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Series: Welcoming All Families: Supporting the Native American Family

November 18th, 2014 by avatar

By Melissa Harley, CD/BDT(DONA), LCCE

November is Native American Heritage Month and LCCE Melissa Harley shares some interesting facts about the rich culture included in some of the varied childbearing year traditions observed by some of the U.S. tribes.  There are many different tribal nations, and each one has their own ceremonies and practices around pregnancy and birth.  Beautiful and fascinating stories that are each unique in their own right.  This post is part of Science & Sensibility’s “Welcoming All Families” series, which shares information on how your childbirth class can be inclusive and welcoming to all. – Sharon Muza, Community Manager, Science & Sensibility.

© Bob Zellar http://bit.ly/1EVALCk

© Bob Zellar http://bit.ly/1EVALCk

As childbirth educators of today, we must strive to have a connection to childbirth of yesterday.   As educators, we should continually be looking for ways to be welcoming of all cultures, customs, and traditions in the classroom setting and when working individually with students.  In order to achieve these goals, it is helpful to better understand how such traditions played out in years gone by.  So often, we look at birth from a very telescopic lens of the past (singling out one or two cultures) rather than looking at history from a more wide panoramic view point.  As we strive to embrace cultural diversity, we should continue to explore populations that are perhaps a little less known.    Have you considered the culture of Native Americans in childbirth and how the past compares to childbirth in our society now? According to the Centers for Disease Control and Prevention (CDC), currently, there are roughly 5.2 million American Indians and Alaska natives spread throughout 565 federally recognized tribes in the US. (CDC, 2013)  Let’s take a look at some of the commonalities that we have with our Native American ancestors and learn a little together about being welcoming, helpful, and inclusive of Native Americans in our classes today!

Native Americans and Pregnancy

Although there are some differing opinions regarding historical pregnancy and birthing traditions of Native Americans, according to historian Ellen Holmes Pearson, PhD, Native Americans were known to take exceptional care of themselves during pregnancy.  Similar to today, maintaining good health throughout pregnancy often led to an uncomplicated labor and birth.  Much regard was taken to ensure that a Native American mother’s health needs were met in a way that would support the nutritional and physical needs of both mom and baby.  From the website teachinghistory.org, Dr. Pearson states   “During their pregnancies, women restricted their activities and took special care with their diet and behavior to protect the baby. The Cherokees, for example, believed that certain foods affected the fetus. Pregnant women avoided foods that they believed would harm the baby or cause unwanted physical characteristics. For example, they believed that eating raccoon or pheasant would make the baby sickly, or could cause death; consuming speckled trout could cause birthmarks; and eating black walnuts could give the baby a big nose. They thought that wearing neckerchiefs while pregnant caused umbilical strangulation, and lingering in doorways slowed delivery. Expectant mothers and fathers participated in rituals to guarantee a safe delivery, such as daily washing of hands and feet and employing medicine men to perform rites that would make deliveries easier.”

In addition to caring for the body in pregnancy, it was extremely important for Native Americans to care for their mind and spirit.   In the Navajo communities, pregnancy and childbirth were approached as a spiritual event.  Much time and effort was spent making sure that the mother had a positive pregnancy.  Ceremonies in the Navajo community in general were very important.  Some ceremonies could last for days and days.  It was only natural that the tribes would hold Blessing Ways for expectant mothers.   Unlike many other Navajo ceremonies, the Blessing Way was not held to cure a sickness, but rather to invoke positive blessings and avert misfortune. Contrary to current use of the Blessing Way, the traditional Navajo tribes used the Blessing Way for more than just pregnancy and birth.  The ceremony was also used for blessing of the home, and also to enhance good fortune through the kinaalda (girl’s puberty rites).  Native Americans today that wish to connect with their heritage during the childbearing time often do so by being very careful about their spiritual surroundings.  It is quite important for mothers to keep their thoughts positive, and to maintain a climate of peace with those around them.  It is also suggested that mothers should avoid arguing with others during pregnancy, or to allow bad thoughts to enter their minds.

