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Peanut Balls for Labor – A Valuable Tool for Promoting Progress?

April 8th, 2014 by avatar

 Today, Andrea Lythgoe, LCCE and doula, takes a look at the peanut ball as a tool for promoting labor progress for women resting in bed or with an epidural.  Many more facilities are making this new tool available to laboring women. Childbirth educators will benefit by understanding how to teach peanut ball use to families in the classroom and those professionals who attend births will want to know about the benefits and proper usage as well. Andrea shares the research that is available along with the personal perspectives of those who have used them firsthand. – Sharon Muza, Science & Sensibility Community Manager.

PeanutBall-measure

Most experienced peanut ball users recommend either the 45 cm or 55 cm sized peanut ball. The size is measured from the floor to the tallest point on one of the larger ends. Because it will be used between the legs to open up the pelvic outlet, you don’t want it to be as large as the balls that are used for sitting and swaying. As I learned about the peanut ball, I found that many moms who did not like the peanut ball in labor felt it was too big. For this reason, I chose to purchase and use the 45 cm sized ball, which is the size used in the photos that accompany this article.

The peanut ball is most commonly used when mom needs to remain in the bed, whether because of epidural use, complications, or simply because mom is exhausted. There are two main ways in which peanut balls are used, with plenty of room for variation. The first is with mom in a semi reclined position, one leg over the ball, one leg to the side of the ball. The ball is pushed as close to mom’s hips as is comfortable. As the ball can have a tendency to slide away from the mom, a rolled up towel can be used to hold it in place. This position seems to be most commonly used to promote dilation and descent with a well-positioned baby.

The second common use is with mom in a side-lying or semi-prone position, with the peanut ball being used to lift the upper leg and open the pelvic outlet. The ball can be angled so that the leg hooks around the narrower part, or aligned with both mom’s knee and ankle resting on the ball. Mom’s comfort level is key to knowing the right placement. Most women who used this position used it to help rotate a posterior baby to a more favorable position for delivery.

PeanutBallCollage

© Maternal Focus

The Research

There is not much research out there on the use of the peanut ball. In my search, I found one study, presented as a poster presentation at the 2011 AWHONN Convention. Tussey and Botsois (2011) randomized 200 women (uncomplicated labor with an epidural) into two groups. One group used the peanut ball in either the semi Fowler’s position (bottom photos) or the sidelying position (top photos), switching sides every 1-2 hours. The sample size was small, but the results were very promising. The first stage of labor was shorter by an average of 90 minutes, and second stage was roughly half as long (43.5 min in the control group, 21.3 min in the peanut ball group). The use of vacuum and forceps was also lower in the peanut ball group. There were no serious adverse events reported in the study. This looks very promising, and I will be watching for more studies on the peanut ball in future years.

Many have speculated that the more upright semi Fowler’s position might also be helpful in preventing the increase in operative deliveries seen with epidurals (Anim-Somuah (2011), but a recent Cochrane Review found insufficient evidence to demonstrate a clear effect. (Kemp, 2013) A similar review looking at the benefits of upright positions in moms without an epidural did show some benefit. (Gupta, 2012)

Since it is known that babies in an Occiput Posterior (OP) position can increase the length of second stage and the rate of operative delivery (Lieberman, 2013; Caseldine, 2013) the reports of posterior babies turning when the peanut ball is used may be a big reason for its effectiveness.

The Mother’s Experience

Jennifer Padilla, a mom who used the peanut ball in labor, described to me her experience with using the ball to rotate her posterior baby after 20 hours of labor. She had an epidural that did not take as well as she would have liked, and still found the peanut ball in the side lying position to be comfortable enough to take short naps. She said it took 1-2 hours with the peanut ball to rotate her baby, but that once the baby rotated to an anterior position, she was ready to push.

In preparing for this article, I read through over 30 online birth stories that included the peanut ball and noticed a few common themes:

Maternal Preferences and Positioning

Moms who were unmedicated preferred upright positions to the peanut ball nearly every time. Even when they used it and felt it was beneficial, the comments were not very positive. For example, one mom described it like this:

Being positioned on the peanut ball was excruciating, I couldn’t see straight and was howling in agony. I wanted to push it away and jump up but I could feel it working.

Moms with an epidural liked the peanut ball almost universally, except for a few instances where moms complained it “made their butt go numb” when using it in the semi-Fowler’s position. Some commented that it was difficult to sleep when needing to switch the ball from side to side. Most moms described switching every 1-2 hours, some as frequently as every 20 minutes. (Women with epidurals usually switch side to side with the same frequency, even without the epidural.) One mom felt that using it semi-prone made her feel “undignified” and she wished her nurse had kept her covered with a sheet while lying in the position.
Some birth stories described moms leaning over the peanut ball, straddling the peanut ball, or using it in the shower in some capacity, but the vast majority used the ball in a side lying or semi prone position, with the reclined semi Fowlers a distant second.

Epidural Experiences

None of the moms who had an epidural reported any troubles with the epidurals losing effectiveness on one side while using the peanut ball, though several nurses I spoke with expressed concern that this would be a problem. More than a few moms who had an epidural said that they asked to stop using the peanut ball because of pressure in their back that turned out to be complete dilation.

