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Evidence for the Vitamin K Shot in Newborns – Exclusive Q&A with Rebecca Dekker on her New Research

March 18th, 2014 by avatar

 Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just published a new article, “Evidence for the Vitamin K Shot in Newborns that examines Vitamin K deficiency bleeding (VKDB)- a rare but serious consequence of insufficient Vitamin K in a newborn or infant that can be prevented by administering an injection of Vitamin K at birth.  I had the opportunity to ask Rebecca some questions about her research into the evidence and some of her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Note:  Evidence Based Birth website may be temporarily unavailable due to high volume loads on their server.  Please be patient with the site, I know the EBB team is working on it.

Sharon Muza: Why was the topic of Vitamin K an important one for you to cover and why now?

Rebecca Dekker: Well, I try to pick my articles based on what my audience wants me to cover. I heard over and over again that people were confused and concerned about Vitamin K. A lot of parents told me they weren’t sure if they should consent to the injection or not. There was just so much confusion, and even I didn’t understand what the Vitamin K shot was all about. I didn’t know what I was going to do at the birth of my own child last December. It seemed like there was a need for an evidence-based blog article to clear up all the confusion once and for all.

So as usual, I dove in head first into the research, with no up-front biases one way or the other. I just wanted to get to the bottom of this mess!

SM: Were you surprised by what the current research showed about the rates of VKDB, and the apparent significant protection offered by the Vitamin K shot?

RD: I knew that Vitamin K deficiency bleeding (VKDB) was rare, but I didn’t realize—until I started reading the research—how effective the shot is at basically eliminating this life-threatening problem.

I was surprised by how low the rates of VKDB are in European studies, and by how VKDB is more common in Asian populations. I was also surprised by the fact that we don’t track VKDB in the U.S. and we have no idea how many infants in the U.S. would develop VKDB if we stopped giving the shot.

The number of infants in Tennessee last year who developed VKDB is very concerning to me. They had 5 cases of life-threatening VKDB in Nashville during an 8 month period—7 if you count the infants who were found to have severe Vitamin K deficiencies but didn’t bleed. None of these infants received Vitamin K, mostly because their parents thought it was unnecessary and weren’t accurately informed about the risks of declining the shot.

So the Tennessee situation makes me worry that maybe there is something about our diets in America, or our genetics, that makes us at higher risk for VKDB if we decline the Vitamin K shot for our newborns. But we don’t know our underlying risk, because we don’t track these numbers on a nationwide scale.

SM: What was the most surprising finding to you in writing this article?

RD: That the research on Vitamin K for newborns goes back as far as the 1930’s and 1940’s… that we have literally eight or nine decades of research backing up the use of Vitamin K for newborns. I was under the impression that we were using the shot without any supporting evidence. That turned out not to be the case.

I even forked out the money to buy the landmark 1944 study in which a Swedish researcher gave Vitamin K to more than 13,000 newborns. He observed a drastic decrease in deaths from bleeding during the first week of life. I am usually able to read all of my articles through my various subscriptions, but this article was so old the only way I could read it was to buy it. It was pretty eye-opening. There was some really good research going on back then on Vitamin K. About 15 years later, the American Academy of Pediatrics finally recommended giving Vitamin K at birth. We know that it takes about 15 years for research to make its way into practice. It looks like the same was true back then.

But there is this misconception that “Vitamin K doesn’t have any evidence supporting its use,” and I found that belief is totally untrue. There is a lot of evidence out there. People have just forgotten about it or not realized it was there.

SM: What was the most interesting finding to you in writing this article?

RD: That the two main risk factors for late Vitamin K deficiency bleeding (the most dangerous kind of VKDB that usually involves brain bleeding) are exclusive breastfeeding and not giving the Vitamin K shot.

Parents who have been declining the shot are the ones who are probably exclusively breastfeeding. So their infants are at highest risk for VKDB.

SM: What do you think is the biggest misconception around the Vitamin K shot?

