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The Roadmap of Labor: A Framework for Teaching About Normal Labor

September 2nd, 2014 by avatar

By Penny Simkin, PT

Regular contributor, Penny Simkin developed the roadmap of labor as a teaching tool.  Today, Penny shares how she uses the roadmap of labor to help families in her childbirth classes to understand normal labor from a physiological standpoint. She hopes that her students will take away an understanding of comfort and coping mechanisms along with recognizing the emotions a mother might be experiencing and how a partner can help with both the physical and emotional aspects. Penny is one of the Plenary Speakers at the upcoming Lamaze International/DONA International Confluence scheduled for later this month in Kansas City, MO.  Read how Penny, a master childbirth educator, with this handy tool, helps parents understand what to expect  during labor and birth. – Sharon Muza, Community Manager, Science & Sensibility

Introduction

© Sarah Sweetmans

© Sarah Sweetmans

Childbirth educators strive to provide timely, accurate, woman-centered information. We adapt our content and teaching methods to the time allowed, and the variety of learning styles, educational levels and cultural backgrounds of our students. We hope to build trust in the normal birth process, and instill the confidence and competence necessary for parents to meet the challenges of childbirth, and also to communicate effectively with their maternity caregivers.

In this paper I describe a teaching aid, the roadmap of labor, and some ideas to help guide parents through normal childbirth, from early labor to active labor, transition, and the resting, descent and crowning-to-birth phases of the second stage. The discussion of each stage and phase includes what occurs, women’s and partners’ common emotional reactions, and advice on comfort measures and ways to work together to accomplish a safe and satisfying birth.

I do not describe how I teach about routine or indicated interventions, complications, pain medications, or surgical birth. Aside from space limitations, the real reason lies in my firm belief that when expectant parents appreciate the pure unaltered (and elegant!) physiological process of labor, they have more confidence that birth usually goes well, and they may feel reluctant to bypass it (with induction or cesarean) or alter it unnecessarily. Normal labor becomes the clear standard against which to assess the benefits and risks of specific interventions and the circumstances that increase or decrease their desirability.

If I combined the discussion of straightforward labor with complications and common procedures (along with their risks, benefits, and alternatives), parents would have a fragmented and confused perception of childbirth and an almost impossible burden of separating normal from abnormal, and elective from indicated procedures. All these topics must be covered, however, if parents are to participate in their care, whether labor is straightforward or not. Therefore I teach these topics in subsequent classes, using normal birth as the reference point. I also follow this approach in some other writings.1,2

Initiation of labor, the six ways 
to progress and signs of labor

There are some key concepts that childbirth educators can use to raise parents’ awareness and appreciation of events of late pregnancy and normal birth and how they can help the process flow smoothly. Parents need to understand these concepts well, so they can use the roadmap of labor to best advantage, and play a more confident and active role in labor.

For example, before introducing the roadmap, the teacher should inform parents about the hormonally- orchestrated processes in late pregnancy that prepare for birth, breastfeeding, and mutual mother-infant attachment. This is important because teachers face two common challenges: first, parents’ impatience to end the pregnancy due to discomfort, fatigue and eagerness to hold their baby; and second, the possibility of a long, discouraging pre-labor phase.

These challenges make parents more accepting of induction or vulnerable to the belief that there is something wrong. Parents need to understand that labor normally begins only when all of the following occur:

• The fetus is ready to thrive outside the uterus (breathing, suckling, maintaining body temperature, and more).
• The placenta has reached the point where it can no longer sustain the pregnancy.
• The uterus is ready to contract, open and expel the baby.
• The mother is ready to nourish and nurture her baby.

If parents understand that fetal maturity is essential in initiating the chain of events leading to labor, they may be more patient with the discomforts of late pregnancy, and less willing or anxious to induce labor without a medical reason.

The six ways to progress to a 
vaginal birth

Progress before and during labor and birth occurs in many ways, not simply cervical dilation and descent, which is what most people focus on. Labor unfolds gradually and includes six steps, four of which begin weeks before labor and involve the 
cervix. The cervix moves forward, ripens, effaces and then dilates. When parents understand that a long pre- or early labor is accomplishing necessary progress – preparing the cervix to dilate – they are less likely to become anxious or discouraged that nothing seems to be happening. The two other steps involve the fetus: the fetal head repositions during labor by flexing, rotating, and moulding to fit into the pelvis; and lastly, the fetus descends and is born.

Three categories of signs of labor

By placing these in the context of the six ways to progress, parents may be better able to recognize the differences between pre-labor (often called ‘false labor’) and labor.

Possible signs of labor

These include: nesting urge; soft bowel movements; abdominal cramping; and backache that causes restlessness. These may or may not continue to the clearer signs of labor and may be associated with early cervical changes.

Pre-labor signs

The most important of these is the first one:

  • Continuing ‘nonprogressing’ contractions (that is, over time,
the pattern remains the same; they do not become longer, stronger or
closer together)
  • Possible leaking of fluid from the vagina
  • Possible ‘show’ – bloody mucus discharge from the vagina

With these signs, the cervix is probably not dilating significantly, but is likely to be ripening and effacing (steps two and three of the six ways to progress).

Positive signs of labor

The most important of these is the first one:

  • Continuing, progressing contractions, i.e. contractions that become longer, stronger, and closer together (or at least two of those signs). These progressing contractions cause cervical dilation (steps four and five of the six ways to progress), which is the clinical definition of labor.
  • Spontaneous rupture of the membranes (SRM), especially with a gush of fluid. This happens before or at the onset of labor in about 8% of women at term.3 It most often happens late in labor. SRM is only a positive sign of labor 
in conjunction with continuing progressing contractions.

