24h-payday

Archive

Archive for the ‘Cesarean Birth’ Category

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 , , , ,

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) , , , , , , ,

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

April 22nd, 2014 by avatar

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

© Sharon Muza

© Sharon Muza

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

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

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

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

Solutions and Teaching Points

Insufficient glandular tissue and low milk supply

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

Creative positioning and latch techniques

© http://flic.kr/p/5f29EK

© http://flic.kr/p/5f29EK

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

Frequent feeding

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

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

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

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

Dealing with a sleepy baby

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

Dealing with engorgement

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

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

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

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

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

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

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

About Tamara Hawkins

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

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

April is Cesarean Awareness Month – Resources and a Test Your Knowledge Quiz

April 10th, 2014 by avatar

fb profile cam 2014April is Cesarean Awareness Month, an event meant to direct the American public’s attention to the United States’ high cesarean rate. 32.8% of all birthing women gave birth by cesarean in 2012. A cesarean delivery can be a life-saving procedure when used appropriately, but it takes one’s breath away when you consider that one third of all women birthing underwent major abdominal surgery in order to birth their babies.

Professionals that work with women during the childbearing year can be a great resource for women, pointing them to evidence based information, support groups and organizations that offer non-biased information to help women lower their risk of cesarean surgery, receive support after a cesarean and work towards a trial of labor after a cesarean (TOLAC) and achieve a vaginal birth after a cesarean (VBAC) for subsequent births if appropriate.

Here are my top suggestions for websites and resources every birth professional should have on their short list to share with students and clients when it comes to cesarean awareness.

1. International Cesarean Awareness Network – an international organization with almost 200 volunteer led chapters, (most in the USA) offering peer to peer support for cesarean recovery and VBAC information by way of a website, e-newsletters, webinars, online forums, Facebook groups and monthly meetings in the community.

2. VBACFacts.com – Led by birth advocate Jen Kamel, this website is big on research and helps consumers and professionals alike understand the evidence and risks and benefits of both repeat cesareans and vaginal birth after cesarean, including vaginal birth after multiple cesareans.

3. Lamaze International’s “Push for Your Baby” – is a great resource for families to learn about the Six Healthy Care Practices, what evidence based care looks like and how to work with your health care provider to advocate for a safe and healthy birth. Also Lamaze has an wonderful infographic that can be shared online or printed.

4. Spinning Babies – Midwife Gail Tully really knows her stuff when it comes to helping babies navigate the pelvis during labor and birth. Many cesareans are conducted for “failure to progress” or “cephalopelvic disproportion” when really it is a case of a malpositioned baby who needed to be in a different position. This website is a wealth of information on what women can do to help their babies into the ideal position to be born, prenatally and during labor. It includes valuable information about helping a breech baby turn vertex. This is important, because finding a health care provider who will support vaginal breech birth is like finding a needle in a haystack.

© Patti Ramos Photography

© Patti Ramos Photography

5. Childbirth Connection – This website is a virtual goldmine of evidence based information about cesareans and VBACs including a valuable guide “What Every Pregnant Woman Needs to Know about Cesareans.” There are questions to ask a care provider and includes information on informed consent and informed refusal.

6. Cesareanrates.com is a great website run by Jill Arnold for those who love the numbers. Find out the cesarean rates of hospitals in your area. All the states are represented and families can use the information when searching out a provider and choosing a facility. Jill’s resource page on this site is full of useful information as well.

7. Safe Prevention of the Primary Cesarean –  The American Congress of Obstetricians and Gynecologists along with the Society for Maternal Fetal Medicine recently published a groundbreaking document aimed at reducing the first cesarean. While fairly heavy reading, there is so much good information in this committee opinion that I believe every birth professional should at least take a peek. You may be pleasantly surprised.

Test your knowledge of the facts around cesareans and VBACs with this informative quiz:

As a birth professional, you can be a great resource for all your clients, helping them to prevent their first cesarean, providing support if they do birth by cesarean and assisting them on the journey to VBAC by pointing them to these valuable resources. You can make every day “Cesarean Awareness Day” for the families you work with, doing your part to help the pendulum to swing in the other direction, resulting in a reduction in our national cesarean rates and improving outcomes for mothers and babies. What are your favorite resources on the topic of cesareans and VBACs? Share with us in the comments section.
Images

  1. Patti Ramos
  2. creative commons licensed ( BY-NC ) flickr photo shared by Neal Gillis
  3. creative commons licensed ( BY-SA ) flickr photo shared by remysharp
  4. creative commons licensed ( BY-NC-SA ) flickr photo shared by mikeandanna
  5. creative commons licensed ( BY-NC-SA ) flickr photo shared by mikeandanna
  6. creative commons licensed ( BY-SA ) flickr photo shared by Kelly Sue
  7. creative commons licensed ( BY ) flickr photo shared by Marie in NC
  8. creative commons licensed ( BY-NC-SA ) flickr photo shared by lucidialohman
  9. creative commons licensed ( BY-NC-ND ) flickr photo shared by soldierant
  10. creative commons licensed ( BY-NC-SA ) flickr photo shared by emergencydoc
  11. creative commons licensed ( BY-NC-ND ) flickr photo shared by Mwesigwa