Native Americans and Birth

Native Americans were known to give birth in a simple way, with only other women in attendance as men were never allowed to see a woman give birth.   In general, Indian women likely gave birth without much assistance at all.  A midwife would at times attend the birth, along with other female family members from the tribe.  In very simplistic style, the baby would be birthed directly onto the leaves below the mother who used upright posturing for birth.   The baby would be welcomed by the earth, rather than by man’s hands.

To hasten labor and reduce pain during the birth, tribes sometimes utilized herbal remedies.   Cherokees made a tea with Partridgeberry and started consuming it several weeks before the birth.  They were also known to use Blue Cohosh to promote rapid delivery and to speed delivery of the placenta. To relieve pain, the Cherokees turned to wild black cherry tea made with the inner bark from the tree. The Koasati tribes made a tea of the roots from the plant of cotton that reduced pain for birthing women.

In some tribes, rituals to “scare” the baby out were utilized.  An elder female would often yell “Listen! You little man, get up now at once. There comes an old woman. The horrible [old thing] is coming, only a little way off. Listen! Quick! Get your bed and let us run away. Yu.”

Another common tradition in birth was the use of the rope or Sash Belt thrown over tree limbs for the mother to hold.  The traditional Navajo sash belt is made of intricate-colored sheep wool that is woven upon a wooden loom.  Some hospitals today near Indian reservations have a Sash Belt installed in the ceiling for mothers to use.

Connecting the Past and the Present

While the mothers of today might not fear that eating speckled trout will cause birthmarks, most do still have concerns  and want to take steps to ensure a healthy baby.  We see mothers avoiding large amounts of caffeine and high mercury fishes. While we don’t often see our students choosing to give birth without much assistance onto the leaves of the trees, many do still choose upright posturing.  We also see a desire at times to hasten the labor, and some mothers turn to herbal or medicinal means to help that happen.   As childbirth educators, we can at times be of comfort to our students as they prepare for the healthiest birth possible. We can connect the past with the present, allowing parent’s space to explore the traditions within their cultures while also honoring current evidence and research based maternity care.  As I say in my classes, while pointing students to the evidence associated with Healthy Birth Practice #5, those mamas from long ago knew something intuitive: that using upright positions for labor and birth made a difference!

Health Services for Native Americans Today

If you live and work near an Indian reservation, you may be familiar with Indian Health Service (IHS).   IHS was established in 1955 with a goal to raise the health status to the highest possible level for Native Americans registered in a federally recognized tribe.   As childbirth educators, some of our students may seek medical attention at one of the nation’s 33 IHS hospitals or 59 IHS health centers.   Dr. Michael Trujillo, past director of IHS states in regard to IHS, “The values of human dignity, honesty, compassion, coupled with shared values of many different tribes and cultures, that have come to be spoken of as “Indian values, of listening, mutual respect, dignity, and harmony must always be at the forefront of what we do and how we do it. We must be professional in all our actions.”

This year, in accordance with the Affordable Care Act, the Indian Health Care Improvement Act was permanently reauthorized.  This provision in the current law will increase access of quality health care to Native Americans near IHS facilities as well as those who do not live near an IHS facility.  The ACA includes some very specific benefits that will impact American Indians and Alaskan Natives.  Tribes across the country are encouraging members to become familiar with the new laws, and to evaluate how the provisions can increase access and affordability to quality healthcare for their members.

Connecting our Native American clientele with quality prenatal care is extremely important.   Consider the following statistics from the CDC:

  • American Indian/Alaska Natives have 1.6 times the infant mortality rate as non-Hispanic whites.
  • American Indian/Alaska Native babies are 2.2 times as likely as non-Hispanic white babies to die from sudden infant death syndrome (SIDS).
  • American Indian/Alaska Native infants were 2.5 times as likely as non-Hispanic white infants to have mothers who began prenatal care in the 3rd trimester or not receive prenatal care at all.

What’s a Childbirth Educator to Do?