The roadmap of labor

I have created a visual guide to labor progress using the metaphor of a road map. It shows key labor landmarks, and appropriate activities and measures for comfort as labor progresses (see Figure 1).4 Parents can use it during labor as a reminder of where they are in the process and what to do. Teachers can use it as a tool for organized discussion of normal labor progress, and as a backdrop for discussing laboring women’s emotional reactions, and how partners or doulas may assist. Health professionals can use it to help parents identify where they are in labor, adjust their expectations and try appropriate comfort measures.

© Penny Simkin

© Penny Simkin

Normal labor pathway

The roadmap portrays three pathways. The main brick road represents normal labor and shows helpful actions, positions, and comforting techniques to use as labor progresses. The twists and turns in the brick road indicate that normal labor does not progress in a straight line; the large turns between three and five-to-six centimeters and between eight and ten centimeters indicate large emotional adjustments for the laboring woman, and present an opportunity to discuss emotional support and comfort measures for the partner or doula to use. After ten centimeters, the woman’s renewed energy and confidence are represented by the second wind sign. Along with discussion of emotional support and comfort measures, the teacher can offer perspective and practical advice for partners and doulas, to use both when the woman is coping well and when she feels challenged or distressed.

The roadmap provides a clear and effective way to teach about normal labor. It keeps the discussion focused purely on the physiological and psychological processes, without inserting discussions of pros and cons of interventions, complications, or usual policies and hospital practices that alter labor.

Image Source: © Sharon Muza

Image Source: © Sharon Muza

Once parents have a solid understanding of normal labor, the teacher can explain usual care practices and possible options for monitoring maternal and fetal well being during labor. She can also discuss labor variations or complications and treatments with medical (including pain medications), surgical or technological procedures. With this approach, parents are better equipped to discuss risks, benefits and alternatives, because they can distinguish situations and conditions that are more likely to benefit from the intervention from those in which the intervention is optional, unnecessary, or harmful.

Planned and spontaneous rituals

The normal labor road suggests measures to use for distraction, comfort, and progress. Distraction is desirable for as long as it helps. The Relax, Breathe, Focus sign reminds parents to use this pre-planned ritual for dealing with intensifying contractions when distraction is no longer possible. Parents need to rehearse these rituals in childbirth class (i.e. slow breathing, tension release, and constructive mental focus) and use them in early labor. They set the stage for the spontaneous rituals that emerge later in labor (as women enter active labor), when they realise they cannot control the contractions or continue their planned ritual, and give up their attempts to do so, though sometimes after a stressful struggle. Spontaneous rituals replace the planned ones. They are not planned in advance – they are almost instinctual – and almost always involve rhythmic activity through the contractions – breathing, moaning, swaying, stroking, rocking, or even letting rhythmic thoughts or phrases repeat like a mantra.

The three Rs

The spontaneous rituals usually involve the three Rs: relaxation (at least between contractions), rhythm, which is the most important, and ritual, the repetition of the same rhythmic activity for many contractions. In order to give herself over to spontaneous instinctual behavior, the woman needs to feel emotionally safe, uninhibited, accepted unconditionally by partner and staff, and to be mobile in order to find comfort.

The motto ‘Rhythm is everything’ means that if a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult. The rhythmic ritual keeps her from feeling totally overwhelmed. The goal is to keep her rhythm during contractions in the first stage. Once in second stage, however, rhythm is no longer the key. The woman becomes alert and her spirits are lifted. An involuntary urge to push usually takes over and guides her behavior.

The role of the partner in labor

The partner helps throughout labor, comforting the mother with food and drink, distraction, massage and pressure, assistance with positioning, and constant companionship. Sometimes a doula also accompanies them, providing continuing guidance, perspective, encouragement, and expertise with hands-on comfort measures, positions, and other techniques gained from her training and experience.2

The role of an effective birth partner includes being in the woman’s rhythm
– focusing on her and matching the rhythm of her vocalizations, breathing or movements – by swaying, stroking, moving hand or head, murmuring softly in her same rhythm. Then, if she has difficulty keeping her rhythm, and tenses, cries out or struggles – as frequently occurs in active labor or transition – her partner helps her get her rhythm back, by asking her to focus her eyes on their face or hand and follow their rhythmic movements. This is the take-charge routine, and is only used if the woman has lost her rhythm, is fearful, or feels she cannot go on. Partners who know about this are less likely to feel helpless, useless or frightened. Simple directions, given firmly, confidently, and kindly (‘look at me,’ or ‘look at my hand’), rhythmic hand or head movements, and ‘rhythm talk’ with each breath (murmuring, ‘Keep your rhythm, stay with me, that’s the way…‘) are immensely effective in helping the woman carry on through demanding contractions. During the second stage, rhythm is no longer important; now the partner encourages her bearing-down efforts and release of her pelvic floor, and also assists her with positions.

The motto “Rhythm is everything” means that if
 a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult.

The detour for back pain

A second pathway, a rocky, rough road, represents the more difficult ‘back labor’, which may be more painful, longer, or
more complicated than the normal labor pathway. Fetal malposition is one possible cause. The measures shown for back labor are twofold: reduce the back pain and alter the effects of gravity and pelvic shape to encourage the fetus’s movement into and through the pelvis. It helps a woman endure a prolonged or painful back labor if she and her partner use appropriate comfort measures, and if they know that dilation may be delayed while the baby’s head molds or rotates to fit through, or that changing gravity and pelvic shape may give the extra room that the baby needs to move into an optimal position.

The epidural highway

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

This third pathway represents a dramatically different road – smooth, angular, man- made, more comfortable – but it comes with extensive precautions and numerous procedures, monitors, and medications, which are necessary to keep the epidural safe. The woman adopts a passive role while the staff manage labor progress, and monitors the mother’s and fetus’s well being closely. The excellent pain relief and chance to sleep are the usual rewards. Discussion of how to work with an epidural in order to optimize the outcome is beyond the scope of the paper, but the basic principle is: treat the woman with an epidural as much as possible like a woman who does not have one! This essentially means,‘Keep her cool. Keep her moving. Keep her involved in the work of pushing her baby out. And don’t assume that if she has no pain, she has no distress! Do not leave her alone.’