Effect on Labor Progress

A few moms reported some pretty dramatic results:

A Doula’s Perspective

I spoke with Heidi Thaden-Pierce, a doula and CBE in Denton, Texas. She has been using the peanut ball with her doula clients for a while now, and she says women are very receptive to the idea. Many of them have already discovered that sleeping on their sides with a stack of pillows between their knees is very comfortable. The peanut ball replicates this and doesn’t slip and slide around as much as a stack of pillows can.

In her experience, most unmedicated moms will get up and get active in other positions over using the peanut ball, but “if a mom is needing some rest then we’ll tuck her into bed with the peanut ball because it’s comfortable and helps keep things in good alignment.” She also will occasionally use it while mom is on the bed on all fours as a place to rest mom’s upper body that is not as high as a regular birth ball. This can be nice if mom is more comfortable with her hips slightly higher than her shoulders.

Whenever I bring the ball to a hospital birth, I do explain what it is to the nurse and ask if there is any reason we should not use it. If a mom needs to labor in a certain position or there are concerns with the baby then I want to make sure that the peanut ball isn’t going to be in the way. I think it’s important that the mom’s care team be aware of and comfortable with the use of the peanut ball, so I make sure we talk about it before we try it at the birth.

The L&D Nurse’s Perspective

Carly Trythall, a nurse at the University of Utah Hospital in Salt Lake City, has worked with the peanut ball for labor in two different hospitals in her career as a nurse. She has mostly used the ball in the side lying position for helping to shorten labor. She said that most of her patients have been “accepting and eager” to try the ball and find it very comfortable. She finds that the ball is “most beneficial for moms who are not able to change positions frequently and utilize gravity (i.e. women with epidurals).”

The peanut balls are new to University Hospital; Carly was integral to introducing their use there, and she continues to work to educate patients and nurses about the balls and their use. Some providers have expressed a little resistance to their use, thinking it wouldn’t be beneficial for moms, but as they have gained experience, that is changing.

The Childbirth Educator’s Perspective – Teaching With The Peanut Ball

Because the effects of the peanut ball seem to be most pronounced in moms who use epidural anesthesia, teaching it in conjunction with epidural use seems the most logical. I teach techniques and support for moms with epidurals just after we learn the mechanics of an epidural and the benefits and risks of an epidural. This is where I recently integrated teaching about the peanut ball into my classes. Because I have a limited number of balls to work with (one peanut ball and one elliptical shaped ball of similar proportions) I can’t have all the moms practicing with the ball at the same time. I break up the group into smaller groups of 2-3 moms and partners, and have the other groups working on other epidural support activities while each group has a chance to practice with the peanut. We allow enough time for every mom who wants to experience the 2 main positions with the peanut to try them. I warn them the week before to be sure they wear comfortable loose clothing that they will be able to freely move around in as we practice.
We practice with mom trying out both of the main uses of the ball:

  1. Semi-sitting position (Semi Fowler’s) with one leg over the birth ball and one leg open to the side. In the absence of a hospital bed in the classroom, I use a traditional birth ball or mom’s partner sitting against the wall for moms to recline against as we practice this position.
  2. Side lying or semi prone with the peanut ball between the legs. We experiment with different positions to find a variation that is comfortable, reminding the parents that what they like now may not be the one they like in labor.

We also brainstorm possible ways to do these positions in the event there is not a peanut ball available.

Carly Trythall said that, as a nurse, she wished that women were learning more about the peanut ball in their classes: “I would like for moms to be taught the benefits of using a peanut ball during labor such as assisting with fetal rotation and descent by widening and opening the pelvis (great for OP babies), shortening the active phase of labor (because baby is in a more optimal position) and shortening the pushing phase of labor.

Conclusion

While there remains much to be learned about the efficacy and circumstances in which the peanut ball might be most useful, the peanut ball appears to be a promising technique for laboring women, in particular those who have a posterior baby and/or need to remain in bed. Teaching this technique in your childbirth class can help women go back to their care providers and birth places informed about another option that is becoming more and more widely available.

Are you teaching about peanut balls in your childbirth classes?  Are you seeing the balls in use in your communities?  Have you had personal experiences either as a birthing mother or a professional with the peanut balls?  Please share your experiences and information in the comments below so we can all learn about this new labor tool to help promote vaginal birth.- SM

To learn more about peanut balls:

http://betterbirthdoula.org/peanut-ball-and-epidurals-tips-for-doulas/

http://www.cappa.net/documents/Articles/Peanut%20Ball.pdf

My thanks to the University of Utah Labor and Delivery unit for the use of their room for the photos included in this article.

