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A Tale of Two Births – Comparing Hospitals to Hospitals

December 9th, 2014 by avatar

By Christine H. Morton, PhD

Today, Christine H. Morton, PhD, takes a moment to highlight a just released infographic and report by the California Healthcare Foundation that clearly shows the significance of birthing in a hospital that is “low performing.”  This is a great follow up post to “Practice Variation in Cesarean Rates: Not Due to Maternal Complications” that Pam Vireday wrote about last month. Where women choose to birth really matters and their choice has the potential to have profound impact on their birth outcomes.   – Sharon Muza, Science & Sensibility Community Manager.

An Internet search of “A Tale of Two Births” brings up several blog posts about disparities in experience and outcomes between one person’s hospital and subsequent birth center or home births. Sometimes the disparity is explained away by the fact that for many women, their second labor and birth is shorter and easier than their first. Or debate rages about the statistics on home birth or certified professional midwifery. Now we have a NEW Tale of Two Births to add to the mix. However, this one compares the experiences of two women, who are alike in every respect but one – the hospital where they give birth.

Screen Shot 2014-12-08 at 5.15.04 PM

 

The California HealthCare Foundation has created an infographic drawn from data reported on California’s healthcare public reporting website, CalQualityCare.org. In this infographic, we meet two women, Sara, and Maya who are identical in every respect – both are the same age, race, and having their first baby, which is head down, at term. However, Sara plans to have her baby at a “high-performing” hospital while Maya will give birth at a “low-performing” hospital. “High performing” is defined as three or more Superior or Above Average scores and no Average, Below Average, or Poor scores on the four maternity measures. “Low performing” is defined as three or more Below Average or Poor scores on the four maternity measures.

Based on the data from those hospitals, the infographic compares the likelihood of each woman experiencing four events: low-risk C-section, episiotomy, exclusive breastmilk before discharge, and VBAC (vaginal birth after C-section) rates (the latter one of course requires us to imagine that Sara and Maya had a prior C-section).

First-time mom Sara has a 19% chance of a C-section at her high-performing hospital, while Maya faces a 56% chance of having a C-section at her low-performing hospital. These percentages reflect the weighted average of all high- and low- performing hospitals.

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The readers of this blog will no doubt be familiar with these quality metrics and their trends over time. Two of these metrics (low risk C-section and exclusive breastmilk on discharge) are part of the Joint Commission’s Perinatal Care Measure Set. The other two – episiotomy and VBAC are important outcomes of interest to maternity care advocates and, of course, expectant mothers.

Hospitals with >1100 births annually have been required to report the five measures in the Joint Commission’s Perinatal Care Measure Set since January 2014, and these metrics will be publicly reported as of January 2015.

Childbirth educators can help expectant parents find their state’s quality measures and use this information in selecting a hospital for birth. In the event that changing providers or hospitals is not a viable option, childbirth educators can teach pregnant women what they can do to increase their chances of optimal birth outcomes by sharing the Six Healthy Practices with all students, but especially those giving birth in hospitals that are “low-performing.”

You can download the infographic in English and en Español tambien!

About Christine H. Morton

christine morton headshotChristine H. Morton, PhD, is a medical sociologist. Her research and publications focus on women’s reproductive experiences, maternity care advocacy and maternal quality improvement. She is the founder of an online listserv for social scientists studying reproduction, ReproNetwork.org.  Since 2008, she has been at California Maternal Quality Care Collaborative at Stanford University, an organization working to improve maternal quality care and eliminate preventable maternal death and injury and associated racial disparities. She is the author, with Elayne Clift, of Birth Ambassadors: Doulas and the Re-emergence of Woman Supported Childbirth in the United States.  In October 2013, she was elected to the Lamaze International Board of Directors.  She lives in the San Francisco Bay Area with her husband, their two school age children and their two dogs.  She can be reached via her website.

Babies, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Newborns, Push for Your Baby , , , , , ,

Series: On the “Independent Track” to Becoming a Lamaze Trainer

December 2nd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD/BDT(DONA)

Last month, LCCE Jessica English began the path to become an independent trainer with Lamaze International, as part of the just opened “Independent Track”  trainer program.  This new program helps qualified individuals become Lamaze trainers – able to offer Lamaze childbirth educator trainings which is one step on the path for LCCE certification.  She’s agreed to share her trainer journey with us in a series of blog posts; “On the Independent Track to Becoming a Lamaze Trainer”, offering insights at key milestones in the process. If this is a program you are interested in, look for information in 2015 on how to apply for the 2015 cohort.- Sharon Muza, Science & Sensibility Community Manager.

