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Intrapartum Antibiotics for GBS Positive Mothers – Still Clear as Mud

September 30th, 2014 by avatar

 In July, 2009, former blog community manager Amy Romano wrote about the Cochrane systematic review of intrapartum antibiotics for mothers with GBS colonization.  The researchers recently went back and did another review of for new literature and updated their research.  Melissa Garvey of the American College of Nurse-Midwives updated the original article with recent information from the June 2014 review and I wanted to share that with you now.- Sharon Muza, Community Manager, Science & Sensibility.

iv line

© Wikipedia

But sometimes Cochrane reviews leave us with more questions than answers.

Last June, the Cochrane Library released a systematic review evaluating the effectiveness of intrapartum antibiotics for known maternal group B streptococcal (GBS) colonization. And it’s a hot mess.

The 4 included trials that compared IV antibiotics with no treatment in labor collectively had only 852 participants, which we automatically know is far too small to find statistically significant differences in a condition that affects 1 in 2000 newborns, and results in death or long-term complications even less frequently. But small sample sizes were the least of the problems here. The reviewers noted several other problems with the trials:

  • In one study, researchers tracked their findings and halted the trial as soon as a significant difference was found (favoring treatment with antibiotics). This is a blatant form of bias – it is like flipping a penny until you get heads 5% more often than you got tails. If you keep flipping long enough (or stop flipping soon enough) you’ll be able to find that 5% difference simply by chance.
  • In the same study, researchers changed to a different statistical test that allowed them to achieve statistical significance with their data, when the originally planned (and more appropriate) test would have produced a nonsignificant finding.
  • None of the studies used placebos, so women, care providers, and hospital staff knew which women received antibiotics and which did not. This may have altered treatment of the women or the babies, possibly in ways that would make no antibiotics appear safer (for instance, avoiding or delaying membrane rupture in a woman who is GBS+ but not getting antibiotics).
  • One study excluded women who developed fevers in labor. GBS colonization can cause maternal fever and newborn sepsis, so excluding these cases makes no sense.
  • Some women included in the studies were likely GBS negative because methods used to determine GBS status were inadequate.
  • Outcomes were poorly defined.
  • Data on a substantial proportion of women and babies were missing.
  • Groups were mysteriously differently sized.
  • Need I go on?

The Cochrane reviewers, in my opinion, did a respectable job with what they had, but what they had was garbage and as the saying goes, “Garbage in, garbage out.” You can’t make reliable conclusions out of a bunch of bad research, even if you’re a Cochrane reviewer.

So what were the findings? Three trials, which were more than 20 years old, compared ampicillin or penicillin to no treatment and found no clear differences in newborn deaths although the occurrence of early GBS infection in the newborn was reduced with antibiotics.

More, better research is needed, but the Cochrane reviewers are not optimistic:

Ideally the effectiveness of IAP to reduce neonatal GBS infections should be studied in adequately sized double-blind controlled trials. The opportunity to conduct such trials has likely been lost, as practice guidelines (albeit without good evidence) have been introduced in many jurisdictions.

In the meantime, women should be aware that other evidence, albeit not from randomized controlled trials, suggests that antibiotic treatment reduces deaths from early onset GBS disease in newborns. According to the Centers for Disease Control and Prevention, a steady decline in GBS disease has been seen in individual institutions, in the whole US population, and in other countries as antibiotic use has risen. But these population-level data cannot tell us whether antibiotics or some other factor caused the decline.

What other advice can we share with women?

  1. Be aware that antibiotics are not harmless. Severe allergic reactions are possible, and antibiotic use in labor can result in thrush (candida infection) which causes painful breastfeeding and sometimes early weaning. We do not know other possible harmful effects because they have never been studied adequately or at all.
  2. No study confirms the effect of labor practices on GBS infection in newborns, but here we can use our common sense. Care providers should avoid or minimize sweeping/stripping membranes before labor, breaking the bag of waters, vaginal exams, and other internal procedures, especially those that break the baby’s skin and can be a route for infection. These include internal fetal scalp electrodes for fetal heart rate monitoring and fetal blood sampling.
  3. Keep mothers and babies skin-to-skin after birth. This exposes the baby to beneficial bacteria on the mother’s skin, facilitates early breastfeeding, and lowers the likelihood that the baby will exhibit signs or symptoms that mimic infection, such as low temperature or low blood sugar, which could cause the need for blood tests or spinal taps to rule out infection.

