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A Tale of Two Cities from a Childbirth Educator’s Perspective

January 16th, 2014 by avatar

Today on Science & Sensibility, Laurie Levy, LMP, MA, CD(DONA, PALS), CBE, shares her experiences as a childbirth educator and doula recently relocated to a new state.  Her exposures to a new birth culture and method of doing things has taken her breath away, as she settles in to supporting families in her new home.  Learn more about Laurie’s experiences below.  Have you moved around the country and been surprised at the differences in practice you found?  Why do you think there is this difference?  Please discuss with us in the comments section. – Sharon Muza, Community Manager, Science & Sensibilityimage: http://screnews.com/greer/

hospital-signI moved from Seattle to Northern California this past September.  In Seattle, I was privileged to train and teach with leaders in the birth community for many years. Couple this with the 1998 passage of the WA Every Category of Health Care Provider Statute which compelled insurance agencies in WA state to cover licensed midwives and you can see why I would use the word ‘spoiled’ to describe my experience with birth in Seattle.

At a meeting with some of my new colleagues, I joked that I sound like I am saying, “And one time, at band camp…” when I talk about typical Seattle birth practices.  In the seven hospitals in the metro Seattle area, it was common to see moms moving about the halls with telemetry units.  Occasionally you would even see a woman out of bed and moving with an epidural in place. Vaginal exams were limited after the amniotic sac had ruptured. Babies were not routinely separated from their mothers.  The NICU came to the birth room if needed in most cases.  Mothers were encouraged to hand express colostrum to help a baby with unstable blood sugar. Babies were born directly on to their mother’s chest in some cesarean births. Hospitals competed for patient’s maternity care dollar offering ever improving birth suites with each remodel. Tubs, showers, mood lighting and comfortable spaces for partners to rest were expected in birth spaces. VBACs were encouraged. Mother-baby friendly hospitals were the rule not the exception.

Births in my new community

I recently attended my first series of births near my new home and, while these experiences are only a thumbnail of a much bigger picture, I found the differences in environment to be very stark indeed.  In fact, few of the practices I saw lined up with Lamaze International’s Six Healthy Birth Practices.  I am not a Pollyanna. I know that Archie Cochrane awarded obstetrics the “wooden spoon” in 1979 for being the least evidence based medical speciality.  I have talked with nurses from other states who tell stories about mothers being confined to bed after their water breaks for fear of a cord injury or other such superstitious practices. Still I was surprised at what I saw and have been thinking about the challenges that will face me here as I start teaching childbirth education in my new home.

My intent is not to malign any of the practitioners who I met.  In fact, I found that virtually every staff member that I observed wanted the best for their clients and were trying to make the best of a less-than-ideal situation. To protect confidentiality, I have combined information from several births and changed insignificant details, though I have not fictionalized any of the practices.

Healthy Birth Practice 1: Let labor begin on its own & Healthy Birth Practice 4: Avoid interventions that are not medically necessary

My client had some complications and I believe most practitioners would agree that the benefits of an induction outweighed the potential drawbacks. While I have no issue with that, I question why a provider would offer to break a mother’s amniotic sac when she was only 3cm and clearly not in labor.  There was no discussion of possible complications, no discussion that this practice sometimes slows labor or does nothing rather than speeds it up (Smith, et al 2013.)  AROM did nothing to progress my client’s labor and after 9 hours and 5 vaginal exams, she spiked a fever. This led to antibiotics, Tylenol and a spiral of other outcomes that I will address later.

Healthy Birth Practice 2: Walk, move around and change positions throughout labor

My client wanted to move around in labor but was being continuously monitored.  Her window-less room measured 10’ by 8’. She and her family spent a full 24 hours in this room. No one offered a telemetry unit which would allow her greater mobility and when she asked, was told that the L&D floor had one telemetry unit, but the cord to connect the device to the EFM machine was missing. My client requested to shower, and the only shower on the floor was down the hall, none of the rooms had their own.  Showers were also not allowed when Pitocin was being used.

Healthy Birth Practice 3: Bring a loved one, friend or doula for continuous support

I have to say on this point the facility did pretty well. Like most hospitals, they had a practice of only allowing one support person in the room when an epidural is being administered and during cesarean birth.  My client had her epidural reinserted repeatedly.  I was only asked to leave the room once and was allowed into the surgery after much pleading and crying by the mom.

Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push

My client was asked to do a “pushing trial” to see if the physician could reduce the anterior lip that seemed to be holding up progress.  She pushed on her back as that was the only position her provider was comfortable with and, as you will see below, she was unable to support herself in other positions.

After 24 hours, we did end up in a room that had its own toilet.  Few other rooms did.  None of the rooms had a tub and clients were not allowed to bring one in.  The standard was communal bathrooms for women in labor, one shower for the entire unit and no refrigerators anywhere to store patient food for use during labor.

It was my client’s intention to hold off on pain medications until after six centimeters (active labor.)  We were creative but a 24 inch movement radius, lack of access to a tub or shower and continuous pitocin led to an epidural earlier than planned. There were some complications with the block and it needed to be replaced several times, and the final medication level was so significant that the mother had absolutely no ability to move her legs on her own at at all.

