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The Science Behind the Lamaze Exam and the Lamaze Certified Childbirth Educator Credentials

May 1st, 2014 by avatar

Last week, around the world, candidates for certification sat for the Lamaze Certified Childbirth Educator exam.  That test represented the culmination of weeks, months and often years of planning, preparation, studying and hard work.  While the results are still some weeks out, I thought it would be interesting to learn about the science behind the Lamaze exam and what makes it the gold standard of childbirth educator certifications from Judith Lothian, PhD, RN, LCCE, FACCE, the chairperson of the Lamaze Certification Council Governing Body. Today’s families deserve the best, so they can push for their baby, with all the evidence and research that stands behind the LCCE credentials of their childbirth educator. Learn more about attending a Lamaze workshop and explore becoming an LCCE yourself so you can offer families in your community the gold standard of childbirth education. – Sharon Muza, Science & Sensibility Community Manager.
LCCE

Lamaze International is extremely proud of the fact that the Lamaze certification examination is the only examination for childbirth educators that is accredited by the National Commission for Certifying Agencies (NCCA).  Achieving and maintaining this accreditation is a rigorous and ongoing process.

Accreditation by NCCA assures you that the exam you take will accurately measure the competencies of a childbirth educator. The seven competencies of a Lamaze Childbirth Educator are supported by job analysis research that is done every 5-7 years. The last job analysis was conducted in 2012. The results of that analysis were published in the latest issue of the Journal of Perinatal Education. Lamaze members may access the full journal online after logging in to the Lamaze website. Basing the exam on the results of a job analysis is an important way to ensure that the exam accurately evaluates the competencies of a childbirth educator. Fairness is a very important issue and to that end NCCA has evaluated our policies, our procedures and the actual exam, including the construction of items and the exam itself as well as the evaluation of its performance. The NCCA stamp of approval is a vote of confidence that experts in the certification field believe that the Lamaze certification policies are fair and that the certificate examination accurately evaluates the competencies of a Lamaze Certified childbirth educator.

Lamaze is the only childbirth educator certification program that has received NCCA accreditation. Professional standards set by the Institute for Credentialing Excellence describe the difference between professional certification and assessment based certificate programs. “Professional or personnel certification is a voluntary process by which individuals’ pre-acquired knowledge, skills, or competencies are evaluated against predetermined standards. The focus is on an assessment that is independent of a specific class, course, or other education/training program. Participants who demonstrate that they meet the standards by successfully completing the assessment process are granted the certification.” The American College of Nurse Midwives and the International Board of Certified Lactation Consultants are examples, like Lamaze, of professional certification.

In contrast, an assessment-based certificate program is a non-degree granting educational program that provides instruction and training to help participants gain specific knowledge and skills and then evaluates achievement of expected learning outcomes and awards a certificate to those who successfully pass the assessment. Childbirth educator certifications, other than Lamaze, are assessment-based certificate programs. Because of this, many educators who have childbirth educator credentials from other organizations  choose to sit for the Lamaze exam.

Why is this important? It assures you that the certification examination has met the rigorous standards of professional certification, that the exam is fair and actually measures what it is should to insure that you indeed have achieved the competencies to practice as a Lamaze childbirth educator.

The certification exam consists of 150 multiple choice questions and the questions reflect the essential information a childbirth educator should know (the competencies of a Lamaze Certified Childbirth Educator). An inside look at the process of item writing and exam construction and evaluation will give you a taste for how rigorous, and interesting, the process actually is.

The exams are put together by a test development committee that meets twice a year for 4-5 days. The committee includes expert childbirth educators, a public member who is not a childbirth educator, and, often a novice childbirth educator (a high scorer on a recent exam). Using the test blueprint (based on the latest job analysis) the committee writes questions and then a smaller group “constructs” individual exams from the item bank of questions.

nccaDraft items are written in small groups, usually 2 or 3 educators. It is actually very, very difficult to develop a fair question that measures knowledge and skills that are important for the childbirth educator to know. It is tedious work and challenges all of us without exception! Once a small group has developed an item they think has potential it is, often with great trepidation, presented to the entire committee for discussion. Leon Gross, PhD, the psychometrician (a testing specialist) is at the meetings and at this stage he will often point out potential psychometric issues related to the items, including things like “it’s too long”, “there is extraneous information,” “could there be 2 answers?” In developing and evaluating each item we ask ourselves: Is it clear? Is there only one right answer? Do we know the right answer (if we don’t then we most definitely do not use it)? Is there any overlap in the answers? We edit each draft item for content and language, keeping in mind, that the distracters (the wrong answers) should be “plausable”. It is an extremely honest and often raucous process! We all have to be prepared to have our questions torn apart! It helps to have a sense of humor and remind ourselves of the importance of the process. Then the committee decides to either put the questions in the permanent item bank or not. The entire process is done with expert psychometric support.