References

Anim-Somuah M, Smyth RMD, Jones L. (2011) Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews, Issue 12. Art. No.: CD000331. DOI: 10.1002/14651858.CD000331.pub3

Carseldine, W. J., Phipps, H., Zawada, S. F., Campbell, N. T., Ludlow, J. P., Krishnan, S. Y. and De Vries, B. S. (2013), Does occiput posterior position in the second stage of labour increase the operative delivery rate?. Australian and New Zealand Journal of Obstetrics and Gynaecology, 53: 265–270. doi: 10.1111/ajo.12041

Gupta JK, Hofmeyr GJ, Shehmar M. (2012) Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 5. Art. No.: CD002006. DOI: 10.1002/14651858.CD002006.pub3

Kemp E, Kingswood CJ, Kibuka M, Thornton JG. (2013) Position in the second stage of labour for women with epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 1. Art. No.: CD008070. DOI: 10.1002/14651858.CD008070.pub2.

Lawrence A, Lewis L, Hofmeyr GJ, Styles C. (2013) Maternal positions and mobility during first stage labour. Cochrane Database of Systematic Reviews, Issue 10. Art. No.: CD003934. DOI: 10.1002/14651858.CD003934.pub4.

Lieberman, E, Davidson, K, Lee-Parritz, A, Shearer, E (2005) Changes in Fetal Position During Labor and Their Association With Epidural Analgesia. Obstetrics & Gynecology. 105(5, Part 1):974-982.

Overcoming the Challenges: Maternal Movement and Positioning to Facilitate Labor Progress.
Zwelling, Elaine PHD, RN, LCCE, FACCE
[Article] MCN, American Journal of Maternal Child Nursing. 35(2):72-78, March/April 2010.

Childbirth Education, Guest Posts, New Research, Research, Uncategorized , , , , , ,

Does Epidural Analgesia Predispose to Persistent Occiput Posterior?

February 14th, 2013 by avatar

Photo by Patti Ramos Photography

In my January Science and Sensibility blog post, I answered the question “Can We Prevent Persistent Occiput Posterior?” but because it wasn’t relevant to the study that prompted the post, and the piece was already long, I didn’t look at the role of epidural analgesia. Let me now rectify that.

All five studies examining the relationship between epidural analgesia and persistent occiput posterior (OP) find an association between them. Three studies compared women with an epidural versus no epidural according to whether they had an OP baby at delivery and found that 4 to 10 more women per 100 having an epidural had an OP baby at delivery (Cheng, 2006; Lieberman, 2005; Sizer, 2000). The other two compared women with an OP baby at delivery according to whether they had an epidural and found that 13 and 27 more women per 100 with a persistent OP baby had an epidural (Fitzpatrick, 2001; Ponkey, 2003).

Their results, however, aren’t sufficient to convict epidurals because we can’t tell whether having an epidural led to persistent OP or more painful and prolonged OP labor led to having an epidural. Investigators in one of the five studies argued for OP labor coming first on the grounds that while epidurals were more common in women with an OP baby at delivery than in women with an OA baby at delivery (74% vs. 47%) at their institution, a rise in epidural use from 3% in 1975 to 47% in 1998 had, if anything, decreased the hospital’s overall rate of persistent OP (4% vs. 2%) (Fitzpatrick, 2001). This must mean that as epidurals became more freely available, women having difficult OP labors were more likely to opt for one. Epidurals were the result, not the cause, of persistent OP. On the other hand, we have some corroborating evidence for their guilt. For one thing, back pain is thought to be a major reason why women with OP babies are more likely to want epidurals, but it turns out that back pain isn’t unique to OP. Serial sonograms reveal that virtually identical percentages of women laboring with an OA baby report back pain (Lieberman, 2005). For another, three of the five studies took into account other factors associated with difficult labor such as labor induction, labor augmentation, and birth weight and still found that epidurals were an independent risk factor for persistent OP (Cheng, 2006; Lieberman, 2005; Sizer, 2000).

Nevertheless, evidence from observational studies isn’t strong enough to close the case. As I noted, observational studies can determine association but not causation. In addition, investigators may not be able to identify all the confounding and correlating factors that affect outcomes. For a more definitive answer, we need experimental studies. This brings us to randomized controlled trials (RCTs), in which participants are randomly allocated to one form of treatment or the other, and to meta-analysis of RCTs, in which statistical techniques are used to pool data from more than one trial.

The Cochrane systematic review of epidural versus no epidural in labor pools data from four RCTs (673 women overall) that reported on persistent OP (Anim-Somuah, 2011). Five more women per 100 assigned to the epidural group had a persistent OP baby, but meta-analysis found that the difference just missed achieving statistical significance. The risk ratio was 1.4, meaning a 40% increased risk of persistent OP in women assigned to the epidural group compared with women assigned to the no-epidural group, but the 95% confidence interval ranged from 1.0 to 2.0, meaning a 95% probability that the true value lies between no increase (ratio of 1:1) and double the risk (2.0). However, a problem with the RCTs of epidural versus no epidural is that substantial percentages of women assigned to the no-epidural group actually had epidurals, but, as is prescribed in RCT data analysis, they were kept in their original group. In two of the four trials (204 women), though, 10% or less of women assigned to the no-epidural group had epidurals. If we calculate the excess rate of persistent OP in these two trials, we find that the gap widens to 9 more women per 100 with epidurals having a persistent OP baby. We don’t know whether this difference would achieve statistical significance, but the fact that the excess is in the same range as reported in the observational studies (4 to 10 more per 100) gives confidence in its validity.