Healthy Birth Practice 6: Keep mother and baby together – It’s best for mother, baby and breastfeeding

I already gave away the ending – this mother gave birth by cesarean section.  The operating suite was a fairly good size and I was allowed in the operating room as a doula.  Baby was born immediately yelling and pinking up.  Mom got to see her newborn over the blue screen but baby was immediately brought to the warmer.  I heard the pediatrician say “This baby looks so great I am going to leave!” Even with all of that, routine procedure was for baby to be recovered in a separate room.  Staff would give baby all of her injections, weigh and measure her and bathe the baby before returning the baby to mom’s recovery room.  Standard procedure.  Baby was away from her for a full hour before they had any more than a cursory hello.

After the birth, my client asked that I let her family know that she and the baby were healthy.  The extended family seemed very calm when I told them the good news.  They were unconcerned because they had already seen the baby.  I turned around to see into the nursery where one of the grandmothers was cuddling the baby in a rocking chair.  The extended family was holding the baby before the mother.

Thoughts for the future

Upon leaving, the attending physician told my client, “There is no reason for you not to have a vaginal birth next time.  Just not here.”  Apparently, there has been no change in policy about VBACs even with the recent change to the ACOG guidelines (ACOG, 2010).  This hospital has a VBAC ban.

I am not trying to demonize the health care providers or nurses.  I don’t believe that anyone enters maternity work with the idea of oppressing women.  I do believe they were doing the best they could within this system.  This hospital does have plans to address the facility issues but those will take quite some time and hundreds more women will labor and birth before those changes are made.  Probably more important, I wonder how long it will take for a cultural shift even with floor plan improvements.

Jerome Groopman, M.D. in his book How Doctors Think discusses at length how medical providers – and really all of us – make the same errors of logic and repeat them over and over.  So, while I am all for cheerleading and encouraging parents to advocate for themselves, ask for change in the system, understand the evidence for various practices, I also know that most people have a hard time hanging onto their personal power in a medical setting having been socialized to defer (see another Jerome Groopman book, Your Medical Mind) to their provider.

I am much more interested in preparing parents with real world expectations about what practices actually take place in their local birth community. The childbirth classes that I teach here will by necessity be different from what I taught in Seattle. Best practices are just that, but navigating the realities of what is and still having a positive birth experience vary from locale to locale.

To truly prepare parents, it is imperative that I include curriculum about what really makes up informed consent.  Research may tell us one thing, but choice of provider, provider’s preferences and the personal values of the birthing woman all figure into what makes up this slippery thing called “informed consent.” I have found that many expecting parents have never made a health care decision together and have never discussed their values around health care.  Exploring values and how they relate to medical decision making must also be included in childbirth classes to adequately prepare parents. This self-knowledge is not limited to the labor as it will serve parents well as together they navigate future medical decisions for their child.

And finally, parents need concrete tools and classroom practice talking to providers about their wants and desires.  ‘What the brain fires it wires,’ neuroscience tells us. By tools, I mean a concrete list of conversation starters. For example, “I hear what you are suggesting.  I would like to tell you a bit more about where we are coming from.  We would like delayed cord cutting because we value an unrushed separation)” (James, et al, 2012). The role play speaking values and truth in a safe classroom environment can help make parents more likely to actually do this during the stress of prenatal visits and labor ( Arrien, 1993).

I am so grateful that I get to work as both a doula and a childbirth educator.  I gain so much information from each role that helps improve my work when I am wearing the other hat. I know that not every childbirth educator can attend births but I would encourage educators who can, to do so, and also to work in concert with doulas and other childbirth professionals to find out what is really happening in their area.  Additionally, surveying past students to find out if our presented curriculum addressed the real needs of parents as they progressed through labor can help educators to adapt what we teach to meet those needs.

I am confident that the families that I work with both as a childbirth educator and a doula will benefit from my experiences of what is possible and together we can encourage change to practices that are more in line with best practices in obstetrical care.

References

Arrien, A. (1993). The four-fold way: walking the paths of the warrior, teacher, healer, and visionary. New York, NY: Harper.

James, K., Levy, L. (2012, October). Doubters, believers and choices, oh my. Concurrent session presented at the Lamaze International Annual Conference, Nashville, TN.

Smyth RMD, Markham C, Dowswell T. Amniotomy for shortening spontaneous labour. Cochrane Database of Systematic Reviews 2013, Issue 6. Art. No.: CD006167. DOI: 10.1002/14651858.CD006167.pub4.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63.

About Laurie Levy

Laurie LevyLaurie Levy, LMP, MA, CD(DONA), CD(PALS), CBE is a licensed massage practitioner, birth doula and childbirth educator, human anatomy and physiology instructor, and mother of three rambunctious boys.  Laurie has presented at the 2011 Lamaze InternationalConference and hopes to sit for the LCCE exam in 2014.  She can be reached through her website, laurielevy.net

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, informed Consent, Maternity Care , , , , ,

Does the Hospital “Admission Strip” Conducted on Women in Labor Work as Hoped?