Our philosophy, in the writing of the items, in the evaluation of the items, and then ultimately choosing the items that will be on each exam, is that we only test what is really important to know. There are no intentional “trick” questions. It’s important to know that if the committee struggles with identifying the correct answer it is automatically not used. And, the questions are written in order to evaluate the competencies of what we constantly refer to as the ‘just good enough candidate.’ So, this is most definitely not an exam where you have to be an “expert” to pass. In order to pass this exam you need to be “just good enough”. This exam is intended to measure competencies of a beginning childbirth educator.

When the committee decides to put a question in the item bank we then establish the level of difficulty for the question. We look at each correct answer and then we look at distractors, the wrong answers. We discuss the distracters related to how plausible this distracter would be to a candidate who is just able to pass the exam. This is an example of the process:

What is the capital of Maryland?
1. Baltimore
2. Chevy Chase
3. Annapolis
4. Fredricksburg

There is one correct answer and three distracters. If you know the capital of Maryland, this is a very easy question. It’s straight recall. If you, however, don’t know what the capital of Maryland is, then you will be tempted to go for a plausible but wrong answer. The correct answer is Annapolis, but Baltimore is a plausible answer because it’s the largest city in Maryland and, of these four choices, it is the most well-known city. For someone who does not know for sure that Annapolis is the capital of Maryland they would be tempted to think it was Baltimore. Therefore, we would label Annapolis the correct answer and Baltimore a “sophisticated distracter”. We aim to have at least 50% of the exam questions with “sophisticated distracters”. The more questions with sophisticated distracters the higher the level of difficulty of the exam. It’s important to know this to understand how the passing score is determined for each test administration.

This exam is criterion referenced which means that the passing score is determined before the test is given based on the level of difficulty of the questions on the exam. Candidates who sit for the exam are never compared to each other and the passing scored is determined by how difficult the questions are, not a predetermined passing score. Candidates are evaluated against a standard not against the scores of the other candidates sitting for the exam. The more items on the exam that have sophisticated distracters, the higher the level of difficulty, the lower the score you need to pass. The fewer items with sophisticated distracters, the higher the score is that you need to pass the exam. The pass score, the cut score, for passing the Lamaze certification exam has over the last years ranged 70 to about 75.

After the exam is given, the exam is scored and reviewed by the psychometrician. A detailed statistical analysis is done. There is an analysis of each item on the exam. How many testing participants got the answer right? What distracters did those who got it wrong go for? The item analysis also identifies what percentage of the high scorers got the question correct and what percentage of the low scores got the question correct. A “good” question statistically is one that discriminates between the high scorers and low scorers. This means that you would expect a high percentage of the people that did well overall on the exam to get a question correct and those that did not perform as well on the overall exam to get the question wrong. If we find that there is an item that most of the low scores got correct and only a few of the high scorers got that question correct, we would wonder why.

After the psychometrician reviews the overall exam and each item, he will flag the questions that may look like they may not be “performing” well. The small group that constructed the exam meets by conference call to discuss both the flagged items and the comments the candidates have made related to the exam. Every comment is reviewed. Whether or not we keep an item, or don’t keep the item, is the decision of the committee. We also look at the performance of the exams that are translated into other languages and look at how individual questions performed for instance in Spanish compared to in English. We try to determine if there are cultural differences or whether there are translation problems. At times a question may be deleted from scoring in a language other than English and not in the English exam. Once we determine if there are items we will drop then the psychometrician will re-score the exam and determine, based now on the questions that remain on the exam (and their level of difficulty), a final cut score. It takes about 6 weeks to get exam results. During that time the certification team is working hard to make sure your exam is fairly evaluated.

The rigor of developing the exam, including the job analysis, and then the scoring of the exam are only one part of the requirements for NCCA accreditation. In addition, our policies and procedures related to everything from exam eligibility and grievance procedures, as well as confidentiality issues and the qualifications of both the staff and volunteers involved in the certification process, are rigorously evaluated. The end result, we hope, is a valid, reliable, fair certification exam that protects the value of the LCCE credential, and, most importantly, assures women and their families that the Lamaze Certified Childbirth Educator is competent. NCCA accreditation is a vote of confidence that we are indeed doing what we intend.

Are you an LCCE?  Can you share why you chose Lamaze International and your journey?  Are you considering becoming a childbirth educator?  Have you explored Lamaze as an option?  I invite you to consider certifying with Lamaze International and achieving the gold standard for childbirth educators. – SM

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

Judith Lothian, PhD, RN, LCCE, FACCE is a nurse and childbirth educator. She is an Associate Professor at the College of Nursing, Seton Hall University and the current Chairperson of the Lamaze Certification Council Governing Body. Judith is also the Associate Editor of the Journal of Perinatal Education and writes a regular column for the journal. Judith is the co-author of The Official Lamaze Guide: Giving Birth with Confidence. Her research focus is planned home birth and her most recent publication is Being Safe: Making the Decision to Have a Planned Home Birth in the US published in the Journal of Clinical Ethics (Fall 2013).