Patti Ramos Photography

We also have two studies that suggest that the timing of the epidural may matter. One, of 320 women, reports that, after controlling for age, induction of labor, and birth weight, initiating an epidural at fetal station less than zero (above the ischial spines) resulted in 16 more women having a persistent OP or occiput transverse (OT) baby compared with initiation at 0 station or greater (at or lower than the ischial spines), an excess that rose to 20 more per 100 in first time mothers (Robinson, 1996). The other study analyzed outcomes in 500 first-time mothers according to whether an epidural was administered early (at or before 5 cm dilation), late (after 5 cm dilation), or not at all (Thorp, 1991). Seventeen more women per 100 in the early group had a persistent OP or OT baby compared with women in the late-epidural group, and 12 more had a persistent OP or OT baby compared with the no-epidural group, but rates were similar in women in the late and no epidural groups.

Taken all together, we may not have absolute proof of epidural culpability in predisposing to OP, but if I were on the jury, I would vote them “guilty as charged.”

Take home: Even without certainty, the precautionary principle dictates recommending to women desiring an epidural that they use other measures to cope with labor pain until they enter active labor and until it seems clear that positioning and activities are not putting a slow labor on track.

What do you tell your clients, students and patients about the impact on fetal positioning in labor and birth?  Will having this information change what you say?  Let us know in the comments section.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews(12), CD000331.

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. Journal of Maternal Fetal and Neonatal Medicine, 19(9), 563-568.

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstetrics and Gynecology, 98(6), 1027-1031.

Lieberman, E., Davidson, K., Lee-Parritz, A., & Shearer, E. (2005). Changes in fetal position during labor and their association with epidural analgesia. Obstetrics and Gynecology, 105(5 Pt 1), 974-982.

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstetrics and Gynecology, 101(5 Pt 1), 915-920. 

Robinson, C. A., Macones, G. A., Roth, N. W., & Morgan, M. A. (1996). Does station of the fetal head at epidural placement affect the position of the fetal vertex at delivery? American Journal of Obstetrics and Gynecology, 175(4 Pt 1), 991-994.

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstetrics and Gynecology, 96(5 Pt 1), 749-752.

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. American Journal of Perinatology, 8(6), 402-410.

Childbirth Education, Epidural Analgesia, Evidence Based Medicine, Guest Posts, informed Consent, Medical Interventions, Pain Management, Research , , , , , , ,

It Takes a Professional Village! A Study Looks At Collaborative Interdisciplinary Maternity Care Programs on Perinatal Outcomes

September 19th, 2012 by avatar

The  Canadian Medical Association Journal, published in their September 12, 2012 issue a very interesting study examining how a team approach to maternity care might improve maternal and neonat aloutcomes.  The study, Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes  is reviewed here.

The Challenge

Photo Source: http://www.flickr.com/photos/jstownsley/28337593/

The number of physicians in Canada who provide obstetric care has declined in past years for reasons that include increasing physician retirement, closure of rural hospitals, liability concerns, dissatisfaction with the lifestyle and a difficulty in accessing maternity care in a variety of settings.  While registered midwife attended births may be on the rise, midwives in Canada attend less than 10% of all births nationwide.   At the same time as the number of doctors willing or able to attend births decline, cesarean rates are on the rise,  causing pressure on the maternity care system, including longer hospital stays both intrapartum and postpartum, which brings with it the associated costs and resources needed to accommodate this increase.

The diversity of the population having babies in many provinces is increasing, presenting additional challenges in meeting the non-French/English speaking population, who are more at risk for increased obstetrical interventions and are less likely to breastfeed.

The Study

In response to these challenges, the South Community Birth Program was established to provide care from a consortium of providers, including family practice physicians, community health nurses, doulas, midwives and others, who would work together to serve the multiethnic, low income communities that may be most at risk for interventions and surgery.

The retrospective cohort study examined outcomes between two matched groups of healthy women receiving maternity care in an ethically diverse region of South Vancouver, BC, Canada that has upwards of 45% immigrant families, 18% of them arriving in Canada in the past 5 years.  One group participated in the South Community Birth Program and the other received standard care in community based practices.

The South Community Birth Program offers maternity care in a team-based shared-care model, with the family practice doctors, midwives, nurses and doulas working together .  Women could be referred to the program by the health care provider or self refer.  After a few initial standard obstetrical appointments with a family practice doctor or midwife occur to determine medical history, physical examination, genetic history, necessary labs and other prenatal testing, the women and their partners are invited to join group prenatal care, based on the Centering Pregnancy Model.  Approximately 20% of the first time mothers choose to remain in the traditional obstetric care model.  10-12  families are grouped by their expected due date, and meet for 10 scheduled sessions, facilitated by either a family physician or midwife and a community nurse.  Each session has a carefully designed curriculum that covers nutrition, exercise, labor, birth and newborn care, among other topics.  Monthly meetings to discuss individual situations and access to comprehensive electronic medical records enhanced the collaboration between the team. Trained doulas, who speak 25 different languages, also meet with the family once prenatally and provide one on one continuous labor support during labor and birth. The admitting midwife or physician remains in the hospital during the patient’s labor and attends the birth.

