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Preparing Mothers for Breastfeeding after a Cesarean – The Educator’s Role

April 22nd, 2014 by avatar

By Tamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE

© Sharon Muza

© Sharon Muza

April is Cesarean Awareness Month (CAM).  In a post earlier this month, I shared my favorite websites for birth professionals to learn and share with students and clients about cesarean prevention, recovery, vaginal birth after cesarean along with a fun quiz to test your knowledge about cesarean and VBAC information.  Today, as Lamaze International continues to recognize CAM, LCCE and IBCLC Tamara Hawkins shares information on how professionals can help prepare women who will be breastfeeding after a cesarean to get off on the right track for a successful breastfeeding relationship. – Sharon Muza, Science & Sensibility Community Manager.

Working in New York City,  I see many women who have given birth to their babies via cesarean section. Most hospitals in my area have a cesarean rate close to 40% and 30% of those births are primary cesareans.  April is Cesarean Awareness Month and I wanted to discuss cesarean birth and breastfeeding.  As both a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant, I work with women both before and after a cesarean birth.  I meet mothers who could have prevented many lactation issues if equipped with a few practices to get breastfeeding off to a good start after a cesarean birth. I want to share some practical teaching tips on preparing a mother to successfully breastfeed after having a cesarean birth. In a childbirth class,  it is important to give anticipatory guidance to mothers in class who are preparing to birth about the realities of breastfeeding after a cesarean.

I recommend discussing breastfeeding after cesarean births in all portions of your childbirth class; labor and birth, newborn care and breastfeeding classes, in order to cover different aspects of breastfeeding initiation.  During the labor and birth variations class, discuss how cesarean births affect baby and mother physically and emotionally. Provide tips on how to get through the first days in the hospital such as skin to skin, rooming in, explain the normalcy of cluster feeding and give breastfeeding support resources for the mother to use once she returns home. I find giving a wealth of well researched information in class will not help a mother who may be having breastfeeding trouble several weeks later after the baby has arrived. In newborn care and/or breastfeeding class, provide additional details: latch, positioning, signs of hunger, feeding length and times, cluster feedings, care for engorgement and sore nipples. Supplement with your list of resources.

Many birth professionals report cesarean births as a common reason for delayed Lactogenesis I. I like to lay out solutions for common concerns and problems that arise for mothers when breastfeeding after a cesarean. These solutions include care for the areola/nipple complex, swelling, positioning and latch techniques, anticipating frequent feedings, feeding a sleepy baby, and caring for engorged breasts.

Solutions and Teaching Points

Insufficient glandular tissue and low milk supply

I have seen an explosion of mothers who have insufficient glandular tissue and low milk supply. During class discussions about baby’s first feeding, explain normal breast changes to expect during pregnancy such as prominent veining, dark areola/nipple complex, growth of about one cup size in breast tissue, and tenderness. These changes indicate the process of Lactogenesis Stage I – when the epithelial cells of the breasts begin to convert to milk secreting cells under the influence of the hormone prolactin. When mothers have no or very little breast growth during pregnancy this indicates a deficiency in stage I of lactogenesis. Often, this is why a mother may have trouble with milk supply and not just because she had a cesarean. It is important we make a distinction in this for the mother because if the mother is blaming herself for an unplanned cesarean and then believes the cesarean birth caused the low milk supply it can cause undue distress. I typically just present the expected breast growth information and state, “If you have not had any changes, feel free to reach out to me or speak with your health care provider about your concerns.” When a mother is empowered with anticipatory guidance, it can help her make solutions to adequately feed her baby at birth, build her milk supply and find appropriate breastfeeding support. Even if she has a cesarean, she should not expect low milk supply unless she has the markers of IGT.