October 3rd, 2013 by avatar

The 20 minute electronic fetal monitoring strip is a “right of passage” for any woman being admitted to the hospital in labor.  But is this automatic 20 minute strip evidence based?  Regular Science & Sensibility contributor Henci Goer takes a look at a recent Cochrane systematic review and lets us know what the research says.  Do you discuss this with your students?  Do you share about this practice  in your classes and with your patients and students?  What do you tell them? Will it change after reading Henci’s review below? – Sharon Muza, Science & Sensibility Community Manager

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© http://www.flickr.com/photos/jcarter

Some weeks ago, I did a Science and Sensibility post summarizing the latest version of the Cochrane systematic review of continuous electronic fetal monitoring (EFM)—AKA cardiotocography (CTG)—in labor versus intermittent listening. A couple of commenters on that post asked if I would tackle the “admission strip,” the common practice of doing EFM for 20 minutes or so at hospital admission in labor to see whether ongoing continuous monitoring is warranted.

I was in luck because the Cochrane Library has a recent systematic review of randomized controlled trials of this practice versus intermittent listening in women at low risk for fetal hypoxia (Devane 2012). The rationale for the admission strip, as the reviewers explain, is that pregnancy risk factors don’t predict all babies who will experience morbidity or mortality in labor. The admission strip is an attempt to identify women free of risk factors whose babies nevertheless might benefit from closer monitoring. Let’s see whether the admission strip succeeds at identifying those babies and improving their outcomes.

As to whether the admission strip identifies babies believed to be in need of closer surveillance, the answer is “yes.” Pooled analysis (meta-analysis) of the trials found that 15 more women per 100 allocated to the admission strip group went on to have continuous EFM (3 trials, 10,753 women), and 3 more babies per 100 underwent fetal blood sampling (3 trials, 10,757 babies).

Furthermore, women almost certainly underwent more cesareans as well (4 trials, 11,338 women). All four trials reported more cesareans in the admission strip group. The pooled increased risk of 20% just missed achieving statistical significance, but this is probably because cesarean rates were so low, only 3 to 4% in by far the biggest trial, which contributed 8056 participants. Because of the lack of heterogeneity among trials, the reviewers think the difference is likely to be real. If it is, then using an admission strip in low-risk women results in 1 additional cesarean for every 136 women monitored continuously (number needed to harm). I would add that not separating out first-time mothers, who are at greater risk for cesarean delivery, probably masked a bigger effect in this subgroup. How big an effect might this be?  Let’s assume a 9% cesarean rate in low-risk first-time mothers, that being the rate found  in first-time mothers still eligible for home birth at labor onset in the Birthplace in England study (2011). At this cesarean rate, a 20% increase over baseline would calculate to 1 additional cesarean for every 55 first-time mothers monitored continuously.

The crucial question, though, is whether increased monitoring and surgical deliveries produced better perinatal outcomes. To that, the answer is “no.” Combined fetal and neonatal death rates in infants free of congenital anomalies were identical at 1 per 1000 in both groups (4 trials, 11,339 babies). The reviewers acknowledge that their meta-analysis of over 11,000 babies is still “underpowered,” i.e., too small to detect a difference in outcomes. However, they continue, the event is so rare in low-risk women that no trial or meta-analysis would likely be big enough to do so. Additionally, no differences were found for cases of hypoxic ischemic encephalopathy (1 trial, 2367 babies), admissions to neonatal intensive care (4 trials, 11,331 babies), neonatal seizure (1 trial, 8056 babies), evidence of multi-organ compromise within the first 24 hours (1 trial, 8056 babies), or even 5-minute Apgar scores less than 7 (4 trials, 11,324 babies).

The reviewers therefore conclude:

We found no evidence of benefit for the use of the admission CTG for low-risk women on admission in labour. Furthermore, the probability is that admission CTG increases the caesarean section rate by approximately 20%. . . . The findings of this review support recommendations that the admission CTG not be used for women who are low risk on admission in labour. Women should be informed that admission CTG is likely associated with an increase in the incidence of caesarean section without evidence of benefit (Devane 2012, p. 2). [Emphasis mine.]

Conclusion

According to the best evidence, the admission strip isn’t just ineffective, it’s harmful, and its use should be abandoned

References

Birthplace in England Collaborative Group. (2011). Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ, 343, d7400.  http://www.ncbi.nlm.nih.gov/pubmed/22117057?dopt=Citation

Devane, D., Lalor, J. G., Daly, S., McGuire, W., & Smith, V. (2012). Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database Syst Rev, 2, CD005122. doi: 10.1002/14651858.CD005122.pub4 http://www.ncbi.nlm.nih.gov/pubmed/22336808

Childbirth Education, Do No Harm, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Maternity Care, Medical Interventions, Metaanalyses, New Research, Research, Uncategorized , , , , , , , ,

New Cochrane Review: Delayed Cord Clamping Likely Beneficial for Healthy Term Newborns

July 25th, 2013 by avatar

By Mark Sloan, M.D.

