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Does the Hospital “Admission Strip” Conducted on Women in Labor Work as Hoped?

October 3rd, 2013 by avatar

The 20 minute electronic fetal monitoring strip is a “right of passage” for any woman being admitted to the hospital in labor.  But is this automatic 20 minute strip evidence based?  Regular Science & Sensibility contributor Henci Goer takes a look at a recent Cochrane systematic review and lets us know what the research says.  Do you discuss this with your students?  Do you share about this practice  in your classes and with your patients and students?  What do you tell them? Will it change after reading Henci’s review below? – Sharon Muza, Science & Sensibility Community Manager

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Some weeks ago, I did a Science and Sensibility post summarizing the latest version of the Cochrane systematic review of continuous electronic fetal monitoring (EFM)—AKA cardiotocography (CTG)—in labor versus intermittent listening. A couple of commenters on that post asked if I would tackle the “admission strip,” the common practice of doing EFM for 20 minutes or so at hospital admission in labor to see whether ongoing continuous monitoring is warranted.

I was in luck because the Cochrane Library has a recent systematic review of randomized controlled trials of this practice versus intermittent listening in women at low risk for fetal hypoxia (Devane 2012). The rationale for the admission strip, as the reviewers explain, is that pregnancy risk factors don’t predict all babies who will experience morbidity or mortality in labor. The admission strip is an attempt to identify women free of risk factors whose babies nevertheless might benefit from closer monitoring. Let’s see whether the admission strip succeeds at identifying those babies and improving their outcomes.

As to whether the admission strip identifies babies believed to be in need of closer surveillance, the answer is “yes.” Pooled analysis (meta-analysis) of the trials found that 15 more women per 100 allocated to the admission strip group went on to have continuous EFM (3 trials, 10,753 women), and 3 more babies per 100 underwent fetal blood sampling (3 trials, 10,757 babies).

Furthermore, women almost certainly underwent more cesareans as well (4 trials, 11,338 women). All four trials reported more cesareans in the admission strip group. The pooled increased risk of 20% just missed achieving statistical significance, but this is probably because cesarean rates were so low, only 3 to 4% in by far the biggest trial, which contributed 8056 participants. Because of the lack of heterogeneity among trials, the reviewers think the difference is likely to be real. If it is, then using an admission strip in low-risk women results in 1 additional cesarean for every 136 women monitored continuously (number needed to harm). I would add that not separating out first-time mothers, who are at greater risk for cesarean delivery, probably masked a bigger effect in this subgroup. How big an effect might this be?  Let’s assume a 9% cesarean rate in low-risk first-time mothers, that being the rate found  in first-time mothers still eligible for home birth at labor onset in the Birthplace in England study (2011). At this cesarean rate, a 20% increase over baseline would calculate to 1 additional cesarean for every 55 first-time mothers monitored continuously.

The crucial question, though, is whether increased monitoring and surgical deliveries produced better perinatal outcomes. To that, the answer is “no.” Combined fetal and neonatal death rates in infants free of congenital anomalies were identical at 1 per 1000 in both groups (4 trials, 11,339 babies). The reviewers acknowledge that their meta-analysis of over 11,000 babies is still “underpowered,” i.e., too small to detect a difference in outcomes. However, they continue, the event is so rare in low-risk women that no trial or meta-analysis would likely be big enough to do so. Additionally, no differences were found for cases of hypoxic ischemic encephalopathy (1 trial, 2367 babies), admissions to neonatal intensive care (4 trials, 11,331 babies), neonatal seizure (1 trial, 8056 babies), evidence of multi-organ compromise within the first 24 hours (1 trial, 8056 babies), or even 5-minute Apgar scores less than 7 (4 trials, 11,324 babies).

The reviewers therefore conclude:

We found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour. Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. . . . The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit (Devane 2012, p. 2). [Emphasis mine.]

Conclusion

According to the best evidence, the admission strip isn’t just ineffective, it’s harmful, and its use should be abandoned

References

Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ, 343, d7400.  http://www.ncbi.nlm.nih.gov/pubmed/22117057?dopt=Citation

Devane, D., Lalor, J. G., Daly, S., McGuire, W., & Smith, V. (2012). Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev, 2, CD005122. doi: 10.1002/14651858.CD005122.pub4 http://www.ncbi.nlm.nih.gov/pubmed/22336808

Childbirth Education, Do No Harm, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Maternity Care, Medical Interventions, Metaanalyses, New Research, Research, Uncategorized , , , , , , , ,

“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.

