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Archive for January, 2011

Blog Carnival Round-Up: Stories of Success from the Field

January 28th, 2011 by avatar

It really is a joy and, I believe, imperative to spend time sharing childbirth success stories amongst those of us who dedicate our professional lives to improving childbirth experiences and outcomes for women all around the globe.  This year’s first blog carnival is about just that:  celebrating success while illuminating some ways in which Lamaze’s Six Healthy Birth Practices can and have been implemented in the process of realizing these successes.

Lisa, at Journey Through Lamaze, shared with us a lovely story of one of her recent clients who allowed labor to start on its own, and labored at home long enough before checking into the hospital to find herself fully dilated and ready to begin pushing shortly after admission.  Having begun with Healthy Birth Practice #1, this mama progressed through a non-medicated birth which Lisa describes as, “…the calmest birth I’ve ever been at.”  (Read Lisa’s post to find examples of other Healthy Birth Practices exemplified during this baby’s birth.)

Childbirth Educator, Judith, from Dance While You Cook relates how she incorporates teaching the importance of walking, moving around and changing positions throughout labor (Healthy Birth Practice #2) into her childbirth preparation classes.  Beyond “typical” teaching strategies, Judith shows her students how movement in labor can be effective by demonstration through a labor and birth dramatization. Read her post, and I guarantee you, you will pick up on the renewed energy and empowerment Judith gains each time she conducts this portion of her curriculum.

Many of our carnival contributors wrote about experiencing childbirth from a doula’s point of view.  Wendy from Mom and Little Me wrote about her strong belief in extending Healthy Birth Practice #3 into the prenatal period as much as possible.  It is during the prenatal visits that some of her most effective doula support takes place.  (Follow the link to Wendy’s post to also read about her ambitions for educating “a younger generation on natural childbirth and breastfeeding.”)  Hillary at Infinitely Learning shares with us a lovely anecdote about the birth of one of her doula clients that showed her the importance of holding space and bearing witness to the great journey of another human being, as she describes below:

She was a really independent birther and mostly needed the midwives and me (the doula) there for reassurance during some strong moments, but mostly I just stood Witness. A couple of times I doubted that I was even needed and became self-conscious that I wasn’t doing enough, but when I checked in internally to be guided I heard, “Witness”.

Kate, at Two Bee Birth Services shared the story, as written by the mother, of a successful, un-medicated VBAC.  With a history of multiple medical interventions during previous birth experiences plus some other recent pregnancy-related complications, this mama pursued a vaginal birth in the safest way possible, considering a present and extenuating medical circumstance.  In order to do this, she dedicated herself to avoiding interventions that were not medically necessary (Healthy Birth Practice #4) and succeeded in achieving the VBAC she hoped for.

Providing a fantastic success story that illustrated all six Healthy Birth Practices, in the setting of one birth, “Anthro Doula” Emily at Doula Ambitions simply and beautifully describes the end of one of her first birth experiences as a doula:

Once in the labor and delivery room she crawled up onto the bed on all fours, following her instinct and her urges to push on her own. She changed positions to a squat, leaning against the back of the raised bed, so that she would be able to catch her own baby. (Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push!)

This is my favorite part of the story, and my favorite part of any birth so far…
While the baby’s head was crowning, she reached down and felt his head, and she looked up with a face full of wonderment and said, “His head is coming out and then going back in a little!” She was so calm and intrigued, fully experiencing the birth of her first child. Then she pushed out her baby and pulled him up onto her stomach, all the while calm and grinning like mad!

The husband had tears streaming down his face, and the new mother was immensely pleased with herself. Mama and baby stayed together, skin-to-skin, and began to initiate breastfeeding, for the whole first hour.
(Healthy Birth Practice 6: Keep mother and baby together - It’s best for mother, baby and breastfeeding)

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Thank you to all blog carnival contributors for your thoughtful words and illustrative stories which collectively remind us that safe, healthy, fulfilling birth experiences are not an anomaly, but an achievable reality!
**Don’t forget to swing on over to Giving Birth With Confidence to read additional results of this blog carnival!