After a hospital stay of 24-48 hours, the family receives a home visit from a family practice physician or midwife the day after discharge. Clinic breastfeeding and postpartum support is provided by a Master’s level clinical nurse specialist who is also a board certified lactation consultant.  At six weeks, the mother is discharged back to her physician, and a weekly drop in clinic is offered through 6 months postpartum.

The outcomes of the women in the South Community Birth Program were compared to women who received standard care from their midwives or family practice physicians.  Similar cohorts were established of women carrying a single baby of like ages, parity, and geographic region, and all the mothers were considered low risk and of normal body mass index.

The primary outcome measured was the proportion of women who underwent cesarean delivery.  The secondary outcomes measured were obstetrical interventions and maternal outcomes (method of fetal assessment during labor, use of analgesia during labor, augmentation or induction of labor, length of labor, perineal tramau, blood transfusion and length of stay) and neonatal outcomes (stillbirth, death before discharge, Apgar score less than 7, preterm delivery, small or large for gestational age, length of hospital stay, readmission, admission to neonatal intensive care unit for more than 24 hours and method of feeding at discharge).

Results

There was more incidence of diabetes and previous cesareans in the comparison group but the level of alcohol and substance use was the same in both groups.  Midwives delivered 41.9% of the babies in the birth program and 7.4% of babies in the comparison group.

When the rate of cesarean delivery was examined for both nullips and multips, the birth group women were at significantly reduced risk of cesarean delivery and were not at increased risk of assisted vaginal delivery with forceps or vacuum.

Interestingly, the birth program women who received care from an obstetrician were significantly more likely to have a cesarean than those receiving in the standard program who also received care from an obstetrician.  More women in the birth program with a prior cesarean delivery planned a vaginal birth in this pregnancy, though the proportion of successful vaginal births after cesareans dd not differ between the two groups.

The women in the community birth program experienced more intermittent auscultation vs electronic fetal monitoring and were more likely to use nitrous oxide and oxygen alone for pain relief and less likely to use epidural analgesia (Table 3).  Though indications for inductions did not differ, the birth program women were less likely to be induced.  More third degree perineal tears were observed in the birth program group but less episiotomies were performed.  Hospital stays were shorter for both mothers and newborns in the community program.

When you look at the newborns in the birth program, they were at marginally increased risk of being large for gestational age and were readmitted to the hospital in the first 28 days after birth at a higher rate, the majority of readmissions in the community and standard care group were due to jaundice. Exclusive breastfeeding in the birth program group was higher than in the standard group.

Discussion

The mothers and the babies in the community birth program were offered collaborative, multidisciplinary, community based care and this resulted in a lower cesarean rate, shorter hospital stays, experienced less interventions and they left the hospital more likely to be exclusively breastfeeding. Many of the outcomes observed in this study, especially for the families participating in the South Birth Community Program are in line with Lamaze International’s Healthy Birth Practices.  There are many questions that can be raised, and some of them are are discussed by the authors.

Was it the collaborative care from an interdisciplinary team result in better outcomes?  Was there a self-selection by the women themselves for the low intervention route that resulted in the observed differences?  Are the care providers themselves who are more likely to support normal birth self-selecting to work in the community birth program? Did the fact that the geographic area of the study had been underserved by maternity providers before the study play a role in the outcomes? Did the emotional and social support provided by the prenatal and postpartum group meetings facilitate a more informed or engaged group of families?

I also wonder how childbirth educators, added to such a model program, might also offer opportunity to reduce interventions and improve outcomes  Could childbirth educators in your community partner with other maternity care providers to work collaboratively to meet the perinatal needs of expectant families?  Would bringing health care providers interested in supporting physiologic birth in to share their knowledge in YOUR classrooms help to create an environment where families felt supported by an entire skilled team of people helping them to achieve better outcomes.

Would this model be financially and logistically replicable in other underserved communities and help to alleviate some of the concerns of a reduction in obstetrical providers and increased cesareans and interventions without improved maternal and newborn outcomes? And how can you, the childbirth educator, play a role?

References

Azad MB, Korzyrkyj AL. Perinatal programming of asthma: the role of the gut microbiota. Clin Dev Immunol 2012 Nov. 3 [Epub ahead of print].

Canadian Association of Midwives. Annual report 2011. Montréal (QC): The Association; 2011. Available: www .canadianmidwives.org /data/document /agm %202011 %20inal .pdf

Farine D, Gagnon R; Maternal Fetal Medicine Committee of the Society of Obstetricians and Gynaecologists of Canada. Are we facing a crisis in maternal fetal medicine in Canada? J Obstet Gynaecol Can 2008;30:598-9.

Getahun D, Oyelese Y, Hamisu M, et al. Previous cesarean delivery and risks of placenta previa and placental abruption.Obstet Gynecol 2006;107:771-8.

Giving birth in Canada: the costs. Ottawa (ON): Canadian Institute of Health Information; 2006.

Godwin M, Hodgetts G, Seguin R, et al. The Ontario Family Medicine Residents Cohort Study: factors affecting residents’ decisions to practise obstetrics. CMAJ 2002;166:179-84.

