Science & Sensibility

Today, S&S contributor Jackie Levine discusses the potential risks of routine cervical checks near term and how to help your clients and students be prepared to have a discussion with their health care provider about the necessity of such exams. – SM

There are some studies that show a link between routine weekly pelvic exams in the last month or so of pregnancy and an increase in rupture of membranes (ROM) that occur well before labor was meant begin, meaning the membranes have ruptured prematurely, (adding a P to ROM, for premature rupture).   The natural onset of labor may be a week or perhaps only days away, but everything is not quite ready, and if effective labor does not begin induction frequently follows.  And when induction fails, as often it will, since the rupture was premature, and the body and the baby are not ready, cesarean is often the outcome.

photo credit: flickr (link below)

Many women find that their health care providers may start doing pelvic exams at about 37 weeks gestation.  Women should consider asking their doctor or midwife whether these exams are necessary to insure the health and safety of herself and her baby, before providing consent for this invasive procedure.  When I discuss these near term cervical exams with my childbirth class students and look at the studies, mothers-to-be have to ask themselves whether the benefits of weekly exams outweigh the other risks; potential PROM, induction and the increased possibility of cesarean section.

“How do I tell my health care provider that I don’t want an exam, and not have those uncomfortable moments when my doctor or midwife thinks I’m defying him or her and not letting them do what they always do?”  That’s the common and sensible worry, that our students may have, but if we provide an opportunity to role-play with our students and clients and also provide the studies, they will feel confident about having this discussion. They will know the facts and are informed health consumers who could consider saying “Oh, I just don’t want that exam today, so can we do it next week?” They might also share that they’ve researched this topic, mention the studies and ask how routine exams week after week will help insure good health.

An older study examining the relationship between late term pelvic exams and the incidence of PROM stated:

 In the 174 patients on whom pelvic examinations were done weekly starting at 37 weeks gestation, the incidence of PROM was 18%,   which was a significant increase (P=.001).  The primary cesarean section rate was comparable in both groups with PROM; however, the overall primary cesarean rate when PROM occurred was found to be twice that of the remaining population. The study suggests that routine pelvic examinations may be (sic) a significant contributing factor to the incidence of PROM. Women with uncomplicated pregnancies were randomly assigned to one of two groups. The author theorizes that the probing finger carries up and deposits on the cervix bacteria and acidic vaginal secretions capable of penetrating the mucous plug and causing sufficient low-grade inflammation or sub-clinical infection to rupture membranes.“  “It would therefore seem prudent to recommend that no pelvic examinations be done routinely in the third trimester unless a valid medical indication [sic] exists to examine the cervix … especially since the information gained from these routine examinations is often of little or no benefit to either the physician or the patient.” (Lenahan, 1984.)

We have all been subtly bullied at one time or another by those in positions of authority, and it’s easy to understand the courage and confidence needed to question a caregiver. It’s a mother’s right and responsibility first to know and then to question, but confidence is the key.  We must make an effort to give real meaning to a women’s right to choose, and to the principle of informed refusal.  The American Congress of Obstetrics and Gynecology (ACOG) has addressed informed refusal several times with its membership since at least 1992¹, speaking powerfully  about the autonomy of the individual.  Although these writings and bulletins are aimed mainly at assuring legal protection for caregivers, they are a resounding affirmation of the legal and moral right of the patient to decide for herself.

Since the studies assert that routine exams are neither predictive nor probative, the doctor or midwife must be able to say something medically strong to counter the available studies.  When mothers have asked their providers for the reasons to do an exam, they bring a myriad of interesting answers back to class for discussion, but rarely any facts or science.  Remember, ACOG  itself published a study last year examining the basis for its care guidelines and found that “One third of the recommendations put forth by the Congress in its practice bulletins are based on good and consistent scientific evidence” ACOG, 2011) meaning Level A, and that gives us pause to consider the 70% of practices represented by Levels B and C . Care providers will often reconsider when an informed mother-to-be can ask politely and tactfully, about the science that recommends a weekly routine cervical assessment.

Again, women should be able to weigh the risks of routine exams against the possibility of that cascade of interventions that follow on with PROM, interventions that will, at the least, lead to an uncomfortable and harder-to-manage induction, and at worst, put our students and clients on that gurney ride into the operating room.

When a mother is motivated to discuss routine pelvic exams with her caregiver, it may be the first test of the mutual trust and respect she hopes for in that relationship.  Until that point in her pregnancy, she may not have had the opportunity, or the necessity to assert her rights as a maternity patient.  She may have refused to have a routine sonogram or two because her insurance policy would not cover extra routine assessments, but refusing pelvic exams unless there is a valid medical reason will tell her how little or much her HCP is willing to act on best evidence, give her individuated care and show respect for her informed refusal.

The first time she refuses the exam may not be an accurate opportunity for her to judge; many caregivers will let refusal ride that once, but as pregnancy nears term, most docs begin to be insistent about cervical assessment, even without medical indication. A mother-to-be can begin to learn her caregiver’s view of best-evidence care and his or her willingness to listen to her so that she will have an idea, going forward, of how best to assert her rights, with knowledge and confidence in herself, and can get support she may need in our classes.