Conclusion

The roadmap of labor provides a useful framework for teachers to explain the psychological and physiological processes of labor, and a variety of activities for comfort and labor progress for women and their partners to use. By focusing on the normal unaltered process, parents learn to separate the norm from the numerous interventions that alter the process, sometimes for the better, sometimes for the worse. The intention is to give them confidence that they can handle normal labor and to participate meaningfully in decision-making when interventions are suggested.

Do you use the roadmap of labor as a teaching tool in your childbirth classes or with your clients?  How do you use it?  I would love to hear the innovative ways that you have found to incorporate this valuable tool in your classes.  Please share with Penny and all of us in the comments section. – SM

References

1. Simkin P. Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia. Birth 2012;39(4):327-32.

2. Simkin P. The birth partner: a complete guide
to childbirth for dads, doulas, and all other labor companions. 4th edition Harvard Common Press; 2013.

3. Marowitz A, Jordan R. Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health 2007;52(3):199-206.

4. Simkin P. Road map of labor. Childbirth Graphics; 2003. Available from: www.childbirthgraphics. com/index.php/penny-simkin-s-road-map-of- labor-interactive-display.html

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 11,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2008), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

Copyright © NCT 2014. This article first appeared in NCT’s Perspective journal, edition March 2014.   http://www.nct.org.uk/professional/research

2014 Confluence, Cesarean Birth, Childbirth Education, Continuing Education, Guest Posts , , , ,

Breastfeeding & Racial Disparities in Infant Mortality: Celebrating Successes & Overcoming Barriers

August 28th, 2014 by avatar
© mochamanual.com

© mochamanual.com

August has been designated as World Breastfeeding Month, and Science & Sensibility was happy to recognize this with a post earlier this month that included a fun quiz to test your knowledge of current breastfeeding information.  Today, we continue on this topic and celebrate Black Breastfeeding Week 2014 with a post from regular contributor, Kathleen Kendall-Tackett, Ph.D., IBCLC, FAPA sharing information about the increased breastfeeding rates rates among African American women.  Kathleen also discusses some of the areas where improvements can help this rate to continue to increase. 

Celebrating Successes

Many exciting changes occurred in 2013 in the breastfeeding world. One of the best trends was the increase in breastfeeding rates in the African American community. The CDC indicated that increased breastfeeding rate in African American women narrowed the gap in infant mortality rates.  As the CDC noted:

From 2000 to 2008, breastfeeding initiation increased…from 47.4% to 58.9% among blacks. Breastfeeding duration at 6 months increased from…16.9% to 30.1% among blacks. Breastfeeding duration at 12 months increased from… 6.3% to 12.5% among blacks.

Much of this wonderful increase in breastfeeding rates among African Americans has come from efforts within that community. In 2013, we saw the first Black Breastfeeding Week become part of World Breastfeeding Week in the U.S. Programs, such as A More Excellent Way, Reaching Our Sisters Everywhere (ROSE), and Free to Breastfeed, offer peer-counselor programs for African American women.


We can celebrate these successes. But there is still more to do. Although the rates of infant mortality have dropped, African Americans babies are still twice as likely to die. In addition, although rates of breastfeeding have increased among African Americans, they are still lower than they are other ethnic groups.

For each of the 2000–2008 birth years, breastfeeding initiation and duration prevalences were significantly lower among black infants compared with white and Hispanic infants. However, the gap between black and white breastfeeding initiation narrowed from 24.4 percentage points in 2000 to 16.3 percentage points in 2008.

Barriers to Overcome

In order to continue this wonderful upward trend in breastfeeding rates, we need to acknowledge possible barriers to breastfeeding among African American women. Here are a couple I’ve observed. They are not the only ones, surely. But they are ones I’ve consistently encountered. They will not be quick fixes, but they can be overcome if we recognize them and take appropriate action.

1) Pathways for IBCLCs of Color

In their book, Birth Ambassadors: Doulas and the Re-Emergence of Women-Supported Birth in America, Christine Morton and Elayne Clift highlight a problem in the doula world that also has relevance for the lactation world: most doulas (and IBCLCs) are white, middle-class women. And there is a very practical reason for this. This is the only demographic of women that can afford to become doulas (or IBCLCs). The low pay, or lack of job opportunities for IBCLCs who are not also nurses, means that there are limited opportunities for women without other sources of income to be in this profession. Also, as we limit tracks for peer-counselors to become IBCLCs, we also limit the opportunities for women of color to join our field. I recently met a young African American woman who told me that she would love to become an IBCLC, but couldn’t get the contact hours needed to sit for the exam. That’s a shame. (I did refer her to someone I knew could help.)

2) We need to have some dialogue about how we can bring along the next generation of IBCLCs. We need to recognize the structural barriers that make it difficult for young women of color to enter our field. ILCA has started this dialogue and held its first Lactation Summit in July to begin addressing these issues.

These discussions can start with you. Sherry Payne, in her recent webinar, Welcoming African American Women into Your Practice, recommends that professionals who work in communities of color find their replacement from the communities they serve.  Even if you only mentor one woman to become an IBCLC, you can have a tremendous impact in your community. If we all do the same, we can change the face of our field. (Note, here is a wonderful interview with Sherry as she discusses “Fighting Breastfeeding Disparities with Support.”)

3) Bedsharing and Breastfeeding

 This is an issue that I expect will become more heated over the next couple of years. But it is a reality. As we encourage more women to breastfeed, a higher percentage of women will bedshare. As recent studies have repeatedly found, bedsharing increases breastfeeding duration. This is particularly true for exclusive breastfeeding.