Posted By:  Kimmelin Hull, PA, LCCE

Blog Carnivals, Doula Care, Healthy Care Practices, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,

“Except When Medically Necessary” : Making informed choices about induction of labor

January 27th, 2011 by avatar

It’s not hard for women to find advice and recommendations to avoid induction of labor “except when medically necessary.”  But what do those words mean and who decides when an induction is medically necessary?

Lamaze’s Healthy Birth Practice Paper cites ACOG Guidelines that define medical induction of labor as necessary in the following circumstances:

  • your water has broken and labor has not begun.
  • your pregnancy is postterm (more than 42 weeks).
  • you have high blood pressure caused by your pregnancy.
  • you have health problems, such as diabetes, that could affect your baby.
  • you have an infection in the uterus.
  • your baby is growing too slowly.

Yet a systematic review of the highest quality research found evidence only to support the first three. Even in these three cases, differences in important health outcomes were small, study methodologies have been criticized, and some important questions remain unanswered.

For the rest of this list and other so-called “medical” reasons for induction, we simply lack scientific evidence that induction offers any clear health benefits, and for other conditions the available evidence suggests induction is more likely to harm than help.

When trade-offs are uncertain for a proposed course of treatment, that treatment is known as “preference-sensitive care.”  According to the Dartmouth Atlas of Health Care, a leader in studying practice variation, “Decisions about these interventions — whether to have them or not, and which ones to have — should thus reflect patients’ personal values and preferences, and should be made only after patients have enough information to make an informed choice, in partnership with the physician.”

As the Dartmouth Atlas has demonstrated for many types of medical and surgical interventions, however, decisions are more likely to reflect local practice patterns and the preferences of individual providers than the preferences of patients themselves. While the Dartmouth Atlas does not track induction rates, a 2004 study in New York State found that risk factors (at least those documented in birth certificate records) explained just 12.6% of the four-fold variation in induction rates across hospitals.

But what of the variation in the use of interventions when clear evidence suggests is harmful? Shouldn’t rates of those interventions be stable at or near 0%?  Take, for example, the rate of elective (non-medically indicated) deliveries before 39 weeks. In a landscape where clinical consensus is hard to come by, all of the major players from ACOG and ACNM to the March of Dimes, the National Quality Forum, and the Joint Commission, have gotten on the no elective deliveries before 39 weeks bandwagon. Yet this week a major hospital watchdog group, The Leapfrog Group, partnering with Childbirth Connection and the March of Dimes, released for the first time hospital rates of elective deliveries before 39 weeks and the results are all over the map (pun intended). Some hospitals are in the low single digits, rates we know are possible when quality improvement efforts are taken seriously, while others report up to half or more of all births between 37 and 39 weeks are electively delivered.

Women need individualized, evidence-based information about the likely benefits and harms when considering induction of labor in the face of complications or significant risk factors. Childbirth Connection has launched a new web resource dedicated to Induction of Labor to help fill this need. But evidence is just one piece of the puzzle. Women also need information about maternity care practice patterns in their communities, since this factor seems to affect their likelihood of induction more than any other. Leapfrog’s voluntary database of elective early delivery rates stands to drive significant quality improvement. Let’s hope it’s just the first step toward full transparency of maternity care quality.

Uncategorized , , , ,

The Trap of Overselling and Underdelivering

January 24th, 2011 by avatar

The following article is being re-posted with permission from The Unnecesarean.  The article was originally posted on January 11, 2011, as a part of the Defending Ourselves Against Defensive Medicine series.  Dr. Henry Dorn is an Obstetrician-Gynecologist currently practicing in High Point, NC.  Thank you to Jill and Dr. Dorn for allowing us to re-post this fantastic piece in which Dr. Dorn takes on the issue of ritual-based vs. evidence-based practice of medicine.
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In 1974, the noted obstetrician Marcus Filshie published a review of the relatively new electronic fetal monitoring in the British Journal of Hospital Medicine. He stated, somewhat fatefully:

“Now that the appropriate technology is available, the obstetrician may virtually eliminate intrapartum stillbirths and reduce morbidity to a minimum.”

