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Epidural Analgesia: To Delay or Not to Delay, That Is the Question

October 23rd, 2014 by avatar

By Henci Goer

Unless you have been “off the grid” on a solitary trek, surely you have read and heard the recent flurry of discussion surrounding the just released study making the claim that the timing of when a woman receives an epidural (“early” or “late” in labor) made no difference in the rate of cesarean delivery.  Your students and clients may have been asking questions and wondering if the information is accurate.  Award winning author and occasional Science & Sensibility contributor Henci Goer reviews the 9 studies that made up the Cochrane systematic review: Early versus late initiation of epidural analgesia for labour to determine what they actually said.  Read her review here and share if you agree with all the spin in the media about this new research review. Additionally, head on over to the professional and parent Lamaze International sites to check out the new infographic on epidurals to share with your students and clients.- Sharon Muza, Science & Sensibility Manager. 

Epidural infographic oneArticles have been popping up all over the internet in recent weeks citing a new Cochrane systematic review- Early versus late initiation of epidural analgesia for labour, concluding that epidural analgesia for labor needn’t be delayed because early initiation doesn’t increase the likelihood of cesarean delivery, or, for that matter, instrumental vaginal delivery (Sng 2014). The New York Times ran this piece. Some older studies have found that early initiation appeared to increase likelihood of cesarean (Lieberman 1996; Nageotte 1997; Thorp 1991), which is plausible on theoretical grounds. Labor progress might be more vulnerable to disruption in latent than active phase. Persistent occiput posterior might be more frequent if the woman isn’t moving around, and fetal malposition greatly increases the likelihood of cesarean and instrumental delivery. Which is right? Let’s dig into the review.

The review includes 9 randomized controlled trials of “early” versus “late” initiation of epidural analgesia. Participants in all trials were limited to healthy first-time mothers at term with one head-down baby. Five trials further limited participants to women who began labor spontaneously, three mixed women being induced with women beginning labor spontaneously, and in one, all women were induced. Analgesia protocols varied, but all epidural regimens were of modern, low-dose epidurals. So far, so good.

Examining the individual trials, though, we see a major problem. You would think that the reviewers would have rejected trials that failed to divide participants into distinct groups, one having epidural initiation in early labor and the other in more advanced labor, since the point of the review is to determine whether early or late initiation makes a difference. You would think wrong. Of the nine included trials, six failed to do this.

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

cc photo bryanrmason http://flickr.com/photos/b-may/397189835

The two Chestnut trials (1994a; 1994b) had the same design, differing only in that one was of women who were laboring spontaneously at trial entry and the other included women receiving oxytocin for induction or augmentation. Women were admitted to the trial if they were dilated between 3 and 5 cm. Women in the early group got their epidural immediately while women in the late group could have an epidural only if they were dilated to 5 cm or more. If late-group women were not dilated to 5 cm, they were given systemic opioids and could have a second dose of opioid one hour later. They could have an epidural when they attained 5 cm dilation or regardless of dilation, an hour after the second opioid dose. Let’s see how that worked out.

Among the 149 women in the trial that included women receiving oxytocin (Chestnut 1994b), median dilation in the early group at time of epidural initiation was 3.5 cm, meaning that half the women were dilated more and half less than this amount. The interquartile deviation was 0.5 cm, which means that values were fairly tightly clustered around the median. The authors state, however, that cervical dilation was assessed using 0.5 increments which meant that dilation of 3-4 cm was recorded as 3.5. In other words, women in the early group might have been dilated to as much as 4 cm. The median dilation in the late group was 5.0 cm, again with a 0.5 cm interquartile deviation. Some women in the late group, therefore, were not yet dilated to 5 cm when their epidural began, and, in fact, the authors report that 26 of the 75 women (35%) in the late group were given their epidural after the second dose of opioid but before attaining 5 cm dilation. The small interquartile deviation in the late group tells us that few, if any, women would have been dilated much more than 5 cm. Add in that assessing dilation isn’t exact, so women might have been a bit more or less dilated than they were thought to be, and it becomes clear that the “early” and “late” groups must have overlapped considerably. Furthermore, pretty much all of them were dilated between 3 and 5 cm when they got their epidurals, which means that few of these first-time mothers would have been in active labor, as defined by the new ACOG standards.

Overlap between early and late groups must have been even greater in Chestnut et al.’s (1994a) trial of 334 women laboring spontaneously at trial entry because median dilation in the early group was greater than in the other trial (4 cm, rather than 3.5) while median dilation in the late group was the same (5.0 cm), and interquartile deviation was even tighter in the late group (0.25 cm, rather than 0.5 cm). As before, dilation was measured in 0.5 cm increments, which presumably means that women in the early group dilated to 4-5 cm would have been recorded as “4.5,” thereby qualifying them for the “early” group even though they might have been as much as 5 cm dilated.

