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60 Tips for Healthy Birth – Resources for Students and Suggested Teaching Activities

February 12th, 2014 by avatar

GBWC buttonIf you are in any way familiar with Lamaze International, hopefully you are aware of the Six Healthy Birth Practices.  Many years ago, I fell in love with these nifty “guidelines” that supported and reinforced everything that I had been teaching in my childbirth classes. These six care practices promoting safe and healthy birth each have their own list of citations of research supporting each care practice and a short, but extremely informative video to go along with each one.  As it has been a few years since the Six Healthy Birth Practices was released, Lamaze International is in the process of updating the citation sheets to source the most current information.

I want to bring your attention to a fantastic resource guide on the Six Healthy Care Practices that Community Manager Cara Terreri put together on Giving Birth With Confidence,  the Lamaze blog for parents and expectant families.  Cara created the “Sixty Tips for Healthy Birth” series, and in six separate blog posts provides ten tips for each Birth Practice that highlights working toward a healthy birth practice that promotes physiological birth.

60 Tips for Healthy Birth – From Giving Birth With Confidence

Part 1: Let Labor Begin on Its Own

Part 2: Walk, Move Around and Change Positions Throughout Labor

Part 3: Bring a Loved One, Friend or Doula for Continuous Support

Part 4: Avoid Interventions that Are Not Medically Necessary

Part 5: Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

Part 6: Keep Mother and Baby Together, It’s Best for Mother, Baby and Breastfeeding

Teaching Activities Using the Sixty Tips

childbirth ed classI have created several interactive teaching activities using Cara’s tips.  As each Healthy Birth Practice come up in your class, have the ten tips from the GBWC blog on strips of paper or small cards available to each family for individual work, or larger laminated cards for small group or whole class work.  Ask the families (or the class as a whole) to sort the cards into a logical order from easiest to hardest to accomplish.  They can indicate which tips have already been completed in their family and which ones might still be left to do.  If they completed the activity by individual family, facilitate a discussion as they share with the whole class.  If you conduct this activity as a whole class, this discussion will unfold naturally of course.  Alternately, they can sort the cards into the most important to least important for achieving this goal.  Or any other number of ways.

Families can build confidence that they have already successfully achieved several of the recommendations and identify things they still can do to support the type of birth they are planning.  They can also connect with other families, recognizing that everyone is working hard to be prepared.

Another way to use these tips in class is to provide the tips as a checklist and ask families to check off those that they have completed.  Ask families to challenge themselves to complete one of the items that they have not already done.  If it is a series class, you can check in at the end of the series and award a small prize to the family that has completed the largest number of tips.

A third suggestion is to ask students to add their own tips or create their own list for each Healthy Birth Practice.  Using newsprint, have one sheet for each Healthy Birth Practice, and break the class into groups, with each group working on one of the Practices, creating their own thoughts to go along with the 60 that Cara shared.

How do you see using the Sixty Tips for Healthy Birth in your childbirth classes?  Please share your ideas in our comments section so we can all learn and collaborate on great teaching ideas that help families have safer and healthier birth experiences.

 

 

 

Childbirth Education, Giving Birth with Confidence, Healthy Birth Practices, Healthy Care Practices, Maternity Care , , , , ,

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

January 16th, 2014 by avatar

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

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

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

Births in my new community

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Thoughts for the future

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

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

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

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

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

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

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

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

References

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

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

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

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

About Laurie Levy

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

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

The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

Click image to see full size

The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

Continuous Electronic Fetal Monitoring (Cardiotocography) in Labor: Should It Be Routine?

September 3rd, 2013 by avatar

Regular Science & Sensibility contributor and author Henci Goer takes a look at the recent Cochrane review “Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour” to determine if the researchers found any new information on the benefits or risks of CTG for normal, low risk labors.  Read on to see if things might have changed and are the hospitals in your area conforming with recommendations of ACOG, SCOG and RCOG?  Are these recommendations based on the evidence?  - Sharon Muza, Community Manager, Science & Sensibility

___________________

http://flic.kr/p/o43Lw

Almost all women laboring in U.S. hospitals undergo continuous electronic fetal monitoring (EFM) (Declercq 2006), but should they? A new iteration of the Cochrane systematic review of randomized controlled trials of EFM versus intermittent auscultation (listening) can answer that question (Alfirevic 2013).

The rationale behind continuous EFM was that insufficient oxygen (hypoxia) in labor was a major cause of intrapartum fetal death and permanent brain injury. It was thought that enhanced ability to pick up changes in fetal heart rate (FHR) patterns signaling distress would enable doctors to rescue the fetus in time to prevent perinatal death and cerebral palsy. Does that theory hold up in practice?