As we strive to better serve the mothers of today, first and foremost, we should recognize the importance of the history that First Nations people bring to birth.   Many Native Americans today still practice customs and traditions from years gone by.  If you currently service a population that includes American Indians and Alaskan Natives, then you may already be aware of the customs in your area.

© Ursula Knoki-Wilson

© Ursula Knoki-Wilson

To help Native Americans feel welcomed in class, ensure that visuals of contemporary Native Americans are included in your curriculum.   You might also offer a segment in your comfort measures class that specifically addresses the customs from that population.  In general, keeping language inclusive of a variety of cultures can also lead to a sense of acknowledgement and acceptance. Simply recognizing that you are aware of different cultural traditions in class can lead to parents feeling more comfortable, thus opening a door for sharing and further education.

Regardless of your target clientele, it would be helpful for a childbirth educator to become familiar with the many different traditions surrounding childbirth in the cultures around us.  A quick internet search can lead to a wealth of information that might be helpful in class.  As with any tradition or culture that you are not familiar with, education is power!  If you are on or near a reservation, perhaps reaching out to the IHS facility nearby might be an option.  Some facilities have staff members that hold workshops and courses to help the people within their tribes stay connected with tradition. In addition, it might be helpful to inform area IHS facilities that there is a childbirth educator nearby who is sensitive to the mental, physical and spiritual needs of the tribe members. It would also be advisable for childbirth educators to become aware of the provisions in the ACA for American Indians, as to be prepared with resources, if you are asked any questions in regard to healthcare for American Indians.   As childbirth educators, we are in a unique position to encourage our clients to seek quality prenatal care.  Working together with the families in our classes, we can positively impact the infant mortality rates among these populations by educating the families about safe and healthy birth practices and the options available to them.

Ultimately, it is important to keep our space open for all cultures and honor the individual traditions of the parents that attend our classes.  By becoming more educated and sensitive to the cultures around us we can better serve our clientele as a whole.  And for our Native American students, I’ll leave you with this blessing:

Earth’s Prayer
From the heart of earth, by means of yellow pollen blessing is extended.
From the heart of Sky, by means of blue pollen blessing is extended.
On top of pollen floor may I there in blessing give birth!
On top of a floor of fabrics may I there in blessing give birth!
As collected water flows ahead of it [the child], whereby blessing moves along ahead of it, may I there in blessing give birth!
Thereby without hesitating, thereby with its mind straightened, hereby with its travel means straightened , thereby without its sting, may I there in blessing give birth!S.D. Gill, Sacred Words

Note: to read more information about the images of the cradleboard welcoming home two generations of families, please follow this link to the Turtle Track organization for the full story. – SM

References

American Indian & Alaska Native Populations. (2013, July 2). Retrieved November 15, 2014, from http://www.cdc.gov/minorityhealth/populations/REMP/aian.html

Blessingway (Navajo ritual). (n.d.). Retrieved November 15, 2014, from http://www.britannica.com/EBchecked/topic/69323/Blessingway

Holmes Pearson, E. (n.d.). Teaching History.org, home of the National History Education Clearinghouse. Retrieved November 15, 2014, from http://teachinghistory.org/history-content/ask-a-historian/24097

Infant Mortality and American Indians/Alaska Natives. (2013, September 17). Retrieved November 15, 2014, from http://www.minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=38

Knoki-Wilson, U.M. (2008). Keeping the sacred in childbirth practices: Integrating Navajo cultural aspects into obstetric care. [PowerPoint slides].  Retrieved from Naho.ca website http://www.naho.ca/documents/naho/english/IG_Presentations2008/009KnokiWilsonUrsula.pdf