Based on my analysis, I would argue that there was no clinically meaningful difference in dilation between early and late groups in either trial.

A second pair of trials, one a mixed trial of spontaneous labor onset and induction and the other all induced, also had the same design in both trials (Wong 2005; Wong 2009). All women were less than 4 cm dilated at first request for pain medication. In the early group, women had an opioid injected intrathecally, i.e. the “spinal” part of a combined spinal-epidural, and an epidural catheter was set. At the second request, an epidural was initiated. In the late group, women were given a systemic opioid. At second request, they were given a second dose of systemic opioid if they hadn’t reached 4 cm dilation and an epidural if they had dilated to 4 cm or more. At third request, they were given an epidural regardless of dilation. Women who had no vaginal exam at second request and were given an epidural were “assumed,” in the authors’ words, to be dilated to at least 4 cm. What were the results?

Wong (2005) included 728 women, some beginning labor spontaneously and some induced. You may already have noticed the flaw in the trials’ design: Wong and colleagues confused the issue by considering intrathecal opioid to be equivalent to epidural anesthetic in the early group, although women didn’t actually receive anesthetic until their second request for pain medication some unknown time later. So far as I know we have no evidence that opiods, spinal or epidural, have any effect on labor progress. As to dilation at the time of epidural initiation, 63% of women in the so-called “early” group were either determined or assumed to be at 4 cm dilation or more while in the late group, some unknown proportion were less than 4 cm dilated either because they got their epidural at third pain medication request regardless of dilation or they were assumed to be at 4 or more cm dilation at second request, but weren’t assessed.

Wong (2009), a study of 806 induced women, was set up the same way but reported data somewhat differently. Early-group women were administered a spinal opioid at a median of 2 cm dilation and an interquartile range of 1.5 to 3 cm, which means that values in the middle 50% of the dataset ranged from 1.5 to 3 cm. We have no information on dilation at the time they received their epidural. The median dilation at which late-group women had their epidural initiated was 4 cm with an interquartile range of 3 to 4 cm, that is, in the middle 50% of the dataset ranged from 3 to 4 cm dilation.

As with the Chestnut trials, dilation at time of epidural initiation in the two Wong trials must have overlapped considerably between groups. And, again, few women in the late epidural group would have been in active labor. The Wong trials, however, muddy the waters even further by considering spinal opioid to be the same thing as epidural anesthetic, and while the authors were careful to use the term “neuraxial analgesia,” the Cochrane reviewers made no such distinction.

This brings us to Parameswara (2012), a trial of 120 women that included both spontaneous onset and induced labors. This trial defined the early group as women less than 2 cm dilated at time of epidural initiation and the late group as women more than 2 cm dilated. That’s all the information they provide on group allocation.

Last of the six, we have Wang (2011), a trial of 60 women in spontaneous labor. All women were given intrathecal anesthetic plus opioid. The early group was started on epidural anesthetic plus opioid 20 minutes later whereas the late group had their epidural initiated when they requested additional pain relief. No information is given on dilation at time of epidural initiation. Not only do we have no idea whether early and late groups differed from one another, women in both groups received neuraxial anesthetic at the same time.

In summary, “garbage in, garbage out.” No conclusions can be drawn about the effect of early versus late epidural administration from these six studies.

The other three studies are a different story. They achieve a reasonable separation between groups. Luxman (1998) studied 60 women with spontaneous labor onset. The early group had a mean, i.e., average, dilation of 2.3 cm with a standard deviation of + or – 0.6 cm while the late group had a mean dilation of 4.5 cm + or – 0.2 cm. Ohel (2006) studied a mixed spontaneous onset and induced group of 449 women. The mean dilation at initiation in the early group was 2.4 cm with a standard deviation of 0.7 cm, and the late group had a mean dilation of 4.6 cm with a standard deviation of 1.1 cm. Wang (2009), the behemoth of the trials, included 12,629 women who began labor spontaneously. The early epidural group had a median dilation of 1.6 cm with an interquartile range of 1.1 to 2.8 and the late group a median of 5.1 cm dilation with an interquartile range of 4.2 to 5.7. Cesarean and instrumental delivery rates were similar between early and late groups in all three trials, so had reviewers included only these three trials, they would still have arrived at the same conclusion: early epidural initiation doesn’t increase likelihood of cesarean and instrumental delivery.

We’re not done, though. Wang (2009) points us to a second, even bigger issue.