Hannah ME. Planned elective cesarean section: A reasonable choice for some women? CMAJ 2004;170:813-4.

Harris, S., Janssen, P., Saxell, L., Carty, E., MacRae, G., & Petersen, K. (2012). Effect of a collaborative interdisciplinary maternity care program on perinatal outcomes. Canadian Medical Association Journal, doi: DOI:10.1503 /cmaj.111753

Ontario Maternity Care Expert Panel. Maternity care in Ontario 2006: emerging crisis, emerging solutions: Ottawa (ON): Ontario Women’s Health Council, Ministry of Health and LongTerm Care; 2006.

Reid AJ, Carroll JC. Choosing to practise obstetrics. What factors influence family practice residents? Can Fam Physician 1991; 37:1859-67.

Thavagnanam S, Fleming J, Bromley A, et al. A meta-analysis of the association between cesarean section and childhood asthma. Clin Exp Allergy 2008;38:629-33.

 

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, Healthy Care Practices, Maternity Care, Medical Interventions, Midwifery, New Research, Research, Uncategorized , , , , , , , , , , , , , , ,

Pain Management for Women in Labor: A Research Review

April 11th, 2012 by avatar

As a childbirth professional or an expectant parent, do you wonder about the multitude of pain management techniques offered for childbirth?

As part of the Cochrane Collaboration, Leanne Jones and eight of her colleagues (2012) has published new research synthesizing divergent data constructs and summarizing 355 trials on pain management during childbirth. There are many detailed data tables associated with this study.

To view the entire study, Lamaze members can access the full Cochrane Library, via the Members Only Section.

A summary of the study is below.

Background

In 2007, the Cochrane Pregnancy & Childbirth Group (PCG) consumer’s group identified pain relief in childbirth as the topic of most importance to them.

This study was funded to provide an evidence-based summary of the efficacy and safety of pain management methods in childbirth for consumers, policy-makers, and childbirth educators.

Women experience pain in childbirth in varying degrees of intensity, influenced by physiological and psychosocial factors. Most women require some type of pain relief. Both non-pharmacological and pharmacological methods are used for pain management.

312 Studies Reviewed

Collecting the totality of evidence from existing randomized controlled trials, the researchers identified 18 total systematic reviews for inclusion in their study. 15 reviews were Cochrane reviews (257 included trials) and 3 were non-Cochrane reviews (55 included trials). Data from a total of 312 studies were reviewed in this study.

There were more studies of pharmacological interventions than non-pharmacological interventions.

13 Outcomes Identified for Inclusion

The researchers, in partnership with the PCG consumer group, identified these outcomes for inclusion in the study.

Effects of interventions

  • Pain intensity (as defined by trialists)
  • Satisfaction with pain relief (as defined by trialists)
  • Sense of control in labor (as defined by trialists)
  • Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

  • Effect (negative) on mother/baby interaction
  • Breastfeeding (at specified time points)
  • Assisted vaginal birth
  • Cesarean section
  • Adverse effects (for women & babies)
  • Admission to special care baby unit / NICU
  • Apgar score less than at five minutes
  • Poor infant outcomes at long-term follow-up (as defined by trialists)

15 Childbirth Management Methods Identified

The researchers identified a list of 15 childbirth pain management methods:

  • placebo/no treatment
  • hypnosis
  • biofeedback
  • intracutaneous or subcutaneous sterile water injection
  • immersion in water
  • aromatherapy
  • relaxation techniques (yoga, music, audio)
  • acupuncture or acupressure
  • massage, reflexology or manual methods
  • TENS
  • inhaled analgesia
  • opioid
  • non-opioid drugs
  • local anesthetic nerve blocks
  • epidural

 As a Lamaze childbirth educator, how will you incorporate respect for your client’s individual decisions while presenting the Six Lamaze Healthy Birth Practices?

Results: Non-pharmacological Studies

The authors found that non-pharmacological methods are mostly used in midwife-led continuity of care births and/or where women had continuous intrapartum support. Such non-pharmacological methods are meant to break the fear-pain-tension cycle and to work within the pain paradigm. The pain paradigm of birth is a philosophy based on the idea that pain is a normal part of the physiology of labor and that women can use coping methods to manage the pain (Leap, 2008; as cited in Jones et al, 2012).

The researchers found the evidence for many non-pharmacological methods to be mostly incomplete as there is an average of only two studies for each method.

However, the following non-pharmacological methods are shown to provide pain relief and positive maternal psychological outcomes without invasive side effects: immersion in water, relaxation, acupuncture/acupressure and massage.

In addition, women report greater emotional satisfaction with childbirth when using immersion and relaxation. With the use of relaxation and acupuncture/acupressure, there is a decrease in the use of forceps and ventouse. There is a decrease in the amount of cesarean section associated with the use of acupuncture/acupressure.

The researchers report there is insufficient evidence to report on pain relief using the following methods: hypnosis, biofeedback, sterile water injection, aromatherapy and TENS.

Results: Pharmacological Studies

There are more studies of pharmacological methods versus non-pharmacological methods. The authors found that pharmacological methods relieve pain and have side effects.