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© 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.

ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , ,

Preventing Cesarean Delivery – What is the Nurses’ Role?

January 8th, 2013 by avatar

By Christine H. Morton, PhD

 ”Experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.” 

Today, on Science & Sensibility, Christine Morton, PhD takes a look at a study examining the role of nurses in helping to achieve a vaginal birth for patients under their care.  No surprise from my point of view, my professional experience as a doula has demonstrated that L&D nurses play a critical role in the birth, and can really help a mother to achieve the outcome she desires.  Please enjoy Christine’s synopsis and interview with one of the study authors.- Sharon Muza, Community Manager

© 2013 Patti Ramos Photography

Readers of this blog are well aware of the 50% increase in cesarean delivery rates over the past decade, and are likely aware that the high US cesarean delivery rate is on the maternal quality and patient safety agendas for many organizations.  More attention will soon be focused on hospital rates (the Joint Commission recently expanded its performance measurement requirements such that as of January 1, 2014, all hospitals with more than 1100 annual births will be REQUIRED to report on the Perinatal Care Measure Set, which was the subject of a past blog post).  The Perinatal Care Measure Set includes a measure on the first birth cesarean among low risk women (nulliparous women who have cesareans at term, with singleton, vertex babies).  Furthermore, Centers for Medicare and Medicaid Services (CMS) is requiring that all states report rates of Elective Deliveries <39 Weeks as of 1/1/13 and it is likely that a similar requirement for the NTSV (Nulliparous Term Singleton Vertex) Cesarean measure is not far behind.

One indicator of this trend was the February 2012 symposium on preventing the first cesarean held jointly by National Institute of Child Health and Human Development (NICHD), the Society for Maternal Fetal Medicine (SMFM) and American Congress of Obstetricians and Gynecologists (ACOG.)  A comprehensive summary of the proceedings of that symposium was published in the November 2012 issue of Obstetrics and Gynecology, which is well worth reading but is available only with a subscription.  That same issue had a commentary on how to create a public agenda for reducing cesarean delivery, written by me and my California Maternal Quality Care Collaborative colleagues, which is free to all, thanks to our funder.

The attention to the detrimental health impact of our country’s cesarean rate for women and their babies is a good sign, coming as it does from powerful organizations with interests in providing care and paying for it.  Most of the focus on quality measurement reporting on cesarean delivery has been directed at hospital level (i.e., Leapfrog and The Joint Commission), though there is interest among payers and consumers for public reporting of provider-specific rates.  Virginia is one example where obstetric outcomes (cesarean, episiotomy) are publicly reported at the hospital and provider levels.  However, it is complicated to attribute outcome rates in obstetrics, which is increasingly a ‘team sport’ with multiple clinicians (physicians, midwives and nurses) involved in the care of a woman throughout her pregnancy and birth.

Yet, in all these domains (institutional, measurement, quality improvement), the role of nurses on cesarean delivery decisions and outcomes has been barely mentioned.  Neglecting the labor & delivery nurse’s role is unfortunately all too typical in public discourse around quality reporting, shared decision-making and improving outcomes in birth. I have become very interested in the nursing perspective as the more I learn about hospital birth, the more I realize that nurses are central to the management of labor & delivery units, and in measuring and reporting outcomes.  Thus, it was with great delight that I saw a new study, Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes in the January 2013 issue of JOGNN

Nurse-researchers Joyce K. Edmonds and Emily J. Jones conducted a semi-structured interview study with 13 nurses who were employed at a hospital with about 2000 births a year and overall cesarean rate of 36%.  These nurses work within a “nurse-managed labor model” which is characterized by a relatively autonomous nursing role, with intermittent communication with an off-site obstetrician.  Most nurses in the US practice within this type of model.  Nationally less than 10% of hospitals that do births are teaching hospitals, which have 24/7 access to physician consultation.  Other hospitals with 24/7 physicians on staff include HMOs like Kaiser Permanente, or those who have hospitalists.  In California, about half of all birthing facilities do not have an OB available onsite 24/7.

Shockingly few studies have looked at nurses’ role on the mode of delivery.   This is more striking when one considers the many specific nursing clinical practice responsibilities that may affect cesarean rates.  Nurses are largely responsible for assessing women during triage for admission, monitoring and assessing the health of mother/baby after hospital admission.  Nurses manage and administer oxytocin, assess and assist with labor pain, and are primary managers of second stage labor.  These practices occur within the administrative context of each hospital’s policies on admission in early labor, rates of interventions such as inductions (especially those for no medical indication), cesarean (especially those among the low risk population) and availability and rates of Vaginal Birth After Cesarean (VBAC).

