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The Childbirth Educator’s Role in The Cesarean Epidemic: 10 Steps You Can Take Now!

April 29th, 2014 by avatar

As Cesarean Awareness Month (April 2014) comes to a close, I wanted to share ten things that childbirth educators can do in their childbirth classes to support families to avoid unneeded cesareans, help families to have a cesarean birth that is respectful and family centered and support families who give birth by cesarean, (planned or unplanned) both during the birth, in the postpartum period and when planning future births.

1. Birth plan exercises

Have your birth planning/birth choices activity include preferences for a cesarean birth.  Allow parents the option to select items such as delayed cord clamping, skin to skin in the operating room, delaying newborn weights and measurements, and more.  While these may not be available options in all areas, encouraging discussion amongst families and their health care providers is a good place to start.  Additionally, consider role playing a cesarean section in class and discuss ways to make the procedure family friendly.  Remember to suggest ways that the partner and other support people can best support mother and baby during the surgery. Consider sharing “The natural caesarean: a woman-centred technique” video so families can explore options for a family friendly cesarean birth.

2. Access teaching resources on the Lamaze International website

Lamaze International offers some great teaching resources on cesareans for educators on their website and for families on the Lamaze International parent site.  There are two infographics that cover the topic of cesarean sections; “Avoiding the First Cesarean” and “What’s the Deal with Cesareans.”  You might consider showing the brand new infographic video to your families in class. At only 3 minutes long, it does a great interactive job of highlighting important information. In addition to using these materials in class, encourage families to explore them more thoroughly at home.

3.  Provide current statistics

Access and share statistics about national and provincial or state cesarean rates and VBAC rates, along with local rates for facilities and providers if available.  Help your families to understand the difference between overall cesarean rates and primary cesarean rates and why facilities caring for high risk mothers or babies might have higher rates.  Make sure that you are providing the most current information available, and update your figures when new numbers are released. Encourage discussion in class with families who are considering changing birth location or providers if they feel so inclined.

4. Encourage the use of birth doulas

The addition of trained labor support has been shown to reduce common interventions and cesareans. (Hodnett, 2012)  Take some time during class to share how doulas can help support both the laboring woman and her partner and team.  Provide resources for families to locate doulas (DONA.org and DoulaMatch.net are two such lists that come to mind) and briefly share information on questions to ask a doula during an interview, so the families are prepared.

cam two ribbon5.   Share current best practice information

Be sure that the information in your classes is current, accurate and based on best practices and evidence.  Know the sources of the information you cover.  Make sure it is up to date and verifiable.  Have a short list of favorite online resources to share with families, including Lamaze International’s Giving Birth with Confidence blog- written specifically for parents.  Utilize the references that make up the Six Healthy Birth Practices, there is a citation sheet for all six of the birth practices.

6. Support the midwifery model of care

Share information in your classes about the midwifery model of care, which has been shown to be an appropriate choice for healthy, low risk women.  Let your class families know how to find a midwife by using the search functions on the American College of Nurse-Midwives website and information on finding a midwife on the Citizens for Midwifery website.

7. Have meaningful class reunions

If your childbirth class includes a reunion, create a space for all the families to share their stories, both the vaginal births and the cesarean births.  Honor the work that the families did to birth their babies and celebrate their intention and teamwork.  Highlight their shining moments and let them know that you recognize how hard they worked.  Model excellent listening skills and support all the families as they share their birth stories.

8. Provide support group information

Make sure that all families that leave your class have been given resources for a support group for women who birth by cesarean section.  Access the International Cesarean Awareness Network (ICAN) to find the nearest local ICAN chapter website or Facebook group. Or refer the families to the main ICAN Facebook page.  VBACFacts.com also has a large peer to peer support network active on Facebook as well.

9.  Share postpartum resources

Families that birth by cesarean section might find themselves needing additional support from professionals during the postpartum period.  Be sure that they have resources to find lactation consultants, mental health counselors, postpartum doulas, physical therapists and other professionals that might be useful for healing emotionally and physically from a cesarean section.  In the throes of postpartum hormones, exhaustion, sleep deprivation and physical recovery, having to hunt down appropriate professionals can be a daunting task for any new families, never mind a mother recovering from surgery with a newborn.