The Wang (2009) trial, as did all of the trials, limited participants to healthy first-time mothers with no factors that would predispose them to need a cesarean. The Wang trial further excluded women who didn’t begin labor spontaneously. Nevertheless, the cesarean rate in these ultra-low-risk women was an astonishing 23%. Comparing the trials side-by-side reveals wildly varying cesarean and instrumental vaginal delivery rates in what are essentially homogeneous populations.

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

Comparing the trials uncovers that epidural timing doesn’t matter because any effect will be swamped by the much stronger effect of practice variation.

Analysis of the trials teaches us two lessons: First, systematic reviews can’t always be taken at face value because results depend on the beliefs and biases that the reviewers bring to the table. In this case, they blinded reviewers from seeing that two-thirds of the trials they included weren’t measuring two groups of women, one in early- and one in active-phase labor. Second, practice variation can be an unacknowledged and potent confounding factor for any outcome that depends on care provider judgment.

Conclusion

So what’s our take home? Women need to know that with a judicious care provider who strives for spontaneous vaginal birth whenever possible, early epidural administration won’t increase odds of cesarean or instrumental delivery. With an injudicious one, late initiation won’t decrease them. That being said, there are other reasons to delay an epidural. Maternal fever is associated with epidural duration. Running a fever in a slowly progressing labor could tip the balance toward cesarean delivery as well as have consequences for the baby such as keeping the baby in the nursery for observation, testing for infection, or administering prophylactic IV antibiotics. Then too, a woman just might find she can do very well without one. Epidurals can have adverse effects, some of them serious. Comfort measures, cognitive strategies, and all around good emotionally and physically supportive care don’t. Hospitals, therefore, should make available and encourage use of a wide range of non-pharmacologic alternatives and refrain from routine practices that increase discomfort and hinder women from making use of them. Only then can women truly make a free choice about whether and when to have an epidural.

After reading Henci’s review and the study, what information do you feel is important for women to be aware of regarding epidural use in labor?  What will you say when asked about the study and timing of an epidural?  You may want to reference a previous Science & Sensibility article by Andrea Lythgoe, LCCE, on the use of the peanut ball to promote labor progress when a woman has an epidural. – SM 

References

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology210(3), 179-193.

Chestnut, D. H., McGrath, J. M., Vincent, R. D., Jr., Penning, D. H., Choi, W. W., Bates, J. N., & McFarlane, C. (1994a). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are in spontaneous labor? Anesthesiology, 80(6), 1201-1208. http://www.ncbi.nlm.nih.gov/pubmed/8010466?dopt=Citation

Chestnut, D. H., Vincent, R. D., Jr., McGrath, J. M., Choi, W. W., & Bates, J. N. (1994b). Does early administration of epidural analgesia affect obstetric outcome in nulliparous women who are receiving intravenous oxytocin? Anesthesiology, 80(6), 1193-1200. http://www.ncbi.nlm.nih.gov/pubmed/8010465?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Luxman, D., Wolman, I., Groutz, A., Cohen, J. R., Lottan, M., Pauzner, D., & David, M. P. (1998). The effect of early epidural block administration on the progression and outcome of labor. Int J Obstet Anesth, 7(3), 161-164. http://www.ncbi.nlm.nih.gov/pubmed/15321209?dopt=Citation

Nageotte, M. P., Larson, D., Rumney, P. J., Sidhu, M., & Hollenbach, K. (1997). Epidural analgesia compared with combined spinal-epidural analgesia during labor in nulliparous women. N Engl J Med, 337(24), 1715-1719. http://www.ncbi.nlm.nih.gov/pubmed/9392696?dopt=Citation

Ohel, G., Gonen, R., Vaida, S., Barak, S., & Gaitini, L. (2006). Early versus late initiation of epidural analgesia in labor: does it increase the risk of cesarean section? A randomized trial. Am J Obstet Gynecol, 194(3), 600-605. http://www.ncbi.nlm.nih.gov/pubmed/16522386?dopt=Citation

Parameswara, G., Kshama, K., Murthy, H. K., Jalaja, K., Venkat, S. (2012). Early epidural labour analgesia: Does it increase the chances of operative delivery? British Journal of Anaesthesia 108(Suppl 2):ii213–ii214. Note: This is an abstract only so all data from it come from the Cochrane review.

