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April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
Images

  1. Patti Ramos
  2. creative commons licensed ( BY-NC ) flickr photo shared by Neal Gillis
  3. creative commons licensed ( BY-SA ) flickr photo shared by remysharp
  4. creative commons licensed ( BY-NC-SA ) flickr photo shared by mikeandanna
  5. creative commons licensed ( BY-NC-SA ) flickr photo shared by mikeandanna
  6. creative commons licensed ( BY-SA ) flickr photo shared by Kelly Sue
  7. creative commons licensed ( BY ) flickr photo shared by Marie in NC
  8. creative commons licensed ( BY-NC-SA ) flickr photo shared by lucidialohman
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  10. creative commons licensed ( BY-NC-SA ) flickr photo shared by emergencydoc
  11. creative commons licensed ( BY-NC-ND ) flickr photo shared by Mwesigwa

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

April 8th, 2014 by avatar

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

PeanutBall-measure

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

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

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

PeanutBallCollage

© Maternal Focus

The Research

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

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

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

The Mother’s Experience

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

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

Maternal Preferences and Positioning

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

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

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

Epidural Experiences

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

Effect on Labor Progress

A few moms reported some pretty dramatic results:

A Doula’s Perspective

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

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

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

The L&D Nurse’s Perspective

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

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

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

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

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

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

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

Conclusion

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

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

To learn more about peanut balls:

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

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

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

References

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

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

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

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

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

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

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

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Home Birth After Hospital Birth: Women’s Choices and Reflections – A Research Review by Jessica English

April 3rd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD(DONA), BDT(DONA)

Today’s research examines the factors that influenced women who chose home birth for the subsequent child, after their previous child was born in a hospital.  Lamaze Certified Childbirth Educator Jessica English, along with midwifery colleagues just published “Home Birth After Hospital Birth: Women’s Choices and Reflections” in the Journal of Midwifery and Women’s Health.  Jessica shares about the research, some of the findings and wraps up speaking about the role that childbirth educators can play in helping women to find satisfaction in their chosen birth location. Are you an LCCE and have published research?  Consider writing a review for S&S.  I would love to highlight our LCCEs.  - Sharon Muza, Science & Sensibility Community Manager.

As a childbirth educator and doula, I have been listening to women’s birth stories for many years. I’m honored that they trust me again and again with the details of their triumphs, frustrations, joys and sometimes outright trauma. When my agency, Birth Kalamazoo, organized a meeting in 2011 to discuss the midwifery model of care, I didn’t think much of it when the attendees introduced themselves and shared a few details about their births. After all, I knew most of them very well (having taught them or in some cases even attended their births), and I knew their stories.

But one of the midwives we’d invited to speak that day took special note of those stories. Ruth Zielinski, PhD, is a hospital-based nurse-midwife, university professor and researcher in my community. She noticed that a handful of the women who spoke mentioned that they had given birth to their first baby in the hospital, then chose home birth for later babies. She approached me after the meeting, curious about why the women might have chosen home birth after their hospital experiences. I shared my perceptions based on my experience listening to women. Intrigued, Ruth wondered if this was something we could research? Neither of us had ever seen academic research on the topic of women who chose home birth after a hospital experience. Soon enough, we had a four-woman research team in place: Ruth; myself; Kelly Ackerson, an academic colleague from Ruth’s department of nursing; and one of Ruth’s undergraduate students, an honors nursing student who was planning a career in midwifery.

Our first task was to identify the structure of the research process. How would we get the information we needed? We settled quickly on focus groups, and wrote a series of open-ended questions that we expected to elicit the participating women’s honest assessments of both their home and hospital experiences, as well as the reasons behind their decision to choose home birth. The next step was to recruit the participants. Through Birth Kalamazoo’s Facebook page, our e-newsletter and via local midwives, we invited women who fit our criteria to participate in a focus group. The primary requirement was that they needed to have had at least one hospital birth followed by at least one home birth within the past 10 years.

Five focus groups followed, each with four participants and two researchers (one who asked the questions and one who took field notes). The focus groups were transcribed verbatim by members of the research team. After each focus group, team members conferred to make sure that we were in agreement about the themes that were starting to emerge. After the fifth focus group, we agreed that no new themes were emerging and we had reached “saturation of the data.” Led by Ruth and her student Casey Bernhard, the research team identified five themes that summarized what the mothers had shared. A sixth focus group of women (one from each prior focus group) provided “member checking” – we shared the themes we’d identified and asked them to verify whether or not they were in keeping with what they had heard during the focus groups.

The resulting research, “Home Birth After Hospital Birth: Women’s Choices and Reflections,” is published in the current issue of the Journal of Midwifery & Women’s Health.

Some Key Findings: Women’s Choices and Reflections

To summarize, five recurring themes were identified from the women’s reflections on both their hospital and home births: choices and empowerment; intervention and interruptions; disrespect and dismissal; birth space; and connection.