About Melissa Harley

melissa harley head shotMelissa Harley, CD/BDT(DONA), LCCE has worked with birthing women since bearing witness to the vaginal birth of her twin nieces in early 2002. She is a Native American registered in the  Cherokee Nation Tribe (OK) and the owner of Capital City Doula Services in Tallahassee, Florida.   Melissa holds certifications as a Lamaze Certified Childbirth Educator, DONA International Certified Doula and an Approved Birth Doula Trainer(DONA). She currently holds leadership positions with DONA International as a Florida state representative, and she sits on both the DONA International Education and Certification Committees.Melissa is a contributor to several birthing publications including the Journal for Perinatal Education (JPE), the Bearing Witness Series: Childbirth Stories Told By Doulas, and the sequel book Joyful Birth: More Childbirth Stories Told By Doulas.Married for 16 years and the homeschool mother of two teenagers, Melissa, values education and a life-long pursuit of learning. Her teaching style is comfortable, fun, and interactive, with an emphasis on leading the learner to have their own “light bulb” moments. As a childbirth educator and doula, Melissa most enjoys watching women become empowered to listen to their inner voice and acknowledge their own strength to birth.  Mentorship and education are both her passions, and Melissa is dedicated to fulfilling those passions by actively facilitating childbirth education classes as well as training and mentoring new doulas regularly.  Melissa can be reached at Melissa@capitalcitydoulaservices.com

Babies, Childbirth Education, Newborns, Series: Welcoming All Families , , , , ,

Lamaze International Online Classes for Parents Expands Offerings!

November 11th, 2014 by avatar

Screen Shot 2014-11-10 at 5.16.54 PM

The Lamaze International Strategic Framework 2014-2017 that resulted from in-depth strategic planning meetings held earlier this year with the Board of Director and Lamaze Management resulted in many forward thinking, comprehensive and courageous goals, including plans to “innovate education and expand to the childbearing years” by:

  • reaching more women earlier and more frequently throughout childbearing years,
  • expanding delivery methods for online education (e.g., virtual classes, Facetime consults, and mobile apps), and
  • developing a strategy to broaden outreach at the electronic level and cultivate moms ‘up’ the ladder for more personalized services and training.

As part of fulfilling this mission, Lamaze International is pleased to announce that three online childbirth education classes are developed, online and open for business.  The first class to go live was ”Safe and Healthy Birth: Six Simple Steps,” a class designed to help families prepare for birth by presenting six simple practices shown to greatly improve birth outcomes for both mothers and babies. The next two were recently added – VBAC: Informed and Ready and Breastfeeding Basics: From Birth to Back to Work.

The online classes are presented in an interactive, engaging format with unlimited access for parents, so they can complete the class(es) at their own pace. The classes are meant to be used as an important beginning point in a families’ complete prenatal education. They provide vital information, and throughout the online course, families are encouraged to find a comprehensive in person Lamaze class in order receive a thorough preparation for childbirth. Parents are informed that to be fully prepared for labor, birth, breastfeeding, and postpartum, it’s important to attend a good quality childbirth course. There are links to the “Find a Lamaze Class” portion of the parent website.

The online classes can be accessed on a computer (desktop or laptop), tablet or smartphone and learning can take place at a convenient time and place for each individual family.  There are interactive activities and discussion forums to connect with other participating families.  Fun quizzes are spaced throughout the course to help with the retention of information.

Safe and Healthy Birth: Six Simple Steps

Knowledge is power! It’s our goal to help you prepare for one of the most important days of your life – baby’s birthday! This course presents six simple practices that research has shown to greatly improve birth outcomes for both mothers and babies. These practices have been developed by Lamaze International and are based on recommendations by the World Health Organization. Lamaze has simplified the scientific facts into six healthy birth practices to make it easy for you to choose the safest care, understand your options, and steer clear of care practices or unnecessary interventions that may not be the best for you and your baby.

After completing this course, learners will be able to:

  • Discover how the Lamaze Six Healthy Birth Practices can simplify your labor and birth
  • Find out how your care provider and support team can make a difference
  • Learn about common medical interventions
  • Alleviate fears and learn ways to manage pain
  • Build your knowledge and confidence to make informed decisions

Breastfeeding Basics: From Birth to Back to Work

As comforting and healthy as breastfeeding can be, it is not always easy in the first few weeks while recovering from birth. If you find yourself struggling, know that hard work in the early weeks pays off as you and your baby learn to breastfeed. Having realistic expectations about how breastfeeding will go in the early weeks will help you to meet your breastfeeding goals. With the information in this class, you can prepare to get breastfeeding off to a great start and look forward to the many benefits that breastfeeding can provide to you and your baby.