Bedsharing is a particular concern when we are talking about breastfeeding in the African American community. Of all ethnic groups studied, bedsharing is most common in African Americans. It is unrealistic to think that we are going to simultaneously increase breastfeeding rates while decreasing bedsharing rates in this community. The likely scenario is that breastfeeding would falter. It’s interesting that another recent CDC report, Public Health Approaches to Reducing U.S. Infant Mortality, talks quite a bit about safe-sleep messaging, with barely a mention of breastfeeding in decreasing infant mortality.  A more constructive approach might be to talk about being safe while bedsharing. But as long as the message is simply “never bedshare,” there is likely to be little progress, and it could potentially become a barrier to breastfeeding.


Reason to Hope

BBW-Logo-AugustDates3Even with these barriers, and others I haven’t listed, Baby-Friendly Hospitals are having a positive effect. When hospitals have Baby-Friendly policies in place, racial disparities in breastfeeding rates seem to disappear. For example, a study of 32 U.S. Baby-Friendly hospitals revealed breastfeeding initiation rates of 83.8% compared to the national average of 69.5%. In-hospital exclusive breastfeeding rates were 78.4% compared with a national rate of 46.3%. Rates were similar even for hospitals with high proportions of black or low-income patients (Merewood, Mehta, Chamberlain, Phillipp, & Bauchner, 2005). This is a very hopeful sign, especially as more hospitals in the U.S. go Baby-Friendly.

http://kcur.org/post/kc-group-fights-breast-feeding-disparities-education-support

In summary, we have made significant strides in reducing the high rates of infant mortality, particularly among African Americans. I am encouraged by the large interest in this topic and the number of different groups working towards this goal. Keep up the good work. I think we are reaching critical mass.

Additional resource: Office of Women’s Health, U.S. Department of Health & Human Services Breastfeeding Campaign for African American families.

References

Merewood, A., Mehta, S. D., Chamberlain, L. B., Phillipp, B. L., & Bauchner, H. (2005). Breastfeeding rates in U.S. Baby-Friendly hospitals: Results of a national survey. Pediatrics, 116(3), 628-634.

Reprinted with permission from Clinical Lactation, Vol. 5-1. http://dx.doi.org/10.1891/2158-0782.5.1.7

About Kathleen Kendall-Tackett

kendall-tackett 2014-smallKathleen Kendall-Tackett, Ph.D., IBCLC, FAPA is a health psychologist, International Board Certified Lactation Consultant and Fellow of the American Psychologial Association in both the divisions of Health and Trauma Psychology. Dr. Kendall-Tackett is President-Elect of the Division of Trauma Psychology, Editor-in-Chief of Clinical Lactation, clinical associate professor of pediatrics at Texas Tech University Health Sciences Center, and Owner/Editor-in-Chief of Praeclarus Press, a small press specializing in women’s health. Dr. Kendall-Tackett has authored more than 310 articles or chapters and is the author or editor of 22 books on women’s health, maternal depression, family violence and breastfeeding. Dr. Kendall-Tackett and Dr. Tom Hale received the 2011 John Kennell and Marshall Klaus Award for Research Excellence from DONA International. You can find more from her at Uppity Science Chick

 

Babies, Breastfeeding, Childbirth Education, Guest Posts , , , , , , , ,

Sleeping Like a Mammal: Nighttime Realities for Childbirth Educators to Share With Parents

August 21st, 2014 by avatar

By, Linda J. Smith, MPH, IBCLC, LCCE, FACCE

In recent days, there has been much press and discussion about a new book written by pediatricians that professes to help parents “train” their new baby to sleep through the night. The scathing criticism of the book by both parents and professionals alike are consistent with what we know about the needs of a newborn baby and their sleep and feeding patterns. Today on Science & Sensibility, Linda Smith, MPH, IBCLC, LCCE, FACCE shares accurate, evidence based information that childbirth educators and other professionals can use to talk to new families about newborns and their sleep and feeding patterns. Linda is one of the authors of La Leche League International‘s newest book; Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family.

This book written by Smith along with co-authors Diane Wiessinger,  Teresa Pitman and Diana West provides families with information to help the entire family get more sleep and do so safely, while meeting the nutritional and developmental needs of newborns. Preparing families for life with a newborn is one of the challenges we face as educators. The information Linda provides here along with the resources included in this post can help you to be sure that your information is backed by research and appropriate for your new families. – Sharon Muza, Community Manager, Science & Sensibility

How do I address sleep with my childbirth class participants?

261653 ML Algebra1 2007New parents are instantly thrust into the reality of life with a baby. As Dr. Helen Ball writes, “Sleep (or the lack of it) looms large for parents-in-waiting—and it is pointless to pretend that your sleep will not be disrupted by your new bundle of joy. His body clock, which until recently was controlled by your own, is now free-running, and a day-night pattern does not start to emerge until he is around three months old. His stomach is tiny, and he will need frequent feeds all around the clock—he cannot wait eight hours through the night to be fed just because you need to sleep. If you don’t feed him, he will cry. If he’s cold, he will cry. If he hurts, he will cry. If he misses being in close contact with you, he will cry. He doesn’t know that you will come back once you leave his sight. If he feels abandoned, he will cry frantically—it’s his only method to attract attention and bring himself to safety. If he cries frantically, it will take a long time for him to calm down and you will have to help him.”

“The experience of sleep, and of being left alone for sleep, is very different for babies than it is for adults. The more quickly you can understand your baby’s needs—for comfort, food, reassurance, contact, love—the less disruptive nighttime baby care will become, and the less anxious you will feel. Some of the decisions you make early on about nighttime baby care will affect how you manage sleep disruption and cope with your new baby.” Dr. Helen Ball

What is normal sleep?