According to the Cochrane review, not so much—nor, I might add, is this news since all prior versions have reported the same results. Continuous EFM fails to decrease perinatal mortality, whether in women overall (11 trials, 33,513 participants) or in the subgroups of high-risk women (5 trials, 1974 participants), mixed-risk/risk not specified populations (3 trials, 15,490 participants), or low-risk women (3 trials, 16,049 participants). Neither does it reduce incidence of cerebral palsy whether in women overall (2 trials, 13,252 women) or in high-risk women (1 trial, 173 participants) or in a mixed-risk/risk not specified population (1 trial, 13,079). (No trial reported comparative cerebral palsy rates in low-risk women.) In fact, cerebral palsy rates were increased more than two-fold (risk ratio: 2.54) in the EFM group in the sole high-risk trial reporting this outcome, although with only 173 women and one trial, it is unclear what, if anything, should be made of this. The authors, noting that the delay between diagnosis and taking action was longer in the EFM group, speculated that EFM may have been providing a false sense of feeling in control of the situation (Shy 1990). So it turns out more information isn’t necessarily better information.

Continuous EFM isn’t a total washout. It reduces the incidence of neonatal seizure, which is of some benefit since neonatal seizure can indicate permanent brain injury, the likelihood of which depends on the severity of seizure and whether it is accompanied by other symptoms. Among women overall (9 trials, 32,386 participants), it halved seizure rates (risk ratio: 0.50). In high-risk populations (5 trials, 4805 participants), it reduced seizure rates (risk ratio: 0.67), but the difference failed to achieve statistical significance while in low-risk populations (3 trials, 25,175 participants), the reduction was by nearly two-thirds (risk ratio: 0.36), and in mixed-risk/risk not specified populations (2 trials, 2406 participants), the reduction approached 80% (risk ratio: 0.18). The reviewers calculate that with a baseline seizure risk of 3.0 per 1000 labors among women overall in the intermittent auscultation group, 667 women  would have to have continuous EFM in order to prevent 1 neonatal seizure. In low-risk women, in whom the baseline risk was 1.2 per 1000 labors with intermittent auscultation, my calculation raised that to 833 women.

Although continuous EFM fails in achieving its original goal of preventing perinatal death and cerebral palsy, the reduction in incidence of neonatal seizure would seem to argue for universal continuous EFM, were it not that this benefit comes at a price: continuous EFM increases the likelihood of cesarean surgery, and to a lesser degree, instrumental vaginal delivery, which increased among women overall by 15% (risk ratio: 1.15). Among women overall (11 trials, 18,861 participants), continuous EFM increased likelihood of cesarean by nearly two-thirds (risk ratio: 1.63); among high-risk women (6 trials, 2069 women), it doubled the risk (risk ratio: 1.91); it did the same (risk ratio: 2.06) among low-risk women (2 trials, 1431 participants) while among mixed-risk/risk not specified populations (3 trials, 15,361 participants), the rate was increased (risk ratio: 1.14), but the difference wasn’t statistically significant. The reviewers calculate that assuming a 15% cesarean rate with intermittent auscultation, one additional cesarean would be performed for every 11 women monitored, and 61 additional cesareans would be performed to prevent 1 seizure. In low-risk women, my calculation found that 1 additional cesarean would be performed for every 6 women monitored, and 76 additional cesareans would be performed to prevent 1 seizure.

The Cochrane reviewers conclude that women should be informed that EFM neither reduces perinatal mortality nor cerebral palsy and that while it reduces incidence of neonatal seizures, it does so at the cost of increased cesarean and instrumental vaginal deliveries. Cesarean and instrumental deliveries, I hardly need point out, have their own associated harms, some of them quite serious, and these must be set against the reduction in seizures (Childbirth Connection 2012; Goer 2012). The reviewers write:

Given the perceived conflict between the risk for the mother . . . and benefit for the baby . . . , it is difficult to make quality judgments as to which effect is more important. . . . The real challenge is how best to convey this uncertainty to women and help them to make an informed choice without compromising the normality of labour.

That gives us our marching orders, but how best might we carry them out? One reasonable course would be to see what obstetric guidelines advise.

http://flic.kr/p/98pfNc

The least decisive recommendation comes from the American Congress of Obstetricians and Gynecologists (2009), whose guidelines state: “Given that the available data do not show a clear benefit for the use of EFM over intermittent auscultation, either option is acceptable in a patient without complications” (p. 196). This suggests equivalency between the two, but, of course, they aren’t equivalent because continuous EFM increases likelihood of cesarean and instrumental vaginal delivery. ACOG further recommends that “the labor of women with high-risk conditions (eg, suspected fetal growth restriction, preeclampsia, and type 1 diabetes) should be monitored with continuous FHR monitoring” (p. 196), although they later acknowledge that this recommendation is based on “Level C” evidence, “expert opinion.”