After complete this class, learners will be able to:

  • Recognize the Benefits of Breastfeeding to Mother and Baby
  • Understand how milk supply works
  • Learn about the mechanics of breastfeeding, latch and positioning
  • Recognize good feeding and if baby is getting enough milk
  • Manage nighttime breastfeeding
  • Be prepared for what to do if there is a recommendation to supplement/pump
  • Prepare for returning to work

VBAC: Informed and Ready

This class will help you understand the facts, benefits, and risks of all your delivery options including a vaginal birth after cesarean (VBAC), and set you up for the best chance of success. Prepare yourself and learn how to simplify your labor and birth by participating in this interactive online course.

After completing this class, learners will be able to:

  • Understand the risks and benefits of both VBAC and repeat cesarean birth
  • Recognize the qualities of a VBAC supportive health care provider
  • Identify a strong support team for your  VBAC birth
  • Develop and practice coping and comfort techniques that will help during your VBAC labor
  • Write a VBAC and cesarean birth plan that reflects your informed preferences

International Cesarean Awareness Network (ICAN) has collaborated with Lamaze International to offer all ICAN members a 15% discount on the VBAC class, to help them feel better prepared as they plan for their subsequent birth after a cesarean.  To learn more about ICAN and become a member, in order to take advantage of this discount, follow the link to the “Join ICAN page.”

Additional courses planned include “Labor Pain Management: Techniques for Comfort and Coping” -scheduled to go live next month and an early pregnancy class in the early part of 2015.

Offering online classes serves to increase name recognition of the Lamaze International brand and create demand for in person Lamaze classes offered by LCCEs around the world.  Programs like this position Lamaze as the leader in childbirth education. Additionally, families that do not have Lamaze educators in their community can take advantage of the evidence based information and skills offered in the classes.  Educators can follow the class links above and sample all of the courses in a preview segment.

Breastfeeding, Cesarean Birth, Childbirth Education, Healthy Birth Practices, Lamaze International, Pain Management , , , , , ,

Ebola, Fearbola, and the Childbirth Educator

November 6th, 2014 by avatar

By Rebecca Dekker, PhD, RN, APRN

ebola infographic cc cdcMany news outlets and social media venues have been disseminating information on the Ebola virus and the impact on populations both in West Africa as well as the potential impact on developed nations, including the USA.  The expectant families that you work with may have shared concerns for themselves, their children and their unborn baby with you?  How have you responded?  Did you feel like you had the information that you needed to provide them with facts to calm their concerns?  Occaisonal contributor Rebecca Dekker of EvidenceBasedBirth.com takes a look at the facts about the Ebola virus and shares resources and information applicable to pregnant and breastfeeding families that you can share. – Sharon Muza, Community Manager, Science & Sensibility

What’s the childbirth educator got to fear about Ebola? How do you address your students and clients’ fears?

Well, if you live in the U.S. or in any other country other than Africa—right now, there’s really not much to actually fear. That is, if you’re only worried about yourself and your own community.

The truth is, here in the U.S., there are so many more things that are more likely to kill you than Ebola—other infectious diseases such as influenza, motor vehicle accidents, smoking, secondhand smoke exposure, cardiovascular disease, cancer, even radon—an odorless, colorless gas that exists in many of our homes in the Southeast and can cause lung cancer—you name it, and it’s probably more likely to harm you than Ebola.

So why all the fear here in the U.S.? 

Ebola is a rare but deadly disease, and it has been ravaging West Africa. In developed countries, we feel fear because cases of the disease have finally reached our own shores, when in fact we should have paid attention much sooner to what is happening to our brothers and sisters in Liberia, Guinea, and Sierra Leone.