In a Science & Sensibility post in May 2011, I talked about the importance of giving mothers the same studies that caregivers have access to.  What I said then about giving our classes the actual studies, along with discussion, still applies:

“…perhaps we need to give women a different kind of “evidence”, by giving them a look into the medical community.  If women can know more of what goes on inside the profession, if they know a bit of what the docs know, they feel a different level of empowerment.  They feel a gravitas….Not only do they know that the evidence exists somewhere out there…they see it; they own copies of the studies. They feel trusted with special information that they would never otherwise have access to. In addition to learning to trust their bodies, in addition to knowing how birth works, in addition to practicing comfort measures, they learn about what goes on behind the scenes.  It expands their sense of control and choice. “  

Refusing to have routine pelvic exams in those last weeks of pregnancy is a real opportunity for our students and clients to learn how to ask for, even insist on, best-evidence care for themselves and their babies.  It’s certainly worth a try, and we can support them in the last weeks in a positive way with lots of opportunity for role-play and discussion as they report back to class and share their experiences with informed refusal.

How do you bring up the topic of regular cervical exams for women who are not in labor?  Do you talk about this with your clients and students?  What are your favorite resources for presenting this and facilitating discussions?  Have your students shared stories about their experiences.?  Are you a health care provider?  What are your feelings on routine pelvic exams at the end of pregnancy?  Share your thoughts in our comment section. – SM

References:

ACOG: Ethical dimensions of informed consent: a compendium of selected publications, ACOG Committee Opinion 108. Washington DC, 1992.

ACOG Committee opinion. Informed refusal. Number 166, December 1995. Committee on Professional Liability. American College of Obstetricians and Gynecologists. et al. Int J Gynaecol Obstet. (1996).

ACOG Committee Opinion No. 306. Informed refusal. ACOG Committee on Professional Liability, Obstet Gynecol. 2004 Dec;104(6):1465-6.

Lenahan, JP Jr., Relationship of antepartum pelvic examinations to premature rupture of the membranes. Journal Obstetrics Gynecology 1984, Jan:63(1):33-37.

Levine, J. (May 31, 2011) A Lamaze Story. Retrieved from http://www.scienceandsensibility.org/?p=2954

Vayssière, C. Contre le toucher vaginal systématique en obstétrique Gynécologie Obstétrique & Fertilité, 2005, Volume 33, Issue 1, Pages 69-74.

Wright JD, Pawar N, Gonzalez JS, Lewin SN, Burke WM, Simpson LL, Charles AS, D’Alton ME, Herzog TJ, Scientific Evidence Underlying the American College of Obstetricians and Gynecologists’ Practice Bulletins, Obstet Gynecol. 2011 Sep;118(3):505-12.

photo credit: www.flickr.com/photos/nathansnostalgia/498100786/

Jackie Levine Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized ACOG, cervical exams, Childbirth Education, guest post, interventions, Jackie Levine, labor induction, maternity care systems, prenatal care, rupture of membranes

[Editor's note: This is Part Two of Jackie Levine's essay on The New World of the Newborn in which she explores the frequent dichotomy between up-to-date evidence and common obstetrical practice.  To read Part One of this post, go here.]

In the third class of each of my Lamaze education series, I start to disseminate studies about what happens during the first moments in the life of the new baby and the new mother. One of the articles I give out is a copy of a blog post I read in 2009: Dr. Nick Fogelson’s essay on his blog site, the Academic OBGYN. It gives the mothers in my classes a real hard look at obstetric philosophy, politics and practice.  It helps them to have a really good look at what docs say to each other and rarely to their patients, and supports parents’ abilities to make informed decisions about acceptance or refusal of care…to demand best-evidence practices for themselves and their babies.

I had really mixed feelings about the article.  Fogelson exhorts his colleagues to change the practice of immediate cord clamping and presents a wealth of evidence, yet stays away from a real condemnation of the current practice with language that has a veiled politeness, but he declares that he’s doing due diligence by “blogging” about it.  The title of his blog post is “Delayed Cord Clamping Should Be Standard Practice in Obstetrics.”  That seems really unequivocal to me…a title that calls out for a total change of the current practice of immediate clamping and cutting of the umbilical cord.  In my last post on this subject, I quoted extensively from his article and some of his words are chilling.  To recap just two items from his post: “We ought to give the tykes a few minutes to soak up what blood they can from the placenta before we cut ‘em off,”  and,  “I wonder at times why delayed cord clamping has not become standard already; why by and large we have not heeded the literature. It is sad to say that I believe it is because the champions of this practice have not been doctors but midwives and sometimes we are influenced by prejudice.”  (My emphases.)

Nowhere in Dr. Fogelson’s post does he say, “Let’s stop now!  All of us!  Stop now!  Let’s stop harming babies, let’s change the textbooks, let’s put out new practice bulletins immediately!” In his defense, since the writing of that blog post, Dr. Fogelson has delivered a couple of Grand Rounds lectures on the subject, and he continues to be an advocate for DCC, (delayed cord clamping) but his original words seem to make obeisance to the establishment, to ask politely for them to heed best-evidence care.

