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Cochrane Systematic Review Supports Lamaze Healthy Birth Practice #2- Walk, Move Around And Change Positions Throughout Labor

December 19th, 2013 by avatar
Image Source: © Sharon Muza

Image Source: © Sharon Muza

Today, author Henci Goer takes a look at a new Cochrane Systematic Review; “Maternal positions and mobility during first stage labour” and finds that the results of this review support the 2nd Lamaze International Healthy Birth Practice: Walk, move around and change positions throughout labor. Families taking Lamaze childbirth classes learn how they can promote physiologic birth by using a variety of positions throughout their labor, but women don’t have to take a childbirth class to know that walking and trying different positions reduces pain and speeds up labor.  Intuitively, women respond to the needs of their baby and their body during labor.  Henci examines the review and shares some of the benefits that were found in the women who followed the 2nd Healthy Birth Practice to promote safe and healthy birth. – Sharon Muza, Community Manager.

Advocates for physiologic care in labor will be pleased, although not surprised, to know that a Cochrane systematic review supports mobility and upright positioning in first-stage labor (the cervical dilation phase) (Lawrence 2013.) The review includes 18 randomized controlled trials (RCTs) comprising 3337 women not having epidurals at trial entry and 7 trials comprising 1881 women in which all participants had epidurals or combined spinal-epidurals at trial entry.

The body of data poses challenges in analysis and interpretation. Trials were published between 1963 and 2012 and conducted in 13 countries. As reviewers note, this means that they took place in highly varied cultural and healthcare contexts, equally varied expectations on the part of staff and laboring women, and with evolving healthcare technologies, all of which could influence results. In addition, comparison “treatment” and “control” groups also varied widely and overlapped among them. So, for example, one trial compared walking with remaining in bed in whatever posture, including upright postures; another compared walking with recumbent postures; and still another combined sitting and walking as upright postures and compared them with recumbent postures. That being said, here is what the reviewers found:

Compared with recumbent postures and bed care, upright postures and walking in women without epidurals at trial entry:

• Shortened first-stage labor duration by a mean difference of 1 hour 22 minutes in women overall (15 trials, 2503 women) and by 1 hour 13 minutes in first-time mothers (12 trials, 1486 women). In women with prior births (4 trials, 662 women), duration differed by only 34 minutes, and the difference just missed achieving statistical significance, that is, statistical analysis shows that the difference is unlikely to be due to chance. By comparison, rupturing membranes, commonly used to “get the show on the road,” had no effect on first-stage duration in women overall (5 trials, 1127 women) (Smyth 2013), and too few women were reported according to first-time or prior births to draw meaningful conclusions.

• Decreased likelihood of cesarean delivery (14 trials, 2682 women) by 30%. Likelihood decreased by 20% in first-time mothers (8 trials, 1237 women) and 40% in women with prior births (4 trials, 775 women), but the differences didn’t achieve statistical significance probably because aggregated numbers were too small (underpowered) and cesarean rates too low to detect a difference. By contrast, rupturing membranes increases the likelihood of cesarean surgery by 30%, a risk that misses achieving statistical significance by a whisker and probably would have achieved significance had not so many women assigned to “conserve membranes” actually had their membranes ruptured (Smyth 2013).

• Reduced use of epidural analgesia (9 trials, 2107 women) by 20%.

• Didn’t increase satisfaction or decrease complaints of pain, but only one small study (107 women) measured satisfaction, and among the three trials (338 women) evaluating pain, women reported less pain in two of them, but in the third (201 women), which comprised 60% of the population overall, participants assigned to sit or walk were not allowed to lie down at any time during first stage. Bloom et al. (1998), by far the largest of any of the trials at 1067 participants, wasn’t included in the pain and satisfaction assessments probably because they took a different approach. They asked women who walked whether they would want to walk in a future labor. Ninety-nine percent said “Yes,” which would seem a ringing endorsement of ambulation.

• Showed no evidence of increasing maternal, fetal, or neonatal harm. In fact, one small trial (200 women) reported significantly fewer admissions to neonatal intensive care.

Benefits were maintained when subgroupings of upright postures were compared with subgroupings of recumbent postures, as for example, walking compared with recumbent/supine/lateral or sitting and standing, squatting, kneeling, or walking compared with recumbent/supine/lateral.