Awards, Babies, Cesarean Birth, Healthcare Reform, Lamaze News, Maternal Mortality Rate, Maternal Obesity, New Research, Research, Webinars , , , , , , , , , , , ,

Home Birth In a Risk Society: A Commentary by Sociologist Barbara Katz Rothman

February 4th, 2014 by avatar

By Barbara Katz Rothman, PhD

Today, I am delighted to share with you an essay on risk written by sociologist and author Barbara Katz Rothman, PhD.  There has been much discussion and debate on two papers just published in the Journal of Midwifery and Women’s Health, using the MANA Stats V2.0 data from the Midwives Alliance of North American. You can find these two papers and a research review by Judith Lothian published on January 30th on Science & Sensibility. – Sharon Muza, Community Manager, Science & Sensibility.

We live in what Social Scientists called a ‘Risk Society.”[i] If you simply google “risk and birth,” you get over 402 million ‘hits.’  So no question, birth is understood as  having risks, creating risks, being risky business indeed.  But not the riskiest of businesses – Google “risk and food,” and you get almost twice as many hits – over 746 million. That doesn’t feel right somehow – pregnancy and birth are always and everywhere in our world understood as risky; food not so much.  I nibble some snacks as I write, sip some tea – are you worrying for me? Wishing me luck with that?  Thinking about the odds of food poisoning? Insecticide exposure?  the long term risks of diabetes, joint pain, heart troubles, cancers that might be flowing forth from the snack choices I am making?

image: www.thinknpc.org

image: www.thinknpc.org

 

And what about those snack choices?  Do they not carry much of the same moral weight that pregnancy choices make — if I tell you it’s green tea and carrots, or if I tell you it’s a honey chai latte and multigrain crackers with organic almond butter, or if I tell you it’s a Nestle Iced Tea and Oreo cookies – do I not create different images of myself as a risk-taking or risk-sparing person, even as a more or less ‘good’ and responsible person?  These are of course the arguments that Risk-society thinkers have been addressing: the risks we perceive and the risks we take are judged, by ourselves and by others.

In birth, few choices have been as freighted with the language of risk and responsibility as that of home birth.

The irony here is that birth moved into the hospital with all of the data showing us that move increased risk; and all of the research we have now still shows us that hospitals present unique and particular risks for birth. Birth moved into the hospital long before the era of Risk – that move was done in the era of Science.  The same science that covered our kitchens in white laboratory-style paint and tiles, that replaced local baking with packaged white bread made out of mass-milled white flour, that created industrialized systems to raise cheap meat at whatever costs to health of humans or animals, that moved fruits and vegetables from fresh to canned – that same science that created the industrial diet of the turn of the century, created the industrial birth.

image: sharon muza

image: sharon muza

When I wanted a home birth almost forty years ago, I knew nothing of midwifery. I just assumed that obstetricians had the necessary knowledge and skills to deliver babies (and yes, I called it ‘deliver’) and that those skills could be used in my bedroom as well as in a ‘delivery room.’  Over the course of my scholarly work in the years following, I learned how wrong that was.  Home birth involves a set of skills, practices and competencies that people trained in hospital birth most often never have learned.  Thus the MANA data is not merely a comparison of place: What we are seeing in this data set is a study of midwifery-led care, or as Ronnie Lichtman has called it[ii], midwifery-guided birth, birth in settings where midwives and the women they are guiding have control over practice.

MANA’s data and these articles are showing us that the United States, for all of its problems, is not exceptional:  Fully autonomous, informed midwifery care provides better birth outcomes than does care under Obstetrical management.  Obstetrics and Gynecology is a surgical specialty, magnificently equipped to manage particular illnesses and crises, but neither the discipline nor the hospital settings it has developed for its practice are appropriate for normal, physiologic birth.

Research on women who choose home birth, as well as midwives who provide it, show that their concerns go beyond the risks of what is often called the ‘cascade of interventions’ that follows medical management, leading as it so often does to cesarean section.  In addition to the well-documented iatrogenic risks, they address risks of the hospital itself, what are called when looking at infections, ‘nosocomial’ risks. They were concerned with errors that are made when people are managed in what is essentially a factory-like setting: risks of overcrowding; risks of exposure to others and exposure of self.[iii]

Hospital-industrialized births demand standardized care. Consider something as mundane and yet intrusive as the vaginal exam.  Medical guidelines, the medical story, is that such exams are necessary to determine labor and its stages.  That of course is absurd.  Do you really think that an experienced midwife, someone who has attended hundreds or thousands of births cannot tell if a labor is established without a vaginal exam? What a midwife needs that exam for is to document, not to establish the labor.  Those exams are not only intimate and intrusive, but for women with histories of sexual abuse especially, can be experienced as traumatic.[iv] For all women, raised with ideas of bodily privacy, integrity and what used to be called ‘modesty,’ such exams at a moment of vulnerable transition are problematic. Done for reasons of institutional management and control, they are one more interruption and create risks of their own. Particularly in hospital settings, vaginal exams are one more occasion for the introduction of nosocomial infection.