Dr. G.M. Morley, a Fellow of the American College of Obstetrics and Gynecology says on his website:

The normal healthy newborn with millions of years of experience in its genetic code, clamps its own cord, usually between two to four minutes of birth. After natural closure, the doctor’s cord clamp may be safely applied.”
(morley@cordclamping.com)

 

This advice, when followed, surely cannot harm any doc if he/she heeds it, but can help many newborns.

In an article posted in 2010 by Expert Reviews Ltd., on changing practices in episiotomy, the authors ask in bold subhead: Why Don’t Physicians Follow Clinical Practice Guidelines?¹ They answer: The challenges of obtaining high-quality data to direct evidence-based care have been greater in obstetrics than in many other medical disciplines” and “since obstetrics generally has lagged behind other disciplines in its efforts to have standardized, outcomes-based practices, there may be greater cultural barriers among obstetricians to changing practices based on new data.”

More from the same study:

 

In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice. Concerning comments from this survey included, ‘obstetrics requires manual dexterity more than science’…’evidence-based medicine ignores clinical experience,’ and that following guidelines could result in ‘erosion of physician autonomy.’”

These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education. The following year, Cabana and colleagues published a review of reasons that physicians fail to change their practices in the face of new evidence or published clinical guidelines. They found multiple types of barriers to practice change, including lack of awareness or familiarity with current recommendations, lack of agreement with the recommendations, lack of self-efficacy to make practice changes, inertia and external barriers to practice change. Of those physicians who did not agree with the practice recommendations, a variety of reasons were cited. Some physicians felt the evidence did not support the guidelines, some felt the recommendations were like a ‘cookbook’ or reduced physician autonomy, or did not apply to their patient population. Finally, some physicians had a ‘lack of outcome expectancy,’ or did not believe that making the recommended practice changes would improve clinical outcomes.”

1-Changes in Episiotomy Practice: Evidence-based Medicine in Action, Justin R Lappen; Dana R Gossett Posted: 05/12/2010; Expert Rev of Obstet Gynecol. 2010;5(3):301-309. © 2010 Expert Reviews Ltd.

2Obstetrics & Gynecology: September 2011 – Volume 118 – Issue 3 – p 505–512 doi: 10.1097/AOG.0b013e3182267f4373- Integrated Management of Pregnancy and Childbirth. Managing Newborn Problems: a guide for doctors nurses and midwives. WHO 2003 ISBN 92 4 154622 0 ESS-EMCH SECTION 11 Neonatal Emergencies Last updated 27/4/2009 215

4 Ib id

5-ACOG Recommends Partnering With Patients to Improve Safety, Obstet Gynecol. 2011;117:1247-1249

Jackie Levine Delayed Cord Clamping, Evidence Based Medicine, Uncategorized DCC, Delayed Cord Clamping, G.M. Morley, Jackie Levine, Nichola Fogelson, WHO recommendations for delayed cord clamping

As summer approaches its end, fall just around the corner, I find myself settling into a new schedule.  Children back in school and summer travels dispensed of, it’s time to get my nose back to the grindstone.  This will look a bit different for me this year.  Along with my work here at Science & Sensibility, I have begun my studies in the School of Public Health at the University of Minnesota where I am pursing my Masters of Public Health ~ Maternal & Child Health.  Before any of that gets well under way, I will attend Lamaze’s 2011 Annual Conference in Fort Worth, Texas next week where I will conduct a breakout session, Social Media for the Childbirth Educator:  Helpful or Hindrance?  Five hours after delivering this session, I will virtually (via pre-recorded video) be apart of a panel discussion at the Postpartum Support International conference in Seattle, WA , to discuss issues pertaining to postpartum mood disorders, childbirth educators and social media users—along with the other panelists, Penny Simkin,  Nancy Lantz, Emily Dossett, and Walker Karraa.

Having recently submitted a midwifery-geared textbook chapter to a publisher in the U.K., I expect to do some editorial work on that in the coming weeks/months.  And speaking of editing, I am enjoying do a little substantive editing on childbirth education video scripts for the primary childbirth ed. video production company in the U.S.

Apparently, I am not the only one with a bursting-at-the-seams schedule.  Here are some updates from a few of the other Science & Sensibility contributing writers to keep you up-to-date on the work we are doing to improve maternity care for moms and babies:

Jackie Levine, LCCE, FACCE, CD(DONA), CLC:  After a hiatus of 6 summertime weeks, Jacqueline (Jackie) Levine will be back at her local Planned Parenthood Center teaching Lamaze classes to the pregnant clientele and their families.  Remember, 97% of Planned Parenthood’s services are directed towards providing essential health care for women in the communities they serve. All women in her classes get free labor support and post partum breastfeeding support. She will teach her fall class on the history and policies of childbirth in America at CW Post as a guest lecturer, will teach breast feeding classes for DONA certification candidates,   resume the research-and-writing of RPFs for her doula group, the Long Island Doula Association, and will continue to be an enthusiastic contributor to and supporter of Science and Sensibility.