Childbirth Education, Evidence Based Medicine, Guest Posts, Journal of Perinatal Education, Lamaze International, Lamaze Official Guide Book, Push for Your Baby, Research, Series: Journey to LCCE Certification , , , , , , ,

Top Ten Reasons to Become a Member and Join Lamaze International Now!

January 3rd, 2013 by avatar

Did you know that Lamaze International membership runs with the calendar year?  Did you remember to renew your membership at the end of 2012, or did it get lost in the hustle and bustle of the holidays, along with your normal everyday juggle of work, family and self-care?  Have you considered becoming a Lamaze International member but never followed through or were unsure of how it benefits you?  I would like to take a few minutes to share my “Top 10 List” of why it is simply wonderful to be a Lamaze International member, and how I benefit financially and professionally from my membership every day.

1. Supporting the Lamaze International Mission

The mission of Lamaze International is to promote, support and protect natural, safe and healthy birth through education and advocacy through the dedicated efforts of professional childbirth educators, providers and parents.

I am a childbirth professional, working with birthing families, new doulas and new childbirth educators.  I find that Lamaze’s mission aligns so well with my own, and how I create my classes and work with families and birth professionals.  I am proud to say that I am a member of Lamaze and an LCCE.  I think that many of today’s families and birth professionals can also respect and relate to Lamaze’s mission and find that their values are in sync with what Lamaze offers to the maternity world.  Your membership dollars, combined with other members’ financial support help Lamaze to fulfill this very important mission.

2. Journal of Perinatal Education

The Journal of Perinatal Education (JPE) is a quarterly journal mailed to the home of all Lamaze members and is  filled with relevant, current research that can change the way you teach or practice.  The JPE offers you insights into current maternity trends, access to in-depth articles and the opportunity to learn from international experts.  The JPE is read by childbirth educators, doulas, midwives, RNs, Doctors, Lactation Counselors and other professionals. Additionally, as a Lamaze member, you have access to back issues of the JPE online.

3. FedEx Office Discounts

Being a member of Lamaze International allows you to receive a FedEx Office (Kinko’s) discount that has the opportunity to provide you with significant savings.  All of the discounted services that you can receive at the FedEx Office store along with online discounts have the potential to save you more money than your membership costs.  I am amazed at the level of savings on some of the products and services I use for my business printing and shipping needs.

4. Reduced Fees for Lamaze Products and Events

As a member of Lamaze, you receive member discounts when you register for the annual conference, continuing education contact hours, purchase the Study Guide and other Lamaze materials in the Online Education Store, certification materials and test fees for your LCCE or when you recertify for your LCCE.

5. Birth: Issues in Perinatal Care Journal Discounts

Birth is published quarterly and Lamaze members receive a 50% discount on both the hard copy journal and the online journal. Birth: Issues in Perinatal Care is a multidisciplinary, refereed journal devoted to issues and practices in the care of childbearing women, infants, and families. It is written by and for professionals in maternal and neonatal health, nurses, midwives, physicians, public health workers, doulas, psychologists, social scientists, childbirth educators, lactation counselors, epidemiologists, and other health caregivers and policymakers in perinatal care.

6. Your Lamaze Classes Listed on Lamaze Website

If you are a Lamaze Certified Childbirth Educator and a current Lamaze member, your childbirth classes can be listed on the Lamaze International website for parents, in the “Find a Lamaze Childbirth Class” section so that those families looking for a childbirth class can locate your offerings. Increase your class enrollment with this members only benefit.

7. Full Cochrane Library Access

Lamaze International members have full access to the Cochrane Library, a collection of databases containing independent evidence to inform healthcare decision-making.  The Cochrane Library is considered the gold standard of evidence based information and if you are looking for the most up-to-date research on topics relevant to obstetrics and maternity care, breastfeeding and newborn issues, this is the ideal place to find the information you are looking for.

8. Lamaze Forums and Community

As a Lamaze International member, you have member access to our professional forums, on-line communities and discussion groups, where you can share teaching ideas, learn how your peers feel and respond to different topics of interest and collaborate with professionals around the world, from the comfort of your own home or office.

9. Members Only Teaching Resources

When you join Lamaze International, you are provided access to teaching handouts and resources to share with your students, and a variety of class-enriching resources to make your course more relevant, useful and informative to the families that you are working with.

10. Supporting Lamaze Improves Maternity Care Worldwide

LCCEs attend the DONA Conference
Photo Credit HeatherGail Lovejoy

When you purchase a Lamaze membership, Lamaze International can pool your dollars with other members’ dollars and use some of this income to support other organizations that are leading the way in changing maternity care around the world for the better.  Lamaze International supports and collaborates with the Coalition for Improving Maternity Services (CIMS) and others.  Additionally, Lamaze can send personnel to international conferences to represent Lamaze International, create networking opportunities for all of us, collaborate with other maternity leaders and further work to fulfill the mission of Lamaze International and improve birth for women everywhere.