Managing the management thus becomes necessary in hospital settings: – midwives use the vaginal exam to create the story that will be most in the woman’s best interests, and occasionally in the midwives’ own best interest.  Midwives are thoughtful about when they measure because, for example, they are hesitant to start the clock too early.  In such care, what midwives are trying to minimize is not the risks of a prolonged labor, but the risks of intervening in a labor medically defined as prolonged.

It is reasonable to talk about how recent this language of ‘risk’ is in pregnancy and in birth – but the language of danger, that which we are in risk of, has long been an accepted part of birth.  Calling it “Risk” is adding the numbers – sure there are dangers, but precisely what are the odds? That there are dangers in pregnancy and in birth, and that they can be avoided or overcome, this is not news.  Dangers, disasters even, could happen in the best and healthiest of pregnancies and births.  The difference perhaps is that now there is no such thing as a healthy pregnancy and birth.  There still is an understanding of such a thing as a ‘healthy meal” and even a “healthy diet,’ but no longer, it seems to me, a healthy pregnancy – the best you can hope for is a low risk pregnancy.

It is not that midwives do not have understandings of danger and knowledge about ways to avoid danger, including the dangers of prolonged labors.  That is precisely what midwifery has been throughout time and across place: the development of a body of knowledge and skilled craftsmanship to navigate the dangers of childbirth.  All of that knowledge was discounted with medicalization.

Scientific or ‘Medical’ knowledge is accepted as real and authoritative; other knowledge is reduced to ‘intuition’ or ‘spiritual knowing,’ made all but laughable.   But when a baker adds a bit more flour because the dough is sticky, is that ‘intuition’?  Or is that knowledge based on craft, skill, deep knowledge of the hands?  When a violin-maker rejects a piece of wood in favor of one lying next to it that looks just the same to me or to you, is that ‘intuition’?  Or experience, skill and craft?  And when a leading neurosurgeon examines a dozen stroke patients who all present pretty much the same way on all of their tests and feels hopeful about some and concerned for others, is that ‘intuition’?  Or knowledge based on experience, using a range of senses and information that may not be captured in the tests?

In hospital settings, midwives do not have the authority to use their knowledge fully in the woman’s best interests.  And therein lie the risks.

And finally, it would be helpful to put these risks in contextIf safety were our real concern, if saving the lives of babies and of mothers were the driving force, then there are a number of changes we would make immediately.  We would require helmets for people in cars, something we know would save lives each week.  We would lower the speed limit in urban areas, and end driveway parking in suburbs. To suggest such things makes one look crazy – crazier than suggesting home birth.  But it most assuredly would protect children. If saving babies were our concern, we would invest in public housing, and in the food system.  These are large scale changes that would save far more people than anything that happens in those few hours of late labor to early neonatal period, the 24 or so hours of hospitalization that is now being debated.

Clearly something more or other than saving babies is at stake.

References

[i] Beck, U. (1992). Risk society: Towards a new modernity (Vol. 17). Sage.

[ii] Lichtman, R. (2013). Midwives Don’t Deliver or Catch: A Humble Vocabulary Suggestion. Journal of Midwifery & Women’s Health.

[iii] Katz Rothman, B., (2014) Risk, Pregnancy and Childbirth, Risk, Health and Society, edited by Alaszewski, Intro by Barbara Katz Rothman. Volume 16.1, forthcoming.

[iv]  Adult manifestations of childhood sexual abuse. Committee Opinion No. 498, American College of Obstetricians and Gynecologists. Obstet Gynecol 2011: 118:392-5.

About Barbara Katz Rothman

image: Barbara Katz Rothman

image: Barbara Katz Rothman

Barbara Katz Rothman, PhD, is Professor of Sociology, Public Health, Disability Studies and Women’s Studies at the City University of New York, and on the faculty of the Masters in Health and Society at the Charite in Berlin, the University of Plymouth in the UK, and the International Midwifery Preparation Program at Ryerson University in Toronto Canada. Her books include In Labor: Women and Power in the Birthplace, The Tentative Pregnancy: How Amniocentesis Changes the Experience of Motherhood, Recreating Motherhood, The Book of Life: A Personal and Ethical Guide to Race, Normality and the Human Gene Study,  Weaving A Family: Untangling Race and Adoption and Laboring On: Birth in Transition in the United States.  Dr. Katz Rothman is the proud recipient of an award for “Midwifing the Movement” from the Midwives Alliance of North America.

Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Maternal Quality Improvement, Maternity Care, Midwifery, New Research , , , , , , , , , ,