Sng, B. L., Leong, W. L., Zeng, Y., Siddiqui, F. J., Assam, P. N., Lim, Y., . . . Sia, A. T. (2014). Early versus late initiation of epidural analgesia for labour. Cochrane Database Syst Rev, 10, CD007238. doi: 10.1002/14651858.CD007238.pub2 http://www.ncbi.nlm.nih.gov/pubmed/25300169

Thorp, J. A., Eckert, L. O., Ang, M. S., Johnston, D. A., Peaceman, A. M., & Parisi, V. M. (1991). Epidural analgesia and cesarean section for dystocia: risk factors in nulliparas. Am J Perinatol, 8(6), 402-410. http://www.ncbi.nlm.nih.gov/pubmed/1814306?dopt=Citation

Wang, F., Shen, X., Guo, X., Peng, Y., & Gu, X. (2009). Epidural analgesia in the latent phase of labor and the risk of cesarean delivery: a five-year randomized controlled trial. Anesthesiology, 111(4), 871-880. http://www.ncbi.nlm.nih.gov/pubmed/19741492?dopt=Citation

Wang, L. Z., Chang, X. Y., Hu, X. X., Tang, B. L., & Xia, F. (2011). The effect on maternal temperature of delaying initiation of the epidural component of combined spinal-epidural analgesia for labor: a pilot study. Int J Obstet Anesth, 20(4), 312-317. http://www.ncbi.nlm.nih.gov/pubmed/21840705

Wong, C. A., McCarthy, R. J., Sullivan, J. T., Scavone, B. M., Gerber, S. E., & Yaghmour, E. A. (2009). Early compared with late neuraxial analgesia in nulliparous labor induction: a randomized controlled trial. Obstet Gynecol, 113(5), 1066-1074. http://www.ncbi.nlm.nih.gov/pubmed/19384122?dopt=Citation

Wong, C. A., Scavone, B. M., Peaceman, A. M., McCarthy, R. J., Sullivan, J. T., Diaz, N. T., . . . Grouper, S. (2005). The risk of cesarean delivery with neuraxial analgesia given early versus late in labor. N Engl J Med, 352(7), 655-665. http://www.ncbi.nlm.nih.gov/pubmed/15716559?dopt=Citation

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, informed Consent, Medical Interventions, New Research, Systematic Review , , , , , , ,

Mary Jo Podgurski, EdD, LCCE, Receives National Award for Work With Teens

October 21st, 2014 by avatar

Mary Jo Podgurski, RNC, EdD, LCCE, FACCE has been selected to receive the 2014 Carol Mendez Cassell Award for Excellence in Sexuality Education by the Healthy Teen Network.  Dr. Podgurski will be in Austin, Texas on Wednesday, October 22nd to accept the award at this year’s Healthy Teen Network conference: Synergy: Achieving More Together.

© Mary Jo Podgurski

© Mary Jo Podgurski

The Healthy Teen Network builds capacity among professionals and organizations through education, advocacy, and networking so that they can assist all adolescents and young adults, including teen parents, to have access to the services and education that allow them to make responsible choices about childbearing and family formation, and are supported and empowered to lead healthy sexual, reproductive, and family lives.

Dr. Podgurski could not be more deserving of this award. Her impact on the lives of the young people lucky enough to have been exposed to or participated in one of Dr. Podgurski’s programs is profound.  This woman is has a heart of gold.  At the top of Dr. Podgurski’s CV is the following statement, which so clearly speaks to what drives and shapes her work and her heart:

Perhaps the most important biographical fact needed to know about me deals with joy. I am blessed to spend my days interacting with young people and I treasure every moment; I believe deeply in their wisdom. My primary mantra is simple: Each person is a person of worth. Actually that tenet translates well to my primary value – that all must be respected, regardless of age, size, race, ethnicity, sexuality, sexual orientation, gender, gender identity, socio-economic status, education, religion, or position in society. My papa was my spiritual guide and he taught me that we are “all in this together.”   

Dr. Mary Jo Podgurski is the Director of The Washington Health System Teen Outreach and President and Founder of the Academy for Adolescent Health, Inc. Her undergraduate education is in nursing and education, her master’s work was in counseling, and her doctorate is in education. She began volunteering with pregnant teens in the 70s and has created numerous youth development and education programs using reality-based, interactive educational techniques that are evidence-based and empower youth. Teen Outreach programs have reached over 18,000 students annually through in-school sexuality education in all 14 Washington County school districts. Since the Outreach began she and her team have taught over 231,000 young people in-school comprehensive sexuality education in four counties and 38 schools in Western PA. The Outreach has mentored over 7,000 young parents and trained over 10,000 peer educators. She directs a monthly Adolescent Advisory Board of 75 teens, maintains an active peer educator group (since 1995), and produces original teen educational dramas through the Real Talk Performers. The Outreach’s Ambassador for Respect Program was created in 2006 and models respect throughout the county; the 2013-2014 focus was Respect for Older Adults and the 2014-2015 theme is Smash the Stereotypes.