Does all this fear of Ebola do any good?

Personally, I believe that the fact that so much attention has been drawn to Ebola in developed countries may be a good thing. Fear here means that our governments have finally begun to put energy and resources into stopping the epidemic in Africa– not necessarily for humanitarian reasons– but to prevent the spread of this disease to us.

The Ebola epidemic that has affected parts of West Africa has been a fast-moving event that is only just now showing signs of slowing down. Researchers have conclusive evidence that this is the largest, most severe and most complex Ebola epidemic that we have witnessed since Ebola was first discovered nearly 40 years ago. The number of cases and deaths in this epidemic is many times larger than all past Ebola outbreaks combined.

Before the current epidemic, the Ebola virus had mostly been contained to small outbreaks in rural communities. This time, all of the capital cities in in Liberia, Guinea, and Sierra Leone have experienced large outbreaks.

For the first time, Ebola has entered communities like West Point, in Monrovia, Liberia. According to the World Health Organization, “West Point is West Africa’s largest and most notorious slum: more than 70,000 people crowded together on a peninsula, with no running water, sanitation or garbage collection. The number of Ebola deaths in that slum will likely never be known, as bodies have simply been thrown into the two nearby rivers.”

Ebola has been especially hard-hitting on health care workers. Health workers on the front lines are often exposed to very infectious bodily fluids—blood, vomit, and diarrhea. The fact that health care workers can be at high risk for catching and dying from Ebola was first discovered during the very first Ebola outbreaks that took place in Zaire and Sudan in 1978. Fortunately, researchers have found that proper use and training with personal protective equipment can drastically lower health care workers’ chances of catching the virus. It’s probable that the cases we saw in the U.S. among nurses were due to improper training, inadequate protection equipment, or both.

Interestingly, Ebola actually isn’t as contagious as many other infectious diseases. Measles is an airborne disease, and it is highly contagious. Someone with measles can walk through a room, and another person can walk through that same room two hours later and catch the same measles infection. For every one person who has measles and lives among an unvaccinated population, they will—on average—infect 18 more people.

© CDC

© CDC

In contrast, one person with Ebola infects two other people on average, usually people who have had close, prolonged contact with that person. And the research we have on humans so far shows that Ebola is not airborne—although there have been a few primate studies that suggested otherwise (but some researchers think that maybe the monkeys were spitting on each other!)

One reason Ebola has spread so widely in West Africa – in spite of the fact that this virus is relatively hard to catch compared to other infectious diseases—is that the countries affected are extremely poor. Many people lack running water and soap in their homes.

This means that in West Africa, if one family member comes down with Ebola, there’s a good chance that others in the home will become infected, especially if patients bleed and vomit profusely. Families without modern toilets and washing machines have trouble cleaning up after patients who lose control of their bowels and produce huge amounts of diarrhea. Even burying the dead can spread Ebola in these countries, because common burial rites involve washing the dead and preparing the bodies. However, news organizations are reporting that communities have begun adhering to recommendations to refrain from traditional burial practices that expose more people to the disease.

So, it makes sense that we would fear for our fellow humans in West Africa. They are experiencing what can only be described as a humanitarian crisis. What’s even more concerning is that the virus has—at least for now—crippled an already weak health care infrastructure. This has created what the World Health Organization calls, “an emergency within an emergency.” A great example of this is that pregnant women and infants cannot receive emergency care while resources are drained by the Ebola virus epidemic.

So why are some people panicking about Ebola in the U.S., where the chances of an infection are completely remote? How do we make sense of this?

Well, when it comes to understanding how people perceive risk, and why some people are panicking about Ebola in the U.S., it may be helpful to understand some basic scientific principles behind how people perceive risk.

First of all, risk is subjective. And emotions and our mood change how we interpret risk. So facts matter less when emotions take over.

Also, many people also have an inherent lack of trust in scientists and the government– both here in the U.S. and in West Africa. People often believe their own senses and own experiences more than what scientists say. Many people don’t really understand the scientific process, and have doubts about what they hear. They confuse the research evidence on Ebola with the legal system, and they think there is lots of room for reasonable doubt about whether or not Ebola is airborne, for example.