Similar statements were made in the United States by leaders in the obstetrical community and headlines were created. Although there was significant evidence that spoke to the limitations of this technology, the obstetrical community and the general public leapt to embrace this new found “cure” for adverse neonatal outcomes. Certainly in an age in which man could travel to the moon, computers were becoming commonplace in academic settings and nuclear energy a reality, doctors should be able to reliably detect fetal distress and act upon it safely, sparing parents the grief of the past.

Likewise, ultrasounds have allowed us to peer into the womb, and into the bodies of our unborn children, allowing us to anticipate not only the gender of our babies, but also see things as subtle as heart or spine defects. Yet everyone knows a story of the girl who turned out to be a boy, despite our best imaging efforts, and the mixed feelings that that surprise engenders (pun intended).

Molecular biology has allowed us to go even further, and examine the blueprints of life in utero, allowing parents to prepare for a child with chromosomal issues, or reassuring those with family histories of hereditary disorders.

Altogether, ever advancing science has created a sense of control over what once had been a very insecure time for families and their caregivers. The idea that following the current best medical evidence will virtually guarantee best outcomes is an appealing extension of that new found power over nature, but is a belief system that is inherently flawed, and that fact is often not appreciated by those who are captivated by its seduction.

Joseph Campbell, the comparative mythologist noted that cultures which are the most subject to the variable forces of nature, such as seafaring peoples, have the most rituals, in order to exert some sense of control over the uncontrollable. The obstetrical community must fit that model, insisting on specific rituals of care, even in the absence of absolute evidence of their efficacy, in order to gain a sense of control and mastery of the birthing process. The fetal heart rate tracing is poured over like tea leaves or cast bones, and the doctor becomes the shaman.

This belief system has been preached to future physicians and obstetricians, who passed it along to their students until the whole culture of childbirth medicine became steeped in a religious-like belief in the power of the fetal monitor, labor curves, ultrasound measurements and the like. This belief is similarly conveyed to patients who are assured that if their pregnancy was managed according to the protocols developed by trusted researchers, their babies would be delivered without fail and without harm.

Reality, however, has proven otherwise. Despite close and continuous monitoring in labor by the best trained and most capable staff and doctors, babies still die suddenly, or are born with unexpected asphyxia, or unanticipated illness. Families feel bewildered and betrayed and seek explanation and often recourse. If the latest technology was employed, then certainly human error must have been the cause.

Trial lawyers turn physician’s own promises against them and win huge lottery-like settlements, setting precedence, and further convincing the public that the fault was not in the system but in the individual caregiver.

If, however, one looks critically at the myriad of diagnostic methods, and treatments used by the modern obstetrician, it becomes quite clear that there is much that is uncertain and much we cannot control. Most experienced practitioners know this, but are often resistant to admit this to their patients and the public, but this lack of disclosure has a tendency to backfire.

This is not to say that modern obstetrics with all of its technologies and oft maligned “interventions” is without value. Huge numbers of babies and mothers have been saved by modern medical care, but the failure to admit to ourselves and the patients we serve that we cannot guarantee perfect outcomes does a disservice to us all. Bad things do happen to good doctors (and nurses, and midwives etc.) and the sooner everyone understands this, the sooner we can start practicing evidence-based medicine as opposed to ritual-based medicine.

Conversations need to start with recommendations and explanations of their rationale, but leave room for the ever present uncertainty of outcomes as well as factoring in the patients desires and apprehensions. I believe that “I don’t know” are three of the most powerful words in medicine and should be used more often. Patients who don’t want to hear this need to realize that any practitioner who believes that they truly KNOW anything for certain is more dangerous than the one that makes allowances for the great amount of variability that life entails.