© Mary Jo Podgurksi

© Mary Jo Podgurksi

During 2010, Dr. Podgurski introduced her Real Talk for Real Teens™ trainings on sexuality education for school staff; these trainings provide activities, lesson plans, and PowerPoint presentations for 5th and 6th graders, middle school and secondary school students. Her educational/mentoring programs for pregnant and parenting teens (PPT) reach over 150 young parents annually in three counties. The PRIDE (Parenting Responsibly with Dignity and Empowerment) PPT Program and a program for expectant teen fathers entitled REAL Dads: Strong Fathers, Strong Families Program involve intensive, weekly mentoring contact with professional staff and young parents. The PPT Program averages an 85 – 94% high school graduation rate; over the last decade students in the program have experienced a 3% or less repeat pregnancy rate. The ECHO (Educate Children for Healthy Outcomes) early intervention program she created in 1999 provides intensive educational mentoring on a weekly basis for youth in grades 7 – 12. Founded on the evidenced-based antecedents for early childbearing (history of abuse, internal and external poverty, foster placement, and generational teen pregnancy) ECHO served 581 at-risk young women between 1999-2009. Only three of those young people experienced a pregnancy and all three were 17 or 18. ECHO clients are typically seen for 4 – 5 years. ECHO is currently being evaluated with help from Susan Philliber Associates.

I have had the privilege of meeting Mary Jo several times over the years at various childbirth functions and conferences.  The magic that this wonderful woman possesses is clear from the minute you meet her.  If you are lucky to spend some time with her, her, you cannot help but see her special powers!  When you talk to Mary Jo, she makes you feel like you are the most important person in the world.  You are heard, listened to and valued.

nonnie podgurskiMary Jo dreams big and makes things happen!  The depth and breadth of what she has accomplished is so expansive. In addition to her extensive program development history, she is an accomplished author, with works that include Inside Out: Your Body is Amazing Inside and Out and Belongs Only to You, a body-positive, child-centered, interactive, child abuse prevention program, is a result of her experience with survivors. Her publications include Games Educators Play One and Two, and What’s Up as YOU Grow Up?  In 2014 she authored a cutting edge children’s book on the challenging topic of gender/gender identity. Nonnie Talks about Gender is unique, interactive, and pertinent to today’s culture. Her latest books are Real Talk for Real Teen Parents: A Real Life Workbook for Young Parents, and Real Talk for Real Teens: #communicate, an interactive collection of scenarios to inspire adult/teen communication.  Mary Jo Podgurski is also a Lamaze Certified Childbirth Educator and a Fellow in the Academy of Certified Childbirth Educators.

Mary Jo Podgurski, please accept my personal congratulations and those of the entire Lamaze International organization, as you accept the 2014 Carol Mendez Cassell Award for Excellence in Sexual Education.  We could not be more proud of you and we honor the work you are doing.  It is making a difference in the lives of many.  Thank you for all you do.

 

 

Awards, Childbirth Education, Uncategorized , , , ,

Q&A with Newly Elected Lamaze International President – Robin Elise Weiss

October 16th, 2014 by avatar

Lamaze International has a new board president and we would like to introduce you to Robin Elise Weiss. I am so delighted that Robin has assumed this role and I am confident that she accomplish great things during her term.

“Childbirth education is one of the most foundational elements of a safe and healthy birth.” – Robin Elise Weiss

© Robin Elise Weiss

© Robin Elise Weiss

Robin Elise Weiss has been elected President of Lamaze International, a nonprofit organization that promotes safe and healthy birth. Weiss is the mother of eight children and brings more than 25 years of expertise in maternal child health and building online communities to her role. She is a PhD candidate, author of more than ten books, and a leading online expert in pregnancy and childbirth. Robin will serve a one-year term beginning in the Fall of 2014.

“Childbirth education is one of the most foundational elements of a safe and healthy birth,” said Weiss. “As president, my goal is to build on the more than 50 years of incredible work and accomplishments of Lamaze by further expanding our capacity to meet parents where they – increasingly – can be found: online. I also want to ensure that Lamaze is addressing the needs of all families, by even further developing our educators both in numbers and diversity.”

In her role as president, Robin will oversee governance of Lamaze International, working with the board and committees to ensure that Lamaze programs and activities continue to fulfill the organization’s mission to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy.  Robin will be also supporting the Lamaze vision of “knowledgeable parents making informed decisions.”

“Robin is a respected pregnancy and childbirth expert with years of experience as a Lamaze educator teaching both expecting parents and aspiring new educators. She brings natural leadership skills and social media expertise to her new role as Lamaze president,” said Linda Harmon, MPH, and Executive Director of Lamaze International.