If you would like additional information about GBS treatment, check out Science & Sensibility’s interview with Rebecca Dekker of EvidenceBasedBirth.com and Rebecca’s article “Group B Strep in Pregnancy: Evidence for Antibiotics and Alternatives.”

Reference

Ohlsson A, Shah VS. Intrapartum antibiotics for known maternal Group B streptococcal colonization. Cochrane Database of Systematic Reviews 2014, Issue 6. Art. No.: CD007467. DOI: 10.1002/14651858.CD007467.pub4

Thank  you to Melissa Garvey of ACNM for her reworking of the original article.

 

Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , ,

Series: Journey to LCCE Certification – Countdown to the Lamaze Certified Childbirth Educator Exam

September 25th, 2014 by avatar

By Cara Terreri, BA, Community Manager for Lamaze International’s Giving Birth With Confidence blog

Cara Terreri has been documenting her path to become a Lamaze Certified Childbirth Educator since taking her workshop in August of 2012, in our series: Journey to LCCE Certification. Today ,we have another update as she prepares to sit for the exam next month.  The LCCE credentials are the gold standard for childbirth educators and Cara, along with many other men and women worldwide, are seeing the culmination of learning and preparation coming to a close with an exam date scheduled for late October.  Get an update on Cara and share your exam tips for Cara and others in our comments section. Interested in becoming an LCCE? Find out more. – Sharon Muza, Community Manager, Science & Sensibility.

© Cara Terreri

© Cara Terreri

Since my last installment, my life has taken a near 180 degree turn. Birth work still remains my professional priority and passion of course, but after a huge move out of state, I will now pursue doula work and childbirth education – as well as take the LCCE exam — in Myrtle Beach, SC. When I would have been preparing to take the exam in April in Atlanta, I was in the thick of selling my house, packing out, and preparing my family to move to the East Coast. Thankfully, Lamaze gives you the option to defer taking the exam.

With one month to go until the exam date, I am spending my afternoons and evenings poring over the pages of the Lamaze Study Guide, in particular, the “review” sections for each core competency. Reviewing key questions help me to understand my weak points (pregnancy complications and prenatal tests) and give me a tighter focal point for studying. To further boost my knowledge, I attended the fantastic Lamaze International/DONA International joint conference (“confluence”) last week – the timing couldn’t have been better! The insightful sessions echoed many of the themes throughout the Study Guide. But perhaps most important, I was able to speak directly with several LCCEs about their experience with the exam. I heard things like “fair,” “read questions closely,” “common sense,” and “you’ll do great!”

In the days to follow, I plan to take the Exam Prep Course from Lamaze, which includes a practice test. I feel fairly confident about my depth of knowledge, but this is like the extra bit of insurance I want before the big day.

Of course, taking the LCCE exam is just the tip of the iceberg for me professionally, since having relocated to a new area. Now that my kids are in school and we’re more settled, my goal is to build relationships with local educators, doulas, and lactation professionals, along with moms and families. Lots of work to do, and I’m so energized by my drive to help women and families, I want to do it all! But I remind myself that the key is to help, not help everyone. This will likely be my life’s work and because it is not my sole source of income currently, I do as much as I can that works into my stage and place in life.

Readers, I would love to hear your thoughts on the Lamaze exam! Any last-minute tips? Suggestions for studying?  How to calm those last minute jitters? And of course, positive thoughts in my (and all the exam test takers) direction would be much appreciated next month on “game day”!  I will update readers after I take the exam.  And of course, will share my results – hopefully a passing grade.