No benefits were found for walking or upright postures (7 trials, 1881 women) in women who had epidurals or combined spinal-epidurals at trial entry. This doesn’t really mean much, though, because in some trials, substantial percentages of women assigned to walk didn’t actually do so, and in others “ambulation” was defined to be as little as 5 minutes of walking per hour.

The review leaves some questions open: Can mobility be used to treat delayed progress? Should women with ruptured membranes be allowed to walk? What about women at risk for fetal compromise? To the first question, it makes sense to encourage walking and upright positioning as a first-line measure to treat progress delay. The alternatives, rupturing membranes and oxytocin augmentation, have potential harms while walking and position changes don’t. To the second, when upright, gravity would tend to bring the presenting part downward to block the cervical opening, thereby protecting against umbilical cord prolapse. A common sense approach might be to monitor fetal heart tones throughout a contraction upon the woman first assuming an upright position and repeat whenever she returns to an upright position after lying down. To the last question, studies would need to be done, but rupturing membranes increases risk of fetal compromise by releasing the fluid that prevents umbilical cord compression (you can’t compress a liquid), and augmentation increases contraction intensity, which also could increase risk of compromise in a vulnerable fetus.

The true benefits of mobility are almost certainly much greater than the review shows. This is because RCTs are analyzed according to “intent to treat,” that is, participants are kept with their assigned group regardless of their actual treatment. To do otherwise would negate the point of random assignment, which is to avoid bias; however, when substantial percentages of participants receive the treatment of the other group, as is the case with many of the mobility RCTs, it both diminishes differences between groups and makes it harder to detect a significant difference between them. This was a problem in all the mobility RCTs, not just the ones where women already had regional analgesia on board. Again, take Bloom et al. (1998): among women assigned to walk, 22%—approaching 1 in 4—never walked at all, and of the women who did, the mean time spent out of bed was an hour mostly because of policies that kept them in, or returned them to, bed.

The reviewers conclude:

[W]e believe wherever possible, women should be informed of the benefits of upright positions, encouraged and supported to take up whatever positions they choose, they should not have their freedom of movement options restricted unless clinically indicated, and they should avoid spending long periods supine (p. 23).

It isn’t enough, though, to advise women that it’s a good idea to stay mobile and stay off their backs unless staff follow through on not restricting freedom of movement. As matters currently stand, conventional hospital labor management couldn’t do a better job of restricting mobility if that were its intended goal. To turn that around, hospitals would need to:

• Provide an environment conducive to mobility, including ample space for moving around and props such as birth balls, rocking chairs, and cushions,

• Provide comfort measures such as hot and cold packs, private showers, and soaking tubs to reduce and delay use of epidural analgesia,

• Train staff in encouraging and providing physical assistance in changing positions, in the use of mobility props, and in how to provide emotionally supportive care,

• Welcome doulas who can share the burden of providing physical and emotional support,

• Use intermittent listening to fetal heart tones except when continuous monitoring is medically indicated,

• Reserve IVs for medical indications, which would mean allowing women oral intake of fluids and calories, and

• When mobility-inhibiting interventions are required or the woman desires an epidural, minimize their impact by such measures as telemetry monitoring, inserting IV catheters in the forearm rather than the hand or wrist or using saline locks instead of IVs, and encouraging women with epidurals to assume upright positions and change positions periodically.

In other words, promoting mobility in labor is the proverbial tip of the iceberg. Floating below is the vast bulk of providing physiologic care. That won’t be easy for a number of reasons.

For one thing, medical research principles require that investigators define the intervention under evaluation precisely and maximize compliance with its administration. But this is the direct opposite of women doing what instinctively feels best in an environment that encourages their experimentation and is free from elements that inhibit or restrict them. We have no trials that compare this style of care with conventional medical-model management, which means we don’t have data showing the true degree of harm arising from confining and circumscribing mobility in labor or the magnitude of the benefits to be gained with promoting it. Without that knowledge, there is little incentive to change.

For another, in the topsy-turvy world of medical-model research, maternal movements and physiologically normal behaviors are framed as “interventions.” This means that being up and around and having the freedom to labor in the positions of the woman’s choice has to prove itself, not confinement to bed and positioning restriction. What is more, to institute change, the “intervention” must prove itself superior according to medical model concepts of improved outcomes, or conventional management stands, however much that management lacks an evidence basis. This explains how Bloom and colleagues could entitle their trial “Lack of effect of walking on labor and delivery” despite walking having no harms and 99% of women who walked wanting to do so again in a future labor.