Choices and empowerment. The women in our groups reported that with their hospital births they felt they did not actually have much choice in the direction of their care. Although a few women in the study had generally positive hospital experiences, most reported feelings of disempowerment and limited choices associated with their hospital birth and more meaningful choices and feelings of empowerment with their home births.

Interventions and interruptions. During their hospital births, women experienced significantly more interventions compared to their home births. Many of the women in our study perceived these interventions as unnecessary. They commented on timetables, hospital “agendas” and interruptions both during the birth and postpartum period for their hospital births.

Disrespect and dismissal. Many of the women in our study said they felt that their hospital-based providers tended to focus more on anatomical parts and the medical process of birth, rather than on them as whole people. With their home births, they reported a much more holistic model with great respect for their decisions.

Some women who wanted to continue care with both a home birth provider and a hospital-based provider (known as “dual” or “concurrent” care) were dismissed from their hospital-based practice when they revealed that they were planning a home birth.

Birth space. Universally, women reported feeling more comfortable laboring in their own homes, surrounded by only the people they chose to invite into that space. Several women mentioned the appeal of having their older children with them for the birth, or at least having that option.

Connection. When women in our study reported positive hospital births, they also spoke of their positive connections to their providers. For both home and hospital settings, women said that feeling a sense of trust and connection to their doctor or midwife was important and even helped them to feel more comfortable with the process of birth. That theme of connection extended to women’s reflections that during their home births they also generally felt more connected to their bodies, to their babies and to other family members.

Reflections and Implications for Childbirth Educators

As an experienced Lamaze Certified Childbirth Educator and doula, I wasn’t surprised by the findings of our research. The reflections of the women participating were very much in keeping with the stories I have heard for almost a decade from my students, clients and even random women (and men!) who want to share their experiences. It does help me, however, to see the themes identified so clearly. I can envision sharing this research with women who are choosing a home birth for a second, third or fourth baby after a prior hospital birth. It may be validating to them to see many of their own feelings and reflections mirrored in other women’s experiences.

When I think about limitations of this study, I think about the natural differences between first and subsequent births. First births are often longer and more complex, with second and later births often shorter and more straightforward. Could that have influenced women’s feelings of empowerment? As an educator and doula, I also have observed that, after their first baby, many women in general feel more assertive and empowered to take control of their choices for their later birth experiences, whatever the birth setting.

In fairness to the hospital environment, it’s also important to remember that our study was limited to women who felt compelled to make a change for subsequent births. Women who have had very positive, respectful, low-intervention hospital births often choose that same setting for future babies, and their voices were not represented in our focus groups.

Our research may also have been influenced by the specific birth culture in Southwest Michigan. For example, women in our area sometimes want to receive care from both a hospital-based provider and a home birth midwife, but they are typically discharged from their hospital-based practice if they reveal they are planning a home birth. I know this isn’t the case in all areas of the country, and I can’t help but wonder if it’s due in part to the lack of licensing for Certified Professional Midwives (CPMs) in our state. Fellow LCCEs and doulas in states where CPMs are licensed have shared that women in their communities may have easier access to this kind of dual care. I think this issue merits further exploration, with research comparing the home birth experiences of women in various states where CPMs are licensed, unlicensed and specifically outlawed.

As I analyze our results with my childbirth educator hat on, I keep mulling the impact of feelings of safety and comfort on oxytocin. When women feel safe, nurtured, supported and comfortable, we know that the hormones of labor work more efficiently. Did the women in our study have more straightforward births at home in part because the environment allows their bodies to work optimally? I have given talks to labor and delivery nurses on ways they can boost oxytocin in the hospital environment, and as a doula trainer I also address this issue with new doulas. For many women, the home birth setting is inherently designed to maximize oxytocin.

The connection theme that arose in our study is also closely tied to oxytocin. In attending hospital births as a doula, I try to facilitate moments of connection between a woman and her care providers. Penny Simkin’s landmark research on women’s lasting birth memories also points to the importance of such relationships. (Simkin, 1991) Connection comes very naturally between a doula and her client, and often between a home birth midwife and a laboring woman as well. Those connections can be more difficult in a busy hospital environment where a woman is working with a nurse she has likely never met, and often with a provider who is one of many in a busy practice, and who may have several other patients in labor. Can we make more space within our medical system for nurture, if not for the emotional benefits then for the biological effect on the chemical balance in women’s bodies?

In addition to the connection challenges, the themes identified in our research also point to other weaknesses inherent in the medical model of birth. As an educator, I’m already thinking about how I can use these findings to help prepare families for more positive hospital-based experiences. How can they navigate the system to help prevent some of the pitfalls many of these women experienced during their hospital births? I believe so strongly that meaningful change in our system begins with families who speak up for what they need and want for their births. Childbirth educators are on the front lines to help educate families about what a positive, healthy birth experience can look like, and to prepare our students to advocate within the system they’ve chosen to support them.