When I first saw the invitation to apply to become an independent trainer with Lamaze International, my heart leapt! As a doula trainer, I’d long wanted to extend my training work to include childbirth educators but I’d heard the process to become a Lamaze trainer was complicated. The announcement that landed in my inbox said that there was a new, simplified pathway to becoming an independent Lamaze trainer. As I prepared to launch a new business venture that included many facets of my skill set: DONA birth doula trainings, childbirth classes, business training/coaching sessions and more, it seemed so clear that becoming a Lamaze trainer fit right in with my path. Yes! Count me in!

© Tanya Strusberg

© Tanya Strusberg

I was “in” wholeheartedly, but I still needed to apply and be approved. The application asked about our qualifications and our vision for a Lamaze program. Several days before the application deadline, Laura Ruth in the Lamaze office told me that they’d already received a lot of applications. My nerves set it! The closer the deadline came, the surer I was that becoming a Lamaze trainer was the right path for me; I hoped the review committee would agree.

The wait to hear back was blessedly short. Less than a week after I submitted my application, I heard back from Lamaze International that I’d been approved as part of the first cohort of independent track trainers. How exciting! I immediately started laying plans to travel to Washington, D.C. for the “train the trainer” session, praying that my November doula clients would either have their babies before I left or wait for my return. I also needed a sub to teach my own Thursday night childbirth class.

Thankfully, three babies came in nine days, I found a fantastic sub, and I headed to D.C. with a clear calendar. (Thank you for aligning, birthy stars!) I arrived Wednesday night and met my roommate, Trena Gallant from Halifax, Nova Scotia. Before our official training ever began, our informal education started with the opportunity to share stories and techniques as experienced educators and (doula) trainers. My LCCE heart was already bursting!

I’d been curious from the beginning about who would be in the training, and it was fun to watch the room fill Thursday morning. Several of my fellow DONA-approved birth doula trainers were in the group, there were a handful of other folks whose names I recognized, and I saw a few new faces. The 12 of us hailed from the United States, Canada and even Australia. Everyone participating in the training was an experienced educator, and we had several accomplished Lamaze trainers and leaders in the room to help guide us as well. I was excited know we’d have the chance to connect throughout the weekend.

The morning began with ice breakers and climate setters with our experienced facilitator, Tom Leonhardt. Once we all felt comfortable together, we dove into the science of adult learning. Even as an experienced educator and trainer, I enjoyed the chance to reanalyze how adults learn. One of the things that I love about Lamaze International is its emphasis on evidence-based information, and this training was no different. There’s great science on adult learning, and Lamaze ensures that your trainers understand how to use that science to help new educators create great classes. I appreciated that the training itself was highly interactive – implementing the same proven techniques we were discussing. I picked up some new ideas and other information was reinforced. I was able to explore my own teaching style and its strengths and weaknesses. An expert facilitator, Tom guided us and brought us back to task when we ventured just a little too far down an occasional rabbit hole.

Saturday was spent on additional teaching analysis and introduction of the primary objectives for our Lamaze curricula. Another reason I adore Lamaze is that they lay down core objectives for educators and then allow each LCCE to teach in his or her own way. I discovered that the trainer process was similar. Each trainer will complete a needs assessment for her community, region or country. We are tasked with using a planning table to detail content for each objective, then listing our teaching techniques and evidence-based resources. In part because all Lamaze International training seminars qualify for nursing contact hours, the process of getting your training program accredited is rigorous – just another reason that Lamaze is the gold standard in our field! I could see the work ahead.

On Saturday afternoon we broke into pairs and developed an assigned training module. Each team delivered its 20-minute teaching session beginning Sunday morning. My partner and I volunteered to present first, which allowed us to fully enjoy the rest of the presentations without any thoughts about our own session. What a delight to watch so many incredible educators work their magic! I think we all picked up techniques and language from one another. We reminded ourselves again and again that we were training educators and not parents. That was an interesting shift, as we’ve all been teaching families for years or even decades. We glowed with the praise from our peers and humbled ourselves to received constructive feedback on what could have gone better. What an excellent model for us to follow as we prepare others to teach!