10.  Offer a cesarean only class

Some families know they will be needing a cesarean for maternal or infant health circumstances and are hesitant about taking the standard childbirth class, feeling like they won’t fit in.  While they may not be needing the coping skills or comfort techniques and pushing positions that you cover in the typical childbirth class, they do need information about the cesarean procedure, pain medication options, recovery, breastfeeding and newborn care/procedures and informed consent and refusal information, among other things.  Having a class designed with their needs in mind can help them to make choices that feel good to them and participate in the community building that is such an important part of childbirth classes.

Don’t underestimate the role of the childbirth educator (you!) to offer evidence based information, appropriate resources, respectful dialogue along with skills and techniques to help women to have the best birth possible, avoid a cesarean that is not needed and recover and heal  while feeling supported with options for future births.  Thank you for all you do to help women to avoid cesareans or if needed, have the best cesarean possible.

References

Hodnett, E. D., S. Gates, et al. (2012). “Continuous support for women during childbirth.” Cochrane database of systematic reviews: CD003766.

Cesarean Birth, Childbirth Education, Giving Birth with Confidence, Healthy Birth Practices, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , ,

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

April 17th, 2014 by avatar

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

© http://www.mybirth.com.au/

© http://www.mybirth.com.au/

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

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

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

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

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

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

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

© http://flic.kr/p/3mcESR

© http://flic.kr/p/3mcESR

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

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

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

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

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

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

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

References

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

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

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

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

About the Authors:

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

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

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

Finding Common Ground: The Home Birth Consensus Summit

April 15th, 2014 by avatar
© HBCS

© HBCS

While home birth has a proven safety record in countries outside the U.S., some attribute that to the fact that, in other countries, home birth takes place in the context of an integrated health care system. It is critical that all of the stakeholders in the maternal health care system are working together to ensure safe birth options in the U.S. as well.

The Home Birth Consensus Summit (HBCS) is a unique collaboration of all of the stakeholders currently involved in home birth in the United States. First held in 2011, the Home Birth Consensus Summit offers physicians, midwives, consumers, administrators and policy makers; (a varied group of representatives who do not often share common ground,) a chance to take a 360 degree look at the current maternal health care system and tease out the areas of conflict and common ground in order to increase safety in all birth settings.

Today on Science & Sensibility, our readers learn about the Home Birth Consensus Summit; its participants, purpose and process. Thursday, we will have the opportunity to review one of the groundbreaking products from the past two summits, when the HBCS releases the “Best Practice Guidelines: Transfer from Home Birth to Hospital” for consideration and adoption by maternal health organizations. Learn more about the HBCS from Summit Delegate Jeanette McCulloch as she interviews Saraswathi Vedam, RM FACNM MSN Sci D(hc), Home Birth Consensus Summit convener and chair. – Sharon Muza, Community Manager, Science & Sensibility

Jeanette McCulloch: What was the motivation behind launching the Home Birth Consensus Summit?

Saraswathi Vedam: Women want – and deserve – respectful, high quality maternity care regardless of their planned place of birth. Women and their families are not served by the interprofessional conflict and confusion that occurs in many regions in the US around place of birth.

While there may be points of disagreement, I know from numerous conversations with consumers, midwives, physicians, administrators, and policy makers that there are many more areas in maternity care where we all share a common set of principles and goals. Everyone is committed to working towards improved quality and safety for women and infants.

In 2011, a very intentionally selected group of stakeholders came together for the first Summit at the Airlie Center, in Warrenton, VA. These individuals represented all key leaders of the maternity care team, researchers, policy makers, payors, consumers, and consumer advocates. They came to the Summit with a wide variety of perspectives – including those for and against planned home birth. At the Summit, these delegates engaged in a unique process designed to help those with opposing viewpoints untangle complex issues. This process, called Future Search, guided the group through a complete exploration of every aspect of the maternal health care system. There were frank, challenging, and productive conversations, often among stakeholders who rarely, if ever, had been at the same table before. Once we were able to discover common ground, we were able to create a realistic and achievable strategic action plan together.

JM: Tell us about what common ground the Home Birth Consensus Summit has found so far.

