Science & Sensibility

Guest post by Science & Sensibility contributer Christine H. Morton, PhD

(Full disclosure:  the organization I work for, CMQCC, has been working with representatives from the Preeclampsia Foundation over the past year on the CMQCC task force developing a Preeclampsia Toolkit, and I am a big fan of their executive director, Eleni Tsigas, and frequent re-tweeter of @preeclampsia).

The Preeclampsia Foundation released a new guide to pregnancy and birth books last month, a comprehensive report distilled from a review of more than 60 such books, on their accuracy, coverage and clarity of information on hypertensive complications in pregnancy.    As readers of S&S are well aware, there are numerous books geared to expectant couples, pregnant women, and male partners; by authors who claim their authority by virtue of their clinical degrees and practice, their teaching and research credentials, as well was their personal and celebrity experience.   This is the first time I’ve seen a guide to pregnancy and birth advice books from the lens of a serious disorder in pregnancy:  preeclampsia.

 Seeking to understand their experience, women turn to books, their childbirth educators and doulas to help them navigate through this new and unexpected turn into complicated pregnancy.   While many women have healthy pregnancies and births, those who are having symptoms, or have been diagnosed with preeclampsia, eclampsia or HELLP syndrome, need accurate and clear information.    Early detection, and treatment, is a proven way to lessen the severity of the disease, and mitigate its impact.  Are some pregnancy and childbirth guidebooks better than others in informing readers about these issues?

To answer this question, researchers Jennifer Carney, MA and Douglas Woelkers, MD reviewed more than 60 pregnancy and childbirth advice books and ranked them using a consistent set of criteria in five categories: Depth of Coverage, Placement of Coverage, Clarity and Accuracy of Information, Description of Symptoms, and Postpartum Concerns.  In their methods section, they note that

“Books were downgraded for out-of-date information, missing or inaccurate information and placement issues, including inaccurate or inadequate indexing.    Of the more than 60 books reviewed, none ranked above “8” in all five categories. In fact, only a handful of books scored above “8” in the category of “Postpartum Concerns,” since many books routinely state that the cure for preeclampsia and related disorders is the birth of the baby.”

Childbirth educators and doulas have strong views on the ‘best’ books to guide women through pregnancy and childbirth and might be surprised to find that even best selling books like Ina May’s Guide to Childbirth (2003) scored only a 2.6, while the much excoriated, yet highest selling advice book: What To Expect When You’re Expecting (2009) ranked last in the Preeclampsia Foundation’s TOP TEN list, with a score of 7.2.  All books reviewed are listed in the Appendix of the report.

One helpful feature of the report is a sampling of questionable claims found in pregnancy guidebooks:

“Preeclampsia never happens before the twentieth week, but your blood pressure may start to rise steadily after this. Delivery of the baby and placenta ends the problem.” From Conception, Pregnancy, and Birth by Miriam Stoppard. In rare instances preeclampsia can occur prior to 20 weeks; it can also occur up to six weeks postpartum.

The report further explains why it’s important for books on childbirth to also mention preeclampsia, eclampsia and HELLP Syndrome, since this disease can develop immediately prior to, during or after delivery.  Among the childbirth books, the reviewers found,

Only Penny Simkin’s book The Birth Partner: A Complete Guide to Childbirth for Dads, Doulas, and All Other Labor Companions (2007) provides adequate information about preeclampsia, eclampsia, and HELLP syndrome. Although this book incorrectly uses the term pregnancy-induced hypertension (PIH) to describe preeclampsia and eclampsia, it provides a useful list of symptoms and the possible treatments, including cesarean delivery. It also presents some of the emotional issues that might arise from a diagnosis of PIH and includes some information on HELLP syndrome. It acknowledges the possibility of postpartum preeclampsia and eclampsia, something that many of the general pregnancy books omit.