About Cara Terreri

Cara began working with Lamaze two years before she became a mother. Somewhere in the process of poring over marketing copy in a Lamaze brochure and birthing her first child, she became an advocate for childbirth education. Three kids later (and a whole lot more work for Lamaze), Cara is the Site Administrator for Giving Birth with Confidence, the Lamaze blog for and by women and expectant families. Cara continues to have a strong passion for the awesome power and beauty in pregnancy and birth, and for helping women to discover their own power and ability through birth. It is her hope that through the GBWC site, women will have a place to find and offer positive support to other women who are going through the amazing journey to motherhood.

 

2014 Confluence, Childbirth Education, Giving Birth with Confidence, Lamaze International, Series: Journey to LCCE Certification , , , ,

Tweet with Us! – Share & Experience the 2014 #LamazeDONA Confluence on Twitter

September 11th, 2014 by avatar

 By Robin Elise Weiss, PhDc, MPH, CPH, ICCE-CPE, ICPFE, CLC, CD(DONA), BDT(DONA), LCCE, FACCE

lamaze twitter 2014The 2014 Lamaze International/DONA International Joint Confluence in Kansas City is scheduled to convene in just one week and the excitement is palpable!  Bags are getting packed, presentations finalized and birth professionals of all backgrounds are getting ready to meet old friends and make new ones.  The content and information that will be covered in the plenary  and concurrent sessions will be new and exciting.  Today on Science & Sensibility, Lamaze International’s incoming president, Robin Weiss, a leader on our social media team, shares all the “need to knows” for getting the most out of the conference via Twitter. – Sharon Muza, Science & Sensibility Community Manager

The past few years the idea of using social media in conjunction with the conference has grown. And the 2014 Confluence with Lamaze International and DONA International is no different. Using the hashtag #LamazeDONA, you will be able to find a treasure trove of information about the conference, and even learn from the sessions – even if you aren’t in Kansas City.

If you are new to Twitter, you will simply need to sign up for a free account. This handy guide will help you to get started in five easy steps.  You can search for the #LamazeDONA hashtag.  Using this hashtag helps twitter users sort a specific conversation that is focused on the confluence and just our users.  Simply read and interact with the people who will talk on this search.

You will want to join in the discussion, tweet and retweet your favorite snippets of wisdom from the fabulous speakers.  If you are not attending, you will want to follow the #LamazeDONA hashtag as attendees tweet live from the sessions they are participating in.

Back this year is the fabulous Tweet Up! We are going to try to do two this year. The first is scheduled for Thursday at 4p.m. Meet by the registration desk. @RobinPregnancy and @KKonradLCCE will be there to walk you through a few things if you have questions or just say hello! @KKonradLCCE will also host a simple social Tweet Up, watch #LamazeDONA for specific information to join – all are invited, no personal invitations needed.

We will also have prizes for your participation when you watch the hashtag, including some for those joining in at home, so be sure to watch #LamazeDONA for directions.

A great article on Twitter etiquette for you to review prior to the confluence

You might also want to consider reading Birthswell’s helpful three part series: Twitter 101 for Birth and Breastfeeding Professionals if you are new to this fast moving and captivating social media platform.

Check out Facebook, where it is possible to follow the same hashtag, #LamazeDONA for updates as well.  Many Facebook users use the same hashtag system to share information on that platform.

 People to Follow

@LamazeOnline (Lamaze for parents)

@LamazeAdvocates (Lamaze for educators)

@donaaintl

@RobinPregnancy (Robin Elise Weiss, social media team for Lamaze International and incoming President)

@KKonradLCCE  Kathryn Konrad (preconference and concurrent presenter)

@ShiningLghtPE Deena Blumenfeld (concurrent presenter)

@Gozi18  Ngozi Tibbs  (plenary speaker)

@Christinemorton  (concurrent presenter)

@mariajbrooks Maria Brooks (Lamaze Board Member)

@jeanetteIBCLC Jeanette McCulloch (concurrent presenter)

@doulamatch Kim James (concurrent presenter)

@douladebbie Debbie Young

@mldeck  Michele Deck (plenary speaker)

@pattymbrennan Patty Brennan

@doulasrq Patti Treubert ‏

@babylovemn Veronica Jacobson

@tamarafnp_ibclc &  @storkandcradle Tamara Hawkins (S&S contributor)

@thefamilyway Jeanne Green & Debbie Amis

@gilliland_amy  Amy Gilliland (concurrent presenter)