Creative positioning and latch techniques

© http://flic.kr/p/5f29EK

© http://flic.kr/p/5f29EK

We cannot expect a mother to sit straight up in a chair to nurse after a cesarean and we have to model positions to help mothers understand how to nurse laying back, in football positions and cross cradle. The side lying position for mothers who gave birth by cesarean can be hard as the mother can experience pulling on her incision as she is trying to roll on to her side.  Additionally, as she is laying in the side lying position, there can be pain, and some babies’ legs are long and can kick the incision. Depending on the available space where I teach, I can get on the floor and demonstrate how to hold the baby in multiple positions simulating being in a bed. I also discourage the use of “breastfeeding pillows.” They tend to not fit well around a mother in bed. If a mother is in a chair she’s liable to lean too far over to reach the baby who is resting on the pillow. It’s best to teach good posture in classes to prevent maternal back and neck discomfort and demonstrate having the baby up close to mother’s abdomen and breast to affect a deep latch.

Frequent feeding

Parents will receive many “tips” about breastfeeding after a cesarean delivery. Every nurse, health care provider, lactation consultant/counselor, mother, sister and friend will tell her something different about when to feed her baby. It is the role of the childbirth educator to prepare them for frequent feeds and give rationales as to why feeding a baby frequently is important.  Rather than stating a set “frequency” such as feed every 2-3 hours, I want them to understand the newborn’s normal pattern of sleep and wakefulness and how this influences their feeding behaviors. Mothers may be drowsy after a cesarean birth, particularly if the surgery followed a long labor.  They may also be in pain. Pain medication, while necessary for good pain management after surgery, can also contribute to a mother feeling sleepy. Holding her baby skin to skin will help the mother connect with her baby and relax. Both mother and baby need to be relaxed to get breastfeeding off to a good start. Explain to mothers during class that babies may want to nurse within the first hour and to wait for those cues: rooting, hands to mouth and suckling. Babies are often sleepy after cesarean births, especially if mother was pushing, had been treated with magnesium for pre-eclampsia or had been through a long induction. When a baby does not feed as often as anticipated, this will of course upset the mother and can lead to delayed Lactogenesis II.

Educators have to set expectations properly. Working on a time line, I discuss, breastfeeding in the operating room during the cesarean repair and in the recovery room. When partners are in class, teach them how to place the baby skin to skin with mom and support the baby if the mother’s arms or hands are restricted with blood pressure cuffs and IV lines. Discuss hand expression for those sleepy babies who are not rooting within 45 minutes of birth. Dr Jane Morton has a fantastic video illustrating how to express colostrum by hand. This is especially important for babies born to a mother with gestational diabetes, as these babies tend to be at risk for low blood sugar and formula supplementation.

If the baby has to go to the nursery before breastfeeding has been established, we discuss delaying the newborn bath and the rationale. When babies get a bath, not only is the vernix and amniotic fluid (which is a familiar taste to the baby) washed off, the baby will most likely cry, a lot, and fall into a deep sleep making it harder to wake for a feeding. Also, many babies are kept for a longer time in the nursery to warm up after the bath delaying skin to skin and breastfeeding. If the baby has not breastfed in the operating or recovery room, suggest the parents ask for the bath to be delayed until the next day and expect the baby to be on contact precautions. That means there may be a sign on the bassinet alerting care providers to wear gloves when caring for the baby.

Moving along the timeline, we move right into newborn sleep-wake patterns and cluster feedings. I tell them the baby is not born knowing there is a clock on the wall. There is no magic formula that says the baby should be fed 8x/day or every 3 hours or even for 15 minutes on the breast. Expect the baby to nurse 45 minutes every hour for four to five hours straight. That’s when you will really get their attention and can again discuss normal baby routines, colostrum volumes and the size of the newborn stomach.

Dealing with a sleepy baby

Babies born via cesarean can be sleepy for many reasons; exposure to magnesium sulfate and analgesia, long labors, and long second stage to name a few reasons. These babies need to be fed one way or another. Teach clients how to hand express and feed their baby at the breast. Holding the baby close to the breast, hand express 20 drops from each breast and rotate twice between each breast. Approximately 80 drops equal a teaspoon. This is the estimated amount the baby will take in during breastfeedings on day one and two of life. The mother can hand express directly into the baby’s mouth or into a spoon. I prefer a soft baby spoon as a plastic spoon can be sharp on the edges. Hand expression can prevent serious engorgement and increase likelihood of normal Lactogenesis II by stimulating release of prolactin.