RD: How do I choose which one? There are so many misconceptions and myths. I’ve heard them all. The scary thing is, I’ve heard these misconceptions from doulas and childbirth educators—the very people that parents are often getting their information from. I’ve heard: “You don’t need Vitamin K if you aren’t going to circumcise.” “Getting the shot isn’t necessary.” “Getting the shot causes childhood cancer.” “Getting the shot is unnatural and it’s full of toxins that will harm your baby.” “You don’t need the shot as long as you have delayed cord clamping.” “You don’t need the shot if you had a gentle birth.”

Informed consent and refusal isn’t truly informed if you’re giving parents inaccurate information.

SM: What do you think are the sources of information that families are using to make the Vitamin K decision and where are they getting this information from? Do you think families trust the evidence around this?

RD: This is what I did—I googled “Vitamin K for newborns” and read some of the blog articles that pop up on the front page of results. It is truly alarming the things that parents are reading. “Vitamin K leads to a 1 in 500 chance of leukemia.” “Vitamin K is full of toxins.” Most of the articles on the front page of results are written by people who have no healthcare or research background and did not do any reference checking to see if what they were saying was accurate. It’s appalling to me that some bloggers are putting such bad information out there.

If parents don’t trust the evidence, it may be because they have read so many of these bad articles that it’s hard to overcome the bias against Vitamin K. All I can say is, given the number of bad articles on the internet about Vitamin K, I can totally understand the confusion people have.

I mean, even I was confused before I started diving into the research! I truly went into this experience with no pre-existing biases. I just wanted to figure out the truth. If even I—the founder of Evidence Based Birth—didn’t know all the facts about Vitamin K, then I think that’s a pretty good sign that most other people don’t know the facts, either!

To help remedy the amount of misinformation out there, I’d like for the new Evidence Based Birth article to make it towards the top of the Google results so that parents can read evidence-based information on Vitamin K and check out the references for themselves.

SM: In your article, you state “The official cause of classical VKDB is listed as “unknown,” but breastfeeding and poor feeding (<100 mL milk/day) are major risk factors.” – Why, if breastmilk offers little to no protection against VKBD, is “poor feeding” seen as a risk factor?  What should it matter?

RD: Poor feeding is a risk factor for classical VKDB, which happens in the first week of life. There are limited amounts of Vitamin K in breastmilk overall, but there is more Vitamin K in colostrum than in mature milk. So infants who don’t receive enough milk in those first few days may be at higher risk. This connection was first observed by Dr. Townsend in Boston in the 1890’s. He figured out that he could help some infants with early bleeding by getting them to a wet nurse. These infants weren’t getting enough milk from their biological mothers, for whatever reasons.

SM: Are families in the USA receiving proper informed consent around the issue of Vitamin K and the risks and benefits of the different options available to their children at birth (injection, oral,  or declination of both?)

RD: I’m not sure, but my gut reaction is that I don’t think parents are giving informed consent. In my case, when my first child received the shot, I wasn’t even told that she got it! They just did it in the nursery when they separated me from my daughter after birth. It would have been nice to receive some education on it and be given the chance to consent. Maybe if healthcare providers had been properly consenting parents all along, we wouldn’t have so much misinformation out there! By taking parents out of the equation and doing the shot in the nursery without their knowledge, that certainly doesn’t help educate the public!

I don’t think we are doing a very good job with the parents who decline the shot, either. If you read the part of my article where I wrote about the epidemic in Nashville, all of the parents refused the shot, but none of the parents gave informed refusal. All of them had been given inaccurate information about the shot, so they couldn’t make a truly informed decision. Can you imagine what it must be like for the people who gave them the inaccurate information? That would be so terrible to know that your misinformation may have led to the parents making the choice that they did. 

SM: What should the information look like during the consent process so that families can make informed decisions about having their newborns receive Vitamin K in injection or oral form.

RD: I think the CDC has a really great handout that can be used for informed consent. If parents want more detailed information and references, or if they have concerns that the CDC handout doesn’t answer, then the Evidence Based Birth blog article covers most of the research out there. 