Saturday ended with an exploration of best practices in dealing with challenging participants. I love that Lamaze International wants us to explore these issues with new instructors! Being a great childbirth educator is about so much more than just understanding birth. The science and art of teaching are critically important to our work and Lamaze International is devoted to helping to build truly great teachers around the world.

As I said goodbye to my new colleagues Monday afternoon and wound my way through a weather-challenged journey home, my thoughts turned to next steps. As my new venture- Heart | Soul | Business ramps up, I’m carving out time to work on my Lamaze curriculum. Branding and marketing are on my mind as I solidify plans to combine birth doula workshops, childbirth educator seminars and advanced business trainings to help other birth workers thrive in this heart-centered work. My background is in marketing, public relations and business administration, so that trifecta of trainings feels like the perfect combination!

A variety of questions remain for me. Which cities need childbirth educator, doula and business trainings? How can I help to even further distinguish the Lamaze name in an increasingly crowded marketplace? What are the pieces of a kick-butt curriculum that will help grow strong, confident educators who can make a difference in diverse communities and in their own unique styles? What will it be like to work on that curriculum with Lamaze International’s amazing lead nurse planner, Susan Givens? I’m strongly committed to continuing to teach families and attend births in my home community, but how will those commitments balance with an increased travel schedule?

Stay tuned, friends. I’m diving in and I’m excited to have you along for the journey.

About Jessica English

jessica english head shotJessica English, LCCE, FACCE, CD/BDT(DONA), is the founder of Heart | Soul | Business. A former marketing and PR executive, she owns Birth Kalamazoo, a thriving doula and childbirth education agency in Southwest Michigan. Jessica trains birth doulas and (soon!) Lamaze childbirth educators, as well as offering heart-centered business-building workshops for all birth professionals.

Childbirth Education, Guest Posts, Lamaze International, Series: On the Independent Track to Becoming a Lamaze Trainer, Uncategorized , , , , ,

Series: Welcoming All Families: Supporting the Native American Family

November 18th, 2014 by avatar

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

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

© Bob Zellar http://bit.ly/1EVALCk

© Bob Zellar http://bit.ly/1EVALCk

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

Native Americans and Pregnancy

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

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

Native Americans and Birth

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

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

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

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

Connecting the Past and the Present

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

Health Services for Native Americans Today

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

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

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

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

What’s a Childbirth Educator to Do?

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

© Ursula Knoki-Wilson

© Ursula Knoki-Wilson

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

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

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

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

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

References

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

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

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

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

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

About Melissa Harley

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

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

Practice Variation in Cesarean Rates: Not Due to Maternal Complications

November 13th, 2014 by avatar

By Pam Vireday

Pam Vireday, an occasional contributor to Science & Sensibility reviews the recent study by Katy Kozhimannil, PhD and colleagues that examined the differences in cesarean rates between over a thousand hospitals in the USA.  Consumers of maternity care quite possibly do not realize what a significant impact their choice of facility (and provider) may have on their birth outcome.  Can you think of hospitals in your own community serving similar populations of pregnant families that have drastically different cesarean rates.  Have you considered why that might be?  Do you think that the families you work with have explored this too?  Do they even have access to this information?  Read Pam’s discussion of this recent study below.  - Sharon Muza, Community Manager, Science & Sensibility.

© Patti Ramos Photography

© Patti Ramos Photography

There’s a new study out that discusses the variation in cesarean rates between hospitals in the United States. “Maternal clinical diagnoses and hospital variation in the risk of cesarean delivery: Analyses of a national US hospital discharge database“ was released late last month and has received a lot of press and discussion ever since.

Practice variation is a serious problem in obstetrics (Arcia 2013). Women are often far more at risk for a cesarean in certain hospitals than in others, even when the hospitals serve the same geographical area and population (Arnold, January 2013 and August 2012).

Of course, care providers protest that some hospitals have higher cesarean rates because they serve higher-risk patients. This is a valid point, but it still doesn’t explain the wide variation in rates between many hospitals (Clark 2007).

For example, in a press release about the new study, the mother’s risk status and diagnoses did not explain the variation in cesarean rates between hospitals:

“We found that the variability in hospital cesarean rates was not driven by differences in maternal diagnoses or pregnancy complexity,” said [lead study author] Kozhimannil. “This means there was significantly higher variation in hospital rates than would be expected based on women’s health conditions. On average, the likelihood of cesarean delivery for an individual woman varied between 19 and 48 percent across hospitals.”