Last fall, Dr. Mark Sloan wrote an extremely well-received post on Science & Sensibility, Common Objections to Delayed Cord Clamping; What’s the Evidence Say? that both professionals and consumers could use to understand and discuss the benefits of delayed cord clamping. From that post, we read that early cord clamping is an intervention that needs to change.  Yet, early cord clamping is still observed in L&D rooms across the United States, despite the mounting evidence for waiting at least 1-3 minutes before clamping occurs.  A new Cochrane review was just released in July, 2013, and I am grateful to Dr. Sloan for summarizing this review and sharing the  new information on this topic. – Sharon Muza, Community Manager, Science & Sensibility

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flickr.com/photos/lovemybunnies/4740682244/

A new Cochrane review of the timing of cord clamping in healthy term neonates was released earlier this month: Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. It’s an update of a 2009 review on the subject, and the language is more pro-delayed cord clamping (ie, clamping the cord at 1-3 minutes after birth) this time around. Here’s an excerpt from the Author’s Conclusions:

 “A more liberal approach to delaying clamping of the umbilical cord in healthy term infants appears to be warranted, particularly in light of growing evidence that delayed cord clamping increases early haemoglobin concentrations and iron stores in infants. Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.”

To understand why this change in emphasis since the 2009 Cochrane review is important, let’s first look at why the timing of cord clamping is important to newborns, how current obstetric practice came to be, and what the Cochrane review did (and didn’t) find. 

A brief physiology review

At term, roughly 1/3 of a fetus’s blood supply resides in the placenta. In the course of labor and delivery, much of that blood is transfused from the placenta into the fetus/newborn, driven by the force of uterine contractions. That transfusion continues beyond the moment of birth; if left undisturbed for 1 to 3 minutes, the placenta will deliver about three additional ounces of blood to the newborn.

That may not sound like much, but three ounces of blood is equivalent to a three month supply of iron for the newborn. Iron is critical to brain growth and development; iron deficiency is a known cause of cognitive and social-emotional deficits in infants, which may be permanent. As breast milk alone may not supply a baby with all the iron he or she needs, it’s that additional iron that makes delayed cord clamping (DCC) so important. 

A brief history of cord clamping

Until the relatively recent past, the umbilical cord was generally allowed to stop pulsating before it was cut and tied off. Aristotle and Hippocrates, among many other medical and science writers, wrote approvingly of the practice. The first mention of early cord clamping (ECC)—cutting the cord before pulsation has ceased—is found in the 1600s, when management of the third stage of labor changed with the rise of male midwives, flat-on-the-back birthing practices, and forceps. 

Though ECC gained in popularity, controversy dogged the practice from the beginning. To give just one example, the prominent British physician Erasmus Darwin (Charles’s grandfather) condemned the practice, declaring in 1801 that early cord clamping was “a very injurious thing” that left babies “much weaker than [they] ought to be.” 

Despite ongoing objections, ECC became the obstetrical standard of care in the mid-1960s, promoted primarily as a tool to prevent maternal postpartum hemorrhage (PPH). Though subsequent research has shown that ECC is of no benefit in postpartum hemorrhage (PPH) prevention, the practice remains a firmly entrenched part of obstetrical care in the U.S. 

What did the 2013 Cochrane review find?

The review found that DCC babies had significantly higher body iron stores than ECC babies, an increase that persisted for months.

What didn’t the Cochrane review find?

Maternal adverse outcomes: The review found no significant ECC-versus-DCC differences in any maternal outcomes, including postpartum hemorrhage, length of the third stage of labor, need for blood transfusion, and need for manual removal of the placenta.

Neonatal adverse outcomes: Similarly, with the single exception of a slight increase in the need for phototherapy to treat hyperbilirubinemia (discussed below), there were no significant differences between ECC and DCC babies in neonatal outcomes such as mortality, Apgar scores < 7 at five minutes, need for resuscitation, NICU admission, respiratory distress, polycythemia, and clinical jaundice.

The apparent association between DCC and an increased need for phototherapy is a bit controversial. As pointed out by Dr. Judith Mercer, an expert on the benefits of delayed clamping, this concern is based largely on a single unpublished 1996 study performed by one of the Cochrane review’s authors (McDonald).  McDonald’s study is one of only two of the nearly forty studies considered for inclusion in the current review that includes unpublished data; when that data is removed, the difference between groups loses significance.   

Of note, the two studies added since the 2009 review found no association between delayed clamping and hyperbilirubinemia requiring phototherapy (Al-Tawil 2012, Andersson 2011). It should also be pointed out that none of the babies in these studies was harmed by hyperbilirubinemia. All recovered completely; there were no cases of kernicterus—brain damage caused by severe neonatal jaundice.

Whatever the case regarding delayed clamping and phototherapy, there’s no doubt that iron deficiency in infancy can lead to permanent cognitive and social-emotional deficits. The global benefits of increased iron stores during a critical period of brain development would seem to outweigh that concern.