Also, here is a link to a peer-reviewed manuscript that is free full-text, and although it is written at a higher level, it does a good job addressing the myths about the Vitamin K shot.

SM: Are you aware of any adverse effects from either the injection or the oral administration of Vitamin K, other than bruising, pain and bleeding at the injection site if an injection pathway is chosen?

RD: Not if given via the intramuscular method. Some bloggers out there look at the medication information sheet and immediately start pointing out some scary sounding side effects. It’s important to realize that those side effects refer to intravenous administration. Giving a medication intravenously (IV) is a whole different ballgame than giving an intramuscular shot (IM). In general, medications have the potential to be a lot more dangerous if they are given IV—because when medications are given IV they go straight to the heart and all throughout the circulation in potent quantities. For newborns, the Vitamin K is given IM, not IV, which is a much safer method of giving medications in general.

SM: In a childbirth education class, with limited time and a lot of material to cover, what message do you think educators should be sharing about the Vitamin K options.

RD: If I had to sum it up in a minute or less, I would share that babies are born with limited amounts of Vitamin K, and Vitamin K is necessary for clotting. Although bleeding from not having enough Vitamin K is rare, when it happens it can be deadly and strike without warning, and half of all cases involve bleeding in the baby’s brain.

Breastfed babies are at higher risk for Vitamin K bleeding because there are very low levels of Vitamin K in breastmilk. Giving a breastfed infant a Vitamin K shot virtually eliminates the chance of life-threatening Vitamin K deficiency bleeding. The only known adverse effects of the shot are pain, bleeding, and bruising at the site of the injection.

Right now there is no FDA-approved version of oral Vitamin K, although you can buy a non-regulated Vitamin K supplement online. A regimen of three doses of oral Vitamin K1 at birth, 1 week, and 1 month reduces the risk of bleeding. Although oral Vitamin K1 is better than nothing, it is not 100% effective. It is important for parents to administer all 3 doses in order for this regimen to help lower the risk of late Vitamin K deficiency bleeding.

If parents want to use the oral method, or decline the Vitamin K altogether, I would encourage them to do their research and talk with their healthcare provider so that they truly understand the risks of declining the injection. I would tell them to take caution when reading materials online because there is a lot of misinformation out there and you don’t want them making important healthcare decisions based on faulty information.

 SM: How should a childbirth educator (or other professional who works with birthing women) respond when asked  by parents “Why does breastmilk, the perfect food for babies, not offer the protection that babies need? It doesn’t make sense?”

RD: Breastmilk is the perfect food for babies! But for some reason—we don’t know why—Vitamin K doesn’t do a very good job of going from the mom to the baby through breastmilk. Our diets today are probably low in Vitamin K (green leafy vegetables), which doesn’t help matters, either.

It’s possible that maybe there is some reason we don’t know of that could explain why Vitamin K doesn’t cross the placenta or get into breastmilk very well. Maybe the same mechanism that keeps Vitamin K out of breastmilk is protecting our babies from some other environmental toxin. Who knows?

If it helps, look at it this way—don’t blame it on the breastmilk! Blame it on the Vitamin K! That pesky little molecule doesn’t do a good job of getting from one place to the other. So we have to give our infants a little boost at the beginning of life to help them out until they start eating Vitamin K on their own at around 6 months.

SM: If formula feeding is protective, because of the addition of Vitamin K in the formula, why wouldn’t oral dosing of Vitamin K be effective for the exclusively breastfed infant  – is it just a compliance issue?

RD: Part of the failure of oral Vitamin K is compliance—not all parents will give the full regimen of oral doses, no matter how well-intentioned they are. But research from Germany shows that half of the cases of late VKDB occur in infants who completed all 3 doses. It’s thought that maybe some infants don’t absorb the Vitamin K as well orally. Vitamin K is a fat-soluble vitamin, and it needs to be eaten with fatty foods or fatty acids in order for it to be absorbed. So maybe some of those infants had the Vitamin K on an empty stomach. Or maybe they spit it up!