Robin received her undergraduate degree in Reproductive Health, and Masters in Public Health from the University of Louisville. She is currently completing her Ph.D. in Public Health Management & Systems Science, also from the University of Louisville. Robin has been an innovator for the past 20 years on the Internet, consistently recognized for her significant role in providing unbiased childbirth education information online, including being the owner and creator of one of the first childbirth websites available.

Weiss is the author of more than ten books including: The Complete Illustrated Pregnancy Companion, The Better Way to Care for Your BabyThe Everything New Mother’s First Year, The Everything Pregnancy Fitness BookThe Better Way to Breastfeed, and The Everything Getting Pregnant Book. She is also the winner of Lamaze International’s prestigious Elisabeth Bing Award for outstanding contribution to childbirth on a national level and the Coalition for Improving Maternity Services (CIMS) Forum Award and the Lamaze International’s Presidents Award for her work with The Birth Survey. Robin lives in Louisville, Kentucky, with her husband and eight children.

I asked Robin a few questions about her thoughts on Lamaze International, her hopes and goals for the organization and some key messages for families and educators.  Join me in learning more about Robin she begins her term as Board President.

Sharon Muza: What are some of the opportunities and challenges that face our organization currently and what plan do you and the board have to meet these challenges?

Robin Elise Weiss: Last spring we had an amazing strategic planning session. I am so excited about all of the opportunities that lay ahead for us, and the fact that we all had similar mindsets about what the biggest challenges were, and a great variety of things to help us combat them. One of the things that we have a plan to address is to help increase the number of educators, in order to increase the number of women we reach with the Lamaze message. As a part of this plan, it’s important that we make that obtainable both as potential educators and as potential class attendants. This means thinking outside of the regular classroom and typical childbirth class attendee.

© Sharon Muza

© Sharon Muza

SM: When you think of the many recent accomplishments of Lamaze International, what are a few that you are most proud of? Why?

REW: One of the many things that Lamaze has worked really hard on is to build a great online presence. We all know what the data says about women’s online habits when it comes to parenting and health. Lamaze has built a great reputation with blogs like Giving Birth With Confidence for the consumer, Science & Sensibility for the educators and birth professional; as well as a variety of other means of simply being there, including Twitter accounts, Pinterest, Facebook, etc. Having ourselves out and about online gives women a chance to see that Lamaze International is an active and vital force, something that they want to have as a part of their birth, thus reaching out to their local Lamaze Certified Childbirth Educator. Being online is something that is huge part of my life, and obviously, I’ve been talking to women in this space for over 20 years. Lamaze is a leader in this area.

I am also really excited about the Push for Your Baby Campaign. It launched last year with the video and has included a series of infographics. These are designed to be quick, evidence based ways for women and families to get information and to help build that faith in Lamaze.

 SM: Why is it more important than ever to pursue and maintain certification as a childbirth educator with Lamaze International?

REW: The push for evidence-based care is one that means that all levels of care, from education to execution of the medical side need to be in sync. As we often see with doctors and midwives, it can be really difficult to stay abreast of the vast amount of information that is published in this field on a daily basis. A certification with Lamaze is the bedrock of an education that is based on evidence, but also strives to continue to increase the knowledge levels and stay up-to-date with science and the changing landscape. Maintaining your Lamaze Certification means that you know that Lamaze is helping you filter out the noise and focus on great content that you need to know to be an amazing educator. We do that in a variety of ways, not the least of which is our Journal of Perinatal Education, Inside Childbirth newsletter, our blogs, and other social media platforms.

SM: What do you believe distinguishes Lamaze International from other childbirth education organizations? For educators? For families?

REW: Lamaze International has set a high bar for the childbirth educator. In 2015, Lamaze turns 55. The changes that have happened in birthing children in the last 55 years are astounding and I am not sure that anyone could have predicted where we would be today. That said, Lamaze has always maintained that a knowledgeable childbirth educator was the cornerstone of helping families prepare for their birth, which certainly hasn’t changed in the past 55 years. But something as basic having a loved one with you when you give birth is taken for granted, that wasn’t always so.

Lamaze International reaches families through the Lamaze Certified Childbirth Educator. This is the gold standard by which all other programs are judged. We are a highly accredited certification and maintenance of that certification. You won’t find a once and done philosophy here. This keeps us on our proverbial toes.

SM: How important do you think it is for Lamaze to sit at the table with and be recognized as a serious player amongst maternal infant health organizations? Do you feel like we are there or do we have some growth in that area?

REW: The good news is that Lamaze does sit at that table and is taken seriously. Certainly there are some organizations that are more likely partners than others, but we are certainly reaching out. Just this past year, I’ve personally seen Lamaze interacting with organizations like DONA International, the American College of Nurse Midwives (ACNM), the American Congress of Obstetricians and Gynecologists (ACOG), and many others. There is always room for growth, and we will continue to reach out where it makes sense. (Don’t forget to mark your calendar for our joint conference in 2015 with the International Childbirth Education Association (ICEA)!)