Also, it’s really important to understand that people perceive a higher risk from rare events with really severe outcomes than they do for common outcomes with less severe or delayed outcomes.

[Does this sound familiar? Just take that sentence above and think about the concept of VBAC and repeat Cesarean. Obstetricians perceive a higher risk from rare events with really severe outcomes—such as uterine rupture—than they do for common outcomes with less severe or delayed outcomes—such as serious maternal infections after a planned repeat Cesarean, or placental abnormalities in future pregnancies].

People also tend to worry more over things that we can’t control. We can control our driving, and getting a flu vaccine, and our diet, and cigarette smoking. But we can’t control Ebola, so that scares us more.

So when we bring fear and emotion into the mix, people’s risk perceptions can end up looking like they do for some people in the U.S. right now– paranoia about Ebola.

It is unfortunate that we have overblown fears of contracting Ebola in the U.S., but if we could redirect our thoughts and channel our efforts into containing the outbreak in West Africa, this is where we will make the biggest difference.

So, in summary:

  • Ebola is a rare but deadly viral infection
  • We are currently witnessing the largest Ebola outbreak in history.
  • The chances of any one of us contracting the virus in the U.S. are extremely remote
  • Fear of Ebola will hopefully trigger people in developed countries to reach out to our fellow humans in West Africa and help them fight the virus

Items of interest related to childbirth and breastfeeding

How can we help?

If you’re worried about Ebola, don’t panic but do put your concern into action. Many health and relief organizations in West Africa are in need of resources, and you can help. This blog article has a comprehensive list of charities working in West Africa right now.

Have your clients and students asked you about Ebola?  Have they expressed concern for themselves or their baby?  Have families discussed the fear of entering the hospital to birth, due to their perceived risk of the hospital as being a potential source of exposure to the Ebola virus?  Hopefully after reading this blog post by Rebecca, you can help provide the facts.  You can also direct them to the Evidence Based Birth online class “Ebola, Fearbola: Separating Facts from Paranoia” and the About.com article “Five Things Pregnant Women Need to Know about Ebola” written by Robin E. Weiss. The Centers for Disease Control and Prevention also provides a wealth of information that you can access and share with the families you work with. – SM

About Rebecca Dekker

Rebecca Dekker

Rebecca Dekker

Rebecca Dekker, PhD, RN, APRN, is the founder of Evidence Based Birth and teaches pathophysiology at a research university. She has taught continuing education classes on HIV and recently developed an in-depth class on the pathophysiology and epidemiology of Ebola (2 nursing contact hours). To learn about how Ebola is transmitted, prevented, diagnosed, and treated, check out Rebecca’s class on “Ebola or Fearbola? Separating Facts from Paranoia,” here.

Childbirth Education, Continuing Education, Evidence Based Medicine, Guest Posts, Maternal Mortality, Maternity Care, Newborns, Research , , , ,

October is SIDS Awareness Month – Educators Can Share Information to Help Families Reduce Risk!

October 28th, 2014 by avatar

Safe to Sleep®SIDS PreventionOctober has been designated as a time to observe some solemn occasions that may affect families during pregnancy, birth and postpartum.  This month, Science & Sensibility has previously covered Pregnancy and Infant Loss Awareness Month in two previous posts here and here.  Today I would like to recognize that October is also SIDS Awareness Month.

As childbirth educators, part of our curriculum for expecting parents includes discussing SIDS, providing an explanation of what it is (and what it isn’t)  and how to reduce the risk of a SIDS death.

What is SIDS?

Sudden Infant Death Syndrome (SIDS) is defined as the sudden death of an infant less than 1 year of age that cannot be explained after a thorough investigation is conducted that includes a complete autopsy, examination of the death scene, and a review of the medical history. SIDS is the leading cause of death for infants aged 1 to 12 months in the United States.  About 2000 infants die every year in the USA from SIDS. African American and American Indian/Alaskan Native babies are twice as likely to die of SIDS as white babies.