Where else can a membership that costs only $115 ( or less, depending on your country of residence) produce such tangible benefits and savings for you and combine with other membership funds to improve maternity care world-wide?  I am proud and excited to renew my Lamaze International membership every year and invite you to renew yours, if you haven’t already.  If you are not a member of Lamaze, then now is the time to join, so that you can reap the professional benefits for the full calendar year.  For a full list of member benefits , please see the member benefits page on the website. Don’t hesitate, join or renew now!

Can you share how being a Lamaze International member has benefited you? Why are YOU a Lamaze member?  Tell us what it means to you in the comments section.

Journal of Perinatal Education, Lamaze International, Maternal Quality Improvement, Maternity Care, Push for Your Baby , , , , , , , , ,

“Should We Private Bank Our Baby’s Cord Blood?” Information That Can Help You Answer That Question

September 21st, 2012 by avatar

www.flickr.com/photos/lovemybunnies/4740682244/

I was recently asked my thoughts on private cord blood banking by a couple expecting their first child.  This was something that they were considering and wanted to know what information was out there.  I had read various articles and commentaries on private cord blood banking in recent years, but I viewed this as an opportunity to refresh my knowledge before I provided an answer to them.  I wanted to share this information with Science & Sensibility readers, so that you may use it with your classes, clients and patients as well, if you wish.

Kimmelin Hull wrote a very comprehensive post on Science and Sensibility in April, 2011, discussing “Should we, or should we not retrieve Umbilical Cord blood at all?” along with providing information on delayed cord clamping current research, and referring readers to a fantastic Journal of Perinatal Education article, Umbilical Cord Blood: Information for Childbirth Educators, written by Renece Waller-Wise, MSN, CNS, CLC, CNL, LCCE.  Kimmelin Hull’s post and Renece Waller-Wise’s JPE article were great places for me to start my exploration to be able to answer this couple.

Today’s post is not about the benefits and/or risks of delayed cord clamping.  Information on that topic has been provided previously on this site.  What I was really looking for was more information on the likelihood that private banked cord blood might be used for that child or other relatives in the future.

Research indicates that pregnant women frequently do not have adequate information to make an informed decision about cord blood banking. (Fox, et al, 2007).   Additionally, the information sources for childbirth birth educators are frequently the private blood banks or their designated representatives, adding in the potential for bias. (Cord Blood Registry, 2009; Wolf, 1998, 1999) Interestingly, in the state of Washington, where I live, the state requires practitioners to provide information on cord blood donation and banking. (but not on delayed clamping.)

Revised Code of Washington (RCW) 70.54.220  All persons licensed or certified by the state of Washington to provide prenatal care or to practice medicine shall provide information to all pregnant women in their care regarding:

(1) The use and availability of prenatal tests; and

(2) Using objective and standardized information: (a) The differences between and potential benefits and risks involved in public and private cord blood banking that is sufficient to allow a pregnant woman to make an informed decision before her third trimester of pregnancy on whether to participate in a private or public cord blood banking program; and (b) the opportunity to donate, to a public cord blood bank, blood and tissue extracted from the placenta and umbilical cord following delivery of a newborn child.

Nationwide, 26 states have legislation on providing cord blood information. This legislation is intended to guide health care providers and inform parents about their options concerning donation and banking.  You can access this information on a state by state basis here. In Washington, exactly what information should be provided is not spelled out.

Stem cells are available from a variety of sources, but umbilical cord stem cells are the easiest to collect, collection is painless, and according to studies can be done before or after the placenta is delivered. (Gonzalez-Ryan, VanSyckle, Coyne, & Glover, 2000; Percer, 2009). The stem cells are quickly available to be used. But, according to one study, approximately 50% of all cord blood collection samples contain an insufficient volume of blood.  (Drew, 2005).

Private cord blood banking is often marketed as “biological insurance” for potential problems with that child in the future. “Autologous transplant” is where the cord blood is given back to the child it was taken from.  The chance that a child will need its own cord blood is extremely small; a 1:400 to a 1:200,000 chance over the child’s lifetime (Sullivan, 2008). In the case of some illnesses, it would be unwise to transfer the same cord blood cells as they are considered “contaminated” with the very disease that is hoping to be cured.

There is not a lot of research on the period of time that a collected cord blood sample would be viable after storage, and no research on viability over the course of the average human lifespan.

Private cord blood banking is not without significant expense and cost.  Collection and initial processing can run approximately $3000, and then there is an annual fee that can run several hundred dollars for storage each year after that.

Private cord banking services are not regulated, either on the federal level or by the state, so without oversight, regulations and a quality assurance program managed by a third party, consumers may find themselves dealing with programs that could not be financially viable over the long term or may not be handling or storing stem cell products appropriately.

What do various organizations say about private cord blood banking?