Dealing with engorgement

Mothers that get engorged after a cesarean sometimes are dealing with breasts that are extremely edematous. It is important to discuss the difference of being engorged with milk versus engorged with interstitial fluid or swelling. At the time I cover the topic of cesareans in the childbirth class, I differentiate the two by describing how the breasts feel under both circumstances. I describe the breasts as feeling like a bag of marbles when it is full of breast milk and like an overfilled water balloon when it is just interstitial fluid. The care plan for each type of engorgement is a bit different. To start, emphasize on demand feedings to prevent buildup of fluid and discuss the use of Reverse Pressure Softening to remove local swelling in the areolar/nipple complex to affect a deep latch.

Breasts that appear swollen and feel soft like a water balloon need hand expression to get the milk flowing and to keep the areola soft. No application of heat is warranted with this type of swelling. Warm compresses can cause blood and lymphatic vessels in the breast to dilate and release more fluid. The goal is to reduce the swelling. After every feeding, application of cool compresses to the breasts is best. Cold therapy slows circulation, reducing inflammation, muscle spasm, and pain. The goal here is to keep the areola soft to prevent pressure building up around the milk ducts and prevention of milk flow.

Breasts that are hard with palpable alveoli are full of milk. The mother can once again use hand expression to get the milk flowing and will benefit from warm compresses to the breast for about 5-10 minutes before feeding. If her milk begins to leak, than the warmth is a good tool. If the milk does not begin to leak out, that is an indication that interstitial swelling is present and heat should not be used. Only cool compresses after feeding and/or pumping should be used in this situation.

Mothers that have cesarean births are very vulnerable to the hardships that come along 3-4 days after the birth including sore and swollen breasts, possible low milk supply and general recovery complaints that are associated with major abdominal surgery. Giving anticipatory guidance to succeed with breastfeeding amongst these possible issues and challenges are important to help mothers gain the confidence to succeed in making breastfeeding work.

After birth, a mother may have less support in her postpartum room and at home. She may even be alone most of the time during breastfeeding. After her labor and birth, it is likely she will not be able to access information stored in the left side of her brain if she is having breastfeeding difficulties coupled with fatigue and pain from birth. She will still reach out and ask questions. Very likely her first sources will be an online chat room, on a Facebook page or on a website somewhere. Childbirth educators should provide specific resources to find breastfeeding information. Share local breastfeeding and cesarean birth support groups along with the contact information for breastfeeding professionals during your childbirth classes.

I recognize that there is a lot of work to do in the birth world to bring down the cesarean birth from the current 32.8%. We can inform our students and clients with information to keep breastfeeding as normal as possible if a cesarean birth should occurred. It is our responsibility in the classroom to give our clients those tools to help them succeed in breastfeeding no matter how they give birth.

What information do you share with your clients about cesarean birth and successful breastfeeding? How do you prepare them for possible breastfeeding hurdles after a cesarean birth?

About Tamara Hawkins

tamara hawkins head shotTamara Hawkins, RN, MSN, FNP, IBCLC, CHHC, LCCE is the director of Stork and Cradle, Inc offering Prenatal Education and Breastfeeding Support. She graduated with a BSN from New York University and a MSN from SUNY Downstate Medical Center. She is a Family Nurse Practitioner and has worked with mothers and babies for the past 16 years at various NYC medical centers and the Elizabeth Seton Childbearing Center. Tamara has been certified to teach childbirth classes since 1999 and in 2004 became a Lamaze Certified Childbirth Educator and an International Board Certified Lactation Consultant.  Follow Tamara on Twitter: @TamaraFNP_IBCLC

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Care Practices, Infant Attachment, Newborns , , , , , ,

The Best Practice Guidelines: Transfer from Home Birth to Hospital – Collaboration Can Improve Outcomes