Penny Simkin, PT:  In the coming months, Penny Simkin will participate in several childbirth conferences, among them a 5-days trip to Iceland to give talks and trainings for childbirth professionals. She will also teach a full schedule of childbirth and sibling classes, and will attend the births of a few doula clients who are due in the next few months. She will be working with DONA International on revising the birth doula manual, and has a few other irons in the fire, including a new DVD for siblings-to-be.

Henci Goer: In August, Henci Goer turned in the manuscript (at last!) for a top-to-bottom new edition of Obstetric Myths Versus Research Realities, co-authored by Amy Romano, to its publisher, University of Michigan Press. The working title is Obstetric Myths Versus Research Realities: Optimal Practices and Obstacles to Implementation. She is not, however, resting on her laurels. She is planning on doing a new edition of Thinking Woman’s Guide to a Better Birth that will make use of the updated research gathered for the second edition of Ob Myths. She also will be updating her talks for her fall speaking engagements in Austin, TX; Burbank, CA; Niagara Falls, Ontario; and Moscow, Russia. (See http://hencigoer.com/talks/ for further info.) Now that the big push to get the manuscript done is over, Henci also looks forward to resuming writing blog posts for S&S. In addition, she will be doing a guest appearance on Lamaze’s Facebook page in October, and will, of course, continue with responding to questions and moderating her Lamaze forum, “Ask Henci.”

Edith Kernerman, IBCLC:  Well,  8 weeks to go before my biggest project is due:  crazy about babies, though—they don’t exactly come when you hope they will!   In my case, I am one of those unusual expectant mothers who hopes the little one will come a bit on the late side (my last 2 did!)—not so late that I have to deal with “the system” but late enough so I can finish all that I have to do before then!

So, what is all of that?  I have an e-book on the GamePlan for Protecting and Supporting Breastfeeding in the 24 hours of Life and Beyond (based on the booklet of the same name that has been out since 2006) that I have just finished and sent for editing—so, let’s hope my editor finds no fault and sends it back with no revisions…yeah…right…!  There’s a chapter I must start writing on how the healthcare system supports breastfeeding (or doesn’t), and this is due in October for a book coming out of Australia.  I have another chapter on Pain due for someone else’s book from North America.  I am presenting a talk at the Association of Perinatal Naturopathic Doctors in mid-October on Mammary Constriction Syndrome.  And we are just finishing the study design for the big study on Mammary Constriction Syndrome (following in the footsteps of our pilot study) that we are hoping to team up with a pediatric cardiologist who works with Doppler so we can measure changes in blood flow to the breasts while mothers are experiencing pain.  I am also co-teaching a 2-day workshop in mid-September on Beyond the 20 hour Course in the London, Ontario area.  I have also been working on the iphone app for the L-eat Latch and Transfer Tool, and the electronic charting version of the L-eat for Hospitals (quite late on that as I was asked for this 2 years ago!).    I think I am a couple of blogs behind for Science & Sensibility, I am 4 blogs behind for www.BabyLatch.com  and I have 2 due for www.BreastFeedingInc.ca  and another for www.nbci.ca .  All the above needs to get done before the end of October, while I am working every day in the clinic seeing moms and babes, overseeing IBLCE Pathway 3 students and NBC diploma students and Midwifery and med students on rotation, supervising clinical and administrative staff, and helping to get our 3 new wonderful docs comfortable before my mat leave—all at our International Breastfeeding Centre’s Newman Breastfeeding Clinic in Toronto.   Oh, and I forgot to mention that my book, Breastfeeding the Baby Who Does Not Latch is so behind deadline I can’t even think about it!

Amy Romano, MSN, CNM: I continue to work for Childbirth Connection as the Project Director for the Transforming Maternity Care Partnership. This fall I’ll be dedicating a lot of my time toward our shared decision making initiative, a collaboration with the Foundation for Informed Medical Decision Making. I’ll also continue to oversee the Transforming Maternity Care web site and blog, which offer tons of resources for maternity care quality improvement. 

This fall also marks two major writing milestones. On October 1, the 9th edition of Our Bodies, Ourselves will hit bookstores. I was one of the editors of this edition, responsible for the pregnancy, birth, and postpartum chapters as well as one chapter on navigating the health system. I’ll be attending a global symposium on women’s health and human rights in Boston, an event that will celebrate the 40th anniversary of the landmark book. In addition, Henci Goer and I have recently submitted the manuscript for Obstetric Myths vs. Research Realities (finally!) and I expect to be working through the editorial process on that book as well.  One of the events on my fall calendar that I’m most excited about is my local Nurse-Midwifery Week event which will feature several speakers including Science & Sensibility’s own Tricia Pil, discussing patient safety in maternity care. On a personal note, my “baby” starts kindergarten this fall and my daughter (who was born just a few weeks after I started working for Lamaze) starts 2nd grade!

Kathleen Kendall-Tackett, Ph.D., IBCLC:  Kathleen has a number of exciting projects that she will be working on  this Fall. She started a small publishing company focusing on women’s health in March, 2011 (www.PraeclarusPress.com). She currently has five books under contract and has already received one manuscript. Several others are due by the end of the year. Dr. Kendall-Tackett will also be working on the December issue of the journal, Clinical Lactation in her capacity as editor-in-chief. The upcoming issue has some great articles including an article on ergonomic principles to help prevent pain in breastfeeding mothers, another on breast massage and hand expression, and still another on breastfeeding folklore in American Indians. She will also be finishing her term as associate editor of the journal, Psychological Trauma.