 American Congress of Obstetricians and Gynecologists (ACOG)

ACOG has a statement on Umbilical Cord Blood Banking and in their recommendations and conclusions they state:

  • If a patient requests information on umbilical cord banking, balanced and accurate information regarding the advantages and disadvantages of public versus private umbilical cord blood banking should be provided. The remote chance of an autologous unit being used for a child or a family member (approximately 1 in 2,700 individuals) should be disclosed.
  • Discussion may include information regarding maternal infectious disease and genetic testing, the ultimate outcome of use of poor quality units of umbilical cord blood, and a disclosure that demographic data will be maintained on the patient.
  • Some states have passed legislation requiring physicians to inform their patients about umbilical cord blood banking options. Clinicians should consult their state medical associations for more information regarding state laws.
  • Directed donation of umbilical cord blood should be considered when there is a specific diagnosis of a disease known to be treatable by hematopoietic transplant for an immediate family member.
  • Obstetric providers are not obligated to obtain consent for private umbilical cord blood banking.
  • The collection should not alter routine practice for the timing of umbilical cord clamping.
  • Physicians or other professionals who recruit pregnant women and their families for for-profit umbilical cord blood banking should disclose any financial interests or other potential conflicts of interest.

American Academy of Pediatrics

The American Academy of Pediatrics also has a policy statement out on cord blood banking.  Their recommendations are similiar to ACOG.

  • Cord blood donation should be discouraged when cord blood stored in a bank is to be directed for later personal or family use, because most conditions that might be helped by cord blood stem cells already exist in the infant’s cord blood (ie, premalignant changes in stem cells). Physicians should be aware of the unsubstantiated claims of private cord blood banks made to future parents that promise to insure infants or family members against serious illnesses in the future by use of the stem cells contained in cord blood. Although not standard of care, directed cord blood banking should be encouraged when there is knowledge of a full sibling in the family with a medical condition (malignant or genetic) that could potentially benefit from cord blood transplantation.
  • Cord blood donation should be encouraged when the cord blood is stored in a bank for public use. Parents should recognize that genetic (eg, chromosomal abnormalities) and infectious disease testing is performed on the cord blood and that if abnormalities are identified, they will be notified. Parents should also be informed that the cord blood banked in a public program may not be accessible for future private use.
  • Because there are no scientific data at the present time to support autologous cord blood banking and given the difficulty of making an accurate estimate of the need for autologous transplantation and the ready availability of allogeneic transplantation, private storage of cord blood as “biological insurance” should be discouraged. Cord blood banks should comply with national accreditation standards developed by the Foundation for the Accreditation of Cellular Therapy (FACT), the US Food and Drug Administration (FDA), the Federal Trade Commission, and similar state agencies.
Online Resources on Cord Blood Banking to Share with FamiliesParents Guide to Cord Blood Foundation

American College of Nurse–Midwives—“Cord Blood Banking—What It’s All About” (from 2008 Journal of Midwifery & Women’s Health53[2], 161–162)

National Marrow Donor Program—“Cord Blood Donation: Frequently Asked Questions”

compiled by Renece Waller-Wise

I will provide this information to the family who asked me.  I will encourage them to talk to their doctor or midwife, and determine if it is appropriate for them to consult with a genetic counselor, to address family history and other information that may make it more likely for this child or another family member to need collected cord blood.

I would also provide information on the timing of umbilical cord clamping and suggest they discuss with knowledgable providers and the potential bank, the likelihood of an adequate collection when cord clamping is delayed.

After receiving this information from a variety of sources, I trust the parents will be able to make a decision that feels appropriate to them and I will feel that I have provided evidenced based sources that they found useful in their decision-making process.

How do you answer the question “Should we private bank our baby’s cord blood?” What do you say?  What have been your favorite resources on this topic?  Please share information that you feel we can all benefit from.  I welcome your discussion.

References

American Academy of Pediatrics:Policy Statement: Cord blood banking for potential future transplantation.  PEDIATRICS Vol. 119 No. 1 January 1, 2007 pp. 165 -170 (doi: 10.1542/peds.2006-2901)

American Congress of Obstetricians and Gynecologists. (2008) Umbilical Cord Blood Banking. ACOG Committee Opinion No. 399. Obstet Gynecol 2008;111:475–7.

Cord Blood Registry. (2009). Cord blood spotlight: Childbirth educator’s guide, 1(2), 1–4.

Drew, D. (2005). Umbilical cord blood banking: A rich source of stem cells for transplant. Advance for Nurse Practitioners, 13(Suppl. 4), S2–S7.

Fox, N. S., Stevens, C., Cuibotariu, R., Rubinstein, P., McCullough, L. B., & Chervenak, F. A. (2007). Umbilical cord blood collection: Do patients really understand? Journal of Perinatal Medicine, 35, 314–321.

Gonzalez-Ryan, L., VanSyckle, K., Coyne, K. D., & Glover, N. (2000). Umbilical cord blood banking: Procedural and ethical concerns for this new birth option. Pediatric Nursing, 26(1), 105–110.