There has been a large growth in the number of researchers and research that we take part in as an organization. This will continue to grow as we move forward.

SM: How can our members share with the public that this is not your mama’s Lamaze? That our organization and education offerings have moved beyond the stereotypical breathing exercises that seemed our trademark in decades past?

REW: This is one of those places that you need to simply be out there and be visible. Have your elevator speech, or speeches planned. You will get a good feel for what questions are pervasive in your community. You’ll get questions about the breathing. (I like to explain that as an LCCE, my job is to teach a variety of ways to deal with labor, not simply something like breathing, but also being active physically, and involved with your care.) You might get told that they don’t need a childbirth educator for whatever reason. (This is the perfect place to insert what makes you and your class unique! Hello – Talk up the Six Healthy Birth Practices.) Figure out what’s going on in your community and be ready.

You can also be proactive. Get out and talk about Lamaze International and what you are doing locally. Never hesitate to give a quick presentation someplace. (Yes, I’m known for traveling with a baby and pelvis for an impromptu class!) Offer to teach a quick 10 minute class on a topic at the local library (Give them a list of books to have available ahead of time!), or bookstore. Talk to others in your area and support one another, this is even better if you already have a birth network.

And social media and your online presence is also important. Share the links from our blogs and social media, particularly the infographics. These are great to put on your website, send in an email to a potential client, use as books marks, use the social media sharing buttons around the site. Share, share, share!

SM: Tell us something unusual about you that we might never know!

REW: Thanks to social media, I am not sure that I have anything unusual that’s not known. So let me tell you about something of which I am very proud – I was a Military Police Officer in the 101st Airborne Division. Being an MP has been a really unique facet of who I am as a professional and as a mother. I love to explain that I came to birth from a science perspective – the biology, chemistry, and physics – it just all works! What I didn’t understand was the touchy, feely stuff; that was difficult for me to learn. Now I feel like I have just the right amount of everything going for me – the science, the presence, and the sensitive side.

Please join me in congratulating Robin Elise Weiss on her election as board president and offer her good wishes as she begins her year of service in maintaining Lamaze International as the premier childbirth education organization.

 

 

 

Childbirth Education, Lamaze International, Push for Your Baby, Uncategorized , , , ,

The Role of the Childbirth Educator during a Perinatal or Infant Loss

October 14th, 2014 by avatar
Original Painting © Johann Heinrich Füssli

Original Painting © Johann Heinrich Füssli

As we continue to observe Pregnancy and Infant Loss Awareness Month, I would like to discuss a difficult topic that may come up for childbirth educators.  Last week, Robin Elise Weiss shared ways to commemorate the loss of a baby. Today, I would like to talk about when a class member experiences a perinatal loss while taking your class, or after the class is over.  If you work long enough as an educator, eventually this will be an issue that you are going to need to face.

Sometimes, you may be contacted by the family, with a somber email or phone call, letting you know that they won’t be returning to class. Other times, a family just stops coming, with no explanation, midway through a series.  You are not sure why.  Was it your teaching style?  Did they have their baby early?  Has something happened?  You will also have to consider that this family may have experienced a late term loss.

When a family does not return to class, I always suggest that the childbirth educator reach out to the family via phone or email to politely inquire and determine that all is okay.  Possibly the mother has been placed on bedrest and will need some accommodations or arrangements in order to complete her childbirth education.  Often, you will find out that something has come up and the date and time no longer work, and you breathe a sigh of relief at this information.  You may find out that their baby arrived prematurely, and you have an opportunity to connect them with resources that they may find useful while dealing with a baby in the NICU and adjusting to the new reality of having a baby weeks or months before they thought they would.  It is likely that their baby may require additional resources and have some immediate needs they had not thought about.  And sometimes, unfortunately, you learn that they have lost their baby either in utero or after birth.

If you are a successful childbirth educator, you work hard to build community in your childbirth classes, helping families to connect with each other through engaging activities and interactive learning.  The families start to see each other as resources and comrades in the transition to parenthood.  Connections are made, friendships are developed and a feeling of community is established.  You are faced with the task of sharing with the class that a family will not be returning.  They are missed and class members usually will be inquiring as to their absence.

When you learn of such a loss, I believe you have several responsibilities as a childbirth educator.  First, determine if the family is open to receiving resources that can help them as they deal with the loss of a baby.  These resources may included peer to peer and facilitated support groups in their community, counselors and therapists specializing in perinatal grief and loss, lactation consultants who can help with the transition of not needing to breastfeed, online resources to help them and more.