The report can help childbirth educators and doulas point women to the best information about hypertensive disorders, but its authors also hope these results will guide authors in future revisions.  At the very least, up to date terminology, accurate information and complete indexing is critical in revisions. Books geared primarily to women with relatively healthy pregnancies always face the challenge of balancing reassurance, the optimality of physiological birth and the diverse range of potential complications in pregnancy.  Yet such books can point readers to resources like the Preeclampsia Foundation for up-to-date and user-friendly information and community pages.

Take-away points for Childbirth Educators and Doulas:

• Check your website and be sure to link to Preeclampsia Foundation website for unbiased, evidence-based information on this disease.  They are on Facebook too.
• Tell your students to ask about their blood pressure at all prenatal visits and during labor.  They should know what their ‘normal’ range is, and if their BP is ever above 140 systolic or 90 diastolic, to be alert to signs and symptoms of preeclampsia, and report these changes to their care providers.
• Many factors can affect BP readings:  BP cuff size should be appropriate, especially among women with a high BMI; the measurement should be taken while sitting, with arm at heart level; automated BP machines may underestimate the BP.
• Remind pregnant women (and their partners) that although lots of attention will naturally be focused on the baby, they have to be alert to the new mother’s health symptoms postpartum too.  While postpartum is a whole new normal, women need to know that any significant bleeding, fever, headaches, nausea, or visual disturbances, are NOT normal, and they should follow up with their health care provider immediately.

Preeclampsia is a serious, if unlikely, complication of pregnancy.  Women diagnosed or at risk for developing hypertensive disorders of pregnancy can find accurate information for all literacy levels (and some Spanish language resources), as well as a supportive community at the Preeclampsia Foundation, a US-based 501(c)(3) not-for-profit organization whose mission is to reduce maternal and infant illness and death due to preeclampsia and other hypertensive disorders of pregnancy by providing patient support and education, raising public awareness, catalyzing research and improving health care practices.

 References

1. American College of Obsetricians and Gynecologists. Diagnosis and management of preeclampsia and eclampsia; ACOG Practice Bulletin No. 33. Obstetrics & Gynecology. 2002;99:159-167.

2. Repke JT PM, Holzman GB, Schulkin J. Hypertension in Pregnancy and Preeclampsia: Knowledge and Clinical Practice Among Obstetrician-Gynecologists. Journal of Reproductive Medicine. 2002;47(6):472-476.

3. Caetano M OM, von Dadelszen P, Hannah ME, Logan AG, Gruslin A, Willan A, Magee LA. A Survey of Canadian Practitioners Regarding Diagnosis and Evaluation of the Hypertensive Disorders of Pregnancy. Hypertens Pregnancy. 2004;23(2):197-209.

4.  Hogan JL, et al.  Hypertens Pregnancy. Body Mass Index and Blood Pressure Measurement during Pregnancy. 2011;30(4):396-400.  PMID: 20726743

Read more about Christine H. Morton, PHD on our contributor page.

Christine Morton Book Reviews, Childbirth Education, Guest Posts, informed Consent, Maternity Care, Medical Interventions, Patient Advocacy, Practice Guidelines, Pre-eclampsia, Pregnancy Complications, Uncategorized blood pressure, Childbirth Education, Christine Morton, Christine Morton PhD, eclampsia, gestational hypertension, guest post, HELLP, interventions, maternity care quality, MD, midwives, PIH, pre-eclampsia, preeclampsia, safety, treatment for pre-eclampsia

You can get from New Jersey to Maryland in less than an hour, but despite the proximity, New Jersey hospitals, on average, charge 3-4 times more than Maryland hospitals for both vaginal and cesarean births. This is just one of the notable facts gleaned from Childbirth Connection’s analyses of the latest maternity charges data. Although the data do not show whether higher charges reflect better care, researchers who look at price variation generally find no relation between prices and the quality of care, complexity of patient care needs, or costs of actually delivering care. Such unwarranted price variation amounts to billions in wasted spending across the health care system, according to a February report from Thomson Reuters that looked at various hospital procedures.