As leaders in our birth communities, educators can also directly work for change by talking with nurses, midwives and physicians about what women are looking for in their births. Respectfully discussing both the points of dissatisfaction and satisfaction mentioned in this study can help reinforce positive behaviors and change those that may be detrimental to women and to birth. Many of the things women say they want for their births are strongly supported by quality scientific evidence. Take kangaroo care as an example. Ten years ago, a woman in our community might have said in this focus group that she wanted a home birth in part because her hospital providers refused to allow uninterrupted skin-to-skin contact for a few hours after the birth. Today, we have a hospital in our community that is a national leader in kangaroo care for all families and another that is trying to reach that benchmark.

Change is slow, but childbirth educators can help make it happen! Better birth is not just an issue of physical health and emotional well being, it is also financially beneficial to hospitals to flex to provide the compassionate, evidence-based care that will keep families within their system, coming back for subsequent births.

However, the intention of our research was not to dissuade women from home birth. For those who continue to choose that setting for later babies, it may be helpful for educators, doulas, midwives, physicians and others within the maternity care system to understand the factors that motivate them to make that informed choice for their families.

Would you share this research with your childbirth education students and expecting families?  How would you use it?  Do you think that the conclusions are valid?  Do you see things differently? Discuss with us in the comments section. – SM

References

Bernhard, C., Zielinski, R., Ackerson, K. and English, J. (2014), Home Birth After Hospital Birth: Women’s Choices and Reflections. Journal of Midwifery & Women’s Health. doi: 10.1111/jmwh.12113

Simkin, P. (1991). Just Another Day in a Woman’s Life? Women’s Long‐Term Perceptions of Their First Birth Experience. Part I. Birth, 18(4), 203-210.

About Jessica English

jessica english-bw head shotJessica English, LCCE, FACCE, CD(DONA), BDT(DONA) is a Lamaze Certified Childbirth Educator, birth doula and DONA-approved birth doula trainer. She is the owner of Birth Kalamazoo, which offers birth and postpartum doula services, natural childbirth and breastfeeding classes, birth photography, in-home lactation consulting and renewal groups for mothers. She is currently producing a short film about birth, due out in the fall.

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Midwifery, New Research, Research, Transforming Maternity Care , , , , , ,

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 , , , , , , , ,

Lamaze International Webinar- Six is the New Four: A Review of the Safe Prevention of the Primary Cesarean Delivery Consensus Report

March 24th, 2014 by avatar

Lamaze International is delighted to be offering a continuing education opportunity for all interested professionals.  ”Six is the New Four: A Review of the Safe Prevention of the Primary Cesarean Delivery Consensus Report” is being facilitated by Richard Waldman, M.D. and Peggy DeZinno, BSN, RN, LCCE from OB-Consult on Tuesday, April 8th, 2014 at 4 PM EDT.

A few weeks ago, Science & Sensibility’s Judith Lothian highlighted and reviewed the just released joint ACOG/SMFM report “Safe Prevention of the Primary Cesarean Delivery” and many agreed it was a game changer.  Many of the recommendations listed in the report appeared to be shifting away from current, but outdated practices and encouraging more evidence based care that promotes patience, expectant management and acknowledges that protocols need to be changed if there is to be a reduction in cesareans, particularly that primary (first) cesarean.
In this upcoming webinar, Dr. Richard Waldman and Peggy DeZinno will discuss the gap between current practice and the opinion paper’s recommendations.  What will it take to get us there?  What needs to change and where are the challenges?
Dr. Waldman is the former president of the American Congress of Obstetricians and Gynecologists and a keynote speaker at the 2013 Lamaze International Annual Conference that was held in New Orleans, LA.  You can read an interview I did with Dr. Waldman last summer and also read his article, “Birth as the Ultimate Collaboration” that he wrote for Science & Sensibility in advance of his keynote presentation.
Co-presenter Peggy DeZinno, BSN, RN, LCCE provides OB-Gyn-specific risk management services at OB- Consult. She has over 35 years of experience in the healthcare industry, specifically as a coordinator and instructor of women’s health and education programs.
At the end of this webinar, learners will be able to:
  • List two reasons why the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine developed a Consensus for the safe prevention of primary Cesarean Delivery.
  • Describe the definition and management of abnormally progressing first-stage labor.
  • Describe the definition and management of abnormal second-stage labor
  • Discuss the role of continuous labor support in decreasing primary Cesarean births.

Participants in the full hour of the webinar will be able to receive 1.0 Lamaze Contact Hour and 1.0 Nursing Contact Hour after completion of a post-webinar evaluation. Lamaze International is an approved provider of continuing nursing education by the American Nurses Credentialing Center Commission on Accreditation.

This webinar and the associated continuing education hour is provide free as a benefit of Lamaze International membership.  Non-Lamaze members are invited to participate for the reasonable fee of $20, which includes the continuing ed contact hour.  Register for the webinar now to reserve your place at this exciting event scheduled for April 8th, 2014 ag 4:00 PM EDT.

ACOG, Childbirth Education, Continuing Education, Evidence Based Medicine, Maternal Quality Improvement, New Research, Webinars , , , , , , ,