Finally, powerful forces line up against instituting the sweeping changes that would be required to convert to mobility-friendly care. Inertia is one. People will generally resist change even when it benefits them personally, which in this case it doesn’t. Economics is another. The costs of maintaining a 24/7 obstetric analgesia service demand that most women have epidurals while any renovation expenses, such as providing private showers, soaking tubs, or telemetry monitoring, would not be reimbursed. Hospital culture is perhaps the biggest obstacle of all. “This is the way we’ve always done it” and “what is must be right” are potent impediments to improvement. Specifically, so long as reducing cesarean rates isn’t a shared, strongly-held goal—and a cursory glance at hospital cesarean rates shows that it isn’t in most hospitals—motivation to change will be low.

All of this is to say that reform won’t be easy, not that it can’t be done, and, I would add, the wellbeing of mothers and babies obliges us to try. In that interest, can we crowd source strategies? Are any hospitals in your community mobility friendly? What are their practices and policies? Have any of you been involved in projects to increase mobility in labor, and if so, what went well and what would you do differently?

References

Bloom, S. L., McIntire, D. D., Kelly, M. A., Beimer, H. L., Burpo, R. H., Garcia, M. A., & Leveno, K. J. (1998). Lack of effect of walking on labor and delivery. N Engl J Med, 339(2), 76-79. http://www.ncbi.nlm.nih.gov/pubmed/9654537?dopt=Citation

Lawrence, A., Lewis, L., Hofmeyr, G. J., & Styles, C. (2013). Maternal positions and mobility during first stage labour. Cochrane Database Syst Rev, 10, CD003934. doi: 10.1002/14651858.CD003934.pub4 http://www.ncbi.nlm.nih.gov/pubmed/24105444

Smyth, R. M., Markham, C., & Dowswell, T. (2013). Amniotomy for shortening spontaneous labour. Cochrane Database Syst Rev, 6, CD006167. doi: 10.1002/14651858.CD006167.pub4 http://www.ncbi.nlm.nih.gov/pubmed/23780653

 

Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, New Research, Push for Your Baby, Research , , , , , ,

The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

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The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

Ten Facts on the State of Premature Birth – Honoring World Prematurity Day

November 19th, 2013 by avatar

November 17th is recognized as World Prematurity Day and many maternal-infant health organizations share research, blog posts, information, fact sheets, videos and other resources on the topic to be used by professionals and consumers alike. The purpose of the  international effort has been to focus on the the impact that premature birth has on the babies themselves, families and society.  This year marks the third annual event.

The four worlds into which 135 million newborns are born each year. © Born Too Soon: The Global Action Report on Preterm Birth.

Here are 10 facts about premature birth that you may not have known:

1. 15 million babies are born prematurely every year out of the 135 million babies worldwide. This number is equal to the entire population of Guatemala or Kazakhstan.

2. 1 million of those babies born early die due to prematurity and account for 1/3 of the world’s newborn deaths.

3. Boys are 14 percent more likely than girls to be born prematurely, and preterm boys have a greater risk of disability and death than preterm girls.  This may be because mothers are more likely to have pre-eclampsia, placental problems and gestational hypertension if they are carrying a boy.  These conditions are more likely to result in a preterm birth.

4. Preterm girls are more likely than boys to die in the first month of life in some countries where girls receive less nutrition and medical care than boys.

5. The USA has seen a 30 percent increase in preterm births in the past 20 years, reaching a high in 2006 at 12.8% of all births in the USA.

6. 450,000 babies in the USA are born too soon, around 1 out of 9 babies.  The USA has a prematurity rate that is higher than most other developed nations.

7. Three states, Louisiana, Mississippi and Alabama, along with Puerto Rico receive a grade of “F” for their prematurity rates; Preterm birth rate greater than or equal to 14.6%

8. In the United States, African-American and Native American babies have the highest neonatal death rate associated with prematurity.  Yet another unfortunate consequence of the health disparities and inequities that families of color face in the USA.another way that racial disparities and inequities in health care.

9. 10% of premature babies born before 28 weeks die in high-income countries, while 90% of premature babies born before 28 weeks die in low-income countries.

10. “Three quarters of the 1 million babies who die each year from complications associated with prematurity could have been saved with cost-effective interventions, even without intensive care facilities.” - UN Secretary General Ban Ki-moon.  These two interventions are antenatal steroids and Kangaroo Care.