Other key points highlighted included:

  • Among lower risk women, likelihood of cesarean delivery varied between 8 and 32 percent across hospitals.
  • Among higher risk women, likelihood of cesarean delivery varied between 56 and 92 percent across hospitals.
  • Hospital variability did not decrease after adjusting for patient diagnoses, socio-demographics, and hospital characteristics.

This shows that practice variation in cesarean rates is real, substantive, and not just a reflection of the mother’s risk level. 

Perhaps now we can stop playing the mother blame-game when we talk about cesarean rates? (Declerq 2006, Oganowski 2011)

This study is not the first to show that the culture of a hospital, its policies, and its routine practices all help determine how likely a woman is to “need” a cesarean in that hospital.

For example, Cáceres 2013 found that even after adjusting for socio-demographic and clinical factors and including only NTSV (Nulliparous, Term, Singleton, Vertex) pregnancies, the cesarean rate varied significantly between Massachusetts hospitals, “suggesting the importance of hospital practices and culture in determining a hospital’s cesarean rate.”

In addition, a 2014 consensus statement from the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine notes, “Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed.”

Preventing cesareans when possible is important because while cesareans can be life-saving at times, they present more risk for maternal infection, bleeding and blood clots, and more neonatal breathing problems (Liu 2007, Visser 2014).

Notably, a large case-control study in U.K. maternity units found that delivery by cesarean was a strong risk factor for severe sepsis (Acosta 2014). Other research has found a high rate of maternal complications (Pallasmaa 2010) and poorer neonatal outcomes (Kolås 2006) associated with cesareans.

In addition, a cesarean’s potential negative effect on future pregnancies is important (Silver 2012). One American study found that the rate of an abnormal placental attachment increased in conjunction with the rise in cesarean delivery rate (Wu 2005), while a Canadian study found that a prior cesarean was associated with an increased risk for adverse neonatal outcomes in subsequent pregnancies (Abenhaim and Benjamin 2011).

Bottom line, it matters where and with whom a woman gives birth in order to lessen the risk for complications, both now and in the future.

But many women naively choose their care provider for pregnancy based mostly on convenience and location, not realizing that their chances of surgical birth may vary greatly depending on which hospital and caregiver they use (Arnold 2014, Arnold January 9 2013).

Childbirth Connection, a leading consumer education site, points out:

Research suggests that the same woman might have a c-section at one hospital but a vaginal birth if she gave birth at another, just because of the different policies and practices of those hospitals. One of the most effective ways to lower your chance of having a c-section is to have your baby in a setting with a low c-section rate.

Yet it is not always easy to find out the cesarean rates of local hospitals in some areas. For example, the health departments of Missouri, South Carolina, and Washington D.C. do not make hospital-level cesarean rates available to consumers.

Hospitals remain largely unaccountable for high cesarean rates, although we are beginning to see marginal progress in some places towards more accountability (Gentry 2014 and Dekker 2014). In the meantime, however, thousands of women are undergoing cesareans, many of which might be preventable with changes in clinical practices (Boyle 2013).

And even when a cesarean is truly necessary, there can be large discrepancies in complications afterwards between hospitals (Alonso-Zaldivar 2014). It’s not just about how many cesareans are done, but also about which hospitals have the best outcomes when a cesarean is done. Without more information, how is a woman to know which hospital to choose?

Bottom line, more transparency and accountability are needed. As the lead author of the study states:

Women deserve evidence-based, consistent, high-quality maternity care, regardless of the hospital where they give birth…and these results indicate that we have a long way to go toward reaching this goal in the U.S.

*To search for hospital-level cesarean rates in your area, see www.cesareanrates.com or the 2014 Consumer Reports article (subscription required) rating hospitals in 22 states.

Do you ever encourage your students and clients to look at the cesarean rates (and rates of other interventions which may lead to cesareans) of the hospitals they are considering birthing in.  Please share your experience in our comments section. – SM

References

Abenhaim, H. A., & Benjamin, A. (2011). Effect of prior cesarean delivery on neonatal outcomes. Journal of perinatal medicine39(3), 241-244. PMID: 21426242

Acosta, C. D., Kurinczuk, J. J., Lucas, D. N., Tuffnell, D. J., Sellers, S., & Knight, M. (2014). Severe Maternal Sepsis in the UK, 2011–2012: A National Case-Control Study. PLoS medicine11(7), e1001672. PMID: 25003759

Alonso-Zaldivar, R (2014, August 27). Study: Wide hospital quality gap on maternity care. Retrieved from http://www.fosters.com/apps/pbcs.dll/article?AID=/20140827/GJLIFESTYLES/140809539/0/SEARCH.