@yourdoulabag Alice Turner (concurrent presenter)

Are you going to be live tweeting from the confluence?  Share your Twitter handle in the comments section and we can add you to our list.- SM 

About Robin Weiss

robin weiss head shotRobin Elise Weiss,  PhDc, MPH, CPH, ICCE-CPE, ICPFE, CLC, CD(DONA), BDT(DONA), LCCE, FACCE, is a childbirth educator in Louisville, KY. She is also the President-Elect of Lamaze International. You can find her at pregnancy.about.com and robineliseweiss.com

2014 Confluence, 2014 Confluence, Childbirth Education, Confluence 2014, Continuing Education, Guest Posts , , , , , ,

The Roadmap of Labor: A Framework for Teaching About Normal Labor

September 2nd, 2014 by avatar

By Penny Simkin, PT

Regular contributor, Penny Simkin developed the roadmap of labor as a teaching tool.  Today, Penny shares how she uses the roadmap of labor to help families in her childbirth classes to understand normal labor from a physiological standpoint. She hopes that her students will take away an understanding of comfort and coping mechanisms along with recognizing the emotions a mother might be experiencing and how a partner can help with both the physical and emotional aspects. Penny is one of the Plenary Speakers at the upcoming Lamaze International/DONA International Confluence scheduled for later this month in Kansas City, MO.  Read how Penny, a master childbirth educator, with this handy tool, helps parents understand what to expect  during labor and birth. – Sharon Muza, Community Manager, Science & Sensibility

Introduction

© Sarah Sweetmans

© Sarah Sweetmans

Childbirth educators strive to provide timely, accurate, woman-centered information. We adapt our content and teaching methods to the time allowed, and the variety of learning styles, educational levels and cultural backgrounds of our students. We hope to build trust in the normal birth process, and instill the confidence and competence necessary for parents to meet the challenges of childbirth, and also to communicate effectively with their maternity caregivers.

In this paper I describe a teaching aid, the roadmap of labor, and some ideas to help guide parents through normal childbirth, from early labor to active labor, transition, and the resting, descent and crowning-to-birth phases of the second stage. The discussion of each stage and phase includes what occurs, women’s and partners’ common emotional reactions, and advice on comfort measures and ways to work together to accomplish a safe and satisfying birth.

I do not describe how I teach about routine or indicated interventions, complications, pain medications, or surgical birth. Aside from space limitations, the real reason lies in my firm belief that when expectant parents appreciate the pure unaltered (and elegant!) physiological process of labor, they have more confidence that birth usually goes well, and they may feel reluctant to bypass it (with induction or cesarean) or alter it unnecessarily. Normal labor becomes the clear standard against which to assess the benefits and risks of specific interventions and the circumstances that increase or decrease their desirability.

If I combined the discussion of straightforward labor with complications and common procedures (along with their risks, benefits, and alternatives), parents would have a fragmented and confused perception of childbirth and an almost impossible burden of separating normal from abnormal, and elective from indicated procedures. All these topics must be covered, however, if parents are to participate in their care, whether labor is straightforward or not. Therefore I teach these topics in subsequent classes, using normal birth as the reference point. I also follow this approach in some other writings.1,2

Initiation of labor, the six ways 
to progress and signs of labor

There are some key concepts that childbirth educators can use to raise parents’ awareness and appreciation of events of late pregnancy and normal birth and how they can help the process flow smoothly. Parents need to understand these concepts well, so they can use the roadmap of labor to best advantage, and play a more confident and active role in labor.

For example, before introducing the roadmap, the teacher should inform parents about the hormonally- orchestrated processes in late pregnancy that prepare for birth, breastfeeding, and mutual mother-infant attachment. This is important because teachers face two common challenges: first, parents’ impatience to end the pregnancy due to discomfort, fatigue and eagerness to hold their baby; and second, the possibility of a long, discouraging pre-labor phase.