SM: Do you expect a strong reaction from any particular segment of professionals or consumers about your findings?

RD: No more so than when I published the Group B Strep article!

I anticipate that some people may think that the shot is too painful for newborns, and they may theorize that this pain will cause life-long psychological distress. Unfortunately there really isn’t any evidence to back that claim up, and so I can’t really address this theory. But I have spoken with parents and nurses, and they say that having the baby breastfeed while the shot is administered can drastically reduce the pain of the shot.

I would encourage parents who are worried about pain to weigh these two things: the chance of your infant experiencing temporary pain with an injection, versus the possibility of a brain bleed if you don’t get the shot.

 SM: Any last thoughts that you  would like to share with Science & Sensibility readers on this topic?

RD: You can be a natural-minded parent… interested in natural birth and naturally healthy living, and still consent to your newborn having a shot with a Vitamin K to prevent bleeding. These things are not mutually exclusive. One hundred years ago, infants with Vitamin K deficiency bleeding would have died with no known cause. But today, we have the chance to prevent these deaths and brain injuries using a very simple remedy. The discovery of Vitamin K and its ability to prevent deadly bleeds is a pretty amazing gift. I am thankful to all of the researchers and scientists who used their talents and gifts and got us to this point, where we now have the power to prevent these tragedies 100% of the time.

I want to thank Rebecca Dekker for taking the time to answer my questions  I always look forward to Rebecca’s new articles, and appreciate the effort she puts into preparing them,  Have you had a chance to read Rebecca Dekker’s new post on the Evidence for Vitamin K Shots in Newborns?  Will you be changing what you say to your clients or patients based on what you read or based on this interview with Rebecca?  What are your thoughts on this information?  Are you surprised by anything you learned?  I am very interested in your thoughts – please share in our comments section. – SM

Babies, Childbirth Education, Evidence Based Medicine, informed Consent, New Research, Newborns, Research, Vaccinations , , , , , , , ,

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 , , , , , , , , , , ,

Lamaze International Releases Valuable Cesarean Infographic For You To Share!

October 10th, 2013 by avatar

Lamaze International has long been a leader in providing resources for both parents and birth professionals that promote safe and healthy birth for women and babies.  Evidence based information, appealing handouts, useful webinars for both parents and professionals, continuing education opportunities and more can all be found within the Lamaze International structure.  In May, 2012, Lamaze International released  (and later went on to be a co-winner for the 2013 Nonprofit PR Award for Digital PR and Marketing) the Push For Your Baby campaign, which encouraged families to “push for better” and “spot the best care,” providing resources to help parents wade through the overabundance of often inaccurate information swimming past them, and make choices that support a healthy pregnancy, a healthy birth and a healthy mother and baby.

Today, as I make my way to New Orleans, to join other professionals at the 2013 Annual Lamaze International Conference, “Let the Good Times Roll for Safe and Healthy Birth,” Lamaze International is pleased to announce the release of a useful and appealing infographic titled “What’s the Deal with Cesareans?” In the USA today, 1 in 3 mothers will give birth by cesarean section.  While, many cesareans are necessary, others are often a result of interventions performed at the end of pregnancy or during labor for no medical reason.  For many families, easy to understand, accurate information is hard to find and they feel pressure to follow their health care provider’s suggestions, even if it is not evidence based or following best practice guidelines.

Families taking Lamaze classes are learning about the Six Healthy Birth Practices, which can help them to avoid unnecessary interventions. Now, Lamaze childbirth educators and others can share (and post in their classrooms) this attractive infographic that highlights the situation of too many unneeded cesareans in our country.  Parents and educators alike can easily see what the risks of cesarean surgery to mother and baby are, and learn how to reduce the likelihood of having a cesarean in the absence of medical need.