Arcia, A (2013, February 3). What is practice variation in obstetrics and why should I care? Retrieved from http://www.cesareanrates.com/blog/2013/2/3/what-is-practice-variation-in-obstetrics-and-why-should-i-ca.html.

Arnold, J (2012, August 22). Practice variation in New Jersey: 27 miles and 28 percentage points. Retrieved from http://www.cesareanrates.com/blog/2012/8/22/practice-variation-in-new-jersey-27-miles-and-28-percentage.html.

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Arnold, J (2014, March 13). Three miles/Cinco Kilometros. Retrieved from http://www.cesareanrates.com/blog/2014/3/13/three-miles-cinco-kilometros.html.

Boyle, A., Reddy, U. M., Landy, H. J., Huang, C. C., Driggers, R. W., & Laughon, S. K. (2013). Primary cesarean delivery in the United States. Obstetrics & Gynecology122(1), 33-40. PMID: 23743454

Cáceres IA, Arcaya M, Declercq E, Belanoff CM, Janakiraman V, Dohen B, Ecker J, Smith LA, Subramanian SV (2013). Hospital differences in cesarean deliveries in Massachusetts (US) 2004-2006: the case against case-mix artifact. PLOS One, 8(3):e57817. doi: 10.1371/journal.pone.0057817. PMID:23526952

Clark SL, Belfort MA, Hankins GD, Meyers JA, Houser FM (2007). Variation in the rates of operative delivery in the United States. American journal of obstetrics and gynecology, 196(6):526.e1-526.e5.  PMID: 17547880

Caughey, A. B., Cahill, A. G., Guise, J. M., & Rouse, D. J. (2014). Safe prevention of the primary cesarean delivery. American journal of obstetrics and gynecology,210(3), 179-193. doi: 10.1016/j.ajog.2014.01.026. PMID:24565430

Declercq, E., Menacker, F., & MacDorman, M. (2006). Maternal risk profiles and the primary cesarean rate in the United States, 1991–2002. American journal of public health, 96(5), 867. PMID: 16571712

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DePoint, M (2014, October 22). Maternal diagnoses doesn’t explain variation in cesarean rates across US hospitals. University of Minnesota, School of Public Health. Retrieved from http://sph.umn.edu/maternal-diagnoses-doesnt-explain-variation-cesarean-rates-across-us-hospitals/.

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Kolås, T., Saugstad, O. D., Daltveit, A. K., Nilsen, S. T., & Øian, P. (2006). Planned cesarean versus planned vaginal delivery at term: comparison of newborn infant outcomes. American journal of obstetrics and gynecology,195(6), 1538-1543. PMID: 16846577

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Liu, S., Liston, R. M., Joseph, K. S., Heaman, M., Sauve, R., & Kramer, M. S. (2007). Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. Canadian medical association journal176(4), 455-460. PMID: 17296957

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Pallasmaa, N., Ekblad, U., AITOKALLIO‐TALLBERG, A. N. S. A., Uotila, J., Raudaskoski, T., ULANDER, V., & Hurme, S. (2010). Cesarean delivery in Finland: maternal complications and obstetric risk factors. Acta obstetricia et gynecologica Scandinavica89(7), 896-902. PMID: 20583935

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A version of this post originally appeared on www.wellroundedmama.blogspot.com

About Pam Vireday

Painting by Mary Cassatt, 1844-1926. (public domain) Image from Wikimedia Commons.

Pam Vireday is a childbirth educator, writer, woman of size, and mother to four children. She has been collecting the stories of women of size and writing about childbirth research for 17 years. She writes at www.wellroundedmama.blogspot.com and www.plus-size-pregnancy.org.

 

Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,

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

October 23rd, 2014 by avatar

By Henci Goer

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

© Henci Goer

© Henci Goer

© Henci Goer

© Henci Goer

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

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

Conclusion

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

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

References

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

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

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

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

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

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

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

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

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

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

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

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

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

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

About Henci Goer

Henci Goer

Henci Goer

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

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