These challenges make parents more accepting of induction or vulnerable to the belief that there is something wrong. Parents need to understand that labor normally begins only when all of the following occur:

• The fetus is ready to thrive outside the uterus (breathing, suckling, maintaining body temperature, and more).
• The placenta has reached the point where it can no longer sustain the pregnancy.
• The uterus is ready to contract, open and expel the baby.
• The mother is ready to nourish and nurture her baby.

If parents understand that fetal maturity is essential in initiating the chain of events leading to labor, they may be more patient with the discomforts of late pregnancy, and less willing or anxious to induce labor without a medical reason.

The six ways to progress to a 
vaginal birth

Progress before and during labor and birth occurs in many ways, not simply cervical dilation and descent, which is what most people focus on. Labor unfolds gradually and includes six steps, four of which begin weeks before labor and involve the 
cervix. The cervix moves forward, ripens, effaces and then dilates. When parents understand that a long pre- or early labor is accomplishing necessary progress – preparing the cervix to dilate – they are less likely to become anxious or discouraged that nothing seems to be happening. The two other steps involve the fetus: the fetal head repositions during labor by flexing, rotating, and moulding to fit into the pelvis; and lastly, the fetus descends and is born.

Three categories of signs of labor

By placing these in the context of the six ways to progress, parents may be better able to recognize the differences between pre-labor (often called ‘false labor’) and labor.

Possible signs of labor

These include: nesting urge; soft bowel movements; abdominal cramping; and backache that causes restlessness. These may or may not continue to the clearer signs of labor and may be associated with early cervical changes.

Pre-labor signs

The most important of these is the first one:

  • Continuing ‘nonprogressing’ contractions (that is, over time,
the pattern remains the same; they do not become longer, stronger or
closer together)
  • Possible leaking of fluid from the vagina
  • Possible ‘show’ – bloody mucus discharge from the vagina

With these signs, the cervix is probably not dilating significantly, but is likely to be ripening and effacing (steps two and three of the six ways to progress).

Positive signs of labor

The most important of these is the first one:

  • Continuing, progressing contractions, i.e. contractions that become longer, stronger, and closer together (or at least two of those signs). These progressing contractions cause cervical dilation (steps four and five of the six ways to progress), which is the clinical definition of labor.
  • Spontaneous rupture of the membranes (SRM), especially with a gush of fluid. This happens before or at the onset of labor in about 8% of women at term.3 It most often happens late in labor. SRM is only a positive sign of labor 
in conjunction with continuing progressing contractions.

The roadmap of labor

I have created a visual guide to labor progress using the metaphor of a road map. It shows key labor landmarks, and appropriate activities and measures for comfort as labor progresses (see Figure 1).4 Parents can use it during labor as a reminder of where they are in the process and what to do. Teachers can use it as a tool for organized discussion of normal labor progress, and as a backdrop for discussing laboring women’s emotional reactions, and how partners or doulas may assist. Health professionals can use it to help parents identify where they are in labor, adjust their expectations and try appropriate comfort measures.

© Penny Simkin

© Penny Simkin

Normal labor pathway

The roadmap portrays three pathways. The main brick road represents normal labor and shows helpful actions, positions, and comforting techniques to use as labor progresses. The twists and turns in the brick road indicate that normal labor does not progress in a straight line; the large turns between three and five-to-six centimeters and between eight and ten centimeters indicate large emotional adjustments for the laboring woman, and present an opportunity to discuss emotional support and comfort measures for the partner or doula to use. After ten centimeters, the woman’s renewed energy and confidence are represented by the second wind sign. Along with discussion of emotional support and comfort measures, the teacher can offer perspective and practical advice for partners and doulas, to use both when the woman is coping well and when she feels challenged or distressed.

The roadmap provides a clear and effective way to teach about normal labor. It keeps the discussion focused purely on the physiological and psychological processes, without inserting discussions of pros and cons of interventions, complications, or usual policies and hospital practices that alter labor.

Image Source: © Sharon Muza

Image Source: © Sharon Muza

Once parents have a solid understanding of normal labor, the teacher can explain usual care practices and possible options for monitoring maternal and fetal well being during labor. She can also discuss labor variations or complications and treatments with medical (including pain medications), surgical or technological procedures. With this approach, parents are better equipped to discuss risks, benefits and alternatives, because they can distinguish situations and conditions that are more likely to benefit from the intervention from those in which the intervention is optional, unnecessary, or harmful.