SV:  As the delegates discussed their shared responsibilities and vision for providing the best possible care, we realized that the vision applied to all birth settings. The nine common ground statements describe a maternity care environment that respects the woman’s autonomy, ensuring she has safe access to qualified providers in all settings, and that the whole team that may care for her are well prepared with the clinical skills and knowledge that best applies to her specific situation. This will require attention to equity, cross-professional education, and research that includes the woman in defining the elements of “safety” and accurately describes the effects of birth place, or different models of care, on outcomes. The delegates shared a goal of increasing knowledge and access to physiologic birth, access to professional education and systems for quality monitoring for all types of midwives, from all communities; and reduction in barriers like cost and liability. Coming to this place of understanding and agreement, though, was only the beginning. Each of those action statements had to be turned into a concrete action plan that all of the stakeholders collaborated on developing.

© HBCS

© HBCS

JM: What is happening with the common ground statements now?

SV: Multi-disciplinary work groups have formed around each common ground statement. In 2013, the work groups came together for the second summit, again at the Airlie Center, to discuss progress made so far and tackle challenges.

Coming to this place of understanding and agreement, though, was only the beginning. The common ground statements are also encouraging a dialogue outside of our action groups that we could have never predicted. For example, the statements were read into the congressional record by Congresswoman Roybal-Allard, who said that the publication of the Home Birth Consensus document was “of critical importance to all current and future childbearing families in this country.” In the following year, several of the Summit delegates were invited panelists and presenters at an Institute of Medicine Workshop on Research Issues in the Assessment of Birth Settings.

JM: What are some of the top outcomes of the work groups?

SV: One exciting outcome – a set of Best Practice Guidelines to provide optimal care for mothers and families transferring from home to hospital – will be released by the Home Birth Consensus Summit later this week. This project represents what the Summits are all about: bringing together stakeholders to look at every facet of an issue, and work together on concrete initiatives to improve outcomes. These guidelines are based on the best available research on effective interprofessional collaboration. Delegates who are leading midwives, physicians, nurses, policy makers and consumers from across the U.S. formed the Collaboration Task Force. They met regularly over eight months on weekends and after hours to research and carefully design a concrete evidence-based tool to improve quality and safety for women and increase respectful communication among providers. Easing the friction that can sometimes occur when families arrive at the hospital can not only increase safety for families, but also build trust and collaboration between providers.

© HBCS

© HBCS

Another group is collaborating to develop a Best Practice Regulation and Licensure Toolkit – a resource for state policy makers that will provide a best practice model of midwifery regulation to be used as a template to enact or improve licensure in a particular state.

Another important outcome is a study of midwives and mothers of color to better understand social and health care inequities that lead to higher incidence of prematurity and low birth weight.

JM: What comes next for the Summit?

SV: The action groups are continuing their work on initiatives in each of the common ground areas. At Summit III, scheduled for Fall 2014 in Seattle, WA, each action work group will share the products of their collaborations, and address some remaining priorities. These include research and data collection, ethics, and access to equitable care during pregnancy. We plan to expand the participants to include more leaders from policy and practice to disseminate the documents and engage more in this exciting work.

I have been working towards ensuring equitable birth options for women and their families for nearly 30 years. My goal for the Summits is to increase the probability that my four daughters – and everyone’s daughters, wives, and sisters – will experience high quality, respectful maternity care.

What are your thoughts on the Home Birth Consensus Summits and this collaborative model?  How do you see this further maternal infant health and safety.  What would you like to see discussed by the stakeholders at Summit III in Seattle this fall?  Let us know in the comments and join us on Thursday to learn more about the details of the soon to be released “Best Practice Guidelines: Transfer from Home Birth to Hospital.”

Bios:

© Saraswathi Vedam

© Saraswathi Vedam

Saraswathi Vedam, RM FACNM MSN Sci D(hc), is the convener and chair of the Home Birth Consensus Summit. She has been active in setting national and international policy on home birth and midwifery education and regulation, providing expert consultations in Mexico, Hungary, Chile, China, Canada, and the United States. She serves as Senior Advisor to the MANA Division of Research, Chair of the ACNM Transfer Task Force, and Executive Board Member, Canadian Association of Midwifery Educators. Over the past 28 years she has cared for families in all birth settings. Professor Vedam’s scholarly work includes critical appraisal of the literature on planned home birth, and development of the first US registry of home birth perinatal data. Contact Saraswathi Vedam.