The U.K. Royal College of Obstetricians and Gynaecologists takes a stronger stance: “Intermittent auscultation of the FHR is recommended for low-risk women in established labour in any birth setting” (p.155) (National Collaborating Center for Women’s and Children’s Health 2007). The Royal College advises switching to continuous EFM in low-risk women for these reasons:

  • significant meconium, with consideration for making the switch with light meconium
  • abnormal FHR is detected by intermittent auscultation
  • maternal fever
  • fresh bleeding developing in labor
  • oxytocin use for augmentation [I would assume this would also cover oxytocin induction.]
  • the woman’s request

The Canadian Society of Obstetricians and Gynaecologists provides the most detailed advice of all (Liston 2007). SOGC guidelines state: “Intermittent auscultation . . . is the recommended method of fetal surveillance [in healthy term women in spontaneous term labor who are free of risk factors for adverse perinatal outcome]” (p. S6). In women with risk factors for adverse perinatal outcome, the SOGC, like ACOG, recommends continuous EFM while acknowledging that “little scientific evidence” (p. S33) supports it. However, SOGC guidelines additionally state: “When a normal tracing is identified, it may be appropriate to interrupt the electronic fetal monitoring tracing for up to 30 minutes to facilitate periods of ambulation, bathing, or position change, providing that (1) the maternal-fetal condition is stable and (2) if oxytocin is being administered, the infusion rate is not increased” (p. S6).

The consistent recommendation that intermittent auscultation is preferable (in the case of RCOG and SOGC), or at least acceptable (in the case of ACOG), in low-risk women in spontaneous labor answers the question posed in the title. No, continuous EFM should not be routine, and we are on solid ground sharing this information and its sources with pregnant women.

Unfortunately, this doesn’t help most low-risk women laboring in U.S. hospitals because they will have either an epidural, be receiving oxytocin, or both. The SOGC guidelines can serve us here. With epidural analgesia, the guidelines state: “Intermittent auscultation may be used to monitor the fetus when epidural analgesia is used during labour, provided that a protocol is in place for frequent intermittent auscultation assessment (e.g., every 5 minutes for 30 minutes after epidural initiation and after bolus top-ups as long as maternal vital signs are normal)” (p. S6), and the SOGC guidelines treat induction and augmentation the same as women with risk factors, that is, with continuous EFM but permitting breaks if mother, baby, and oxytocin dose are stable. Suggesting that women in these categories request that their caregivers follow SOGC guidelines seems a pragmatic approach to achieving any benefits continuous EFM may provide while potentially reducing harms.

I could end here, but I can’t help asking: Why stop with search and rescue of hypoxic babies? Why not look at prevention? Among the 10,053 low-risk women at the Dublin Maternity Hospital, the neonatal seizure rates were 10 times (14 per 10,000 continuous EFM vs. 38 per 10,000 intermittent auscultation) those in the 14,618 women in the Dallas trial (1 per 10,000 continuous EFM vs. 4 per 10,000 intermittent auscultation) (Alfirevic 2013). I doubt that it’s coincidental that the Dublin Maternity Hospital is the home of Active Management of Labor, which prescribes routine early rupture of membranes and high doses of oxytocin with a short interval between dose increases for any woman not progressing at a minimum 1 cm dilation per hour. Early rupture of membranes, induction, and high-dose/short interval oxytocin regimens all increase stress on the fetus (Goer 2012). I think educators and doulas have a role to play here too. We can point women to Lamaze’s Healthy Birth Practices #1 and #4 to help them start a conversation with their care providers about labor induction and artificial rupture of membranes. And while women aren’t in a position to dictate oxytocin regimen, nurses and other hospital insiders can lobby for uniformly instituting the more physiologic oxytocin protocol found in Pitocin packaging if their hospital doesn’t mandate it already. An ounce of prevention is worth a pound of cure not the least because prevention has no adverse effects.

References

ACOG. (2009). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. ACOG Practice Bulletin No. 106. http://www.ncbi.nlm.nih.gov/pubmed/19546798

Alfirevic, Z., Devane, D., & Gyte, G. M. (2013). Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev, 5, CD006066. doi: 10.1002/14651858.CD006066.pub2 http://www.ncbi.nlm.nih.gov/pubmed/23728657

Childbirth Connection. (2012). Vaginal or Cesarean Birth: What Is at Stake for Women and Babies? New York. http://transform.childbirthconnection.org/reports/cesarean/

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II:  Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Goer, H., & Romano, Amy. (2012). Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle: Classic Day Publishing.

Liston, R., Sawchuck, D., & Young, D. (2007). Fetal health surveillance: antepartum and intrapartum consensus guideline. J Obstet Gynaecol Can, 29(9 Suppl 4), S3-56. http://www.sogc.org/guidelines/documents/gui197CPG0709r.pdf

National Collaborating Centre for Women’s and Children’s Health. (2007). Intrapartum care. Care of healthy women and their babies during childbirth. London: NICE. http://www.nice.org.uk/nicemedia/live/11837/36275/36275.pdf

Shy, K. K., Luthy, D. A., Bennett, F. C., Whitfield, M., Larson, E. B., van Belle, G., . . . Stenchever, M. A. (1990). Effects of electronic fetal-heart-rate monitoring, as compared with periodic auscultation, on the neurologic development of premature infants. N Engl J Med, 322(9), 588-593. http://www.ncbi.nlm.nih.gov/pubmed/2406602?dopt=Citation

 

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

July 11th, 2013 by avatar

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

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© www.momaroo.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

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