  • Pregnant women do not sleep in long unbroken stretches, i.e., “all night.” Neither do postpartum mothers – not for many months, regardless of how they feed their babies.1 Breastfeeding mothers get more sleep than formula-feeding mothers; breastfeeding mothers who bedshare get the most sleep of all new mothers.2,3
  • Before birth, babies sleep rather randomly, not necessarily closely synchronized to their mothers’ body clock. After birth, babies sleep in short (1 to 1½ hour) cycles and need to be fed approximately hourly because of their very small stomachs.4 They do not even begin to develop day-night sleep patterns for several months, regardless of how they are fed.5
  • Frequent feeding day and night is normal, essential for the baby, yet is often called ‘inconvenient’ for parents. Let’s face it – all babies are “inconvenient.” Most of us didn’t get pregnant just to make our lives less complicated. Babies need to be touched – a LOT, day and night, and skin-to-skin.6 Touch is nearly as important to babies’ overall development as food.7 Breastfeeding is an easy way to assure plenty of touch; so is safe bedsharing.8 Most breastfeeding mothers nurse their babies to sleep and sleep with their babies at least part of the night.9

LLLI | Safe Sleep 7 Infographic

Safety issues

  • SIDS (Sudden Infant Death Syndrome) and suffocation are two distinct and rare risks to infants in the early months. SIDS is a diagnosis of exclusion: there’s no obvious reason for a baby’s death. Risk factors for SIDS are well- documented, so avoiding these can help parents reduce the already-small risk: (1) smoking;10 baby sleeping prone;11 formula feeding;12 and baby sleeping unattended.13 (details below)
  • Suffocation is a more easily-preventable risk to babies than SIDS. The main risks for suffocation (entrapment) are putting the baby to sleep on a sofa with or without an adult,14 and/or a drunk/drugged adult sleeping with a baby on any surface.15 “Never bedshare” warnings don’t tell tired parents/mothers where they CAN safely feed their babies at night. A new infographic by La Leche League, “Safe Sleep Seven: Smart Steps to Safer Bedsharing,” lists seven steps that vastly reduce the major SIDS and smothering risks.
  • Prenatal smoking is very bad for babies and increases risk of SIDS at least five-fold. Smoking is a significant hazard to babies if the mother smokes during pregnancy, and smoking in the household (and everywhere) continues to be a risk to the baby after the baby is born. Smokers exhale carbon monoxide for many hours after each cigarette,16 and secondhand smoke is harmful to babies.17 Smoking is a well-known risk to adults, too.
  • Every health authority in the world recommends exclusive breastfeeding for the first six months starting in the first hours after giving birth, then continued breastfeeding while adding family foods till the child is at least two years old.18 Formula-fed babies are less arousable from sleep than breastfed babies;19 have more than double the risk of (SIDS);12 and have many other health problems.20 If families need help with breastfeeding, contact WomensHealth.gov or La Leche League International or the federal government Women, Infants and Children program (WIC).
  • Unattended babies (sleeping out of sight and sound of a competent adult) are at higher risk of SIDS and entrapment/smothering accidents. People are better monitors than electronic devices. Babies should always sleep face-up, in a safe container, and within sight and sound of a competent adult for all sleeps, naps and nights – unless they are safely tied on someone’s body or safely in someone’s arms or sleeping next to their sober, nonsmoking, breastfeeding mother on a safe surface. Baby should be lightly clothed (not overheated. One study reported swaddling as an independent risk factor for SIDS. 21).
  • Recommend that parents baby-proof the family bed, even if they think they won’t ever bedshare. Sleep happens, and exhaustion overrules common sense. No thick covers, no toys, no pets, firm clean flat mattress. Most breastfeeding mothers sleep with their babies at least part of the night, and breastfeeding mothers have the lowest rates of SIDS and other sleep-related accidents.12 Accidental bedsharing is riskier than planned bedsharing.22 A side-car attached to the bed can be a good option – baby is close enough for touching and feeding, yet separate enough to avoid rollovers and exhaled breath of smokers. A safe crib for the baby in the bedroom is safer than baby sleeping unattended in another room.
  • Adults should never lie down with a baby on a sofa or in a recliner, even “just for a minute” – the threat of suffocation, entrapment or dropping the baby is high especially when (not if) the adults falls asleep.23 If a sofa or recliner is the only option for sleep, the adult can lean back and tie the baby securely onto their chest with a scarf, shawl or soft carrier so their arms aren’t holding the baby when the adult dozes off.
  • Wearing a baby many hours a day in a soft-tie-on carrier or sling is a great way for everyone to nap, and helps baby’s motor development besides. Baby’s face should be fully visible and her head should be close enough to kiss. This babywearing guide has information on how to safely wear an infant.

The 4 big questions

1. When will the baby sleep through (longer) the night?

Probably not for many months. Welcome to parenthood! (Sorry, biology rules!)

Babies are growing faster in the early months than they ever will, and need food and comfort very often for normal physical, emotional, and psychological development. A famous scientist described the first 9 months of a baby’s “outside” life as the period of “external gestation.24” The best way to get enough sleep is for parents to plan to safely bedshare with their breastfed baby, and take naps with the baby. (see the Safe Sleep Seven and “Sweet Sleep25 for more information.)

Beware of “sleep training” programs, books and advice, which have a long sad history.26 New strong evidence of baby’s biological and emotional needs suggests that babies remain highly stressed even when the parents think sleep training “worked,” with serious long-term negative consequences for the baby. Babies cry because they need to be touched held, fed, rocked, and nurtured, and simply cannot meet their own needs for any of those comforts.

2. When will the mom sleep like she did before she got pregnant?

The research definition of “sleeping through the night” range is inconsistent and arbitrary.27 Parents can make up any definition they want when quizzed about the baby “sleeping through.” A useful (and vague) response: “Of course the baby is a good sleeper.”

3. Will parents ever have sex again?

Beds aren’t the only places where sex can happen.

4. Will parents ever get the baby out of their bed?

Babies who bedshare get their emotional needs met sooner and more fully than those who sleep separately.28 All babies are inconvenient for a while.

Where can parents get more information?