April 17th, 2014 by avatar

 By Lawrence Leeman, MD, MPH and Diane Holzer, LM, CPM, PA-C

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

On Tuesday, readers learned about the history and objectives of the Home Birth Consensus Summit, a collective of stakeholders, whose goal is to improve maternal infant health outcomes and increase collaboration between all those involved in serving women who are planning home births.  The interdisciplinary collaboration that occurs during the Summits brings representatives from many different perspectives to the table in order to improve the birth process for women and babies. You may want to start with the post “Finding Common Ground: The Home Birth Consensus Summit“ and then enjoy today’s post on the Home Birth Consensus Summit’s just released “The Best Practice Guidelines: Transfer from Home Birth to Hospital.”  Today’s post was written by Dr. Lawrence Leeman and Midwife Diane Holzer, two of the members on the HBCS Collaboration Task Force, a subgroup tasked with developing these transfer guidelines.  Share your thoughts on these new guidelines and your opinion on if you feel that they will improve safety and outcomes for mothers and babies. – Sharon Muza, Community Manager, Science & Sensibility

Leea Brady was a second-time mother whose first baby was born at home. One day past her due date, an ultrasound revealed high levels of amniotic fluid, which can pose a risk during delivery. Although she planned to have her baby at home, on the advice of her midwife, Leea transferred to her local hospital.

“I knew that we needed to be in the hospital in case anything went wrong,” said Brady. “I was really surprised when I arrived and the hospital staff told me they had read my birth plan, and they would do everything they could to honor our intentions for the birth. My midwife was able to stay throughout the birth, which meant a lot, because I had a trusting relationship with her. She clearly had good relationships with the hospital staff, and they worked together as a team.”

A recent descriptive study (Cheyney, 2014) reports that about ten percent of women who plan home births transfer to the hospital after the onset of labor. The reason for the overwhelming majority of transfers are the need for labor augmentation and other non-emergent issues. Brady’s transfer from a planned home birth to the hospital represents the ideal: good communication and coordination between providers in different settings, minimizing the potential for negative outcomes.

However, in some communities, lack of trust and poor communication between clinicians during the transfer have jeopardized the physical and emotional well being of the family, and been frustrating for both transferring and receiving providers. Lack of role clarity and poor communication across disciplines have been linked to preventable adverse neonatal and maternal outcomes, including death.(Guise, 2013,Cornthwaite, 2008) With optimal communication and cooperation among health care providers, though, families often report high satisfaction, despite not being in the location of their choice.

Recent national initiatives have been directed at improving interprofessional collaboration in maternity care.(Vedam, 2014) This is why a multi-disciplinary working group of leaders from obstetrics, family medicine, pediatrics, midwifery, and consumer groups came together to form a set of guidelines for transfer from home to hospital. The Best Practice Guidelines: Transfer from Planned Home Birth to Hospital are being officially launched today by the Home Birth Consensus Summit and will be highlighted at a series of upcoming presentations at conferences and health care facilities.

The authors of the guidelines, known as the Home Birth Summit Collaboration Task Force, formed as a result of their work together at the Home Birth Summits.

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

“Some hospital based providers are fearful of liability concerns, or they are unfamiliar with the credentials and the training of home birth providers,” said Dr. Timothy Fisher, MD, MS, at the Hubbard Center for Women’s Health in Keene, NH and an Adjunct Assistant Professor of Obstetrics and Gynecology, Dartmouth Medical School. “But families are going to choose home birth, for a variety of cultural and personal beliefs. These guidelines are the first of their kind to provide a template for hospitals and home birth providers to come together with clearly defined expectations.”

The guidelines provide a roadmap for maternity care organizations developing policies around the transfer from home to hospital. They are also appropriate for transfer from a free-standing birth center to hospital.

The guidelines include model practices for the midwife and the hospital staff. Some guidelines include the efficient transfer of records and information, a shared-decision making process among hospital staff and the transferring family, and ongoing involvement of the transferring midwife as appropriate.

“When the family sees that their midwife trusts and respects the doctor receiving care, that trust is transferred to the new provider,” said Dr. Ali Lewis, a member of the HBCS Collaboration Task Force. She became involved with the work of the committee in part because of her experiences with a transfer that was not handled optimally. “It is rare that transfers come in as true emergency. But when they do, if the midwife can tell the family she trusts my decisions, then I can get consent much more quickly, which results in better care and higher patient satisfaction.”