Data for this study were drawn from semi-structured interviews with nurses who had a range of 10-40 years clinical experience in L&D.  Questions were specifically designed to elicit active practice and interaction with physicians (interactions with women were not addressed).  An example of a question asked of respondents, “Can you tell me about a time when you intervened to promote vaginal delivery or avoid a cesarean?”

The overarching theme in this study was how nurses described their efforts to ‘negotiate for more time’ during labor, to positively impact the likelihood of a vaginal delivery.   Negotiating for more time was defined in this study as “a form of nurse-physician interaction and an action taken to create the temporal space in which nursing interventions thought to affect delivery mode decisions operate”.    The authors found that nurses’ ability to negotiate for more time was based on their knowledge of labor and birth over their many years of experience, as well as their knowledge of individual physician practice patterns.  Furthermore, nurses’ awareness of physician and institutional-imposed time constraints was a key factor in negotiating for more time.

The important conclusion reached by the authors was that “experienced nurses practicing in a nurse-managed labor model have the potential to change patient outcomes.”  Despite the known limitations of this study – small sample of highly experienced nurses working at a single institution – I was intrigued and excited by the practice implications and the potential to develop quality improvement strategies for reducing cesarean deliveries that are specific to nurses.  So often, the labor & delivery nurses’ role is overlooked in this area and this study is an important contribution to our understanding of nurses’ influence in cesarean outcomes.   There is clearly more research and work to be done, and one of the authors, Joyce K. Edmonds, graciously responded to questions I had about the study and future directions for this research and quality improvement initiatives:

CHM: It was interesting that the range of experience represented in your study was 10-40 years – do you think your sample was more weighted toward the more experienced nurses?  Do you have any theories for why the lower end of the range was so high?  Were there nurses in that hospital with 2-3 years of experience?  Any thoughts about why they did or did not participate?

JKE:  Our sample was without doubt weighted to the experienced nurse, and we used the term experienced as a qualifier throughout the paper. This particular hospital staff was highly experienced, although, there were nurses with less than < 5 years experience. We think the sample was a self-selecting group of nurses who felt strongly about birth mode and the influence they had on birth mode decisions. Perhaps, less experienced nurses’ perspectives on birth mode were not as clearly developed as those who participated. It could also be that those who volunteered to participate were more supportive of promoting vaginal deliveries than those who did not participate. It could also be that scheduling conflicts with less experienced nurses prohibited them from participating.

Joyce Edmonds

CHM: I think the fluid nature of ‘time’ and the constraints on physician time bear further exploration.  In this regard, it would have been helpful have analyses of accounts where nurses felt they were ‘unsuccessful’ in buying more time for labor.  The counter-factual example can sometimes shed light on the dynamics – what didn’t work in this case? Do you have any unsuccessful stories in your data and/or did you analyze those?   It seemed as though all the nurses in your study DID negotiate for time, or at least provided you with accounts of when they did.  Were there any nurses who did NOT have a story to share about negotiating for more time?

JKE: All the nurses did talk about negotiating for time, which is the reason it emerged as the overarching theme.  Nurses did talk about not being able to negotiate for more time when cesareans were scheduled because the course of labor management was already established. They also seemed to have less influence when inductions were scheduled because again the labor management plan was established prior to their involvement in the care. I’d have to look back at the interviews with an eye toward specific counter-factual examples.

CHM: I also found it fascinating to read the quote that begins, “It almost feels like you’re working against the machine.” I was curious to know more about the justifications for that taboo of not being able to talk or confront the physician with the ‘agenda.’   In my interviews with OB nurses, I also came across this and think it is an important factor to explore further.  I imagine that nurses with less clinical experience are even less able to identify or recognize this ‘agenda’ and that comes with its own set of practice and policy issues for nursing training.  

JKE: I think the nurse physician relationship shapes the day-to-day work environment of the nurse. It is a long-term relationship relative to the nurse-patient relationship. It is likely that talking about or confronting a particular physician about the potential of an agenda could negatively disrupt the work environment, which is significantly related to nurses’ job satisfaction. Nurses want to be seen as team players and discussing the potential of physician ‘hidden agendas’ is like being a whistle blower. In addition to not wanting to disrupt the power balance, they may not want to invite scrutiny into their own practice patterns.