The bottom line

For healthy term babies, a delay of 1-3 minutes before cord clamping has been shown to increase neonatal iron stores at a critical period of brain development, with virtually no risk of harm to mother and baby. Conversely, there is no convincing argument in support of clamping the umbilical cord before a minute of age.

Given that ECC has been shown to have no impact on maternal PPH, and that it offers no demonstrable benefit to healthy term newborns (and may in fact be harmful, by reducing body iron stores during a critical period of brain development), the question isn’t “Why switch to delayed cord clamping?” It’s this: “Why continue to intervene?”

Will obstetric practice change? Not immediately, if the recent Huffington Post comments of Dr. Jeffrey Ecker, ACOG chair of obstetric practice, are any indication: 

“Over time, I believe we’ll see an evolution in practice with appropriate women and babies — babies that don’t otherwise need immediate attention,” Ecker said. “I don’t think it is all going to change in a year. But in five, 10 years, we’ll look back and say, ‘Boy, this is different.’”

The best way to speed up that process is for pregnant women and providers of maternity care services to press their local hospitals for change now.

References

Al-Tawil, M. M., Abdel-Aal, M. R., & Kaddah, M. A. (2012). A randomized controlled trial on delayed cord clamping and iron status at 3–5 months in term neonates held at the level of maternal pelvis. Journal of Neonatal-Perinatal Medicine5(4), 319-326.

Andersson, O., Hellström-Westas, L., Andersson, D., & Domellöf, M. (2011). Effect of delayed versus early umbilical cord clamping on neonatal outcomes and iron status at 4 months: a randomised controlled trial. BMJ: British Medical Journal343.

California WIC Association and the UC Davis Human Lactation Center. (2012) Maternity Care Matters; Overcoming Barriers to Breastfeeding. A Policy Update on California Breastfeeding and Hospital Performance. Retrieved from http://calwic.org/storage/restricted/hospitalreport/Maternity%20Care%20Matters_2012.pdf

McDonald, S. J., Middleton, P., Dowswell, T., & Morris, P. S. (2013). Effect of timing of umbilical cord clamping of term infants on mother and baby outcomes. Health.

Pearson, Catherine. “Cord Clamping: How Delaying Helps Babies.” The Huffington Post. TheHuffingtonPost.com, 11 July 2013. Web. 24 July 2013.

About Mark Sloan, MD

Mark Sloan has been a pediatrician and a Fellow of the American Academy of Pediatrics for more than 25 years. Since 1982, he has practiced with the Permanente Medical Group in Sacramento and Santa Rosa, California, where he was Chief of Pediatrics from 1997 to 2002. He is an Assistant Clinical Professor in the Department of Community and Family Medicine at the University of California, San Francisco. Dr. Sloan’s first book, Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth was published in 2009 by Ballantine BooksHis writing has appeared in the Chicago Tribune, the San Francisco Chronicle, the San Francisco Examiner, and Notre Dame Magazine, among other publications.  Dr. Sloan can be reached through his blog.

 

Babies, Childbirth Education, Delayed Cord Clamping, Do No Harm, Evidence Based Medicine, Guest Posts, informed Consent, Medical Interventions, New Research, Newborns, Practice Guidelines, Research, Third Stage , , , , , , , , ,

“I Want to Have a Vaginal Birth!” – A Childbirth Educator Meeting the Needs of Her Students.

July 11th, 2013 by avatar

Regular contributor, Jacqueline Levine, shares her experiences teaching Lamaze classes and ponders the responses to the question “Why have you come to this class?” The responses motivate her to continue to teach evidence based information and provide families with the resources they need to have a safe and healthy birth. – Sharon Muza, Science & Sensibility Community Manager.

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© www.momaroo.com

I teach Lamaze classes to the maternity clients at a Planned Parenthood Center.  Planned Parenthood supports women in all facets of their reproductive lives, including supporting a healthy pregnancy and birth.  As part of the informal protocol of the first session, I ask each woman why she’s come to the class.   Most of the time, the answers are pretty predictable;  “My sister (friend, mother, partner) said I should come”, or “How does this baby come OUT?” or sometimes “I want to have a natural birth with no medication.”  There is always a recognizable and comfortable rhythm to these answers.  Sometimes there’s humor, but there’s always the feeling of community; mothers-to-be will meet each other’s glance and smile.  At times, partners roll their eyes ceiling-ward, but the answers I hear do not discomfit, and they do not surprise.  Everyone understands that we are together under the sheltering umbrella of learning about birth, about who we are in this room, at this moment and in this context; we are preparing to learn together. 

I recently heard another reason for coming to class that in years past would have had me shaking my head in disbelief.  ”I’m here because I want to have a vaginal birth.”  I’ve tried to imagine the look on my face when I first heard those words, and I know that the class read my expression; immediately I was knocked from a comfortable and familiar path, and the lighthearted air that normally suffused the room was neutralized in an instant. 