© Jeanette McCulloch

© Jeanette McCulloch

Jeanette McCulloch, IBCLC, is the co-founder of BirthSwell an organization improving infant and maternal health by changing the way we talk about birth and breastfeeding. She has been using strategic communications and messaging to change policy, spread new ideas, and build thriving businesses for more than 20 years. Jeanette is honored to be working with local, national, and international birth and breastfeeding organizations (including the Home Birth Consensus Summit) and advocates ensuring that women have access to high-quality care and information.

Babies, Healthcare Reform, Home Birth, Legal Issues, Maternal Quality Improvement, Maternity Care, Newborns, Practice Guidelines, Uncategorized , , , , ,

Safe Prevention of the Primary Cesarean Delivery: ACOG and SMFM Change the Game

February 19th, 2014 by avatar

I hope that readers of Science & Sensibility (and anyone working in the field of maternal infant health) are sitting down.  Be prepared to be blown away.  ACOG and SMFM have just released a joint Obstetric Care Consensus statement that has the potential to turn maternity care in the USA on its end.  I feel like this blog post title could be “ACOG and SMFM adopt Lamaze International’s Six Healthy Birth Practices.”  (Okay, that may be a little overenthusiastic!)  I could not be more pleased at the contents of this statement and cannot wait to see some of these new practice guidelines implemented.  Judith Lothian, PhD, RN, LCCE, FACCE summarizes the statement and shares highlights of this stunning announcement. – Sharon Muza, Science & Sensibility Community Manager

Today, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine issued a joint Obstetric Care Consensus statement: Safe Prevention of the Primary Cesarean Delivery. It is being published concurrently in Obstetrics and Gynecology, (the Green Journal).  The ACOG press release is here, with much more detail of the study, not behind a firewall. There is no doubt about it-  this just released statement is a game changer.

acog wordlThe alarming and sustained increase in the cesarean rate in the United States has not improved either maternal or neonatal outcomes. In fact, data suggest that there is increased maternal mortality and morbidity associated with cesarean delivery. This statement describes the myriad of complications associated with cesarean and the increased risks associated with cesarean for mother and baby. The authors suggest that potentially modifiable factors, such as patient preferences and practice variation among hospitals, systems, and health care providers are likely to contribute to the escalating cesarean rates. There is a need to prevent overuse of cesarean, particularly the primary cesarean.

Table 1 acog

source: ACOG

The most common reasons for cesarean include labor dystocia, abnormal or indeterminate fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. The authors revisited the definition of labor dystocia in light of the fact that labor progresses at a rate that is slower than what we had thought previously. They also reviewed research related to interpretation of fetal heart rate patterns, and access to nonmedical interventions during labor that may reduce cesarean rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in a cephalic presentation can lower the cesarean rate. The authors analyzed the research using a rubric that rated the quality of the available evidence. The result is a set of guidelines that have the potential to substantially decrease the cesarean rate.

acog logo  These guidelines change the rules of the labor management game.

These are some of the new recommended guidelines:

  • The Consortium on Safe Labor data rather than the Friedman standards should inform labor management. Slow but progressive labor in the first stage of labor should not be an indication for cesarean. With a few exceptions, prolonged latent phase (greater than 20 hours in a first time mother and greater than 14 hours in multiparous women) should not be an indication for cesarean. As long as mother and baby are doing well, cervical dilation of 6 cm should be the threshold for the active phase of labor. Active phase arrest is defined as women at or beyond 6 cm dilatation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.
  • Adverse neonatal outcomes have not been associated with the duration of the second stage of labor. The absolute risks of adverse fetal and neonatal outcomes of increasing second stage duration appear to be, at worst, low and incremental. Therefore, at least 2 hours of pushing in a multiparous woman and at least 3 hours of pushing in a first time mother should be allowed. An additional hour of pushing is expected with the use of an epidural, as there is progress.  Interestingly, there is no discussion of position change during second stage, including the upright position, to facilitate rotation and descent of the baby. Also, the authors note that second stage starts at full dilatation rather than when the mother has spontaneous bearing down efforts. Research suggests it is beneficial to consider the start of second stage when spontaneous bearing down by the mother  begins. (Enkin et al, 2000; Goer & Romano, 2013). Using this definition might also decrease the incidence of cesarean.
  • Instrument delivery can reduce the need for cesarean. The authors note concern that many obstetric residents do not feel competent to do a forceps delivery.
  • Recurrent variable decelerations appear to be physiologic response to repetitive compressions of the umbilical cord and are not pathologic. There is an in depth discussion of fetal heart rate patterns and interventions other than cesarean to deal with this clinically. Amnioinfusion for variable fetal heart rate decelerations may safely reduce the rate of cesarean delivery.
  • Neither chorioamnionitis nor its duration should be an indication for cesarean.
  • Induction of labor can increase the risk of cesarean. Before 41 0/7 weeks induction should not be done unless there are maternal or fetal indications. Cervical ripening with induction can decrease the risk of cesarean. An induction should only be considered “a failure” after 24 hours of oxytocin administration and ruptured membranes.
  • Ultrasound done late in pregnancy is associated with an increase in cesareans with no evidence of neonatal benefit. Macrosomia is not an indication for cesarean.
  • Continuous labor support, including support provided by doulas, is one of the most effective ways to decrease the cesarean rate. The authors note that this resource is probably underutilized.
  • Before a vaginal breech birth is considered, women need to be informed that there is an increased risk of perinatal or neonatal mortality and morbidity and provide informed consent for the procedure.
  • Perinatal outcomes for twin gestations in which the first twin is in cephalic presentation are not improved by cesarean delivery (even if the second twin is a noncephalic presentation).

smfm logo

These guidelines offer great promise in lowering the cesarean rate and making labor and birth safer for mothers and babies. They also suggest an emerging respect for and understanding of women’s ability to give birth and a more hands off approach to the management of labor. Women will be allowed to have longer labors. Obstetricians will need to be patient as nature guides the process of birth. Hospitals will have to plan for longer stays in labor and delivery. And women will need to have more confidence in their ability to give birth. Childbirth educators can play a key role here. The prize will be safer birth and healthier mothers and babies.

The authors rightly note that changing local cultures and obstetricians’ attitudes about labor management will be challenging. They also note that tort reform will be necessary if practice is to change. It’s interesting to consider whether standards of practice based on best evidence (as these guidelines are) rather than on fear of malpractice might make tort reform more likely.

The American Academy of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine are to be applauded for their careful research and willingness to make recommendations for labor management based on best evidence. These guidelines provide direction for health care providers and women and will make a difference in not just the cesarean rate but women’s experiences. The game has changed. It is a most welcome change.

What are your first impressions after learning of the elements of this new ACOG/SMFM statement?  What impact do you think these changes will have on the care that women receive during labor and birth?  Are you considering what barriers to change might exist in the hospitals you serve?  How will you share this new information with the families that you work with? As a side note, I found it interesting that this Consensus statement did not suggest using midwives for normal, low risk women.  Research has consistently shown that midwives working with low risk populations can reduce the cesarean rate. – SM

Further press information -

Lamaze International Statement – New Consensus Statement Important Step to Reduce Unnecessary Cesareans

Group Calls for Safe Reduction In Cesareans

ACOG Press Release

References

Enkin, M.,  Keirse, M., Neilson, J., Crowther, C., et al (2000). A Guide to Effective Care in Pregnancy and Childbirth. New York: Oxford Press.

Goer, H. &  Romano, A. (2013). Optimal Care in Childbirth: The Case for a Physiologic Approach.  Seattle: Classic Day Publishing (Chapter 13).

Safe prevention of the primary cesarean delivery. Obstetric Care Consensus No. 1. American College of Obstetricians and Gynecologists. Obstet. Gynecol. 2014; 123: 693-711.

About Judith Lothian

@ Judith Lothian

@ Judith Lothian

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

ACOG, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Maternal Quality Improvement, Medical Interventions, New Research, Practice Guidelines, Uncategorized , , , ,

The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

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The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,