Most SIDS deaths occur in babies between 1 month and 4 months of age, and the majority (90%) of SIDS deaths occur before a baby reaches 6 months of age. However SIDS deaths can occur anytime during a baby’s first year. Slightly more boys die of SIDS than girls.

Since the USA introduced the Safe to Sleep® campaign (formerly known as the Back to Sleep Campaign) in 1994, the number of infants dying of SIDS has dropped by 50%.

What SIDS is not

  • SIDS is not suffocation nor is it caused by suffocation
  • Vaccines and immunizations do not cause SIDS
  • SIDS is not a result of choking or vomiting
  • SIDS is not caused by neglect or child abuse
  • SIDS is not contagious
  • SIDS is not caused by strangulation

What causes SIDS?

While the cause of SIDS is not known, there is more and more evidence that infants who die from SIDS have brain abnormalities that interfere with how the brain communicates with the parts of the nervous system that control breathing, heart rate, blood pressure, waking from sleep, temperature and other things.  More information on what researchers are finding as they work to identify the cause of SIDS can be found here.

What are the risk factors for SIDS?

There are several risk factors that put babies at higher risk of SIDS.  Childbirth educators should be providing this information to families during class. These risk factors include:

  • Being put to sleep on their stomachs
  • Being put to sleep on couches, chairs, or other soft surfaces or under soft coverings
  • Being too hot during sleep
  • Being put to sleep on or under soft or loose bedding
  • Being exposed to smoke in utero, or second hand cigarette smoke in the home or car, or the second hand smoke of care-givers or family.
  • Sleeping in an adult bed with parents, other children or pets especially if:
    • Bed-sharing with an adult who smokes, recently had alcohol or is tired
    • Sleeping with more than one bed sharer
    • Covered by a blanket or a quilt
    • Younger than 14 weeks of age

NOTE: If families in your classes are going to be bed-sharing with their infants, (which sometimes is the reality for new parents getting accustomed to life with baby) it is important for you to provide information about what safe bed sharing looks like.  I recommend “Sharing Sleep with Your Baby” by Robin Elise Weiss for resources to share on this topic.

What reduces the risks of SIDS?

New parents can do many things to reduce the risk of their infant dying from SIDS.  You can share this information with your classes.   These risk reductions include:

  • Always place a baby to sleep on his/her back
  • Have the baby sleep on a firm sleep surface (Not a carseat, bouncy seat or swing as your baby’s normal sleep spot.)
  • No crib bumpers, toys, soft objects, or sleep positioning products (even if they claim to reduce the risk of SIDS) in the baby’s sleep space
  • Breastfeed the baby
  • Room sharing with the baby
  • Have regular prenatal care during pregnancy
  • Mothers who refrain from smoking, drinking alcohol or using illicit drugs during pregnancy and after the baby is born
  • Do not allow second hand smoke around the baby or have caregivers or family members who smoke around the baby
  • Once breastfeeding and milk supply is firmly established and baby is gaining weight appropriately, offer a pacifier (not on a string) when baby goes down for their last sleep.
  • Do not overdress the baby for bed or overheat the room
  • Maintain all the healthy baby checkups and vaccines as recommended by the baby’s health care provider
  • Do not use home breathing monitors or heart monitors that claim to reduce the risk of SIDS.

Talking about difficult topics in a childbirth class can be hard for both the eductor and the families.  No one wants to think that the unthinkable might happen to them.  But sharing accurate facts about the risks and how to reduce those risks is an important part of any childbirth curriculum.  How and when do you discuss this topic in your classes?  Do you have a video or handout that you like to share?  Please let us know in the comments section, how you effectively cover SIDS topics in your childbirth classes.

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Babies, Breastfeeding, Childbirth Education, Newborns , , , , ,

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

October 23rd, 2014 by avatar

By Henci Goer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

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

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About Henci Goer

Henci Goer

Henci Goer

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

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