Percer, B. (2009). Umbilical cord blood banking: Helping parents make informed choices. Nursing for Women’s Health, 13(3), 216–223

Sullivan, M. J. (2008). Banking on cord blood stem cells. Nature Reviews Cancer, 8, 554–563

Waller-Wise, Renece. (2011) Umbilical cord blood: information for childbirth educators. Journal of Perinatal Education, 20(1), 54–60, doi: 10.1891/1058-1243.20.1.54

Washington State Legislature, Revised Code of Washington 70.54.220 Practitioners to provide information on prenatal testing and cord blood banking. http://apps.leg.wa.gov/rcw/default.aspx?cite=70.54.220  Accessed September 21, 2012.

Wolf, S. (1998). Cord blood banking: A promising new technology. Neonatal Network, 17(4), 5–6.Wolf, S. (1999). Storing lifeblood: Cord blood stem cell banking. American Journal of Nursing, 99(8), 60–68.

 

Babies, Childbirth Education, Delayed Cord Clamping, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Journal of Perinatal Education, Newborns, Research, Third Stage, Uncategorized , , , , , , , , , ,

Lamaze Breathing: What Every Pregnant Woman Needs to Know

April 27th, 2011 by avatar

The Spring (20.2) issue of the Journal of Perinatal Education is already upon us, and this month’s Continuing Education Module is by our own Judith Lothian, PhD, RN, LCCE, FACCE.

In her article, Lamaze Breathing:  What Every Pregnant Woman Needs to Know, Dr. Lothian reviews the history of the Lamaze organization and its initial focus on breathing-as-pain-reduction.  Describing the birth of the Lamaze method, when Marjorie Karmel brought her experience birthing with Dr. Fernand Lamaze in Paris, France, to the United States and subsequently paired with Elizabeth Bing to form ASPO (now Lamaze), Lothian states:

“…conscious relaxation and controlled breathing [were used] to manage the pain of contractions, avoiding the need for drugs.”

Lothian goes on to suggest that Lamaze’s focus on breathing as a pain reduction strategy, in all its simplicity, tended to “work” well at the time because, “in those years, labors routinely started, continued, and ended naturally.  Intravenous fluids, continuous fetal monitoring, and epidurals were not part of typical labor.  The cesarean rate was 6%.”

And yet, as we all know, the labor and birth environment here in the US has become more complicated since the early 1960s when the Lamaze approach to labor and birth first took hold.

In my childbirth education classes, when discussing breathing and relaxation techniques, I often find myself asking for a show of hands: “How many of you in this class have ever participated in an athletic activity before?”  Most, if not all hands, typically rise. The line of questioning further unfolds like this:

“What happens when you find yourself going from walking…to jogging…to running…to sprinting?  What does your heart begin to do?  What about your breathing pattern?”  The answers, of course, are that heart rate and breathing increase to match the body’s level of effort.

Then my questioning continues.

“What kind of breathing pattern occurs when you hurt yourself, such as stubbing your toe, spraining an ankle, hitting your thumb with a hammer?”  The answer, of course, is no surprise again:  your breathing automatically changes:  perhaps you suck in a quick breath, hold your breath, or take a series of long, deep breaths while adjusting to the pain of the injury.  Alterations in breathing happen naturally.

Members of the hiking/mountain climbing arena may be familiar with the guidance about breathing touted by the famed mountaineer, writer, and founder of National Outdoor Leadership School, Paul Petzoldt, in his book, The New Wilderness Handbook (Petzold, Ringholz, 1984).  Petzoldt  described using rhythmic breathing to control the hiker’s pace and thereby prevent the need for auxiliary oxygen (even at high altitude) as well as avoid potential complications of altitude sickness such as hallucinations, headaches and faulty decision making.

Conscious breathing, as it turns out, really isn’t just a “Lamaze thing,” after all.

Birth, of course, is neither an injury nor a trek up K2 (though, it might feel like the latter at times).  It is a normal event in the continuum of a woman’s lifespan.  However if we, as childbirth educators, help our students tap into the natural ways their bodies already can and do utilize altered breathing—be it during exercise, athletics or injury—then we can more easily convince expectant parents that they already know how to use breathing as a pain-coping technique.

Lothian’s article goes on to described how, since the ‘60s, Lamaze has moved away from “prescribing” particular breathing methods and, instead, encourages women to tap into comfortable and yet purposeful breathing patterns that feel right to the individual. Moving from strict guidelines which suggest the “one right way” to breathe during labor and birth, a more organic, nimble and responsive approach to breathing-as-pain-reduction (and distraction) is urged.

And yet, there are practices out there, which many women find helpfully applicable to labor and birth, which do combine specific breath work with specific intention.