New charts compiled by Childbirth Connection (PDF) show the significant price variation across states that report average labor and birth hospital charges to the Healthcare Cost and Utilization Project (HCUP). The chart set also includes average prices charged by birth centers, which fall well below charges for uncomplicated vaginal births in hospitals. State-by-state analyses (PDF) show charges increasing year-to-year, and reveal differences by mode of birth and presence or absence of complications.

What do these figures mean for improving maternity care?

Labor, birth, and newborn care are the most common and costly hospital conditions for both Medicaid programs and private insurers. The data in Childbirth Connection’s Charges Charts reveal four potential strategies for reining in costs:

1. increase the proportion of vaginal births – Hospital charges for cesareans are about 66% higher than hospital charges for vaginal births (a difference of $5,900- $8,400 depending on complications).
2. provide safer care – Complications increase charges by about 35% (a difference of $2,800 – $5,400 depending on mode of birth). Some complications are preventable with hospital safety initiatives.
3. remove barriers to out-of-hospital birth for low-risk women interested in these options - Birth center charges are $6,600 less than charges for uncomplicated vaginal births in hospitals.
4. reduce charges for births in facilities and states where charges exceed average - Policy makers can work to increase price transparency and align payment with quality.

We can improve the quality and value of maternity care by identifying innovations that safely and fairly achieve these goals and reduce unintended consequences.

Resources from Childbirth Connection

State-by-state Charges Charts

Multi-state Charges Comparisons (PDF)

Quick Facts About Hospital Labor & Birth Charges

Thank you, Amy Romano, for this fascinating guest post on the economic side of birth.  Childbirth is the most common reason for hospital admission in the United States (AHRQ, 2002).  Simple changes that will improve the experience of the families, save significant money and reduce unnecessary interventions, Lamaze’s Healthy Birth Practice #4. have been needed for a long time. Midwifery care for low risk women is one step in that direction. There are many other things that can happen to achieve the goal of healthy mothers, healthy babies while reducing costs. What do you think are some steps that can be taken to reduce the spiraling and often unnecessary medical costs of having a baby?  What should hospitals and health care providers be doing to get these costs under control?  How can consumers play a part in that?  Please share your ideas here, or programs that you are aware of that are working on this very issue!

Sharon Muza

Source

Agency for Healthcare Research and Quality, (2005). Hospitalization in the United States, 2002 (AHRQ Publication No. 05-0056). Retrieved from website: http://archive.ahrq.gov/data/hcup/factbk6/

Amy Romano Guest Posts, Healthy Birth Practices, Maternal Quality Improvement, Medical Interventions, Midwifery, Uncategorized Amy Romano, Childbirth Connection, Healthy Birth Practices, interventions, Lamaze International, maternity care quality, maternity care systems, midwives

A guest post by Deborah Issokson, Psy.D.

Childbearing is a vulnerable process.

Regardless of our profession within the childbirth world, we are working to facilitate an experience that has a positive emotional outcome accompanied by a healthy psychological adjustment to motherhood. It is incumbent upon us to understand and be sensitive to all the ways in which childbearing can be both triggering and potentially healing for women with abuse histories.

It is crucial to remember that not all survivors will have the same experience of pregnancy, birth, postpartum and breastfeeding. And we cannot assume that all women experiencing difficulties with aspects of childbearing such as pelvic exams, touch, immodesty, language, and pain are abuse survivors.

For an abuse survivor, abuse memories may be triggered by the physical changes, social and psychological tasks, medical procedures, and rituals of childbearing.

For some, abuse memories and emotions will be familiar, expected; others may experience these memories as regressive in their healing. For still others, the memories and emotions will be unexpected and intrusive, signaling the first time they are coming forth.

Preserving the Mental Health of Sexual Abuse Survivors

From a mental health perspective, the task with an acknowledged sexual abuse survivor during childbearing is threefold: help her maintain her current level of functioning, help her contain the memories, and facilitate further healing using childbearing as a vehicle for growth.

If the woman is unaware of her abuse history, we may be in the position of suspecting it or listening to her share her own inklings based on the feelings, concerns, fears and distress that she is experiencing and we are observing.