What do you talk about with families in order to prepare them for parenting a newborn? How do you find the balance between providing accurate information and not “frightening” them with the realities of newborn sleep patterns. Have you read this new book? Would you recommend this book to families who are desiring more information about how to provide a safe sleep environment for their breastfeeding newborn? – SM

References

1. Montgomery-Downs HE, Stremler R, Insan SP. Postpartum Sleep in New Mothers and Fathers. Open Sleep Journal. 2013;6(Suppl 1: M11):87-97.
2. Doan T, Gay CL, Kennedy HP, Newman J, Lee KA. Nighttime Breastfeeding Behavior Is Associated with More Nocturnal Sleep among First-Time Mothers at One Month Postpartum. J Clin Sleep Med. 2014;10(3):313-319.
3. Doan T, Gardiner A, Gay CL, Lee KA. Breast-feeding Increases Sleep Duration of New Parents. J Perinat Neonatal Nurs. Jul-Sep 2007;21(3):200-206.
4. Bergman NJ. Neonatal stomach volume and physiology suggest feeding at 1-h intervals. Acta Paediatr. May 10 2013.
5. Rivkees SA. Emergence and influences of circadian rhythmicity in infants. Clin Perinatol. Jun 2004;31(2):217-228, v-vi.
6. Feldman R, Rosenthal Z, Eidelman AI. Maternal-Preterm Skin-to-Skin Contact Enhances Child Physiologic Organization and Cognitive Control Across the First 10 Years of Life. Biol Psychiatry. Jan 1 2014;75(1):56-64.
7. Feldman R, Singer M, Zagoory O. Touch attenuates infants’ physiological reactivity to stress. Dev Sci. Mar 2010;13(2):271-278.
8. Hofer MA. Psychobiological Roots of Early Attachment. Current Directions in Psychological Science. April 1, 2006 2006;15(2):84-88.
9. Ward TC. Reasons for Mother-Infant Bed-Sharing: A Systematic Narrative Synthesis of the Literature and Implications for Future Research. Matern Child Health J. Jul 2 2014.
10. Zhang K, Wang X. Maternal smoking and increased risk of sudden infant death syndrome: a meta-analysis. Leg Med (Tokyo). May 2013;15(3):115-121.
11. Dwyer T, Ponsonby AL. Sudden infant death syndrome and prone sleeping position. Ann Epidemiol. Apr 2009;19(4):245-249.
12. Hauck FR, Thompson JMD, Tanabe KO, Moon RY, Vennemann MM. Breastfeeding and Reduced Risk of Sudden Infant Death Syndrome: A Meta-analysis. Pediatrics. June 13, 2011 2011.
13. Moon RY, Fu L. Sudden infant death syndrome: an update. Pediatr Rev. Jul 2012;33(7):314-320.
14. Blair PS, Sidebotham P, Evason-Coombe C, Edmonds M, Heckstall-Smith EM, Fleming P. Hazardous cosleeping environments and risk factors amenable to change: case-control study of SIDS in south west England. Bmj. 2009;339:b3666.
15. Ball HL, Moya E, Fairley L, Westman J, Oddie S, Wright J. Bed- and sofa-sharing practices in a UK biethnic population. Pediatrics. Mar 2012;129(3):e673-681.
16. van der Vaart H, Postma DS, Timens W, et al. Acute effects of cigarette smoking on inflammation in healthy intermittent smokers. Respir Res. 2005;6:22.
17. Tong EK, England L, Glantz SA. Changing Conclusions on Secondhand Smoke in a Sudden Infant Death Syndrome Review Funded by the Tobacco Industry. Pediatrics. March 1, 2005 2005;115(3):e356-366.
18. American Academy of Pediatrics. Breastfeeding and the Use of Human Milk. Pediatrics. March 1, 2012 2012;129(3):e827-e841.
19. Mosko S, Richard C, McKenna J. Infant arousals during mother-infant bed sharing: implications for infant sleep and sudden infant death syndrome research. Pediatrics. Nov 1997;100(5):841-849.
20. US Department of Health and Human Services. The Surgeon General’s Call to Action to Support Breastfeeding. Washington, DC: US Department of Health and Human Services, Office of the Surgeon General,; 2011.
21. Richardson HL, Walker AM, R SCH. Influence of Swaddling Experience on Spontaneous Arousal Patterns and Autonomic Control in Sleeping Infants. J Pediatr. Mar 12 2010.
22. Volpe LE, Ball HL, McKenna JJ. Nighttime parenting strategies and Sleep-related risks to infants. Social Science & Medicine. 2012(0).
23. Kendall-Tackett K, Cong Z, Hale T. Mother–Infant Sleep Locations and Nighttime Feeding Behavior: U.S. Data from the Survey of Mothers’ Sleep and Fatigue. Clinical Lactation. 2010;1(Fall 2010):27-31.
24. Montagu A. Touching: the Human Significance of the Skin. Third ed. New York: Harper & Row; 1986.
25. La Leche League International, Wiessinger D, West D, Smith LJ, Pittman T. Sweet Sleep: Nighttime and Naptime Strategies for the Breastfeeding Family. New York: Random House – Ballantine Books; 2014.
26. Middlemiss W, Granger DA, Goldberg WA, Nathans L. Asynchrony of mother–infant hypothalamic–pituitary–adrenal axis activity following extinction of infant crying responses induced during the transition to sleep. Early human development. 2012;88(4):227-232.
27. Adams SM, Jones DR, Esmail A, Mitchell EA. What affects the age of first sleeping through the night? J Paediatr Child Health. Mar 2004;40(3):96-101.
28. McKenna JJ, Mosko SS. Sleep and arousal, synchrony and independence, among mothers and infants sleeping apart and together (same bed): an experiment in evolutionary medicine. Acta Paediatr Suppl. Jun 1994;397:94-102.