A friend of mine, Gloria Overcash, teaches both Kundalini and Khalsa Way prenatal yoga classes. During a recent class for members of our local birth network, Gloria introduced us to some of the breathing methods she teaches her students, along with the purpose behind the methods.  Here are some of her insights:

“The science of breathing, known in yoga as Pranayama, is incredibly useful for pregnant women in a variety of circumstances.  A simple, long deep breath can bring one back to the center in the most chaotic of times.”

Here, I think of the usefulness of a calming, purposeful breath to help a laboring woman relax during a vaginal examination, during the insertion of an IV catheter, if needed, or following the conclusion of a contraction.

“There are a number of breathing exercises I teach in my prenatal classes to support mental and emotional balance,” says Overcash, who recommends practicing breathing techniques in a cross-legged, seated position, or in a chair with a straight spine.  “The chin is tucked slightly.  The eyelids are closed and the eyeballs are rolled up, focusing on the “third eye,” also known as the brow point, between the eyebrows.  This ‘drishti,’ or eye focus, stimulates the pituitary gland, the ‘master gland,’ regulating the secretion of the thyroid, adrenal and reproductive glands while also increasing a mother’s intuition.”

When addressing use of the breath for relaxation during the active phase of labor, Gloria suggests, “Women in the active phase of birthing are encouraged to breathe naturally and consciously, creating a rhythmic focus which helps facilitate relaxation and a meditative state while also providing needed energy.”

Lothian does a fantastic job outlining the progress Lamaze has made over the past fifty years teaching women about the labor process and methods of relaxation and pain-coping.  Summarizing the journey of her article, and of Lamaze International, in general, Lothian states:

 

“Although many women continue to think of Lamaze as ‘breathing,’ it is no longer the hallmark of Lamaze.  The six Lamaze Healthy Birth Practices (2009) are the foundation of Lamaze preparation for birth and reflect the evolution of the Lamaze approach to childbirth, one that incorporates a more complete understanding of the physiology of labor and birth and the danger of interfering in the natural physiologic process of birth without clear medical indication.”

 
As always, Lamaze members can access the entire JPE on-line for free, and Springer Publishing also makes the Table of Contents as well as a couple select articles (including the one featured here) free to the general public.  To complete the continuing education modules based on JPE articles, go here.

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Journal of Perinatal Education 20.1 Feature Article: Umbilical Cord Blood: Information for Childbirth Educators

April 11th, 2011 by avatar

The Spring 2011 issue of the Journal of Perinatal Education (JPE 20.1) has already landed in your mailbox and is now available on-line. As always, it is chock-full of illuminating and informing articles about perinatal health care issues.  Considering our recent re-post of Dr. Nicholas Fogelson’s Grand Rounds lecture on delayed umbilical cord (UC) cutting and clamping, the continuing education module contained in this issue of the JPE caught my attention: Umbilical Cord Blood: Information for Childbirth Educators by Renece Waller-Wise, MSN, CNS, CLC, CNL, LCCE.

As options for UC collection and banking/donation are increasing, questions about efficacy and indications grow.  Waller-Wise does a tremendous job in her article providing not only the background on stem cell research (dating back to the 1950s) and transplant and collection (1980s and 1990s, respectively) but she reviews the illnesses that are currently amenable to treatment with umbilical cord blood stem cell transplantation along with the advantages and disadvantages of employing this treatment modality.

While the use of umbilical cord blood stem cells to treat previously identified familial illness in a first degree relative provides a primary indication for collection and banking, the procedure and storage is costly, the cells have a definitive shelf life and success of transplant is not necessarily guaranteed (see Waller-Wise’s article for details).  And the chance of using these stem cells for treatment at all?  At best, the likelihood is estimated to be 1 /2,700.[1]

Beyond whether or not cord blood banking is a reasonable “insurance policy” to invest in, another debate is ensuing which heightens the gravity of the following questions: “Should we, or should we not retrieve UC blood at all?  And if so, should the commonly accepted practices surrounding cord blood collection be altered?”

In Dr. Fogelson’s Grand Rounds videos, his message is clear: immediate clamping and cutting of the umbilical cord deprives the newborn of nearly 20mL/kg of her potential blood volume.  As Fogelson describes it, “…by clamping the umbilical cord [early] you phlebotomize the baby of 40% of its blood volume.”  Dr. Fogelson goes on to explain the various suspected and documented morbidities associated with newborns who have been deprived of this extra (read: nature-intended) blood volume.

Renowned family practice and obstetrics physician, Dr. Sarah Buckley, echoes these concerns in her seminal book, Gentle Birth, Gentle Mothering:  A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Dr. Buckley expands upon the risks of early umbilical cord cutting and clamping this way:

“Active management [of the Third Stage] also creates specific difficulties for mother and baby. In particular, active management can lead to the deprivation of one third,
on average, of a newborn’s expected blood volume. When active
management is used, this extra blood, intended to perfuse the newly
functioning lungs and other vital organs, is discarded along with the placenta.
Possible consequences include breathing difficulties and anemia,
especially in vulnerable babies; long-term effects on brain development
are also very plausible.”[2]

 

But how much of this placental blood is the newborn really deprived of during UC blood collection?