In this infographic, women are encouraged to take Lamaze childbirth classes, work with a doula, select a provider with a low rate of cesarean births, advocate for vaginal birth after cesarean and follow the Six Healthy Care Practices, to set themselves up for the best birth possible.  This infographic clearly states the problem of unneeded cesareans, the risks to mother and baby, and provides do-able actions steps.

It is time for women to become the best advocate possible for their birth and their baby.  With this appealing, useful and informative infographic poster, families can and will make better choices and know to seek out additional information and resources.

Educators and other birth professionals, you can find a high resolution infographic to download and print here.

Send your families to the Lamaze International site for parents, to find the infographic and other useful information on cesarean surgery.

For Lamaze members, log in to our professional site to access this infographic and a whole slew of other useful classroom activities, handouts and information sheets.

I am proud to say that I am a Lamaze Certified Childbirth Educator, and that my organization, Lamaze International, is leading the way in advocating for healthier births for mothers and babies through sources such as the “What’s the Deal with Cesareans?” infographic and other evidence based information and resources.  Thank you Lamaze!

What do you think of this infographic?  How are you going to use it with the families you work with?  Can you think of how you might incorporate this into your childbirth classes or discuss with clients and patients?  Let us know in the comments section, we would love your feedback!  And, see you at the conference!

 

 

Babies, Cesarean Birth, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Lamaze International, Lamaze International 2013 Annual Conference, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, Patient Advocacy, Push for Your Baby , , , , , , , , ,

Supporting Families in Milk Sharing; What are the Responsibilities of the Childbirth Professional

August 15th, 2013 by avatar

By Amber McCann, IBCLC

Today’s post is written by Amber McCann, IBCLC.  Amber is one of the two keynote speakers at the upcoming Lamaze International Annual Conference in New Orleans this October.  Science & Sensibility readers had a chance to “meet” Amber in yesterday’s interview on the blog. Today Amber shares her perspective on discussing milk sharing with the families we work with. To learn more about Amber and what she will be speaking about at the conference, please click here.  See you in New Orleans!  Let the good times roll for safe and healthy birth!

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Almost a year ago, I wrote a post on my blog entitled “Supporting Families in Milk Sharing as an International Board Certified Lactation Consultant”. In it, I laid out some of my key beliefs, not only about the value of human milk for babies, but about what my profession dictates I do when presented with the opportunity to educate and inform about human milk sharing. I’ve come to think that these same obligations are universal to all of those who encounter and advise pregnant families, including childbirth educators. My core belief is this:

 I believe that parents are capable of making the choices that are best for themselves and their families.

It is my job to make sure they have all of the information to do so.

In my work, and I’m sure the same is true for most of you, I encounter families every day who, for a variety of reasons, need to supplement their baby’s nutrition with something other than milk directly from the mother’s breast. There are many options available to them including pumping and feeding their own milk, supplementing with the milk of another human mother, formulas made from cow’s milk, formulas made from soy, formulas that are pre-digested, etc. No option should be assumed as the RIGHT option for any particular family. By educating and providing information, we can help parents make the choices that work best for their own families.

 The World Health Organization, it its Global Strategy for Infant and Young Child Feeding, says, 

“for those few health situations where infants cannot, or should not, be breastfed, the choice of the best alternative – expressed breast milk from an infant’s own mother, breast milk from a healthy wet-nurse or human-milk bank, or a breastmilk substitute…depends on individual circumstance.”

In our current environment, actual wet-nursing is deemed by many to be too inconvenient, too intimate, and – if you will – too gross. But what about the sharing of breast milk from one mother to another? Since most mothers have access to a breast pump, it has become increasingly easy to package milk in a shareable form. Many groups, such as Human Milk 4 Human Babies (HM4HB), have formed in the past years to provide a space for families in need to connect with families who want to give. Feeding a child the milk from a mother not their own is a viable solution to some family’s supplementation needs. Can we, as birth and breastfeeding professionals, share this option with the families I serve? I answer with a strong and firm YES. 