Pharmacological methods are most likely to be used in settings with a pain relief paradigm. In the pain relief paradigm of labor, pain is considered barbaric, the benefits of analgesia outweigh the risks, and women should be free to use whatever pain relief methods she wishes, without guilt (Leap, 2008; as cited in Jones et al, 2012).

Comparative Pain Relief & Side Effects

Epidural, combined spinal epidural (CSE) and inhaled nitrous oxide & oxygen relieve pain better when compared to opioids (Jones et al, 2012).

Epidurals are associated with an increase of the use of forceps or ventouse, an increase in the risk of low blood pressure, low motor blocks, fever and urine retention (Amin-Somanuh, 2005; as cited in Jones et al, 2012). In addition, other side effects such as shivering, tinnitus, and respiratory or cardiovascular depression may occur. The authors state it is uncertain whether the use of epidurals interfere with breastfeeding (Reynolds, 2011; as cited in Jones et al, 2012).

Combined spinal epidurals (CSE) provide faster pain relief than traditional epidurals, but are associated with more feelings of itchiness, giddiness, sweating, and tingling (Jones et al, 2012).

Inhaled nitrous oxide is associated with minimal toxicity and rapid maternal and neonate elimination, but can cause feelings of nausea, drowsiness and sickness (KNOV, 2009; Rosen, 2002; as cited in Jones et al, 2012).

Non-opioid drugs (acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS)) relieve pain for shorter periods of time as compared to opioid drugs (Bayarski, Hebbes, 200; as cited in Jones et al, 2012).

Opioid drugs (morphine, nalbuphine, fentanyl, parenteral and pethidine) are used worldwide. Parenteral opioids are reported to provide less pain relief than epidurals. Side-effects include impaired maternal capacity for decision-making, sedation, hypoventilation, hypotension and urine retention. Opioids readily cross the placenta, thus neonatal respiratory depression and hypothermia are also concerns. Pethidine is shown to affect fetal heart rate variability during labor (Sekhavat, 2009; Solt, 2002; as cited in Jones et al, 2012), thus continuous fetal monitoring is recommended. Neonatal effects are inhibited and early cessation of breastfeeding and decreased alertness (Nissen, 1995; Ransjo-Arvidsen, 2001; Righard, 1990; Rajan, 1994; as cited in Jones et al, 2012).

Limitations Found in the Studies

The authors state the studies use differing methods to measure pain management outcomes. Many do not at all measure maternal psychological outcomes (feelings of intrinsic self-control), mom-baby interaction, or breastfeeding and infant outcomes.

Conclusions

This study shows consumers rate pain management as a high priority in childbirth, however, after 30 years of research, standardized pain management and outcome measurements have not been created.

The authors suggest their outcome guidelines, developed with consumer input, be adopted for use in future research.

Overall, women should feel free to choose whatever methods of pain relief they wish, both non-pharmacological and pharmacological, for their individual childbirth experience.

As part of a childbirth preparation program, women should be informed of the efficacy and potential side-effects on both themselves and their babies of non-pharmacological and pharmacological methods of pain relief for childbirth.

Hopefully this study will generate an effort to standardize the constructs associated with research of measurements of pain management in labor, maternal psychosocial satisfaction, and maternal-baby outcomes.

References

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Babies, Cesarean Birth, Do No Harm, Epidural Analgesia, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, informed Consent, Medical Interventions, Midwifery, New Research, News about Pregnancy, Pain Management, Practice Guidelines, Research , , , , , , , , ,

Changes in Labor Patterns Over 50 Years – A Research Review

April 2nd, 2012 by avatar

New research was published in the American Journal of Obstetrics and Gynecology. Katherine Laughon, MD, and her colleagues, D. Ware Branch, M.D., Julie Beaver, M.S, and Jun Zhang, Ph.D., M.D., (2012) examined differences in childbirth labor patterns over the past fifty years, comparing data from a large study in the 1960′s with data from a large study in the 2000′s.

The researchers found differences both in maternal characteristics and obstetric practice patterns. In the contemporary cohort, the authors found an increase in first stage labor of over two hours and a cesarean section rate four times as high as in the past cohort. In the cohort from the 1960′s, a higher operative vaginal delivery rate was found as compared to the contemporary cohort. The authors link these differences to changes in obstetric practice patterns. The authors state that even after controlling for maternal and obstetrician characteristics, the increased length of labor result for the contemporary cohort persists (Laughon, Branch, Beaver and Zhang, 2012).

Positive Action Items for Moms and Childbirth Educators

The National Institute of Child Health and Human Development (NICHD)ran a conference call on March 31, 2012, where Katherine Laughon, MD, the lead researcher on the study, gavea brief overview of the study and answered questions. Robin Elise Weiss, LCCE, was on the call and summarized Dr. Laughon’s positive steps to take by women and childbirth educators who are interested in natural childbirth. Dr. Laughon’s suggestions fall into Lamaze’s Six Healthy Birth Practices.