However, the Pandora’s box of sexual abuse memories must be opened delicately. Ideally, pregnancy is a time of containment as a woman grows a baby inside her body, preparing psychologically and spiritually for motherhood. And while birth is a time of opening and transforming, it is also a time when we want to limit extraneous, stressful stimuli so that a woman can immerse in her transformation to motherhood.

Strategies for Childbirth Professionals

So what do we do, in our respective roles, to meet these goals, implement these tasks and stay mindful of pacing, timing and professional limitations and boundaries?

• We can encourage a woman to review coping strategies she has previously employed.
• We can encourage her to seek support from a therapist, partner, friends, a support network.
• We can help her stay grounded by contextualizing her physical changes and discomforts, reviewing the real and appropriate changes happening in her body, reflecting on her health and resilience and helping her pace herself as she adjusts to the changes.
• We can be instrumental in helping a woman explore her choices for place of birth, care providers, and birth intentions. Her choice of provider and the manner in which she makes her choices may be affected by her abuse history and by the gender of her abuser. She may choose a provider and a place of birth that could facilitate a healing experience for her. On the other hand, she may unconsciously recreate the dynamics she experienced with her abuser.

Women wonder about sharing their abuse story with everyone who cares for them, be it the medical provider, the educator, the doula or the breastfeeding counselor. While it isn’t necessary to tell the entire story, it can be helpful for certain providers to have a general sense of the history in order to be sensitized to the woman’s issues as they pertain to prenatal care, labor and delivery, postpartum care and breastfeeding assistance.

If a woman is working with a group practice or being taught by a revolving set of educators, she may not want to repeat her story for each provider. Rather, we can encourage her to share with one provider with whom she feels most comfortable, asking that a brief note be put in her chart to inform the others. We can also suggest she write a brief statement herself, highlighting what she most wants her providers to know about her story, her vulnerabilities and her coping strategies.

Emotional dynamics of birth and transition to parenting
For an abuse survivor, normal fears, anxieties and concerns about birth can take on additional psychic charge due to the physical and sexual nature of birth.

On one end of the continuum is the experience of giving birth as healing; on the other end is the feeling that birthing is tantamount to a recurrence of sexual abuse. In between are shades of gray.

Most births have healthy, uncomplicated physical outcomes; the emotional outcome is not so predictable. There is no telling how a woman will experience her birth and how she will make meaning of it. As a witness to her birth, we may perceive it as wonderful, empowering and successful, while the woman may have a completely different emotional experience and perception.

Furthermore, the emotional outcome is an unfolding process for the postpartum woman. The new mother spends part of her postpartum year reviewing and dissecting her birthing experience. It is not unusual for the survivor of abuse, years later, to have a new perspective on her experience. Sometimes it is a more healing perspective.

For an abuse survivor, the postpartum period can be a time of consolidation of past healing efforts as she enters a phase of parenting and protecting a new human being.

For other women, parenting can be the catalyst for new memories and flashbacks, new conflicts with extended family, and even regression in the healing process. Survivors of abuse are at high risk for experiencing postpartum depressive and anxiety disorders. These mental health issues require attention and treatment as soon as possible as they have a detrimental impact not only on the woman, but also on her baby and her entire family.

Empower by Giving Space to the Individual Woman
As providers of care, we are often witness to great courage, strength and healing as survivors of sexual abuse journey toward parenthood.

Empower your client to shape this childbearing experience for herself. Ideally, your work together can culminate in a positive emotional experience of pregnancy and birth, a healthy connection between mother and baby, and a sense of self-efficacy as a mother.

REFERENCES

Issokson, Deborah. 2004. Chapter 11, Effects of Childhood Abuse on Childbearing and Perinatal Health in Health Consequences of Abuse in the Family: A Clinical Guide for Evidence-Based Practice, K. Kendall- Tackett, editor. Washington D.C.: American Psychological Association.