Kathleen and her colleagues, Tom Hale and Zhen Cong, have been analyzing data from their Survey of Mothers’ Sleep and Fatigue. This latest set of analyses focuses on the impact of sexual assault on women’s sleep and depression risk postpartum. The sample includes 6410 women from 59 countries, including 994 women who have reported sexual assault. The first two papers from this study can be found at http://www.kathleenkendall-tackett.com/research-projects.html. And I’ll round out the year with a lot of conferences across the U.S. and the Laktation und Stillen conference in Berlin, and a breastfeeding conference sponsored by the Belgian government at the University of Ghent. It’s looking like a busy, but really interesting, fall.

Tricia Pil, MD:  In October, Tricia is looking forward to traveling to New Haven to speak at the annual Midwifery Week Celebration for the Connecticut nurse-midwives association, which is being hosted and organized by former S&S Community Manager and current Childbirth Connection associate program director Amy Romano. She also has a letter-to-the-editor forthcoming in the American Journal of Obstetrics and Gynecology that provides a critical analysis of an obstetrics patient safety program at a major academic medical center, and she will be sharing that with S&S readers as soon as it is published.

Christine Morton, PhD continues to work at CMQCC – where projects underway include ongoing data analysis of the CA-PAMR Pregnancy Associated Mortality Review.   CMQCC will focus its next toolkit on Preeclampsia/Eclampsia, which emerged as the second leading cause of death in the CA PAMR findings.She is also co-authoring a white paper on the rising Cesarean Delivery rate in California and identifies promising Quality Improvement Opportunities in the domains of clinical care and payment reform.   Christine is engaged in two collaborative research projects with social science colleagues–one is a study of traumatic childbearing experiences (interviews with women, their support persons and providers) and the other is a national survey to be released early next year to all labor & delivery nurses, childbirth educators and doulas about their attitudes and practices on routine interventions in childbirth.  She is also slowly making progress on her book manuscript on doula care based on her dissertation research.

Kimmelin Hull Uncategorized Amy Romano, Edith Kernerman, Henci Goer, Jackie Levine, Kathleen Kendall-Tackett, Kimmelin Hull, MD, Penny Simkin, Tricia Pil

Childbirth educators should be able to discuss sex during pregnancy and sex in the postpartum period with sensitive, evidence-based counseling, so that women need not rely on anecdotal information, old-wives tales or unreliable sources.

The following quote stands as introduction to the chapter on “Sexuality in the Prenatal Period” in Childbirth Education: Practice, Research and Theory:

Childbirth educators, in their evolving role to meet the needs of twenty-first century prenatal couples, must perceive themselves as more than educators.  They must judiciously add counseling skills to their repertoire of classroom strategies.”¹

They should “approach pregnancy as a time of  heightened feelings in which physical contact and affectionate behaviors are particularly important for the pregnant  couple”²,  teaching from a strong “knowledge base”³  but those recommendations may be difficult to implement  when discussing  sex during  and  after pregnancy.  Clinicians have reported that sexuality is a difficult subject to discuss and some even question the appropriateness of any discussion of sex with their clients⁴.  Therefore, guidance, advice and the counseling of pregnant women by childbirth educators about sex is bound to be a tricky task.

I’ve brought up this aspect of our teaching with several CB educators, and have heard the opinion that discussing sex during pregnancy should not be in our purview, that it did seem integral to touch briefly on sex and contraception after birth, but in the main, they felt that the subject of sex was of small importance in our teaching, what with all the other information for which we are responsible.  The Official Lamaze Guide  devotes a mere half-page to information  about sex during pregnancy and only a short paragraph more  about postpartum sex.  In the 2010 edition of the Debby Amis and Jeanne Green Prepared Childbirth, the Family Way, there are two sentences about having sex before birth, confined to a chart on the progression of a pregnancy, and a few sentences about sex postpartum; both books give virtually no importance to the subject.

For those of us who do allocate class time for this subject, there is some very good advice and counsel in Midwifery: Community-Based Care during the Childbirth Year.  Most of us will find the advice properly helpful, sensitive and conservative: obtain permission to discuss the subject, offer concise, simple and basic facts when introducing the subject, make specific suggestions, illustrate with good visuals, and invite women to share experiences with a question like,

Some women have told me that their sex life changes a lot when they are pregnant…what has it been like for you?” ⁵ 

The text also recommends that clinicians, and I suggest, childbirth educators, become knowledgeable about lesbian pregnancy-and-parenting as well.   While there seems to be little research specific to lesbian pregnancy and that family dynamic, it is a contemporary issue, and I submit that it deserves further thought and discussion as we pursue parity and equity for women. This forum might indeed be a good place to start the conversation.

A woman’s feelings about sex may, of course, change during pregnancy for a multitude of reasons, some physical, some emotional and some spiritual. Her partner’s feelings are subject to change as well, even though sexual intercourse during pregnancy is generally fine for healthy women with healthy pregnancies and will not harm the baby.  Nonetheless, women/couples may experience changes in physical and emotional comfort and desire as the pregnancy progresses.