  • These women might be comfortable waiting longer to get pitocin and other interventions, including cesareans.
  • Choose your practitioner carefully. Dr. Laughon suggests a practitioner should be able to think about the differences in labor patterns in modern times, not from textbooks.
  •  Remember there is not an ideal length of labor, long or short. It is based on the individual, woman to woman and baby to baby.

 As a Lamaze childbirth educator, do the results of this study surprise you?

What does this mean to you and the families you serve?

Below is a synopsis of the study methods, statistics and conclusions.

Study Design: Comparing Data from the 1960′s to Data from 2000′s

The researchers compared the data from the National Collaborative Perinatal Project (CPP) dating from 1959 – 1966 to the data from the Consortium on Safe Labor (CSL), dating from 2002- 2008. Data from a combined total of 137,850 women from the two studies were included in the 2012 study.

National Collaborative Perinatal Project (CPP) 1959-1966

The CPP (1959-1966) was a prospective study following 54,000 births to 44,000 women. Twelve university centers across the country enrolled pregnant women and collected data such as demographics, medical history, socioeconomic status, behaviors, blood samples, and information from regular physical exams, did interviews and gathered information from the senior obstetrician. The children were followed for seven years after birth. Laughon and her colleagues (2012) limited the use of the CPP data to only women known to be birthing for the first time. Thus, the 2012 study included data from 39,491 women from the CPP study.

Consortium on Safe Labor (CSL) 2002-2008

The CSL (2002 – 2008) was a retrospective cohort study of 228,668 births, with the majority of births (87%) occurring between 2005 and 2007. Information was examined from 12 clinical centers and 19 hospitals in 9 American College of Obstetrics and Gynecology (ACOG) districts. Data was extracted from both the electronically held maternal medical files and neonatal intensive care units. Data on demographics, medical history, maternal and neonatal outcome, and discharge disposition were extracted from the electronic files. Investigators at delivery sites collected information on obstetrician characteristics. Laughon and her colleagues (2012) limited their use of the CSL data to only those women in spontaneous labor with a single gestation. Thus, the 2012 study examined 98,359 women from the CSL study, inclusive of a total of 137,850 women from both the CPP and CSL dataset.

Results: Differences in Characteristics of the Women

Characteristics of the women, of their labors and of their newborns differed significantly between the earlier CPP and the contemporary CSL study.

Women in the CSL were older than in the CPP (26.8 years vs. 24.1), had a higher average BMI both pre-pregnancy (26.3 vs 24.1) and at delivery (29.9 vs 26.3), were more racially diverse, and delivered an average of 4.9 days earlier. Their babies weighed an average of 99 grams (3.48 ounces) more and Apgar scores were higher in the CLS than the CPP.

Results: Differences in Practice Patterns

Use of epidurals (55% vs. 12%), oxytocin (44% vs. 12%); and cesarean delivery (12% vs. 3%) was higher in the contemporary CSL cohort than the CPP. Cesarean delivery in the contemporary cohort is four times as high as in the 1960′s cohort.

Episiotomy (68% vs. 17%) and operative vaginal delivery (40% vs. 6%) were higher in the 1960′s CPP cohort than the contemporary CSL.

Results: First Stage – Differences in Length of Labor

For nulliparas, the first stage of labor (from 4 cm to completely dilated) was 2.6 hours longer in the contemporary cohort (CSL) than the former cohort (CPP).

For secundagravidas and multigravidas, the length of labor was, on average, 2.0 hours longer for the CSL cohort than the CPP cohort.

Results: Second Stage – Differences in Length of Labor

For nulliparas, in the second stage of labor, in the CLS cohort, there was a 10% operative vaginal delivery rate compared to 66% of the CPP cohort. Among women who spontaneously delivered, there was an increase of 27 minutes in the CSL group as compared to 13 minutes in the (CPP group.

Operative vaginal delivery, in secundagravidas and multigravidas, occurred in the CSL 4% and 2.5 % compared to 36% and 18% in the CPP. In secunagravidas and multigravidas, second stage labor did not have a clinically relevant difference in length of labor between the two groups.

Conclusion

The authors state firm conclusions merit further study.

In summary:

“…for women who presented in spontaneous labor at term, the duration of labor from 4 cm to 5 cm in multiparas to complete dilation and the 2nd stages of labor were longer in the contemporary population than a cohort from the 1960s. The overall median differences in the first stage of labor persisted after controlling for maternal and obstetric characteristics, indicating that modern labor differs from the older cohort largely due to changes in obstetric practices. Since labor times are longer today than in the past,the benefit of extensive interventions such as oxytocin and cesarean delivery in modern labor management needs further evaluation.”(Laughon, Branch, Beaver and Zhang, p. 14).

Hopefully this study will generate increased study of obstetric intervention patterns with an eye towards improved contemporary obstetric process management.

References

Laughon, S.K., Branch, D.W., Beaver, J., Zhang, J., Changes in labor patterns over 50 years, American Journal of Obstetrics and Gynecology (2012), doi: 10.1016/j.ajog.2012.03.003.

Many thanks to Robin Elise Weiss, LCCE, who graciously helped out with her reporting expertise on this post!

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Practice Guidelines, Research , , , , , ,