Kendall-Tackett, K. 1998. Breastfeeding and the sexual abuse survivor. Journal of Human Lactation, 14(2), 125-130.

Simkin, Penny and Phyllis Klaus. 2004. When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse on Childbearing Women. Washington: Classic Day Publishing.

Sperlich, Mickey and Julia Seng. 2008. Survivor Moms: Women’s Stories of Birthing, Mothering and Healing after Sexual Abuse. Oregon: Motherbaby Press.

Deborah Issokson, Psy.D, is a licensed psychologist in Massachusetts specializing in Perinatal Mental Health. She is a contributor to several editions of Our Bodies, Ourselves. She was a faculty member of the Boston University School of Public Health, lecturing on Maternal and Child Health (now closed). She  can be reached at info@reproheart.com. Visit her website at www.reproheart.com.

Kathy Morelli Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Healthy Care Practices, informed Consent, Maternal Mental Health, Perinatal Mood Disorders, Postpartum Depression, Research, Survivors of Sexual Abuse Childbirth Education, Healthy Birth Practices, interventions, Kathleen Kendall-Tackett, Kathy Morelli, lamaze, maternity care systems, postpartum depression, safety, Survivors of Sexual Abuse

As a childbirth professional or an expectant parent, do you wonder about the multitude of pain management techniques offered for childbirth?

As part of the Cochrane Collaboration, Leanne Jones and eight of her colleagues (2012) has published new research synthesizing divergent data constructs and summarizing 355 trials on pain management during childbirth. There are many detailed data tables associated with this study.

To view the entire study, Lamaze members can access the full Cochrane Library, via the Members Only Section.

A summary of the study is below.

Background

In 2007, the Cochrane Pregnancy & Childbirth Group (PCG) consumer’s group identified pain relief in childbirth as the topic of most importance to them.

This study was funded to provide an evidence-based summary of the efficacy and safety of pain management methods in childbirth for consumers, policy-makers, and childbirth educators.

Women experience pain in childbirth in varying degrees of intensity, influenced by physiological and psychosocial factors. Most women require some type of pain relief. Both non-pharmacological and pharmacological methods are used for pain management.

312 Studies Reviewed

Collecting the totality of evidence from existing randomized controlled trials, the researchers identified 18 total systematic reviews for inclusion in their study. 15 reviews were Cochrane reviews (257 included trials) and 3 were non-Cochrane reviews (55 included trials). Data from a total of 312 studies were reviewed in this study.

There were more studies of pharmacological interventions than non-pharmacological interventions.

13 Outcomes Identified for Inclusion

The researchers, in partnership with the PCG consumer group, identified these outcomes for inclusion in the study.

Effects of interventions

• Pain intensity (as defined by trialists)
• Satisfaction with pain relief (as defined by trialists)
• Sense of control in labor (as defined by trialists)
• Satisfaction with childbirth experience (as defined by trialists)

Safety of interventions

• Effect (negative) on mother/baby interaction
• Breastfeeding (at specified time points)
• Assisted vaginal birth
• Cesarean section
• Adverse effects (for women & babies)
• Admission to special care baby unit / NICU
• Apgar score less than at five minutes
• Poor infant outcomes at long-term follow-up (as defined by trialists)

15 Childbirth Management Methods Identified

The researchers identified a list of 15 childbirth pain management methods:

• placebo/no treatment
• hypnosis
• biofeedback
• intracutaneous or subcutaneous sterile water injection
• immersion in water
• aromatherapy
• relaxation techniques (yoga, music, audio)
• acupuncture or acupressure
• massage, reflexology or manual methods
• TENS
• inhaled analgesia
• opioid
• non-opioid drugs
• local anesthetic nerve blocks
• epidural

 As a Lamaze childbirth educator, how will you incorporate respect for your client’s individual decisions while presenting the Six Lamaze Healthy Birth Practices?