The guidelines also encourage hospital providers and staff to be sensitive to the psychosocial needs of the woman that result from the change of birth setting.

“When families enter into the hospital and feel as if things are being done to them as opposed to with them, they feel like a victim in the process,” said Diane Holzer, LM, CPM, PA-C, and the chair of the HBCS Collaboration Task Force. “When families are incorporated in the decision-making process, and feel as if their baby and their body is being respected, they leave the hospital describing a positive experience, even though it wasn’t what they had planned.”

The guidelines are open source, meaning that hospitals and practices can use or adapt any part of the guidelines. The Home Birth Summit delegates welcome endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders.

References

Cornthwaite, K., Edwards, S., & Siassakos, D. (2013). Reducing risk in maternity by optimising teamwork and leadership: an evidence-based approach to save mothers and babies. Best Practice & Research Clinical Obstetrics & Gynaecology, 27(4), 571-581.

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009. Journal of Midwifery & Women’s Health.

Guise, J. M., & Segel, S. (2008). Teamwork in obstetric critical care. Best Practice & Research Clinical Obstetrics & Gynaecology, 22(5), 937-951.

Vedam S, Leeman L, Cheyney M, Fisher T, Myers S, Low L, Ruhl C. Transfer from planned home birth to hospital: inter-professional collaboration leads to quality improvement . Journal of Midwifery and Women’s Health, November 2014, In Press.

About the Authors:

leeman larry headshotDr. Lawrence Leeman, MD, MPH/Medical Director, Maternal Child Health, received his degree from University of California, San Francisco in 1988 and completed residency training in Family Medicine at UNM. He practiced rural Family Medicine at the Zuni/Ramah Indian Health Service Hospital for six years. He subsequently earned a fellowship in Obstetrics. He is board certified in Family Medicine. He directs the Family Medicine Maternal and Child Health service and fellowship and co-medical director of the UNM Hospital Mother-Baby Unit. Dr. Leeman practices the family medicine with a special interest in the care of pregnant women and newborns. He is Medical Director of the Milagro Program that provides prenatal care and maternity care services to women with substance abuse problems. Dr. Leeman is a Professor in the Departments of Family & Community Medicine, and Obstetrics and Gynecology. He is currently the Managing Editor for the nationwide Advanced Life Support in Obstetrics (ALSO) program. Areas of research include rural maternity care, pelvic floor outcomes after childbirth, family planning, and vaginal birth after cesarean (VBAC). Clinic: Family Medicine Center

Diane Holzer head shotDiane Holzer, LM, CPM, PA-C, has been a practicing midwife for over 30 years with experience in both home and birth center. She was one of the founding women who passionately created an infrastructure for the integration of home birth midwifery into the system. She sat on the Certification Task Force which led to the CPM credential and also was a board member of the Midwifery Education and Accreditation council for 13 years. She served the Midwives Alliance of North America on the board for 20 years and is the chair of the International Section being the liaison to the International Confederation of Midwives. Diane is the Chair of the Collaboration Task Force of the Home Birth Summit and currently has a home birth practice and works as a Physician Assistant doing primary health care in a rural Family Practice clinic.

Babies, Guest Posts, Home Birth, informed Consent, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, Newborns, Practice Guidelines, Transforming Maternity Care , , , , , , , ,

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

April 8th, 2014 by avatar

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

PeanutBall-measure

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

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

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

PeanutBallCollage

© Maternal Focus

The Research

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

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

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

The Mother’s Experience

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

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

Maternal Preferences and Positioning

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

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

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

Epidural Experiences

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

Effect on Labor Progress

A few moms reported some pretty dramatic results:

A Doula’s Perspective

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

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

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

The L&D Nurse’s Perspective

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

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

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

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

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

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

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

Conclusion

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

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

To learn more about peanut balls:

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

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

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

References

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

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

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

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

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

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

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

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

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.

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