Planned and spontaneous rituals

The normal labor road suggests measures to use for distraction, comfort, and progress. Distraction is desirable for as long as it helps. The Relax, Breathe, Focus sign reminds parents to use this pre-planned ritual for dealing with intensifying contractions when distraction is no longer possible. Parents need to rehearse these rituals in childbirth class (i.e. slow breathing, tension release, and constructive mental focus) and use them in early labor. They set the stage for the spontaneous rituals that emerge later in labor (as women enter active labor), when they realise they cannot control the contractions or continue their planned ritual, and give up their attempts to do so, though sometimes after a stressful struggle. Spontaneous rituals replace the planned ones. They are not planned in advance – they are almost instinctual – and almost always involve rhythmic activity through the contractions – breathing, moaning, swaying, stroking, rocking, or even letting rhythmic thoughts or phrases repeat like a mantra.

The three Rs

The spontaneous rituals usually involve the three Rs: relaxation (at least between contractions), rhythm, which is the most important, and ritual, the repetition of the same rhythmic activity for many contractions. In order to give herself over to spontaneous instinctual behavior, the woman needs to feel emotionally safe, uninhibited, accepted unconditionally by partner and staff, and to be mobile in order to find comfort.

The motto ‘Rhythm is everything’ means that if a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult. The rhythmic ritual keeps her from feeling totally overwhelmed. The goal is to keep her rhythm during contractions in the first stage. Once in second stage, however, rhythm is no longer the key. The woman becomes alert and her spirits are lifted. An involuntary urge to push usually takes over and guides her behavior.

The role of the partner in labor

The partner helps throughout labor, comforting the mother with food and drink, distraction, massage and pressure, assistance with positioning, and constant companionship. Sometimes a doula also accompanies them, providing continuing guidance, perspective, encouragement, and expertise with hands-on comfort measures, positions, and other techniques gained from her training and experience.2

The role of an effective birth partner includes being in the woman’s rhythm
– focusing on her and matching the rhythm of her vocalizations, breathing or movements – by swaying, stroking, moving hand or head, murmuring softly in her same rhythm. Then, if she has difficulty keeping her rhythm, and tenses, cries out or struggles – as frequently occurs in active labor or transition – her partner helps her get her rhythm back, by asking her to focus her eyes on their face or hand and follow their rhythmic movements. This is the take-charge routine, and is only used if the woman has lost her rhythm, is fearful, or feels she cannot go on. Partners who know about this are less likely to feel helpless, useless or frightened. Simple directions, given firmly, confidently, and kindly (‘look at me,’ or ‘look at my hand’), rhythmic hand or head movements, and ‘rhythm talk’ with each breath (murmuring, ‘Keep your rhythm, stay with me, that’s the way…‘) are immensely effective in helping the woman carry on through demanding contractions. During the second stage, rhythm is no longer important; now the partner encourages her bearing-down efforts and release of her pelvic floor, and also assists her with positions.

The motto “Rhythm is everything” means that if
 a woman has rhythm during contractions, she is coping, even though she may vocalize and find it difficult.

The detour for back pain

A second pathway, a rocky, rough road, represents the more difficult ‘back labor’, which may be more painful, longer, or
more complicated than the normal labor pathway. Fetal malposition is one possible cause. The measures shown for back labor are twofold: reduce the back pain and alter the effects of gravity and pelvic shape to encourage the fetus’s movement into and through the pelvis. It helps a woman endure a prolonged or painful back labor if she and her partner use appropriate comfort measures, and if they know that dilation may be delayed while the baby’s head molds or rotates to fit through, or that changing gravity and pelvic shape may give the extra room that the baby needs to move into an optimal position.