This more open communication should certainly help to restore the trust patients once had in their providers, and begin the process of reducing costs due to defensive medicine, as well as lessen patients’ sense of betrayal that sometimes occurs with unexpected bad outcomes.

Posted By:  Dr. Henry Dorn, c/o Kimmelin Hull, PA LCCE

Evidence Based Medicine, Fetal Monitoring, Guest Posts, Patient Advocacy, Practice Guidelines , , , ,

Antepartum Bedrest: Helpful or Harmful?

January 20th, 2011 by avatar

Each year approximately 750,000 women in the United States are prescribed antepartum bed rest (ABR) for a portion of their pregnancy due to (but not limited to) preterm labor contractions, incompetent cervix, placental issues, multiple gestation, vaginal bleeding, hypertension/pre-eclampsia, gestational diabetes, impaired fetal growth or oligoamnios. The amount of time spent on bed rest can be anywhere from a few days to several months and women are typically confined to bed with activity restricted (AR) to bathroom privileges only. While the indications for ABR vary, the unifying rationale for prescribing ABR and its perceived benefits remain the same—to prevent preterm labor and the delivery of a premature infant. Preterm birth is the leading cause of perinatal infant morbidity and mortality in developed countries. In 2005, 68.5% of all infant deaths <1 year old in the U.S. were in preterm infants.  The rate of preterm birth in 2005 was 12.7% in the US (and continues to climb) compared to 5-7% in European countries. (Go here and here for additional information on these statistics.)

To date, there is no data to support the efficacy of ABR in the prevention of preterm labor and premature birth. Much of the research done on antepartum bed rest actually shows that it does more harm than good (1-5).  Additionally, in-patient ABR has been shown to have worse effects on maternal and infant morbidity and mortality than ABR at home. To further investigate these findings, Judith Maloni, PhD, RN, FAAN performed an integrative literature review on the research to date. Her findings were published in the article, “Antepartum Bed Rest for Pregnancy Complications: Efficacy and Safety for Preventing Preterm Birth” (Biological Research for Nursing, October 2010,Volume 12 (2) 102-124). Although ABR has been a mainstay of clinical obstetrical practice for the past 30 years in the United States, Maloni found no evidence for its effectiveness. On the contrary, she found that there is increasing evidence that ABR leads to several negative physical and psychological effects to both mothers and babies yet these findings have not lead to a change in clinical practice. Here she presents the evidence for the practice of prescribing ABR and its associated physiologic, psychological, and experiential side effects. She also presents recommendations for additional research on ABR including the evidence that supports prescribing home care with support as a safe, efficacious and cost effective model.

Methods
Maloni chose to organize her work following the Human Response Model and its concept of physiologic, behavioral and experiential adaptation. 69 publications made up the sample for this study: 26 articles discussed the physiologic, behavioral and experiential side effects of bed rest; 17 articles compared ABR at home vs. the hospital setting; 5 meta-analyses of RCTs assessed the effectiveness of ABR; and 4 articles analyzed physician use of bed rest. Articles ranged in date from 1990 when major interest in the study of bed rest began, to the present time. The articles come from research in nursing, medicine, psychology, social, biological and aerospace sciences. Maloni searched MEDLINE, CINAHL, PubMed/Medline, and the Cochrane Database of Systematic Reviews.

Results
Several conclusions emerged following the literature review, but none of them supported the idea that ABR with activity restriction (AR) is beneficial in preventing preterm labor. What quickly became apparent is that ABR/AR has some very deleterious effects on mothers and babies. Aerospace research showed that prolonged inactivity in the supine position leads to redistribution of body fluids towards the head, causing functional changes in the cardiovascular/cardiopulmonary systems, fluid and electrolytes balances, hormone balances, hematologic systems, neurosensory and vestibular systems. Additionally, the body weight distribution is shifted and the result is muscle atrophy and bone demineralization. These changes persist far into the postpartum period and may have long standing consequences. They also necessitate a longer than usual postpartum recovery due to deconditioning. Women also reported fatigue, back aches, muscle soreness, sleep changes, round ligament pain, nasal congestion, reflux and indigestion which also persisted well beyond 6 weeks postpartum.