Results: Non-pharmacological Studies

The authors found that non-pharmacological methods are mostly used in midwife-led continuity of care births and/or where women had continuous intrapartum support. Such non-pharmacological methods are meant to break the fear-pain-tension cycle and to work within the pain paradigm. The pain paradigm of birth is a philosophy based on the idea that pain is a normal part of the physiology of labor and that women can use coping methods to manage the pain (Leap, 2008; as cited in Jones et al, 2012).

The researchers found the evidence for many non-pharmacological methods to be mostly incomplete as there is an average of only two studies for each method.

However, the following non-pharmacological methods are shown to provide pain relief and positive maternal psychological outcomes without invasive side effects: immersion in water, relaxation, acupuncture/acupressure and massage.

In addition, women report greater emotional satisfaction with childbirth when using immersion and relaxation. With the use of relaxation and acupuncture/acupressure, there is a decrease in the use of forceps and ventouse. There is a decrease in the amount of cesarean section associated with the use of acupuncture/acupressure.

The researchers report there is insufficient evidence to report on pain relief using the following methods: hypnosis, biofeedback, sterile water injection, aromatherapy and TENS.

Results: Pharmacological Studies

There are more studies of pharmacological methods versus non-pharmacological methods. The authors found that pharmacological methods relieve pain and have side effects.

Pharmacological methods are most likely to be used in settings with a pain relief paradigm. In the pain relief paradigm of labor, pain is considered barbaric, the benefits of analgesia outweigh the risks, and women should be free to use whatever pain relief methods she wishes, without guilt (Leap, 2008; as cited in Jones et al, 2012).

Comparative Pain Relief & Side Effects

Epidural, combined spinal epidural (CSE) and inhaled nitrous oxide & oxygen relieve pain better when compared to opioids (Jones et al, 2012).

Epidurals are associated with an increase of the use of forceps or ventouse, an increase in the risk of low blood pressure, low motor blocks, fever and urine retention (Amin-Somanuh, 2005; as cited in Jones et al, 2012). In addition, other side effects such as shivering, tinnitus, and respiratory or cardiovascular depression may occur. The authors state it is uncertain whether the use of epidurals interfere with breastfeeding (Reynolds, 2011; as cited in Jones et al, 2012).

Combined spinal epidurals (CSE) provide faster pain relief than traditional epidurals, but are associated with more feelings of itchiness, giddiness, sweating, and tingling (Jones et al, 2012).

Inhaled nitrous oxide is associated with minimal toxicity and rapid maternal and neonate elimination, but can cause feelings of nausea, drowsiness and sickness (KNOV, 2009; Rosen, 2002; as cited in Jones et al, 2012).

Non-opioid drugs (acetaminophen and non-steroidal anti-inflammatory drugs (NSAIDS)) relieve pain for shorter periods of time as compared to opioid drugs (Bayarski, Hebbes, 200; as cited in Jones et al, 2012).

Opioid drugs (morphine, nalbuphine, fentanyl, parenteral and pethidine) are used worldwide. Parenteral opioids are reported to provide less pain relief than epidurals. Side-effects include impaired maternal capacity for decision-making, sedation, hypoventilation, hypotension and urine retention. Opioids readily cross the placenta, thus neonatal respiratory depression and hypothermia are also concerns. Pethidine is shown to affect fetal heart rate variability during labor (Sekhavat, 2009; Solt, 2002; as cited in Jones et al, 2012), thus continuous fetal monitoring is recommended. Neonatal effects are inhibited and early cessation of breastfeeding and decreased alertness (Nissen, 1995; Ransjo-Arvidsen, 2001; Righard, 1990; Rajan, 1994; as cited in Jones et al, 2012).

Limitations Found in the Studies

The authors state the studies use differing methods to measure pain management outcomes. Many do not at all measure maternal psychological outcomes (feelings of intrinsic self-control), mom-baby interaction, or breastfeeding and infant outcomes.

Conclusions

This study shows consumers rate pain management as a high priority in childbirth, however, after 30 years of research, standardized pain management and outcome measurements have not been created.

The authors suggest their outcome guidelines, developed with consumer input, be adopted for use in future research.