When I began providing information on milk sharing with my colleagues and clients, I wasn’t quite prepared for the strong backlash I would receive. “What if a baby gets sick and dies?!?” Despite the fact that many in my field have participated in milk sharing themselves, there is a palpable fear, on the professional level, that one bad outcome from milk sharing would halt all of the positive momentum that breastfeeding is gaining in our culture. I even had one colleague say to me, “These women…these women who are doing this are going to hurt or even kill their babies.” I maintain that they are simply trying to provide the food that they were designed to eat.

But, what about the RISKS? Wouldn’t I be putting the lives of the babies I serve at risk if I offer milk sharing as an option? I maintain that there is nothing in life that is without risk. Is milk sharing risk free? Absolutely not. There are also risks to breastfeeding and formula feeding. Dr. Karleen Gribble and Dr. Bernice Hausman discuss these concerns in their paper Milk Sharing and Formula Feeding: Infant Feeding Risks in Comparative Perspective. In it, they explore the issues of contamination of milk with pathogens, chemicals, concerns with milk collection and storage hygiene. They also discuss the risks to formula use that are not present when feeding human milk. In addition, there is a section devoted to the risk of HIV from the use of shared milk. I strongly advise every professional encountering and advising new mothers, as well as any family we are working with, to read this paper and discuss their concerns. Drs. Gribble and Hausman conclude that “instead of proscribing peer-to-peer milk sharing, health authorities should provide parents with guidance on how to manage and minimize the risks of sharing human milk.”

How do childbirth professionals instruct and inform new families about the risks and benefits of consuming or donating shared milk? How do we advise families to mitigate those risks?

For recipients: When someone I work with is in need of milk and is considering milk sharing, I strongly encourage them to think about whether people they already know might be willing to donate. They also might explore location-based online milk sharing groups (like HM4HB), and then groups that facilitate broader-range sharing and the shipping of donor breast milk (like MilkShare). I do not condone the sale and purchase of breastmilk and I strongly encourage those I work with to not consider it as an option.

No matter where the milk is coming from, I encourage those considering milk sharing to thoroughly research what sorts of screening they consider essential (such as blood work from pregnancy and questionnaires about lifestyle choices such as alcohol and medication use). It is important that both parties have clear expectations about what their milk sharing arrangement looks like. At no point should I, as an IBCLC, nor you, as childbirth professional, engage with the recipient family as a “milk broker.” The family is fully responsible for finding, contacting and making arrangements with their milk donors. Our role with milk recipients is only to provide information and resources. 

Of note, it is always my hope that supplementation of any type can be eliminated or minimized because of an increase in a mother’s own ability to make milk. The milk sharing community is often particularly in tune with the need and desire of mothers to work hard to rebuild their milk supply.  Some families get a donor and a cheerleader-in-one! Many mothers feed donor milk through the use of a supplemental feeder, which can help mothers to produce increasing amounts of their own milk by stimulating the breast while delivering the supplement. There are many stories of those who were in need of donor milk, were able to rebuild their supply and then donate milk back into the community. 

For donors: I often have mothers, in their glee at how much milk their body is making, send me an email saying they “had so much we had to dump it down the sink.” Nothing strikes panic into the heart of a lactation professional faster! If a mother tells me, as her lactation consultant, that she has more milk than she knows what to do with, I offer her information about donation. I share with her the options of contributing to a HMBANA milk bank, donating directly to another family or sharing her milk with a for-profit milk bank. (Though I have significant ethical concerns about these banks, I do share the information so that they can make the best decision for their family.)

I stress to the family that the milk they have is first and foremost for their own baby. I know that many families feel incredibly proud and thankful to be able to share of their excess. I encourage families to participate openly and honestly in all screening with their recipient family and to make sure that both parties have clear expectations about what their milk sharing arrangement looks like. At no point should I, as an IBCLC, nor you, as a childbirth professional, engage with the recipient family as a “milk broker.” The family is fully responsible for finding, contacting and making arrangements with their milk donors. Our role with milk recipients is only to provide information and resources.