Non-pregnant women on bed rest (astronauts) tend to lose weight due to fluid and bone loss, and occasional loss of appetite. Carbohydrate and fat metabolism are also altered during bed rest. Similar to findings with female astronauts, (pregnant) women on bed rest have been noted to either maintain or to lose weight which is dangerous for fetal growth. Three of the studies, including one which focused on multiple gestations showed that women on ABR—both in the hospital and at home—did not gain the anticipated one pound per week as recommended by the Institute of Medicine for adequate (fetal) growth.

The literature also demonstrates that behavioral changes ensue as a result of prolonged bed rest. Women reported feeling imprisoned with a sense of sensory deprivation. They worried  about their lives and their families and felt powerlessness to fix anything. This stress led to altered mood and often pre- and postpartum depression. These symptoms were most pronounced in women on hospital bed rest and remained well beyond 6 weeks postpartum. Family members were stressed as well, most notably partners who assumed the role of caring for the family in addition to their partners on bed rest. It was also noted that infants born to mothers on ABR had higher incidences of allergies, motion sickness and the need to be rocked to sleep than those infants born to mothers who were never on ABR.

Alternative Models For Antepartum High Risk Care
While ABR in the hospital is currently the standard of care in the United States, it has not been shown to reduce perinatal morbidity or mortality. The literature has shown that women on hospital ABR often had the most pronounced adverse effects, both physical and psychological. Despite these findings, ABR (in-patient ABR, in particular) continues to be prescribed.

Physicians in other countries often prescribe ABR but have patients remain at home, providing maternal and fetal monitoring as well as light housekeeping, child care, nutritional counseling, education and psychological counseling. In contrast, very limited home care assistance is available in the United States.  Home care in the U.S. consists mostly of uterine and fetal monitoring and infusions of Magnesium Sulfate or Terbutaline—medication thought to (but not proven to) inhibit contractions. Maloni’s study showed that women who underwent ABR at home with support (assistance with familial responsibilities and emotional support) actually fared better than women who completed their ABR in the hospital. Additionally, infants born to mothers who experienced ABR at home had fewer or shorter NICU admissions. All researchers concluded that, when truly warranted, home care of high risk pregnant women with ABR is as effective, safe and feasible as hospital care.

Discussion
Because of the significant burden ABR puts on a pregnant woman, her fetus, her family and the U.S. health care system, and given the fact that there has been no recent evidence to support its efficacy, experts agree that bed rest should no longer be a standard component of treatment for the prevention of preterm birth. In fact, these same experts agree that the practice should be eliminated (1,,3, 5,6,7). While there may be a need for an emergent period of intense hospitalization following a crisis, experts concur that once a pregnant woman and her baby have been stabilized, they should be discharged home and managed with modified/restricted activity and supportive home care visits that not only monitor maternal and fetal well-being, but also support a women and her family psychosocially.

While some experts argue that neonatal mortality has gone down over the last 20 years, this has been primarily due to improved neonatal care in NICU’s and increased access to such care. The incidence of preterm birth has essentially remained unchanged (6,7,10).  As such, researchers are increasingly skeptical that the current U.S. model of prenatal care, in terms of prescribing bed rest for threatened pre-term birth, can prevent prematurity. While some researchers advocate the addition of steroids, sedation, psychosocial support and nutrition, other researchers note that these methods have yet to prove effective in reducing the incidence of preterm birth (6,7,11). Maloni, in agreement with their research findings, believes that there really needs to be a complete overhaul of the management of prenatal care. Maloni and others  advocate a re-evaluation and reconceptualization of prenatal care as part of a broader approach to optimize all of women’s health.