If there is a public funeral or memorial service, I make every attempt to attend if possible, in order to show my respect.  Sometimes this is not possible or the family has decided to keep the event private. Regardless,  I always try and promptly send a sympathy card to the family, expressing my sadness at the loss of their son or daughter.

I also politely inquire if they would like me to share the news with the rest of the class.  This information needs to be handled very sensitively.  The family may not want the news shared, and their privacy and wishes are my first priority.  But no doubt, someone in the class will soon ask where the missing family has gone.  In my experiences, the family usually has given me permission to share the information with the rest of the class.  This can be a huge challenge – finding a balance of informing the class and not creating fear and worry for them.

In my experience, the best way to share the information is toward the end of class, with just a few minutes to go.  I respect the family’s wishes and only share the information I have been asked to share.  I tell the truth, but I don’t feel the need to go into great detail.  I answer any questions from the class as best I can and stick to the facts, while respecting the family’s wishes.  If allowed, I provide information about a service or how to contact the family.  I acknowledge that this event is hard to hear, and may bring up concerns and fears for the class members. Sometimes families get very upset or cry as they hear the news.  I provide some resources where they can get more information and support, and also suggest they speak to their health care provider about their fears.  I make myself immediately available after class and in the future to listen to their concerns if they feel the need to connect.

Sometimes a family loses a baby after the class has ended, but before a reunion (if you do class reunions, which are very common here in my area.)  If I am made aware of the loss by the family, I follow the steps above, but ask how they would like me to handle sharing with the class.  I provide this information to those in attendance at the reunion, sharing only information as allowed by the family.

If you have class email lists, or Facebook groups for your childbirth classes, be sure to find out what the parents’ wishes are regarding remaining on the list or in the group.  Some families will want to be removed and others will want to stay connected.  When in doubt, I would discreetly remove them from further communication about class activities, baby announcements or planned gatherings.

Losing a baby during pregnancy or after birth is one of the most difficult things a family can experience.  Our society does not do a great job in honoring this type of loss.  The role of the childbirth educator becomes very important when one of your class members has lost a baby.  How you handle this loss, with both the family and with other class members is critical and can impact the experience of all.  As childbirth educators, we are in a unique position to help both the family and our other students when given permission by the grieving family.

Have you had this experience as a childbirth educator?  How have you handled this situation?  Do you have any tips for other educators in case they have a similar experience?  What did you find worked?  What did you do?  Please share your thoughts and suggestions along with any resources in our comments section.

 

 

 

 

Babies, Childbirth Education, Trauma work , , , ,

You Are Invited to Participate in an Online Learning Opportunity: Patient, Staff, and Family Support Following a Severe Maternal Event

October 10th, 2014 by avatar

council women safety

Past posts on Science & Sensibility – CDC & ACOG Convene Meeting on Maternal Mortality & Maternal Safety in Chicago and U.S. Maternal Mortality Ratio is Dismal, But Changes Underway, and You are Invited to Participate have shared information on the National Partnership for Maternal Safety, a multidisciplinary initiative focused on reducing the rates of maternal morbidity and mortality in the United States.  This partnership falls under the umbrella of The Council on Patient Safety in Women’s Health Care. This unique consortium of organizations across the spectrum of women’s health has come together to promote safe health care for every woman, at every birthing facility in the U.S. through implementation of safety bundles for common obstetric emergencies (hemorrhage, preeclampsia/hypertension and venous thromboembolism) as well as supplemental bundles on Maternal Early Warning Criteria, Facility Review after a Severe Maternal Event, and Patient/Family and Staff Support after a Severe Maternal Event.

The public Safety Action Series has introduced topics including an overview of the Partnership, efforts underway to define and measure Severe Maternal Morbidity, identify and implement Maternal Early Warning Criteria, Quantification of Blood Loss, and the outlines of the OB Hemorrhage Patient Safety Bundle. These slide sets and audio recordings have been archived and are available to the public.

christine morton headshotThe next event will be Tuesday, October 14 at 12:30 pm EST, with presenters Cynthia Chazotte, MD, FACOG, and Christine Morton, PhD, on Patient, Staff, and Family Support Following a Severe Maternal Event, and you can register for the event here. Registering for any event puts you on a list to be informed of upcoming events and future activities of the Partnership. Childbirth educators and other birth professionals may have students and clients who experience a serious medical event during labor and birth.  Having resources for families and for yourself is absolutely critical.  This information will be covered during the online event.

Christine Morton is a board member on the Lamaze international Board of Directors.   We are lucky to have such an active and knowledgeable professional to serve and support the Lamaze mission and values. Please share this information and get involved.

Childbirth Education, Lamaze International, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Pregnancy Complications , , , ,