birth, Childbirth Education, Continuing Education, Do No Harm, Guest Posts, Midwifery, Pain Management, Uncategorized complementary techniques, massage, Maya Abdominal Massage, midwife, Midwifery Care, mindbody techniques, relaxation, relaxation in childbirth

As a childbirth professional or an expectant parent, do you wonder about the multitude of pain management techniques offered for childbirth?

As part of the Cochrane Collaboration, Leanne Jones and eight of her colleagues (2012) has published new research synthesizing divergent data constructs and summarizing 355 trials on pain management during childbirth. There are many detailed data tables associated with this study.

To view the entire study, Lamaze members can access the full Cochrane Library, via the Members Only Section.

A summary of the study is below.

Background

In 2007, the Cochrane Pregnancy & Childbirth Group (PCG) consumer’s group identified pain relief in childbirth as the topic of most importance to them.

This study was funded to provide an evidence-based summary of the efficacy and safety of pain management methods in childbirth for consumers, policy-makers, and childbirth educators.

Women experience pain in childbirth in varying degrees of intensity, influenced by physiological and psychosocial factors. Most women require some type of pain relief. Both non-pharmacological and pharmacological methods are used for pain management.

312 Studies Reviewed

Collecting the totality of evidence from existing randomized controlled trials, the researchers identified 18 total systematic reviews for inclusion in their study. 15 reviews were Cochrane reviews (257 included trials) and 3 were non-Cochrane reviews (55 included trials). Data from a total of 312 studies were reviewed in this study.

There were more studies of pharmacological interventions than non-pharmacological interventions.

13 Outcomes Identified for Inclusion

The researchers, in partnership with the PCG consumer group, identified these outcomes for inclusion in the study.

Effects of interventions

• Pain intensity (as defined by trialists)
• Satisfaction with pain relief (as defined by trialists)
• Sense of control in labor (as defined by trialists)
• Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

• Effect (negative) on mother/baby interaction
• Breastfeeding (at specified time points)
• Assisted vaginal birth
• Cesarean section
• Adverse effects (for women & babies)
• Admission to special care baby unit / NICU
• Apgar score less than at five minutes
• Poor infant outcomes at long-term follow-up (as defined by trialists)

15 Childbirth Management Methods Identified

The researchers identified a list of 15 childbirth pain management methods:

• placebo/no treatment
• hypnosis
• biofeedback
• intracutaneous or subcutaneous sterile water injection
• immersion in water
• aromatherapy
• relaxation techniques (yoga, music, audio)
• acupuncture or acupressure
• massage, reflexology or manual methods
• TENS
• inhaled analgesia
• opioid
• non-opioid drugs
• local anesthetic nerve blocks
• epidural

 As a Lamaze childbirth educator, how will you incorporate respect for your client’s individual decisions while presenting the Six Lamaze Healthy Birth Practices?

Results: Non-pharmacological Studies

The authors found that non-pharmacological methods are mostly used in midwife-led continuity of care births and/or where women had continuous intrapartum support. Such non-pharmacological methods are meant to break the fear-pain-tension cycle and to work within the pain paradigm. The pain paradigm of birth is a philosophy based on the idea that pain is a normal part of the physiology of labor and that women can use coping methods to manage the pain (Leap, 2008; as cited in Jones et al, 2012).

The researchers found the evidence for many non-pharmacological methods to be mostly incomplete as there is an average of only two studies for each method.

However, the following non-pharmacological methods are shown to provide pain relief and positive maternal psychological outcomes without invasive side effects: immersion in water, relaxation, acupuncture/acupressure and massage.

In addition, women report greater emotional satisfaction with childbirth when using immersion and relaxation. With the use of relaxation and acupuncture/acupressure, there is a decrease in the use of forceps and ventouse. There is a decrease in the amount of cesarean section associated with the use of acupuncture/acupressure.

The researchers report there is insufficient evidence to report on pain relief using the following methods: hypnosis, biofeedback, sterile water injection, aromatherapy and TENS.

Results: Pharmacological Studies

There are more studies of pharmacological methods versus non-pharmacological methods. The authors found that pharmacological methods relieve pain and have side effects.

Pharmacological methods are most likely to be used in settings with a pain relief paradigm. In the pain relief paradigm of labor, pain is considered barbaric, the benefits of analgesia outweigh the risks, and women should be free to use whatever pain relief methods she wishes, without guilt (Leap, 2008; as cited in Jones et al, 2012).

Comparative Pain Relief & Side Effects

Epidural, combined spinal epidural (CSE) and inhaled nitrous oxide & oxygen relieve pain better when compared to opioids (Jones et al, 2012).

Epidurals are associated with an increase of the use of forceps or ventouse, an increase in the risk of low blood pressure, low motor blocks, fever and urine retention (Amin-Somanuh, 2005; as cited in Jones et al, 2012). In addition, other side effects such as shivering, tinnitus, and respiratory or cardiovascular depression may occur. The authors state it is uncertain whether the use of epidurals interfere with breastfeeding (Reynolds, 2011; as cited in Jones et al, 2012).

Combined spinal epidurals (CSE) provide faster pain relief than traditional epidurals, but are associated with more feelings of itchiness, giddiness, sweating, and tingling (Jones et al, 2012).

Inhaled nitrous oxide is associated with minimal toxicity and rapid maternal and neonate elimination, but can cause feelings of nausea, drowsiness and sickness (KNOV, 2009; Rosen, 2002; as cited in Jones et al, 2012).

Non-opioid drugs (acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS)) relieve pain for shorter periods of time as compared to opioid drugs (Bayarski, Hebbes, 200; as cited in Jones et al, 2012).

Opioid drugs (morphine, nalbuphine, fentanyl, parenteral and pethidine) are used worldwide. Parenteral opioids are reported to provide less pain relief than epidurals. Side-effects include impaired maternal capacity for decision-making, sedation, hypoventilation, hypotension and urine retention. Opioids readily cross the placenta, thus neonatal respiratory depression and hypothermia are also concerns. Pethidine is shown to affect fetal heart rate variability during labor (Sekhavat, 2009; Solt, 2002; as cited in Jones et al, 2012), thus continuous fetal monitoring is recommended. Neonatal effects are inhibited and early cessation of breastfeeding and decreased alertness (Nissen, 1995; Ransjo-Arvidsen, 2001; Righard, 1990; Rajan, 1994; as cited in Jones et al, 2012).

Limitations Found in the Studies

The authors state the studies use differing methods to measure pain management outcomes. Many do not at all measure maternal psychological outcomes (feelings of intrinsic self-control), mom-baby interaction, or breastfeeding and infant outcomes.

Conclusions

This study shows consumers rate pain management as a high priority in childbirth, however, after 30 years of research, standardized pain management and outcome measurements have not been created.

The authors suggest their outcome guidelines, developed with consumer input, be adopted for use in future research.

Overall, women should feel free to choose whatever methods of pain relief they wish, both non-pharmacological and pharmacological, for their individual childbirth experience.

As part of a childbirth preparation program, women should be informed of the efficacy and potential side-effects on both themselves and their babies of non-pharmacological and pharmacological methods of pain relief for childbirth.

Hopefully this study will generate an effort to standardize the constructs associated with research of measurements of pain management in labor, maternal psychosocial satisfaction, and maternal-baby outcomes.

References

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

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