CHM: I was struck in particular by the account on page 5 of your paper that ends with the quote, “There are certainly situations where the baby needs to come out via C-section, but it is not as many as we do by any stretch.”  What situations?  What factors influence those decisions?  Where do nurses feel they lost power to bargain /buy more time?  

JKE: In this quote, the nurse is referring to medically indicated versus potentially unnecessary cesareans. I believe when nurses speak about cesareans they are not only focused on unplanned, intrapartum cesareans but also scheduled cesareans or scheduled inductions, which can result in a cesarean. It was clear from the interviews that nurses felt less invested in the decision-making process when women came in for scheduled cesareans or planned inductions. Nurses also spoke of how women are set up for failure during pregnancy—by way of unfavorable media messages, lack of unbiased childbirth education, and lack of risk reduction information from prenatal care providers.

CHM: I was intrigued that in this study you did not appear to ask about nurses’ views toward physiological birth (vaginal) and cesarean, or other indicators of their philosophy of birth.  The comment from the nurses who viewed themselves as a ‘dying breed’ begin to capture some sense of that – whether it is experience, knowledge, or philosophy of birth that unites them against this perceived different group of newer nurses.

JKE:  Great question, although it assumes that nurses’ personal philosophy of birth impacts their practice, which it likely does according to Reagan et al. In an attempt to keep the data focused on our main aim we did not ask nurses directly about their personal philosophy of birth. I believe the nurses in the study were united in their knowledge of childbirth–without the now pervasive assessment and intervention technology–knowledge borne out of experience.

CHM: How do you plan to follow up with this research and what are your future projects?    

JKE: Locally, we want to continue the discussion about the influence of nursing care and knowledge on cesarean rates that started with our interviews. Due to the sensitive nature of the topic and hospital policies, we have not had much success with direct follow-up where the study was conducted. However, we are very interested in presenting and discussing the results with other interested audiences. With regard to future projects, we are currently initiating a study to document the degree of nursing influence on cesarean rates at the level of the individual nurse, at an academic medical center and at a community hospital, building on the sentinel, yet dated, work of Radin et. al.  If the results are significant, we foresee the development of a quality improvement strategy directed at providing individual nurses routine (e.g., bi-monthly or quarterly) feedback on standard measures, such as risk adjusted primary cesarean section rates, cervical dilation at cesarean, and cesarean indication, based on the cohort of women in their care. Clearly, although not without great effort, such a strategy would need to be interdisciplinary and have adequate IT infrastructure and support. I also think nurses, as part of a team, should be involved in giving feedback about physician practice patterns in accordance with obstetric standards.

Are you an L&D nurse?  Can you comment on your experiences and how you feel your actions can influence the mode of birth.  If you are a doula, what has been your observation.  Doctor or midwife?  How do you view the role of the L&D nurse?  I look forward to a robust discussion. – SM

References

Edmonds, J. K. and Jones, E. J. (2013), Intrapartum Nurses’ Perceived Influence on Delivery Mode Decisions and Outcomes. Journal of Obstetric, Gynecologic, & Neonatal Nursing, 42: 3–11. doi: 10.1111/j.1552-6909.2012.01422.x

Main, E.K., Morton, C.H, Hopkins, D., Giuliani, G.,  Melsop, K., and Gould, J.B (2012), Creating a Public Agenda for Maternity Safety and Quality in Cesarean Delivery, Obstetrics and Gynecology, November 2012; 120 (5):1194-1198.

Radin TG, Harmon JS, Hanson DA. Nurses’ Care During labor: Its Effect on the Cesarean Birth Rate of Healthy, Nulliparous Women. Birth. 1993;20(1):14-21.

Regan M, Liaschenko J. In the Mind of the Beholder Hypothesized Effect of Intrapartum Nurses’ Cognitive Frames of Childbirth Cesarean Section Rates. Qualitative Health Research. 2007;17(5):612-624.

Spong, C. Y. MD; Berghella, V. MD; Wenstrom, K. D. MD; Mercer, B. M. MD; Saade, G. R. MD (2012), Preventing the First Cesarean Delivery: Summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop, Obstetrics & Gynecology, Volume 120(5), November 2012, p 1181–1193

ACOG, Cesarean Birth, Fetal Monitoring, Guest Posts, Maternal Quality Improvement, Maternity Care, Research, Transforming Maternity Care , , , , , , , , , , ,

Book Review: Optimal Care in Childbirth: The Case for a Physiologic Approach Reviewed Through a Childbirth Educator’s Eyes