The epidural highway

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

This third pathway represents a dramatically different road – smooth, angular, man- made, more comfortable – but it comes with extensive precautions and numerous procedures, monitors, and medications, which are necessary to keep the epidural safe. The woman adopts a passive role while the staff manage labor progress, and monitors the mother’s and fetus’s well being closely. The excellent pain relief and chance to sleep are the usual rewards. Discussion of how to work with an epidural in order to optimize the outcome is beyond the scope of the paper, but the basic principle is: treat the woman with an epidural as much as possible like a woman who does not have one! This essentially means,‘Keep her cool. Keep her moving. Keep her involved in the work of pushing her baby out. And don’t assume that if she has no pain, she has no distress! Do not leave her alone.’

Conclusion

The roadmap of labor provides a useful framework for teachers to explain the psychological and physiological processes of labor, and a variety of activities for comfort and labor progress for women and their partners to use. By focusing on the normal unaltered process, parents learn to separate the norm from the numerous interventions that alter the process, sometimes for the better, sometimes for the worse. The intention is to give them confidence that they can handle normal labor and to participate meaningfully in decision-making when interventions are suggested.

Do you use the roadmap of labor as a teaching tool in your childbirth classes or with your clients?  How do you use it?  I would love to hear the innovative ways that you have found to incorporate this valuable tool in your classes.  Please share with Penny and all of us in the comments section. – SM

References

1. Simkin P. Moving beyond the debate: a holistic approach to understanding and treating effects of neuraxial analgesia. Birth 2012;39(4):327-32.

2. Simkin P. The birth partner: a complete guide
to childbirth for dads, doulas, and all other labor companions. 4th edition Harvard Common Press; 2013.

3. Marowitz A, Jordan R. Midwifery management of prelabor rupture of membranes at term. J Midwifery Womens Health 2007;52(3):199-206.

4. Simkin P. Road map of labor. Childbirth Graphics; 2003. Available from: www.childbirthgraphics. com/index.php/penny-simkin-s-road-map-of- labor-interactive-display.html

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 11,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2008), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

Copyright © NCT 2014. This article first appeared in NCT’s Perspective journal, edition March 2014.   http://www.nct.org.uk/professional/research

2014 Confluence, Cesarean Birth, Childbirth Education, Continuing Education, Guest Posts , , , ,

The Red/Purple Line: An Alternate Method For Assessing Cervical Dilation Using Visual Cues

July 3rd, 2014 by avatar

By Mindy Cockeram, LCCE

Today’s blog post is a repost of one of the most popular posts ever shared on our blog. It is written by Mindy Cockeram, LCCE.  Mindy explores the “mystical” red/purple line that has been observed to provide information about cervical dilation without the need for a vaginal exam. Have you seen such a line.  Do you have other ways of identifying dilation that do not involve cervical exams?  Please share in the comments- Sharon Muza, Science & Sensibility Community Manager.

When couples in my classes are learning techniques for coping in labor, such as the Sacral Rub (sacrum counterpressure), Double Hip Squeeze and Bladder32 accupressure points,  I always talk about the great position the partner is in for spotting the red, purple or dark line (depending on skin color) that creeps up between the laboring woman’s buttocks and how – by ‘reading’ that line – he or she may be able to assess more accurately the woman’s cervical progress than the health care providers!  This empowering thought is often met with smiles and laughter especially when I translate ‘natal cleft’ into more recognizable words like ‘butt cleavage’.  Strangely, I’ve never had anyone in class mention having heard of this ‘thermometer’ for accessing cervical dilation by sight and I find this interesting considering the number of medical professionals that come through my classes.

Photo CC http://www.flickr.com/photos/alexyra/214829536/

I first came across this body of research as an Antenatal Student Teacher with the National Childbirth Trust in London.  The article I was reading was in Practising Midwife and was a ‘look back’ at the original article (Hobbs, 1998) published in the same magazine.  The original Practising Midwife article was based on a letter referencing a small study by Byrne DL & Edmonds DK published in The Lancet in 1990.

In the 1990 letter to The Lancet, Byrne and Edmonds outlined and graphed 102 observations from eighteen midwifes on 48 laboring women. It states “The red line was seen on 91 (89%) occasions, and was completely absent in five (10.4%) women and initially absent in three (6.25%).”  The report then goes on to talk about the “significant correlation between the station of the fetal head and the red line length.”  Later the authors write: “To our knowledge, this is the first report of this red line.  We believe that it represents a clinical sign which is easy to recognize and which may offer valuable information in obstetric management.”