At this writing, five women in four different class series separated from each other by months, were bound together by the fear of having a cesarean. They had each come to class in order to find some sort of powerful knowledge that would stand as a barrier between themselves and cesarean birth.  They were asking me (and  by proxy, Lamaze) to give them an impenetrable defense, some kind of fortress of information.  They were hoping for some special power or status in the world of birth, a talisman or access to some magical knowledge to stay the knife and keep it at bay.  They had come to a childbirth education class for information that, in essence, would teach them how to succeed in challenging the childbirth system.   

What background and history did these women bring, that they came to class with that simple but remarkable request; “I want to have a vaginal birth.” When I inquired further, the answers were all about the same, each a slight variation on “Every one of my friends had a cesarean section, and I saw what happened to them, and I don’t want that to happen to me.”

I was sure that these women were sounding an alpenhorn blast, a call to us who support natural physiologic birth, that we have to give the women we teach an effective and powerful defense. I was handed a very real challenge.

Throughout the life of the Lamaze International, there has always been the vital re-examination and re-articulation of what Lamaze stands for.  Might there be something else we need to do to prepare our clients for the general medicalization of birth. Do we need to do some refinement or expansion of or addition to our syllabi?  Might there be a mini- parallel to the early days of Lamaze and other birth organizations, when there was a grassroots movement of women who wanted to be “awake and aware” during birth. Will more women begin showing up to our classes determined to avoid cesarean sections? 

Inspiration for meeting this challenge from my classes resides in some of the very words on the Lamaze website describing the Healthy Birth Practices, stating that the birth practices area “supported by research studies that examine the benefits and risks of maternity care practices. Therefore, they represent ‘evidence-based care,’ which is the gold standard for maternity care worldwide. Evidence-based care means using the best research about the effects of specific procedures, drugs, tests, and treatments, to help guide decision-making.”  Keeping up with the latest best-evidence information for our clients is what childbirth educators do; we go to conferences to stay current, we spend our time and our money to make sure that we are ultra-informed.  We feel that we owe it to those we teach.

In my Science & Sensibility post in May 2011 about best-evidence care and childbirth education, I described something I was doing in classes that seemed to give mothers-to-be an extra lift to their confidence. For every facet of birth covered in class, I would hand out one or more best-evidence studies, with the important parts highlighted. No one had to read the whole thing unless they wanted to, but the conclusions were glowing in yellow for all to see and everyone understood what the doctors said as they spoke to each other through the literature.  It was clear that what the doctors were saying to each other was not always what they were saying to the women who were in my class. 

An example; we may teach that continuous fetal monitoring doesn’t change/improve outcomes for babies, but does raise the cesarean section rate.  When we share the actual ACOG practice bulletin to that effect, it just makes sense that the very words in that bulletin confer a new power on our clients. It is doctors telling doctors that continuous EFM isn’t effective and may cause harm. How many doctors tell women outright that CEFM is, at the very least, unnecessary for low risk moms? Authority is speaking and those are the voices that our clients must confront when they are laboring in the hospital.  Now mothers-to-be can know what is said behind the scenes.  They feel supported by the truths the studies tell; this first-time access to those words expands their sense of choice and control. 

Does this approach work?  I’m sure that it does but my proof is only anecdotal. I observe numerous Planned Parenthood Center clients and those in my private practice have births that unfold without interference.  They feel empowered to “request and protest” in whatever measures are appropriate. 

When the women in my class who stated they simply wanted vaginal births first announced their aim to me, I was hoping that documentation of the harms of routine intervention, liberal application of the Six Healthy Birth Practices, lots of role-play and comfort-measures practice would provide these women with the tools to confront hospital policies and routine interventions. But cesarean birth is the ultimate intervention at times. 

Happily, there is much energy devoted to the avoidance of unnecessary cesarean sections from organizations like the International Cesarean Awareness Network supporting vaginal birth and bringing powerful voices to this struggle, but it’s still a one-on-one moment for birthing women.  They will meet that moment face-to-face with a health care provider who may push them to choose a cesarean section for any number of reasons.  At the moment a doctor says “You haven’t made much progress for the last two hours, there’s no guarantee that your baby can tolerate labor much longer and I can have your baby out in 20 minutes,” the pressure can become overwhelming for any woman.

What can we give women so that at that moment they can push back against that pressure?  Is it enough to feel confident in your body? Is it enough to know the cons of unnecessary, capricious cesarean section, its dangers and possible sequelae for mother and baby that make life difficult for  both when they go home? All women are entitled to know that ACOG itself does not recommend cesarean unless it is for a medical reason. While a long labor may not be convenient, labor length is not a medical reason for performing a cesarean section. Every woman should know that long labors are not, in and of themselves dangerous. ( Cheng, 2010.) To quote Penny Simkin; “Time is an ally, not an enemy.  With time, many problems in labor progress are resolved.” (Simkin, 2011.)