About Linda J. Smith, MPH, IBCLC, LCCE, FACCE

© Linda J. Smith

© Linda J. Smith

Linda J. Smith, MPH, IBCLC, LCCE, FACCE, is a lactation consultant, childbirth educator, author, and internationally-known consultant on breastfeeding and birthing issues. Linda is ILCA‘s liaison to the World Health Organization’s Baby Friendly Hospital Initiative and consultant to INFACT Canada/IBFAN North America. As a La Leche League Leader and Lamaze-certified Childbirth Educator, she provided education and clinical support to diverse families over 40 years in 9 cities in the USA and Canada. Linda has worked in a 3-hospital system in Texas, a public health agency in Virginia, and served as Breastfeeding coordinator for the Ohio Department of Health. Linda was a founder of IBLCE, founder and past board member of ILCA, and is a delegate to the United States Breastfeeding Committee from the American Breastfeeding Institute. Linda holds a Masters Degree in Public Health and is currently an Adjunct Instructor at the Boonshoft School of Medicine at Wright State University in Dayton, Ohio. She owns the Bright Future Lactation Resource Centre, on the Internet at www.BFLRC.com.

Babies, Breastfeeding, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Parenting an Infant , , , , ,

You’re Invited to Lamaze International’s Next Twitter Chat: Prenatal Fitness

August 19th, 2014 by avatar
perinatal fitness

CC http://flickr.com/photos/cumidanciki/7807501656

Won’t you consider joining Lamaze International’s President Elect, Robin Elise Weiss, as she hosts our next Twitter Chat on Thursday, August 21, 2014 at 9:00-10:00 PM EST.  The topic to be discussed is prenatal fitness and you can find the party at #LamazeChat.  You will want to put this event on your own calendar as well as share with your clients and students via social media, so everyone can benefit from the fast moving discussion that will no doubt be filled with facts and information that everyone can use.

Perinatal Fitness expert Catherine Cram, M.S.,  owner of Comprehensive Fitness Consulting shares some tips that will be discussed further during the Twitter chat. Childbirth educators may find it useful to share this information when discussing fitness and exercises in your childbirth classes.

• The key to getting the greatest benefits with prenatal exercise for both mom and baby are to continue to workout to the end of the pregnancy.

• Research has shown that women who continue to exercise throughout pregnancy gain less weight, have reduced complications during labor and delivery and return to pre-pregnancy weight faster than those that don’t exercise.

Tips for sticking with exercise during all trimesters:

• Try to include several types of exercise, from walking to swimming or biking and mix it up so mothers don’t overwork muscles and joints.

• Break up workouts into two sessions of a shorter duration if fatigue makes it tough to maintain the usual routine.

• The exercise intensity level should stay within a range that feels challenging, but not so hard that a mother is out of breath.  We use what’s called the “talk test” with prenatal exercise, which simply means that a mother should be able to carry on a conversation while exercising, and if she can’t, then she is working too hard.

• As pregnancy progresses it’s as if women are wearing a backpack that gets heavier each week.  Keep this in mind when workouts seem to be getting harder- the workout is a lot tougher even at the same intensity at 30 weeks than at 15 weeks. Modify routines as needed to keep workout level within safe limits.

• Make sure to add some upper body strength training to the workout.  Mothers will need that strength for all the lifting required with baby care.  Keep in mind that all someone needs to do for strength gains is one set of 10-12 repetitions of a weight.  Exercise bands are a great way to do strength training, and they’re inexpensive and easy to use.

• Buddy up with a friend for fitness sessions. Encourage class members to plan exercise sessions together outside of class.  They will be a lot more successful with maintaining a fitness routine when they are partnered or in a fitness group, and it makes the time go a lot faster.

twitter logoTwitter Chats are a fun way to connect with both families and other educators from all over, learn more about the topic, Prenatal Fitness, share resources and enjoy a pleasant discussion.  Robin Weiss is a skilled facilitator who makes every Twitter Chat she hosts a totally enjoyable event. New to participating in a Twitter chat? Check out this article for information on how to participate and get the most out of your experience. Don’t be shy about jumping in.  Your participation will be totally welcomed! See you August 21st at 9PM EST!  Tweet, tweet!

 

 

 

Childbirth Education, Lamaze International, News about Pregnancy , , , , , ,

Marketing and Blogging with Respect; Avoid Plagiarism

August 14th, 2014 by avatar

Today on Science & Sensibility, Andrea Lythgoe, LCCE shares information on the importance of having a) a website that is created using text and images that you have the right to use; b) marketing material that does the same and c) how to share the great resources, articles and blog posts you find in your internet travels so that you are complying with the law and are respectful of the work of others.   Look for future posts in the series on using materials legally in your classroom.  Previous posts in the the Series: Finding and Using Images and Copy can be found here and here. – Sharon Muza, Science & Sensibility Community Manager

As someone who is both a writer and a photographer, typically on the topic of birth, I am happy to share my creative work online in many formats and locations.  My intent is to provide information that others find both useful and informative.  I enjoy sharing my work very much.  What I don’t enjoy is finding out that someone, someplace, on the “World Wide Web” has, with a simple copy and paste command, stolen my original work.

This theft of creative property is called plagiarism. Plagiarism is where you take the creative work of others and pass it off as your own  Content theft is when you take the work and keep the by-line intact.  In the years that I have been working as a birth professional, I have found my work copied word-for-word, or maybe slightly altered, on other web sites. I have found my pictures and images copied and used without permission. It is important for people to understand that is not OK. And it is illegal.

Writing is protected by copyright law. You cannot simply find someone who “says it better” than you think you could and use the copy and paste feature on your computer, tablet or smartphone. Not even as a placeholder until you come back and replace it with your own writing or image. If you want to have some placeholder wording as you design your site, do what the professionals do and use this.

Your business website

Your website and marketing materials need to represent YOU. They need to be who you are, and how you run your business. In these days when the birth services market is pretty well saturated in a lot of areas around the country, the only way to stand out is by selling YOU. No one else can be you. And copying someone else’s words, design or images is not who you are.  As unbelievable as it might seem, there have been circumstances where people have copied another professional’s “About Me” page, with the only change being the original author’s children’s names replaced with their own.