So how does this line work?  And why does this it appear?  Practising Midwife Magazine presented a graphic which I have attempted to recreate here.  Basically as the baby descends, a red/purplish (or perhaps brown depending on skin color) line creeps up from the anus to the top of the natal cleft in between the bottom cheeks.  When the line reaches the top of the natal cleft, 2nd stage is probably a matter of minutes away.  A line sitting an inch below the natal cleft is probably in transition.  A line just above the anus probably signifies early labor.

Byrne DL & Edmonds DK, the authors of the original study, surmise that the cause of the line is “vasocongestion at the base of the sacrum.” Furthermore, the authors reason that “this congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and red line length.”  Fascinating and logical!

Interestingly, I came across a 2nd Scottish study from 2010 published by BMC Pregnancy & Childbirth: (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M & Niven C) which aimed to assess the  percentage of women in which a line appeared (76%. ) The study cited only 48-56% accuracy of vaginal examinations to determine cervix diameter and fetal station.  So why aren’t clinicians using this less invasive visual measure – especially considering how much some women may dread vaginal exams in labor??  Wouldn’t the thought of using a methodology to lower infection rate after rupture of membranes has occurred enthuse Health Care Providers instead of using higher risk techniques?  Or how about using the accuracy of the line at the natal cleft to know when a women using epidural should really be coached to push?

My educated guess is that this information has not yet reached Medical Textbooks and non-standard practices can take years to become mainstream (for example. delayed cord clamping) – and then only if or when women request them or media sensation activates them.  In addition, since laboring women are only intermittently attended by Labor & Delivery staff during early and active labor and often encouraged to “stay in bed,” Health Care Providers aren’t necessarily faced with a woman’s buttocks in labor.  Also vaginal examinations are considered “accurate” so staff have no need to peek between a woman’s natal cleft.   However both these studies, paired with the roughly 50% accuracy rate of manual vaginal exams, show that there is potentially a more accurate and less invasive way ahead.

In The Practising Midwife (Jan 2007, Vol 10 no 1, pg 27), Lesley Hobbs writes “Accurate reading would seem to the key to this practice.  I sometimes notice in myself a wish to see the line progressing more quickly than it actually does; when I do this – and check with a vaginal exam – only to find the line is right, I get annoyed with myself and wish I’d trusted my observations.”  Later she goes on to say “I can now envisage a time when I shall feel confident enough to use this as my formal measurement mechanism and abandon intrusive and superfluous vaginal exams.”

Licensed Midwife Karen Baker from Yucaipa, CA commented “The purple line is a curious thing.  It’s definitely not present on everybody but is more prominent on some than others – especially right before pushing.  It tells us when she’s in full swing if we are in a good position to spot it!”

I often urge couples to send me a picture of the so called ‘purple line’ which I promise I will use only for educational purposes but so far a picture is as elusive as the Loch Ness Monster.  So, as I say in class, ‘show me your purple line’!

Are you a midwife, doctor, nurse or doula who has observed this in a client or patient? Partners, have you seen this when your partner was in labor? Has anyone heard of it or witnessed it?  If you are a childbirth educator, do you feel this is something that you might mention in your classes?  Do you think that the families in your classes might be likely to ask for this type of assessment if they knew about it? Please comment and share your experiences.

References

Byrne DL, Edmonds DK. 1990, Clinical method for evaluating progress in first stage labour.Lancet. 1990 Jan 13;335(8681):122.

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.

Hobbs 1998. Assessing cervical dilatation without Vaginal Exams. Watching the purple line. The Practising Midwife 1(11):34-5.

About Mindy Cockeram

Mindy Cockeram is a Lamaze Certified Childbirth Educator teaching for a large network of hospitals in Southern California.  She has a BA in Communications from Villanova University and qualified as an Antenatal Teacher through the United Kingdom’s National Childbirth Trust (NCT) in 2006.  A native of the Philadelphia area, she spent 20 years in London before relocating to Redlands, CA in 2010.

 

 

 

 

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