But finding the ultimate tool to give women so that they may avoid this ultimate intervention is a complicated matter.  Obstetricians admit that concerns about  their own possible  jeopardy takes precedence over the real health status of the mother.  This Medscape Medical News headline proclaims “ACOG 2009: Liability Fears May Be Linked to Rise in Cesarean Rates”. The article about these fears was presented at the American College of Obstetricians and Gynecologists (ACOG) 57th Annual Clinical Meeting in May 2009. The article casts the doctor as the victim: “So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” concluded Dr. Barnhart. (ACOG 2009)

It’s been widely reported that, according to a CDC finding in 2011, the cesarean section rate dropped for the first time in a dozen years, and it’s been more recently reported that the rate has stabilized; however, it has stabilized at a at a whopping 31%.  One of every three birthing women will have a cesarean surgery. (Osterman, 2013.)

Will the 2010 ACOG guidelines on VBAC have any effect on the cesarean section rate? The rate of cesareans on first-time mothers is still not declining. (Osterman, 2013.)  The effect of new guidelines will be equivocal if not minimal.  It’s guidelines for first-time mothers that has to change, because both the hardened medical atmosphere surrounding normal, physiologic labor, and the ever-accruing protocols that lead to that primary cesarean will not be subject to new guidelines anytime soon. If women who are past their 40th week of gestation, those thought to be having babies bigger than 8lbs, plus all the women who are older than 35 are now thought to be among the acceptable candidates for VBAC, how can OBs still push for primary sections for those self-same criteria on first-time mothers?   

Finding a way to inform each and every woman of the range of choices she has for her birth and supporting those choices is our ongoing mission. A hopeful sign is ACOG’s call “for evidenced-based practice and greater cooperation between obstetrician-gynecologists and certified nurse-midwives/certified midwives.” (Waldman, 2011) ACOG is “recognizing the importance of options and preferences of women in their healthcare”and the recommendation by ACOG that Obstetricans actively include women in the “planning of health services to reduce risk and improve outcomes” with “shared medical decision-making” (ACOG 2011.)

Yet in the labor room, day-after-day, even the most well-informed, well-prepared, experienced and determined mother may, in the last moment, have her perineum snipped by a health care provider who states “Oh, and I gave you an episiotomy because you were starting to tear…” Or there could be the doctor who shares with a mother, “I was getting nervous about the baby getting too many red blood cells” and clamps the cord a few seconds after birth, despite the parent’s wishes for delayed cord clamping.

I cannot say that I will have an answer for the women who come in the future seeking answers on how to avoid a cesarean birth.  I believe that these women can feel more positive when they read what Dr. Richard N. Waldman, former President of ACOG), said in his August 2010 online letter to his organization:

“…The US maternal mortality ratio has doubled in the past 20 years, reversing years of progress. Increasing cesarean deliveries, obesity, increasing maternal age, and changing population demographics each contribute to the trend. In 2008, the cesarean delivery rate reached another record high—32.3% of all births. There is a community not far from my home in which 45% of the newborns are delivered via an abdominal incision. Let me be very honest. This increase in cesarean delivery rate grieves me because it seems as if we are changing the culture of birth. While it is certainly true that a physician has a contract with an individual patient, our specialty has a covenant with our society…”

As a childbirth educator, I am committed to teaching evidence based information, providing resources and support and helping women to have the best birth possible.  Won’t you join me in that goal?

References:

Cheng, Y. W., Shaffer, B. L., Bryant, A. S., & Caughey, A. B. (2010). Length of the first stage of labor and associated perinatal outcomes in nulliparous women. Obstetrics & Gynecology116(5), 1127-1135.

 Monitoring, I. F. H. R. (2009). nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. American College of Obstetricians and Gynecologists. Obstet Gynecol114, 192-202.

Osterman MJK, Martin JA. Changes in cesarean delivery rates by gestational age: United States, 1996–2011. NCHS data brief, no 124. Hyattsville, MD: National Center for Health Statistics. 2013.

Partnering with patients to improve safety. Committee Opinion No. 490. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:1247–9.

Simkin, P., & Ancheta, R. (2011). The labor progress handbook: early interventions to prevent and treat dystocia. John Wiley & Sons.

Vaginal birth after previous cesarean delivery. Practice Bulletin No. 115. American College of Obstetricians and Gynecologists. Obstet Gynecol 2010;116:450–63.

Waldman, R. N., & Kennedy, H. P. (2011). Collaborative practice between obstetricians and midwives. Obstetrics & Gynecology118(3), 503-504.

ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , ,

Bed Rest to Prevent Preterm Birth Both Ineffective and Harmful

July 9th, 2013 by avatar

 Today, regular contributor, Henci Goer takes a look at the recent study on prescribing bed rest for the prevention of preterm birth.  Despite not preventing a premature baby, and even possibly increasing the likelihood, it is still routinely recommended for pregnant women.  Please enjoy this research review and share your thoughts with Henci and I in the comments section. – Sharon Muza, Science & Sensibility Community Manager.