October 18th, 2012 by avatar

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

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

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

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

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

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

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

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

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

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

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

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

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

Henci Goer

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

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

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

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

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

Amy Romano

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

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

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

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

References

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

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

Book Reviews, Cesarean Birth, Childbirth Education, Epidural Analgesia, Fetal Monitoring, Healthcare Reform, informed Consent, Lamaze 2012 Annual Conference, Maternal Mental Health, Medical Interventions, New Research, Pain Management, Practice Guidelines, Research, Systematic Review, Transforming Maternity Care , , , , , , , , ,

It Takes a Professional Village! A Study Looks At Collaborative Interdisciplinary Maternity Care Programs on Perinatal Outcomes

September 19th, 2012 by avatar

The  Canadian Medical Association Journal, published in their September 12, 2012 issue a very interesting study examining how a team approach to maternity care might improve maternal and neonat aloutcomes.  The study, Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes  is reviewed here.

The Challenge

Photo Source: http://www.flickr.com/photos/jstownsley/28337593/

The number of physicians in Canada who provide obstetric care has declined in past years for reasons that include increasing physician retirement, closure of rural hospitals, liability concerns, dissatisfaction with the lifestyle and a difficulty in accessing maternity care in a variety of settings.  While registered midwife attended births may be on the rise, midwives in Canada attend less than 10% of all births nationwide.   At the same time as the number of doctors willing or able to attend births decline, cesarean rates are on the rise,  causing pressure on the maternity care system, including longer hospital stays both intrapartum and postpartum, which brings with it the associated costs and resources needed to accommodate this increase.

The diversity of the population having babies in many provinces is increasing, presenting additional challenges in meeting the non-French/English speaking population, who are more at risk for increased obstetrical interventions and are less likely to breastfeed.

The Study

In response to these challenges, the South Community Birth Program was established to provide care from a consortium of providers, including family practice physicians, community health nurses, doulas, midwives and others, who would work together to serve the multiethnic, low income communities that may be most at risk for interventions and surgery.

The retrospective cohort study examined outcomes between two matched groups of healthy women receiving maternity care in an ethically diverse region of South Vancouver, BC, Canada that has upwards of 45% immigrant families, 18% of them arriving in Canada in the past 5 years.  One group participated in the South Community Birth Program and the other received standard care in community based practices.

The South Community Birth Program offers maternity care in a team-based shared-care model, with the family practice doctors, midwives, nurses and doulas working together .  Women could be referred to the program by the health care provider or self refer.  After a few initial standard obstetrical appointments with a family practice doctor or midwife occur to determine medical history, physical examination, genetic history, necessary labs and other prenatal testing, the women and their partners are invited to join group prenatal care, based on the Centering Pregnancy Model.  Approximately 20% of the first time mothers choose to remain in the traditional obstetric care model.  10-12  families are grouped by their expected due date, and meet for 10 scheduled sessions, facilitated by either a family physician or midwife and a community nurse.  Each session has a carefully designed curriculum that covers nutrition, exercise, labor, birth and newborn care, among other topics.  Monthly meetings to discuss individual situations and access to comprehensive electronic medical records enhanced the collaboration between the team. Trained doulas, who speak 25 different languages, also meet with the family once prenatally and provide one on one continuous labor support during labor and birth. The admitting midwife or physician remains in the hospital during the patient’s labor and attends the birth.

After a hospital stay of 24-48 hours, the family receives a home visit from a family practice physician or midwife the day after discharge. Clinic breastfeeding and postpartum support is provided by a Master’s level clinical nurse specialist who is also a board certified lactation consultant.  At six weeks, the mother is discharged back to her physician, and a weekly drop in clinic is offered through 6 months postpartum.

The outcomes of the women in the South Community Birth Program were compared to women who received standard care from their midwives or family practice physicians.  Similar cohorts were established of women carrying a single baby of like ages, parity, and geographic region, and all the mothers were considered low risk and of normal body mass index.

The primary outcome measured was the proportion of women who underwent cesarean delivery.  The secondary outcomes measured were obstetrical interventions and maternal outcomes (method of fetal assessment during labor, use of analgesia during labor, augmentation or induction of labor, length of labor, perineal tramau, blood transfusion and length of stay) and neonatal outcomes (stillbirth, death before discharge, Apgar score less than 7, preterm delivery, small or large for gestational age, length of hospital stay, readmission, admission to neonatal intensive care unit for more than 24 hours and method of feeding at discharge).