As for the bare physiological facts surrounding sex during pregnancy, there is general consensus in the medical profession about what sexual behaviors are safe and which ones may be harmful, with agreement to be found across the range of medical organizations and prestigious journals.   As example of the continuing and prevailing view, there is a “new, evidence-based primer to assist physicians in counseling patients regarding sexual activity during pregnancy.”  It was published online, on January 31, 2011 in the Canadian Medical Association Journal.⁶ The primer joins all the other expert opinions that have been telling women essentially the same thing for the last twenty years… that sex during pregnancy is safe in most instances. However, intercourse should be avoided where the following apply: history of miscarriage, history of preterm labor/birth, unexplained vaginal bleeding or discharge of fluids, low-lying placenta or placenta previa, incompetent or dilated cervix, and multiples in utero. Women should avoid having sex when a partner has a sexually transmissible infection in all circumstances. Oral sex is ok as long as a partner does not blow air into the vagina because of the risk of air embolism.

The conventional opinions, ranging from that in the pregnancy book published by the Mayo clinic, to the “cool” website AskMen.com, are all in accord about the facts of sex during pregnancy, mixing what the aforementioned childbirth education text calls  “the unmixable”…  that of mother and lover^7.  The AskMen site says with good humor,  “Luckily you can have lots and lots of sex as long as she’s game and doesn’t have any special medical complications.”⁸

Most women don’t really think in advance about the first couple of months after the birth of their babies with any awareness of the huge physical and emotional changes that birth brings.  There will be new physical stressors like the genuine exhaustion that comes from being the 24/7 caregiver of a newborn, and other demands of parenthood.  This is where childbirth educators may give some anticipatory guidance with a discussion of postpartum contraception, information about the behavior of the newborn in the first weeks after birth, and extend the invitation to discuss facts about resuming sex.  It is common for most women to be told by their caregivers that they can resume having sex about six weeks after the birth, depending of course, on whether their bodies have healed and whether they want do so. The six-week time line usually coincides with a woman’s first postpartum check-up after a vaginal birth, so she can base her decision about resuming sex at least in part on a physical evaluation.  This time-frame may be too stringent for the woman who has had an uneventful birth, with little or no trauma to her birthing body, and the one-size-fits-all prescription to wait six weeks can be set aside; she should be encouraged to resume having sex whenever she feels ready.  Ideally, we hope that a woman will be able to make decisions about her intimate relationship during and after her pregnancy with a loving partner, based on accurate and supportive information.

As promoters and supporters of breastfeeding, Lamaze educators must make themselves knowledgeable about contraceptive methods that don’t have a negative impact on breastfeeding.  The natural infertility conferred by lactation can be very brief, between three and six months or less, and depends upon total and exclusive breastfeeding with nursing frequency at least six times in 24 hours. Depending solely on exclusive breastfeeding for contraception is known as LAM, the Lactation Menorrhea Method. To be sure to prevent unwanted pregnancy, contraception should commence when women resume having sex. The hierarchy of contraceptive methods for nursing mothers begins with barrier methods as first choice…condoms, diaphragms (for which women need to be refitted after the birth of their babies), and spermicides and other non-hormonal methods.  Hormonal contraceptives should be progestin-only, but are considered to be a second choice. We hope that women will get evidence-based advice from their caregivers about contraception, but  we should, nonetheless, be prepared to discuss the topic. As in every other phase of women’s’ reproductive lives, informed choice based on accurate information is the ideal.

Posted by: Jackie Levine, LCCE, FACCE, CD(DONA), CLC

References:

1-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p49, 2^nd edition, WB Saunders, 2000

2-Ibid p.64

3-Ibid p.62

4-Warner PH, Rowe T, Whipple B: Shedding light on the sexual history, American Journal of Nursing 99(6):34-40, 1999.       

5-Midwifery: Community-Based Care during the Childbirth Year, Linda V Walsh, p180 WB Saunders Company, 2001.

6- http://www.medscape.org/viewarticle/736791

7-Childbirth Education: Practice, Research and Theory, Francine H. Nichols and Sharron Smith Humenick, p62 2^nd edition, WB Saunders, 2000

8-www.askmen.com/dating/love_tip_250/259b_love_tip.html

Jackie Levine Science & Sensibility, Uncategorized guidelines for sex during pregnancy, is it safe to have sex during pregnany?, Jackie Levine, postpartum sex, prenatal sex, sex during pregnancy

Mother and Child Reunion

The goal of Lamaze “Healthy Birth Practice #6, Keeping Mother and Baby Together – It’s Best for Mother, Baby, and Breastfeeding” is to encourage and support mothers so they may confidently insist that they not be separated from their newborns, and be allowed to have ample opportunity for skin-to-skin contact without delay or interruption, as recommended by a multitude of sources concerned with infant and maternal health.

Dr. Lennart Righard’s seminal study¹, published in the Lancet in 1990, gave rise to his famous video, “Delivery Self Attachment”², which illustrated parts of that research.  It shows babies who, when left undisturbed on their mothers’ bodies immediately after birth, find the breast by themselves, crawl to it and suckle with competence. It observes also those babies whose abilities are either impaired or negated because of exposure to intrapartum meds, separation from their mothers after birth, or both.