Overall, women should feel free to choose whatever methods of pain relief they wish, both non-pharmacological and pharmacological, for their individual childbirth experience.

As part of a childbirth preparation program, women should be informed of the efficacy and potential side-effects on both themselves and their babies of non-pharmacological and pharmacological methods of pain relief for childbirth.

Hopefully this study will generate an effort to standardize the constructs associated with research of measurements of pain management in labor, maternal psychosocial satisfaction, and maternal-baby outcomes.

References

Jones L, Othman M, Dowswell T, Alfirevic Z, Gates S, Newburn M, Jordan S, Lavender T, Neilson JP. Pain management for women in labour: an overview of systematic reviews. Cochrane Database of Systematic Reviews 2012, Issue 3. Art. No.: CD009234. DOI: 10.1002/14651858.CD009234.pub2

Kathy Morelli Babies, Cesarean Birth, Do No Harm, Epidural Analgesia, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, informed Consent, Medical Interventions, Midwifery, New Research, News about Pregnancy, Pain Management, Practice Guidelines, Research cesarean, Childbirth Education, epidurals, Healthy Birth Practices, interventions, Kathy Morelli, lamaze, maternity care systems, research, Systematic Review

New research was published in the American Journal of Obstetrics and Gynecology. Katherine Laughon, MD, and her colleagues, D. Ware Branch, M.D., Julie Beaver, M.S, and Jun Zhang, Ph.D., M.D., (2012) examined differences in childbirth labor patterns over the past fifty years, comparing data from a large study in the 1960′s with data from a large study in the 2000′s.

The researchers found differences both in maternal characteristics and obstetric practice patterns. In the contemporary cohort, the authors found an increase in first stage labor of over two hours and a cesarean section rate four times as high as in the past cohort. In the cohort from the 1960′s, a higher operative vaginal delivery rate was found as compared to the contemporary cohort. The authors link these differences to changes in obstetric practice patterns. The authors state that even after controlling for maternal and obstetrician characteristics, the increased length of labor result for the contemporary cohort persists (Laughon, Branch, Beaver and Zhang, 2012).

Positive Action Items for Moms and Childbirth Educators

The National Institute of Child Health and Human Development (NICHD)ran a conference call on March 31, 2012, where Katherine Laughon, MD, the lead researcher on the study, gavea brief overview of the study and answered questions. Robin Elise Weiss, LCCE, was on the call and summarized Dr. Laughon’s positive steps to take by women and childbirth educators who are interested in natural childbirth. Dr. Laughon’s suggestions fall into Lamaze’s Six Healthy Birth Practices.

• These women might be comfortable waiting longer to get pitocin and other interventions, including cesareans.
• Choose your practitioner carefully. Dr. Laughon suggests a practitioner should be able to think about the differences in labor patterns in modern times, not from textbooks.
•  Remember there is not an ideal length of labor, long or short. It is based on the individual, woman to woman and baby to baby.

 As a Lamaze childbirth educator, do the results of this study surprise you?

What does this mean to you and the families you serve?

Below is a synopsis of the study methods, statistics and conclusions.

Study Design: Comparing Data from the 1960′s to Data from 2000′s

The researchers compared the data from the National Collaborative Perinatal Project (CPP) dating from 1959 – 1966 to the data from the Consortium on Safe Labor (CSL), dating from 2002- 2008. Data from a combined total of 137,850 women from the two studies were included in the 2012 study.

National Collaborative Perinatal Project (CPP) 1959-1966

The CPP (1959-1966) was a prospective study following 54,000 births to 44,000 women. Twelve university centers across the country enrolled pregnant women and collected data such as demographics, medical history, socioeconomic status, behaviors, blood samples, and information from regular physical exams, did interviews and gathered information from the senior obstetrician. The children were followed for seven years after birth. Laughon and her colleagues (2012) limited the use of the CPP data to only women known to be birthing for the first time. Thus, the 2012 study included data from 39,491 women from the CPP study.