Results

There was more incidence of diabetes and previous cesareans in the comparison group but the level of alcohol and substance use was the same in both groups.  Midwives delivered 41.9% of the babies in the birth program and 7.4% of babies in the comparison group.

When the rate of cesarean delivery was examined for both nullips and multips, the birth group women were at significantly reduced risk of cesarean delivery and were not at increased risk of assisted vaginal delivery with forceps or vacuum.

Interestingly, the birth program women who received care from an obstetrician were significantly more likely to have a cesarean than those receiving in the standard program who also received care from an obstetrician.  More women in the birth program with a prior cesarean delivery planned a vaginal birth in this pregnancy, though the proportion of successful vaginal births after cesareans dd not differ between the two groups.

The women in the community birth program experienced more intermittent auscultation vs electronic fetal monitoring and were more likely to use nitrous oxide and oxygen alone for pain relief and less likely to use epidural analgesia (Table 3).  Though indications for inductions did not differ, the birth program women were less likely to be induced.  More third degree perineal tears were observed in the birth program group but less episiotomies were performed.  Hospital stays were shorter for both mothers and newborns in the community program.

When you look at the newborns in the birth program, they were at marginally increased risk of being large for gestational age and were readmitted to the hospital in the first 28 days after birth at a higher rate, the majority of readmissions in the community and standard care group were due to jaundice. Exclusive breastfeeding in the birth program group was higher than in the standard group.

Discussion

The mothers and the babies in the community birth program were offered collaborative, multidisciplinary, community based care and this resulted in a lower cesarean rate, shorter hospital stays, experienced less interventions and they left the hospital more likely to be exclusively breastfeeding. Many of the outcomes observed in this study, especially for the families participating in the South Birth Community Program are in line with Lamaze International’s Healthy Birth Practices.  There are many questions that can be raised, and some of them are are discussed by the authors.

Was it the collaborative care from an interdisciplinary team result in better outcomes?  Was there a self-selection by the women themselves for the low intervention route that resulted in the observed differences?  Are the care providers themselves who are more likely to support normal birth self-selecting to work in the community birth program? Did the fact that the geographic area of the study had been underserved by maternity providers before the study play a role in the outcomes? Did the emotional and social support provided by the prenatal and postpartum group meetings facilitate a more informed or engaged group of families?

I also wonder how childbirth educators, added to such a model program, might also offer opportunity to reduce interventions and improve outcomes  Could childbirth educators in your community partner with other maternity care providers to work collaboratively to meet the perinatal needs of expectant families?  Would bringing health care providers interested in supporting physiologic birth in to share their knowledge in YOUR classrooms help to create an environment where families felt supported by an entire skilled team of people helping them to achieve better outcomes.

Would this model be financially and logistically replicable in other underserved communities and help to alleviate some of the concerns of a reduction in obstetrical providers and increased cesareans and interventions without improved maternal and newborn outcomes? And how can you, the childbirth educator, play a role?

References

Azad MB, Korzyrkyj AL. Perinatal programming of asthma: the role of the gut microbiota. Clin Dev Immunol 2012 Nov. 3 [Epub ahead of print].

Canadian Association of Midwives. Annual report 2011. Montréal (QC): The Association; 2011. Available: www .canadianmidwives.org /data/document /agm %202011 %20inal .pdf

Farine D, Gagnon R; Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada. Are we facing a crisis in maternal fetal medicine in Canada? J Obstet Gynaecol Can 2008;30:598-9.

Getahun D, Oyelese Y, Hamisu M, et al. Previous cesarean delivery and risks of placenta previa and placental abruption.Obstet Gynecol 2006;107:771-8.

Giving birth in Canada: the costs. Ottawa (ON): Canadian Institute of Health Information; 2006.

Godwin M, Hodgetts G, Seguin R, et al. The Ontario Family Medicine Residents Cohort Study: factors affecting residents’ decisions to practise obstetrics. CMAJ 2002;166:179-84.

Hannah ME. Planned elective cesarean section: A reasonable choice for some women? CMAJ 2004;170:813-4.

Harris, S., Janssen, P., Saxell, L., Carty, E., MacRae, G., & Petersen, K. (2012). Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. Canadian Medical Association Journal, doi: DOI:10.1503 /cmaj.111753

Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions: Ottawa (ON): Ontario Women’s Health Council, Ministry of Health and LongTerm Care; 2006.

Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991; 37:1859-67.

Thavagnanam S, Fleming J, Bromley A, et al. A meta-analysis of the association between cesarean section and childhood asthma. Clin Exp Allergy 2008;38:629-33.

 

 

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