Maybe writing is not your strength. I can understand that. We all have weaknesses and things that we can’t do no matter how hard we try. Two of mine are chemistry and surfing! And that’s OK. You can hire someone (or if you’re lucky, use a friend or spouse who has the skills) to turn your own thoughts and ideas into nicely worded text. But you – and only you – should first sit down with paper and pen and make notes about what you want to say. Make a list of words that appeal to you – words that you feel describe the work you do, why you do it, and what experience you hope your clients will have when working with you. Write a list of facts about yourself you want your clients to know about you.  Think about how you might turn one of those qualities into a short anecdote to include in your “about me” page. Maybe this exercise will take a few days or weeks before you’re even ready to get started working with a writer who can help you turn your jumble of ideas into paragraphs. If it takes time, that is okay.

If you find you have absolutely no ideas to give to your writer, then you may need time to do some evaluating about where you want to go. In order to have a successful business, you need to have your own vision and direction for the business. In the words of a birth photographer, Leilani Rogers: “If you are lacking direction in your business and can’t articulate how you feel about things or how you want to run your business then you are not ready to own one.”

The work of articulating your business vision to your clients through the written word is not an easy one, but it is worth it. Not only will you maintain professional integrity, you will have the opportunity to carefully consider and refine your business in the process.

Your blog content

A blog is a great way to boost the search engine optimization (SEO) of your web site and keep potential clients returning to your site. It is important that your blog and any resources you post on your web site be entirely your own work. You’ll come across lots of interesting articles you may want to share with your readers, but ethically, you need to direct your readers to the original source, and not republish on your site. Giving credit, and then pasting the entire article is not enough. Republishing (or as some call it “cross posting” or “reblogging”) without permission is not acceptable. Writers create original content for many reasons and one of those is to bring traffic to their own site, and keeping readers on your site reading someone else’s material is stealing readers from them.

How to properly share an article or blog post

There are many ways to do this responsibly:

  • You can have a regular feature where you share interesting things you come across. I do this every Wednesday on my own blog.
  • Another common method is to share a small (1-2 paragraph) excerpt with your thoughts and comments on the article, and then direct your reader to the article to read more. A great example of this can be found on Evidence Based Birth here.
  • You could also contact the author of the article and ask to do a short Q&A on the article (by phone or email) that you could publish and then link to the original article. Science and Sensibility does this frequently when we feature a new study.
  • Another way to share is to use topical lists. Have a list of recommended reading on going past your due date. Another list on deciding about induction. Another about breastfeeding resources, etc. Adding a small blurb (1-2 sentences) about what the reader can expect to find there or why you included it in the list is helpful to your readers. Birth and Baby Matters has an example of a topically organized link list.

While sharing other content is helpful, writing your own content is even better! Next time you find yourself speaking passionately and knowledgeably on a topic, turn it into a blog post! Next time you write a particularly eloquent comment on a Facebook question, turn it into a blog post! Go to an interesting conference, share it with your readers like Deena Blumenfeld did. Sharing your own opinions and knowledge helps establish you as an expert in the eye of the reader. And that is a plus to potential students!

If you’ve found yourself doing it incorrectly and you have content on your site that is not your own, please immediately take it down. You can replace those posts with your own thoughts and a small teaser quote with a link in a very short amount of time. It shows that you are professional and are also complying with the law.

What if you find your original material posted elsewhere?

With a simple Google search, or by using sites like Copyscape, it is very quick and easy for incidents of plagiarism to be caught. Back when I taught at a midwifery college, if I suspected a student of plagiarism, I could generally find the source within a minute or two. Using someone else’s creative property is not flattery; rather it is hurtful, disrespectful and illegal.

If you are a writer and find that someone has posted your work without permission, your first step will be to contact the site owner and request it be removed. A firm approach suggesting an alternate way to share the information, with a deadline helps them to know you mean business.

If that is ineffective, you may be able to file a DCMA Takedown request with the site’s host. This is a U.S. law, but many hosting companies internationally still comply. You’ll need to determine where they host their site. I find the database at www.whois.com to be helpful with this. Then do a web search for the hosting company’s web site. Most sites have a Takedown request form on their page. Depending on the hosting company’s policies, they may take down just the content you reported, or they may take down the infringer’s entire site! (Another reason to stay on the right side of copyright law!)

Resources to help create a unique website

10 Rules for Writing About Me Pages - Great list of things to do – and what not to do! – and lots of examples.

Four Steps To Finding Your Writing Voice
 - Excellent advice from a middle school English teacher. Her whole site is full of good tips, so browse around!

How to Write Effective Website Content - Pretty much exactly what the title says. Make sure you read all the way down to the “best practice tips”, because that’s where the best tips are.

How to Decide What to Blog About - I love the focus on the reader’s experience and needs in this one.

Blog Topic Generator - This is an interesting tool, it gives you some interesting titles if nothing else.

Have you found an effective and legal way to share information with others via your website and blog?  Have you found your own material used without permission?  How did you handle it and how did it make you feel?  Please share your ideas, thoughts, resources and suggestions in our comments section. – SM

About Andrea Lythgoe

Andrea Lythgoe

Andrea Lythgoe

Andrea Lythgoe is a doula, hospital-based Lamaze childbirth educator, birth photographer, and former instructor at the Midwives College of Utah. She is the author of the website UnderstandingResearch.com where she aims to help those just beginning to read research to understand the language of research. Her interest in research started while attending the University of Utah, where she made ends meet by working on a large randomized controlled trial and earned a degree in community health. Andrea served on the Board of Directors for the Utah Doula Association for over 10 years. She lives and practices in the Salt Lake City, Utah area. Andrea can be reached through her website.

 

 

Childbirth Education, Guest Posts, Series: Finding and Using Images and Copy , , , ,