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© Sindea Horste sindea.org

In May, The New York Times and Reuters ran articles on a study published the following month finding that restricting activity did not prevent preterm birth in first-time moms with a short cervix (less than 30 mm) (Grobman 2013). A secondary analysis of a randomized controlled trial of injected progesterone vs. placebo, investigators looked at the effect of “activity restriction,” defined as restriction from sexual activity, work, or nonwork activity, in 646 women. They found that 39% of women reported being restricted in one or more of these categories, and two-thirds of them (68%) were restricted in all three with the vast majority (25th to 75th percentile) receiving that prescription between 24 and 28 weeks gestation. Birth before 37 weeks was three times (odds ratio: 2.9) more likely in the restricted group (raw difference: 37% vs. 17%). Adjustment for trial assignment group and factors associated with likelihood of being placed on activity restriction, didn’t much change that ratio (odds ratio: 2.4). The same held true for the likelihood of birth before 34 weeks (odds ratio: 2.3). And here’s the kicker: not mentioned in the secondary analysis is that the trial itself found that progesterone treatment made no difference in preterm birth rate at less than 37 weeks (25% vs. 24%) (Grobman 2012 ).

In other words, not prescribing activity restriction was effective; progesterone treatment was not. Study authors speculated that the reason for the paradoxical effect of activity restriction may be that it is stressful and anxiety provoking and that anxiety and stress may increase risk of adverse pregnancy outcomes.

The uselessness of bed rest is hardly “stop the presses” news. We have known that bed rest was ineffective at least since 1994 when a review reported that this particular emperor had no clothes (Goldenberg 1994). Studies since have reinforced that conclusion. An accompanying commentary in the same issue as Grobman et al’s study reports on the findings of Cochrane systematic reviews on the effects of bed rest (McCall 2013). Bed rest neither prevents miscarriage, preeclampsia, or preterm birth with singleton or multiple gestation, nor treats hypertension or impaired fetal growth. Publication dates for the set of Cochrane reviews range from 2000 (impaired fetal growth) to 2010 (multiple pregnancy). The review on preterm birth with singleton gestation, the subject of Grobman et al.’s study, was published in 2004.

These consistent results, however, have not affected practice. An editorial on the Grobman and McCall articles states that 95% of obstetricians recommend activity restriction or bed rest and that 71% of maternal-fetal medicine specialists responding to a survey would recommend it after arrested preterm labor despite the finding that 72% of survey participants didn’t think it would help (Biggio 2013). Why aren’t doctors paying attention to their own research? Biggio thinks it may be fear of liability if a bad outcome were to occur and bed rest hadn’t been prescribed and the belief that bed rest is harmless. It isn’t, and this is known too. McCall, Grimes, and Lyerly quote from an American College of Obstetricians and Gynecologists’ Practice Bulletin on managing preterm labor (ACOG 2012):

Although bed rest and hydration have been recommended to women with symptoms of preterm labor to prevent preterm delivery, these measures have not been shown to be effective for the prevention of preterm birth and should not be routinely recommended. Furthermore, the potential harm, including venous thromboembolism, bone demineralization, and deconditioning, and the negative effects such as loss of employment, should not be underestimated. [Emphasis mine.]

To this, McCall, Grimes, and Lyerly add adverse psychosocial effects on women and their families, including the potential for women blaming themselves when bed rest fails to avert preterm birth, and now Grobman et al’s study suggests the possibility of increasing the risk of preterm birth.

In the Reuters article, Grobman states that “any pregnant woman who is told to restrict her activity or stay in bed should discuss with her doctor whether there is data to support that recommendation given her condition.” Fair enough, but how is she supposed to know to do that? What role can or should childbirth educators and doulas play? What might Lamaze International or other childbirth-related organizations do to spread the word? What are your thoughts?

References 

ACOG practice bulletin no. 127: Management of preterm labor. (2012). Obstet Gynecol, 119(6), 1308-1317. doi: 10.1097/AOG.0b013e31825af2f0

Biggio Jr, J. R. (2013). Bed Rest in Pregnancy: Time to Put the Issue to Rest.Obstetrics & Gynecology121(6), 1158-1160.

Goldenberg, R. L., Cliver, S. P., Bronstein, J., Cutter, G. R., Andrews, W. W., & Mennemeyer, S. T. (1994). Bed rest in pregnancyObstetrics & Gynecology,84(1), 131-136.

Grobman, W. A., Gilbert, S. A., Iams, J. D., Spong, C. Y., Saade, G., Mercer, B. M., … & Van Dorsten, J. P. (2013). Activity restriction among women with a short cervixObstetrics & Gynecology121(6), 1181-1186.

Grobman, W. A., Thom, E., Spong, C. Y., Iams, J. D., Saade, G. R., Mercer, B. M., … & Van Dorsten, J. P. (2012). 17 alpha-hydroxyprogesterone caproate to prevent prematurity in nulliparas with cervical length less than 30 mm.American journal of obstetrics and gynecology.

McCall, C. A., Grimes, D. A., & Lyerly, A. D. (2013). “Therapeutic” Bed Rest in Pregnancy: Unethical and Unsupported by DataObstetrics & Gynecology,121(6), 1305-1308.

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