References

  1. Crowther, C. (2009) “Hospitalization and bed rest for multiple pregnancy.” Cochrane Database of Systematic Reviews, (2), CD000110. Accession number: 00075320-100000000-00712
  2. Elliott, JP, et al (2005) “A randomized multicenter study to determine the efficacy of activity restriction for preterm labor management in patients testing negative for fetal fibronectin.” Journal of Perinatology, 25, 626-630.
  3. Meher,S., Abalos, E., & Carroli, G. (2005) Bedrest with or without hospitalization for hypertension during pregnancy. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD003514. DOI: 10.1002/14651858.CD003514.pub2. Last update January 18, 2010.
  4. Say, L., Gulmezoglu, A.M., & Hofmeyer, G.J. (2009) Bed rest in hospital for suspected impaired fetal growth. Cochrane Database of Systematic Reviews, (3), CD000034. Accession number: 00075320-100000000-01075.
  5. Sosa, C., Althabe, F., Belizan, J., & Bergel, E. (2009) “Bed rest in singleton pregnancies for preventing preterm birth.” Cochrane Database of Systematic Reviews, (2), CD003581. Accession Number: 00075320-100000000-02667.
  6. Goldenberg, R.L. (2002) “The management of preterm labor.” Obstetrics and Gynecology, 100. 1020-1037.
  7. Lu, M. C., et al (2003) “Preventing low birth weight: Is prenatal care the answer?” Journal of Maternal-Fetal & Neonatal Medicine, 13, 362-380.
  8. Heaman, M., Sprague, A.E., & Stewart, P.J.A. (2001) Reducing the preterm birth rate: A population health strategy.” Birth (30) 20-29.
  9. Hodnett, E.D., Fredericks, S. (2009) “Support during pregnancy for women at increased risk of low birthweight babies.” Cochrane Database of Systematic Reviews , (2) CD 000198. Accession number: 00075320-100000000-00157.

Posted By: Darline Turner-Lee, MHS, PA-C

Bed Rest, Do No Harm, Practice Guidelines, Pregnancy Complications, Research, Science & Sensibility, Systematic Review , , , , , , , , , , , , , ,

United States Breastfeeding Commitee: Breastfeeding ~ A Vision For the Future

January 18th, 2011 by avatar

Following posts like this one from last week, it’s encouraging to see that breastfeeding initiation rates have continued to rise in recent years.  But, as Science & Sensibility contributor Edith Kernerman, IBCLC, pointed out: the rates of breastfeeding exclusivity at the six-month-postpartum mark (as recommended by the World Health Organization) are still less than impressive (world-wide, not just in the U.S.).  Thankfully, progress is being made to change these rates for the better.  Beyond local activism and individual interactions between lactation support specialists & consultants and the women they support, leadership “from the top down” is emerging.

If you haven’t heard of the United States Breastfeeding Committee (USBC), let me bring you up to speed:  This non-profit organization is made up of forty voting member organizations (Lamaze, being one of them) and evolved out of the 1990 UNICEF Innocenti Declaration which, among other things, calls for:

…every nation to establish a multisectoral national breastfeeding committee comprised of representatives from relevant government departments, non-governmental organizations, and health professional associations to coordinate national breastfeeding initiatives.

In the last few years, the USBC has accomplished numerous impressive feats–including communications and collaborations with federal law makers, White House staff members, CDC entities, FDA departments, popular media outlets and more.  Go here to see the complete overview.   Most importantly, go here to view USBC’s Breastfeeding Vision for the Future in which barriers to breastfeeding success are addressed and goals for improved support of mother-baby breastfeeding dyads are delineated.   To show your support for the work USBC is doing on behalf of ALL nursing mothers–current and yet to come–sign the petition which seeks support from all sectors of U.S. society for improving each and every factor that influences a woman’s ability to breastfeed her child(ren) for the duration that is mutually beneficial for mom and baby.

***Our government is taking note:  keep your eyes and ears pealed for an important announcement from the Surgeon General on this very same topic…this coming Thursday, January 20! ***

UPDATE: Go here tomorrow (Thursday) at 10:00EST to see the live webcast of the Surgeon General’s call to action to support breastfeeding!

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