Lamaze International is working alongside other national and international organizations to educate women about preterm births, how to identify premature labor and who is at risk.  In that vein, on Thursday, Lamaze International will reveal a brand new infographic here on the blog covering the topic of induction for professionals to use with their students, clients and patients.  Lamaze International is proud to be doing their part to help reduce needless newborn deaths and increase awareness on the topic.

Resources and References 

Every Newborn

Healthy Babies are Worth the Wait

HealthyChildren.org

March of Dimes

March of Dimes Prematurity Infographic

Lawn, Joy E., Blencowe, Hannah, Darmstadt, Garly L., Bhutta, Zulfigar A. Beyond newborn survival; the world you are born into determines your risk of disability-free survival.  Pediatric Research, International Pediatric Research Foundation, Inc. 2013/11/15.


 

Babies, Childbirth Education, Maternity Care, Newborns, Push for Your Baby , , , , ,

Lamaze International Releases Valuable Cesarean Infographic For You To Share!

October 10th, 2013 by avatar

Lamaze International has long been a leader in providing resources for both parents and birth professionals that promote safe and healthy birth for women and babies.  Evidence based information, appealing handouts, useful webinars for both parents and professionals, continuing education opportunities and more can all be found within the Lamaze International structure.  In May, 2012, Lamaze International released  (and later went on to be a co-winner for the 2013 Nonprofit PR Award for Digital PR and Marketing) the Push For Your Baby campaign, which encouraged families to “push for better” and “spot the best care,” providing resources to help parents wade through the overabundance of often inaccurate information swimming past them, and make choices that support a healthy pregnancy, a healthy birth and a healthy mother and baby.

Today, as I make my way to New Orleans, to join other professionals at the 2013 Annual Lamaze International Conference, “Let the Good Times Roll for Safe and Healthy Birth,” Lamaze International is pleased to announce the release of a useful and appealing infographic titled “What’s the Deal with Cesareans?” In the USA today, 1 in 3 mothers will give birth by cesarean section.  While, many cesareans are necessary, others are often a result of interventions performed at the end of pregnancy or during labor for no medical reason.  For many families, easy to understand, accurate information is hard to find and they feel pressure to follow their health care provider’s suggestions, even if it is not evidence based or following best practice guidelines.

Families taking Lamaze classes are learning about the Six Healthy Birth Practices, which can help them to avoid unnecessary interventions. Now, Lamaze childbirth educators and others can share (and post in their classrooms) this attractive infographic that highlights the situation of too many unneeded cesareans in our country.  Parents and educators alike can easily see what the risks of cesarean surgery to mother and baby are, and learn how to reduce the likelihood of having a cesarean in the absence of medical need.

In this infographic, women are encouraged to take Lamaze childbirth classes, work with a doula, select a provider with a low rate of cesarean births, advocate for vaginal birth after cesarean and follow the Six Healthy Care Practices, to set themselves up for the best birth possible.  This infographic clearly states the problem of unneeded cesareans, the risks to mother and baby, and provides do-able actions steps.

It is time for women to become the best advocate possible for their birth and their baby.  With this appealing, useful and informative infographic poster, families can and will make better choices and know to seek out additional information and resources.

Educators and other birth professionals, you can find a high resolution infographic to download and print here.

Send your families to the Lamaze International site for parents, to find the infographic and other useful information on cesarean surgery.

For Lamaze members, log in to our professional site to access this infographic and a whole slew of other useful classroom activities, handouts and information sheets.

I am proud to say that I am a Lamaze Certified Childbirth Educator, and that my organization, Lamaze International, is leading the way in advocating for healthier births for mothers and babies through sources such as the “What’s the Deal with Cesareans?” infographic and other evidence based information and resources.  Thank you Lamaze!

What do you think of this infographic?  How are you going to use it with the families you work with?  Can you think of how you might incorporate this into your childbirth classes or discuss with clients and patients?  Let us know in the comments section, we would love your feedback!  And, see you at the conference!

 

 

Babies, Cesarean Birth, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Lamaze International, Lamaze International 2013 Annual Conference, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, Patient Advocacy, Push for Your Baby , , , , , , , , ,

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

July 11th, 2013 by avatar

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

______________________

 

© www.momaroo.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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