“Newborns have a great need for love which makes a separation between mother and child most unfortunate”³, Lennart is quoted as saying, poignantly, in a blurb on the packaging of his video. A banner below that quote, set in 16-point type and caps, proclaims “THIS SIX MINUTE VIDEO WILL CHANGE PROTOCOLS!”

It is ”unfortunate” indeed that  many mothers still experience resistance to this best-evidence protocol; hospital staff and caregivers still whisk newborns away for routine procedures, processing and observation after just a few minutes of time with their mothers.   As with so many maternity-care practices, the protocols that Righard thought with certainty would change, are still in place, even as the evidence for keeping mother and baby together mounts.  Some state Departments of Health, as that in Ohio, have got it right, and officially recommend skin-to-skin. That state prints and distributes cards for its WIC program that read, in part:  “Hold me, Mom. Babies who are held skin-to-skin on their mother‘s chest right after birth are happier and less likely to cry, are more likely to latch on and [sic] breastfeeding well, have better heart rates, have better temperatures than under a warmer, have better blood sugars, burn less [sic]  calories than under a warmer. So, be sure to tell your doctor and the hospital nurses that you want to hold your baby for at least the first hour after the birth, skin-to-skin (baby naked, not wrapped in a blanket). That‘s the best way to introduce your baby to the world”⁴. (Emphasis mine.) How can we account for the fact that a mother is advised by a government agency to “be sure” to tell her doc and staff to give her best-evidence care? Even for this well-documented and uncomplicated course of action, we cannot count on our caregivers to act reliably in the interests of mother and baby.  Again, a Healthy Birth Practice can be read as a subtle warning: Do not let them take your baby from you for the first hour!

Mothers have always needed to keep their babies with them, and supporting evidence for that urgent desire has been around for quite a while.  In 1979, Michel Odent proposed, in a theory and review article on human ecology, and under the aegis of his Primal Research Center, that the natural ecology  for an infant is to be skin-to-skin (S2S) with the mother. The Human Ecolog deals with “primal” health, a branch of epidemiology that brings together studies exploring correlations between what happens during the primal period (fetal life, perinatal period and the year following birth) and what occurs later in life in terms of health and personality traits. The treatment of mother and newborn as an inseparable dyad is the basis for those studies and can be found compiled in the Primal Health Research Data base ^5.

With the understanding of what is best for the “primal” health of the newborn, and in light of the wisdom of Healthy Birth Practice #6, the Baby Friendly Hospital Initiative of the WHO and UNICEF very specifically and unequivocally advises that mothers and infants remain together 24 hours a day.  As of May 2011, out of 3,000 or so hospital maternity centers and free standing birth centers in this country, only 110 have achieved the status of Baby Friendly.  No wonder women must be advised and exhorted to ask or demand treatment that should be just pro forma in every LDR. Why must women spend precious energy and focus during labor to advocate for best-evidence care for themselves when that kind of care should just be expectations met?  Period.

Kangaroo Care, “a universally and biologically sound method of care for all newborns,” ⁶ incorporating S2S, breastfeeding and support of mother and baby, has become a standard of care in many NICUs.  While there is no citation to back up that statistic, Wikipedia represents that fully 82% of NICUs in the US practice KC.  That is not surprising, given the wealth of studies going all the way back to 1979 that show how effectively KC helps at-risk babies i.e., improving and normalizing vital signs, stabilizing breathing and heart rate and normalizing glucose and stress levels. Many studies can be accessed at the kangaroo care website: http://www.kangaroomothercare.com.   Kangaroo Care babies have been shown to have significantly higher scores in visual and auditory  orientation, alertness, cuddliness, self-quieting, attention and state regulation, and higher scores at 6 months on the Infant Temperament Questionnaire than standard-care infants.  Kangaroo care has been shown to promote neonatal behavioral organization and enhanced developmental outcomes through the first year of life. ⁷Is it such a stretch to extrapolate that practice to all term healthy newborns whose need for their mothers is just as acute as that of those in NICUs?

There are some fascinating studies about interactions between mother and baby immediately after birth that investigate “the  ‘smellscape’ of mother’s breast: the effects of odor on neonatal arousal, oral and visual responses”.⁸ Here are just a couple of  observations from a multitude of studies available: “volatile compounds originating in areolar secretions or milk, release mouthing, stimulate eye-opening and delay and reduce crying in newborns”.⁹ “The odor of human milk is more attractive to human newborns than formula milk…independent of postnatal feeding experience.”¹⁰

The skin-to-skin interactions between mother and babe are maturational for newborn; the contact stimulates the vagal nerve, causing increased growth in size of the villi in the newborn gut, which provides a larger surface area for the absorption of nutrition. Nancy Mohrbacher, author and breastfeeding expert, in her article “Rethinking Swaddling” ¹¹ has pointed out the differences between the infant held skin-to-skin and those who were wrapped and held by their mothers.  She cites studies showing that swaddling delays the first breastfeed and leads to less effective suckling, greater weight loss, and more jaundice. Routine swaddling has negative effects on the infant whether in the hospital or at home.