Consortium on Safe Labor (CSL) 2002-2008

The CSL (2002 – 2008) was a retrospective cohort study of 228,668 births, with the majority of births (87%) occurring between 2005 and 2007. Information was examined from 12 clinical centers and 19 hospitals in 9 American College of Obstetrics and Gynecology (ACOG) districts. Data was extracted from both the electronically held maternal medical files and neonatal intensive care units. Data on demographics, medical history, maternal and neonatal outcome, and discharge disposition were extracted from the electronic files. Investigators at delivery sites collected information on obstetrician characteristics. Laughon and her colleagues (2012) limited their use of the CSL data to only those women in spontaneous labor with a single gestation. Thus, the 2012 study examined 98,359 women from the CSL study, inclusive of a total of 137,850 women from both the CPP and CSL dataset.

Results: Differences in Characteristics of the Women

Characteristics of the women, of their labors and of their newborns differed significantly between the earlier CPP and the contemporary CSL study.

Women in the CSL were older than in the CPP (26.8 years vs. 24.1), had a higher average BMI both pre-pregnancy (26.3 vs 24.1) and at delivery (29.9 vs 26.3), were more racially diverse, and delivered an average of 4.9 days earlier. Their babies weighed an average of 99 grams (3.48 ounces) more and Apgar scores were higher in the CLS than the CPP.

Results: Differences in Practice Patterns

Use of epidurals (55% vs. 12%), oxytocin (44% vs. 12%); and cesarean delivery (12% vs. 3%) was higher in the contemporary CSL cohort than the CPP. Cesarean delivery in the contemporary cohort is four times as high as in the 1960′s cohort.

Episiotomy (68% vs. 17%) and operative vaginal delivery (40% vs. 6%) were higher in the 1960′s CPP cohort than the contemporary CSL.

Results: First Stage – Differences in Length of Labor

For nulliparas, the first stage of labor (from 4 cm to completely dilated) was 2.6 hours longer in the contemporary cohort (CSL) than the former cohort (CPP).

For secundagravidas and multigravidas, the length of labor was, on average, 2.0 hours longer for the CSL cohort than the CPP cohort.

Results: Second Stage – Differences in Length of Labor

For nulliparas, in the second stage of labor, in the CLS cohort, there was a 10% operative vaginal delivery rate compared to 66% of the CPP cohort. Among women who spontaneously delivered, there was an increase of 27 minutes in the CSL group as compared to 13 minutes in the (CPP group.

Operative vaginal delivery, in secundagravidas and multigravidas, occurred in the CSL 4% and 2.5 % compared to 36% and 18% in the CPP. In secunagravidas and multigravidas, second stage labor did not have a clinically relevant difference in length of labor between the two groups.

Conclusion

The authors state firm conclusions merit further study.

In summary:

“…for women who presented in spontaneous labor at term, the duration of labor from 4 cm to 5 cm in multiparas to complete dilation and the 2^nd stages of labor were longer in the contemporary population than a cohort from the 1960s. The overall median differences in the first stage of labor persisted after controlling for maternal and obstetric characteristics, indicating that modern labor differs from the older cohort largely due to changes in obstetric practices. Since labor times are longer today than in the past,the benefit of extensive interventions such as oxytocin and cesarean delivery in modern labor management needs further evaluation.”(Laughon, Branch, Beaver and Zhang, p. 14).

Hopefully this study will generate increased study of obstetric intervention patterns with an eye towards improved contemporary obstetric process management.

References

Laughon, S.K., Branch, D.W., Beaver, J., Zhang, J., Changes in labor patterns over 50 years, American Journal of Obstetrics and Gynecology (2012), doi: 10.1016/j.ajog.2012.03.003.

Many thanks to Robin Elise Weiss, LCCE, who graciously helped out with her reporting expertise on this post!

Kathy Morelli Cesarean Birth, Childbirth Education, Evidence Based Medicine, Practice Guidelines, Research ACOG, cesarean, epidurals, Healthy Birth Practices, interventions, Kathy Morelli, lamaze