Depending on the system used (needle + syringe extraction vs. needle + dependent bag collection) along with provider skill/preference, cord blood collection requires between 40-200mL of blood such that an adequate volume of stem cells might be retrieved, processed, and made available for transplant.  This volume, incidentally, is on par with the amount of blood a newborn can receive via placental transfusion when the cord is left patent for at least three minutes after birth.  (See Dr. Buckley’s and Dr. Fogelson’s works, referenced above.)  Because of this, common practice is to immediately clamp the umbilical cord following the baby’s birth and initiate cord blood collection moments later—capturing every drop of blood possible into the collection device.

The question, then, becomes:  does the benefit of potentially successful treatment of current familial illness, or future autologous UC blood stem cell transplantation, outweigh the risk of significant newborn phlebotomization?

Before jumping into this debate, my heart tells me there is a third option.

Google “cord blood withdrawal without clamping” and you will find message board and blog site discussions like this one where anecdotal evidence is beginning to emerge and become the subject of hot debate:  it just might be possible to delay clamping & cutting the umbilical cord and collect a cord blood sample that satisfies requirements for banking/transplantation purposes. Make no mistake:  I am not presenting these discussions as science, evidence or infallible support for creating a new Third Stage practice.  I am simply relaying what some maternity care providers have begun doing on their own.  (Isn’t that how medical advances have developed in the past?  Someone tries something new and, low and behold it works…leading to the adoption of the new practice by others?)

The catch, of course, if how much UC blood can be collected after delayed clamping, and whether collection can take place before clotting sets in within the cord/placenta.  One maternity care provider respondent on the Mothering.com message board offered a depiction of how she goes about collecting cord blood after placental delivery:

“The bag is about 500mL, I can usually get about 1/3 of a bag, so a bit more than 150mL, even after the placenta is born.  I usually put the placenta on a counter top, with the bag resting on the floor, start low by the clamp and move up the cord, and use all those juicy veins on the fetal side of the placenta. If you elevate the placenta with the cord hanging, quite a bit will flow into the cord. Obviously, you’re not going to get a full 500mL if you wait for the birth of the placenta, but you can get a decent amount with a little patience and multiple sticks. And you don’t want to wait too long after the birth of the placenta, or the blood coagulates, so someone else should be watching mama and baby while the other does the collection.”

 

If the practice described above is truly reproducible, it would suggest that there is plenty of cord blood available (and perhaps more than what has been previously assessed).

In 2007, the American Academy of Pediatrics released a statement providing the following guidance as a part of its endorsement of cord blood banking when known familial illnesses treatable by stem cell transplant exist:

“The cord blood stem cell-collection program should not alter routine practice for the timing of umbilical cord clamping.”[3]

 

ACOG’s Committee Opinion paper #399 (Feb ’08), Umbilical Cord Blood Banking offers the same guidance. [1]

If we can all agree that in most cases, delaying the clamping and cutting of the umbilical cord constitutes the best, evidence-based practice, then the above AAP statement ought to apply to cord blood collection after a sufficient amount of time has transpired for placental transfusion to take place.

If you look on the website* of one of the largest cord blood banking companies, you can watch a demonstration of umbilical cord blood collection—complete with instructions on how to collect an adequate volume after the birth of the placenta:

The AAP along with ACOG now advise maternity care providers to counsel interested patients on the risks and benefits of cord blood banking.  Factors such as the likelihood of actually using the stem cells, philanthropic drive to donate stem cells to public cord blood banks and the cost of collection and storage should all be taken into consideration when expectant parents are contemplating this choice.  As should the importance of what that added blood volume can do for the newborn whose body is undoubtedly expecting it.  And I, for one, can’t help but to believe a viable third option exists in which the newborn is granted the lion’s share of the placental transfusion while a small and remaining amount is collected for cord blood banking, when the proper indications are present.

Surely a study can be formed to test this hypothesis.

To learn more about umbilical cord blood collection and storage, go here to read Waller-Wise’s full article (compliments of the Journal of Perinatal Education and Springer Publishing) and don’t forget to take the post test to earn continuing education credits!


[1]Umbilical cord blood banking. ACOG Committee Opinion No. 399.  American College of Obstetrics and Gynecologists. Obstet Gynecol 2008;111:475-7

[2] Gentle Birth, Gentle Mothering : A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices by Sarah J Buckley MD (Celestial Arts, Berkeley CA,2009) p 156; www.sarahbuckley.com

[3] http://aappolicy.aappublications.org/cgi/content/full/pediatrics;119/1/165; Recommendations #7

*Neither Lamaze International nor the editor or contributing writers to Science & Sensibility endorse any particular cord blood bank or registry organization or company.

Posted by:  Kimmelin Hull, PA, LCCE

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