In the main, Healthy Birth Practice #6 addresses a mother’s time in the hospital, to promote behavior that is really just a prelude to how mother and baby should proceed together when they go home. But along with that vital and valuable information, another aspect of a new mother’s experience needs to be examined and promoted… we must begin to examine with mothers something that is rarely mentioned, rarely talked about by OBs, and rarely discussed as part of the normal and natural part of a new life coming into the world…the remarkable abilities and competence of the newborn.  Birthing of the placenta gets more coverage in birth literature than do the stellar capacities of a new baby.

The Righard video of newborn behavior amazes because we see the antithesis of what first-time mothers imagine that their infants will be like.  Popular images show a greasy-eyed newborn, wrapped up and be-blanketed as tight as a little taco, handed over to mom to hold. The Righard video, familiar to many of us, causes gasps at the first images of that lively newborn pushing its little legs against its mother’s abdomen, bobbing its little head with power and purpose, and performing the initial latch with brio.  Mothers need to be told that, even if they have had intrapartum medications, they must continually give their newborns the opportunity to perform as they are hard-wired to do, and we must emphasize that newborns are capable and competent. Dr. Christina Smillie’s approach to breastfeeding…and her video “Baby-Led Breastfeeding” ¹² rely on the baby’s instinctive responses to seek and find the breast when they are allowed to stay on their mother’s bodies.  It demonstrates without equivocation how well babies can navigate about to find the breast. Every mother-to-be should be told about the amazing capabilities of her newborn, and encouraged to spend time every day with her newborn skin-to-skin.  That information should be part of every childbirth education syllabus.

A couple of videos that came out this year also address that important hour or so after birth, and illustrate the nine stages through which the newborn progresses.  Sponsored by the Healthy Children Project, the video called The Magical Hour¹³ and based on the research of Anne-Marie Widstrom and colleagues, is aimed at parents-to-be, and shows newborns in all the stages of adaptation to life outside from Stage One, the Birth Cry, to Stage Nine, Sleep. The other video, Skin to Skin in the First Hour after Birth: Practical Advice for Staff after Vaginal and Cesarean Birth ¹⁴, also from the Healthy Children Project, is aimed at hospital staff, delineating the same nine stages as The Magical Hour. It lays out guidelines for the treatment of mother and baby immediately after birth, whether vaginal or cesarean, with the view that the implementation of direct and uninterrupted contact between mother and newborn is the perfect beginning for a new family.

References

1-      Lancet, Vol. 336,1105-07

2-      Delivery Self Attachment, 1995 Lennart Righard & Kittie Franz, Geddes Productions, Los Angeles, CA

3-      Ibid

4-       Ohio Department of Health. (2008). Hold me, Mom. Columbus, Oh: Ohio Dept.  of Health Printing, Warehouse # 3977.23.

5- www.primalhealthresearch.com Odent, M. (2006).  Homo Super-predator to Homo Ecologicus. http://www.wombecology.com/homo.html#top.

6-www.kangaroomothercare.com/whatis01/htm

7-Fukida M, Moriuchi, Akiyama T, Nugent JK, Brazelton, TB, Arisawa K, Takahashi T, & Saito H (2002) The effects of kangaroo care on neonatal neurobehavioral organization, infant development and temperament in healthy infants through one year. J Perinatology, 22(5).384-379

8-Doucet S, Soussignan R, Sagot P, Schaal B, Dev Psychobiol 49(2); 129-38, 2007 Equipe d’Ethologie et de Psycholbiologie Sensorielle Centre des Sciences du Gout Umr 5170 CNRS Dijon, France. doucet@cesg.cnrs.fr

9-Ibid

10-Mizuno K, Mizuno N, Shinohara T, et al; Mother-infant Skin-to-skin contact after delivery results in early recognition of own mother’s milk odour. Acta Paediatrica 93(12):1640-1645, 2004 katsuorobi@aol.com

11-Rethinking Swaddling, International Journal of Childbirth Education, 2010

12-Baby-Led Breastfeeding, Geddes Productions, Los Angeles, CA, 2007, Christina M Smillie, Ivy Makelin, Kittie    Franz

13-The Magical Hour; Holding Your Baby for the First Hour After Birth. DVD Produced by Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc

14-Skin to skin in the First Hour After Birth: Practical Advice for Staff after Vaginal         and Cesarean Birth,  DVD Produced by  Kajsa Brimdyr, Kristin Svensson and Ann-Marie Widstrom, www.healthychildren.cc

Jackie Levine Baby Friendly Initiative, Breastfeeding, Evidence Based Medicine, Films about Pregnancy, Healthy Birth Practices, Healthy Care Practices, Patient Advocacy, Practice Guidelines, Uncategorized delivery self attachment, Healthy Birth Practice #6, Healthy Children Project, Jackie Levine, kangaroo care, Kangaroo Care in NICUs, Kangaroo Mother Care, Keeping Mother and Baby Together, Lennart Righard, Michel Odent, Mother and Child Reunion, no separation of mom and baby, Primal Research Center, skin-to-skin care, skin-to-skin contact