An obvious question in all of this is why wouldn’t a mother in need of additional milk for her child simply obtain it from a milk bank? Then we wouldn’t be talking about risks of disease and contamination. In an ideal world, families would be able to receive ALL the milk they need from milk banks. Milk banks would be located in every community and have an unending supply of milk. I believe this can be a reality. I believe that there can be plenty of milk available to every baby that needs it. As a passionate advocate for getting human milk to human babies, Emma Kwasnica says, “milk is a free flowing resource.” 

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Unfortunately, in the United States, this isn’t yet the reality. As a nation, we need to drastically increase the number of milk banks and the amount of human donor milk available. The Human Milk Banking Association of North America (HMBANA) currently has 12 active banks. These banks do incredible work and, rightly so, their priority is on making sure that the MOST CRITICAL babies receive the milk that they process. For these little ones, having access to human milk can be, quite literally, a matter of life and death. Often, several milk banks, including those in Indiana and Utah, issue pleas in the media for increased donations because their supplies are low. It is absolutely essential that these babies be the first to have access to processed donor milk.

Does every baby need its milk processed by a milk bank focused on the needs of vulnerable infants? For the most fragile babies, the complex processes of a milk bank (milk pooling, pasteurizing, and testing) are critical.  The needs of a healthy term newborn are different. I liken it to this:  If you had a dear friend who had recently received an organ transplant, you would do everything within your power to visit with them in a healthy manner by scrubbing arms and hands and wearing a mask.  But, if that same friend has just gone through a “healthy” event, like birth, you would simply wash your hands. Different circumstances require different levels of caution.

 Where does that leave healthy babies? In my practice, I see many mothers who, for of a variety of physical, emotional or circumstantial reasons don’t make the milk that their baby needs. At some milk banks, families of healthy babies can sometimes purchase donor milk but it is typically in limited quantities, and only available when supplies exist to meet the need of critical infants first. While the cost associated is reasonable, considering the cost of processing by the milk bank, it is often prohibitive to the families in need. 

Is the only option for these families infant formula? I have every confidence that the human milk banking advocates all over the globe would affirm the belief that all babies have the right to human milk. I think that milk banking and milk sharing CURRENTLY serve very different populations of babies. Above all, my loyalties are not to milk banks or the milk sharing movement, but rather to babies and their families. There is room in the community for both methods of getting human milk to human babies.

 I have been privileged to work with a number of families who were involved in milk sharing, both on the donor side and on the recipient side. I have seen milk donations have a significant impact on the health of a child. I have seen milk donations foster community that might not have happened otherwise. I have seen milk donations turn grief into hope. I have seen milk donations empower families and save babies’ lives.

Milk sharing is not the right choice for every mother in need. Milk sharing is not the right choice for every mother who desires to donate her milk. But for many families, milk sharing facilitates health, community building, and an opportunity to reclaim the breastfeeding experience for those whose journey didn’t go as they planned.

Again, I affirm that parents are capable of making the choice that is best for their families.

It is my job to make sure they have all the information to do so.

References

Gribble KD, Hausman BL. Milk sharing and formula feeding: Infant feeding risks in comparative perspective. AMJ 2012, 5, 5, 275-283.http//dx.doi.org/10.4066/AMJ.2012.1222.

World Health Organisation Staff. (2003). Global strategy for infant and young child feeding. World Health Organization.

About Amber

Amber McCann is a board certified lactation consultant. Her current interests are connecting with mothers through social media channels and teaching others in her profession to do the same. In addition to her work as the co-editor of Lactation Matters, the International Lactation Consultant Association’s official blog, she has written for a number of other breastfeeding support blogs and serves as the social media coordinator for lactation related organizations such as: GOLD, Lactation Education Resources and Nourish Breastfeeding Support. McCann’s expertise not only derives from her experience in coordinating social media outreach and writing content for various blogs, but she has also furthered her credibility through her participation as a volunteer as well as engaging in numerous public speaking and presentation opportunities advocating for her passion.

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