Science & Sensibility

[Editor's note: This is a guest post from former Lamaze International President, Jeannette Crenshaw. When Jeannette told me about the video she reviews in this post, I knew I wanted to highlight it as part of the Sixth Healthy Birth Blog Carnival.

I recall  one birth I attended as a midwife, I had to negotiate with the nurse about how long we would "let" the mother and baby remain in skin-to-skin contact after birth. Her reason for wanting to disrupt skin-to-skin time? "I have to put the baby in the computer." Her job (completing birth documentation) was interfering with her job (safeguarding the health and wellbeing of the mother and baby).

Hospital routines are the #1 reason mothers and babies are denied skin-to-skin contact after birth. Changing this  harmful practice is possible, but it takes a commitment to quality and systems improvement.  Now that the Joint Commission is measuring hospital perinatal quality by the proportion of babies exclusively breastfed at discharge,  hospitals need concrete tools to retrain staff and change delivery room culture. Hospitals: it seems like this video may be $39.00 well spent. - AMR]

Skin to Skin in the First Hour After Birth:
Practical Advice for Staff After Vaginal and Cesarean Birth (DVD)

Executive producer and videographer: Kajsa Brimdyr, PhD, CLC; executive and content producers: Kristin Svensson, RN, PhD (cand.) and Ann-Marie Widström, PhD, RN, MTD.
$39.00 at Healthy Children

A new DVD from Healthy Children Project should be mandatory viewing for every labor and delivery nurse and birth attendant. It will help maternity health professionals in hospital settings to implement the best practice of uninterrupted skin to skin care beginning immediately after birth until after the first feeding. This is a “how to” DVD, with the practical advice health professionals need to provide clinical care to mothers and babies who are skin to skin immediately after a vaginal or cesarean birth.

The 40 minute DVD, set to original music by J. Hagenbuckle, has 3 content sections, and a section with a complete list of references. The first section describes the short and long term benefits of skin to skin care for newborns and mothers. It shows the 9 stages healthy newborns experience while skin to skin during the first hour after birth—from the birth cry (stage 1), through suckling (stage 8), and sleep (stage 9). The narrator emphasizes the individual way each baby moves through the 9 stages.

The second section shows how to provide care for mothers and babies while they are skin to skin, after a vaginal, and the third, after a cesarean birth. Both sections begin with health professionals teaching pregnant women about immediate skin to skin care prenatally, and on admission to the hospital—which “sets the stage” for immediate skin to skin contact as a normal part of the birth process. After the vaginal birth, the clinician immediately places the baby on mom’s abdomen. After the cesarean birth, the nurse immediately places the baby on mom’s chest, above the sterile field and drapes, as the doctor continues the surgery and the anesthesiologist monitors the mother. The baby’s father is at mom’s side in both segments. Nurses remove birth fluids as they dry the baby—delicately addressing the common concern that babies should first be “cleaned up” at a warmer. Nurses remove wet blankets, place the baby skin to skin, and cover mom and her baby with warmed blankets. Both sections show competent nurses assessing the newborn, providing care, and supporting the mother and baby as the baby moves through the 9 stages of skin to skin.

I strongly recommend this DVD (only $39.00) for staff in any maternity setting. Childbirth educators will find the first section of the DVD a great addition to their prenatal childbirth and breastfeeding classes (although Breastfeeding—A Baby’s Choice, 2007, may be a better choice). Staff who are working to help their hospitals achieve Baby-Friendly designation will find this DVD useful for training. The narrator uses, for the most part, simple and non-clinical language and the video of mothers and babies will quickly engage the viewer. The DVD’s producers met their objective: “to assist staff in providing behaviorally appropriate, individualized, baby adapted care for the full term newborn using the best practice of skin to skin contact in the first hour after birth”.

Reference:

Healthy Children Project. (Producer). (2007). Breastfeeding—A Baby’s Choice [DVD]. Available from http://www.healthychildren.cc/

Jeannette Crenshaw, MSN, RN, NEA-BC, IBCLC, LCCE, FACCE is a member of the graduate faculty at the University of Texas at Arlington College of Nursing and a family educator at Texas Health Presbyterian Hospital Dallas. She represents Lamaze on the United States Breastfeeding Committee (USBC) and coordinates the Lamaze Breastfeeding Support Specialist Program. She has published articles and presented nationally and internationally on a variety of topics, including evidence based maternity care.

Jeannette Crenshaw Uncategorized DVD, Healthy Birth Practices, hospitals, Joint Commission, newborns, no separation, quality improvement, skin-to-skin contact

If you haven’t heard, the Joint Commission, the organization that accredits U.S. hospitals, has recently rolled out a bundle of perinatal quality measures. These measures are designed for hospitals to track and improve their performance on indicators of perinatal quality, including the proportion of newborns discharged from the hospital having consumed only breast milk during their hospital stay. The US Breastfeeding Committee created a helpful document for hospitals, Implementing the Joint Commission Perinatal Core Measure on Exclusive Breast Milk Feeding (PDF). Right on the first page and repeated two more times, the Committee makes this suggestion:

Compliance with the new core measure may require facilities to modify their paper charts and/or electronic medical records. Thus facilities may want to consider charting modifications that support breastfeeding (such as length of time of skin-to-skin contact, especially immediately following birth). [emphasis is mine]

I don’t know how difficult it is to get hospitals to make changes to their documentation forms. I assume as more hospitals adopt electronic health records, the task is easier. However, even if changing the form is easy and inexpensive, staff will need to be briefed on the rationale for the change and trained to document the new data properly. This all adds to the complexity and cost of providing care, so it’s easy to see how some hospitals would just stick with their old way of documenting.

But if hospitals are serious about improving their exclusive breastfeeding rates, they should get serious about measuring the duration of skin-to-skin care. A new study in the Journal of Human Lactation demonstrates a strong dose-response relationship between skin-to-skin care and exclusive breastfeeding at hospital discharge. The data in fact come from a hospital quality improvement program carried out in 19 hospitals in California – the reason they were able to detect the dose-response relationship is that they were documenting the length of skin-to-skin contact as part of these quality improvement efforts. Using data from nearly 22,000 mothers and their healthy, full-term babies, the researchers found the dose-response relationship even after controlling for whether the woman intended to exclusively breastfeed, education, ethnicity, anesthesia, mode of birth, and other factors. One factor that was not reported and apparently not controlled for was history of prior birth and/or prior breastfeeding experience. This could be a significant confounder, but there is no reason to believe it would negate the strong and consistent findings – the dose-response pattern held up in multiple calculations applying various assumptions.

The quality improvement project that produced this study was supported by the Loma Linda University Perinatal Services Network, a network of hospitals working collaboratively to create policies and practices that keep moms and babies together after birth. Check out these great flyers and handouts they offer to promote early mother-infant attachment and breastfeeding.

Amy Romano Uncategorized breastfeeding, Joint Commission, newborns, skin-to-skin contact

The Joint Commission Sentinel Alert #44: “Preventing Maternal Deaths” is an important document and public recognition that many of the maternal deaths in the United States are preventable. However, the alert is missing important and useful information for women and childbirth educators since the recommendations in the alert are downstream approaches or recommendations for how to save a woman from dying who may have been thrown in the river. It fails to alert our healthcare system about the need to keep women out of the river in the first place.

Let me give you some examples:

One Joint Commission recommendation is to consistently use techniques that have proven effective in the prevention of thromboembolism (blood clots) in women having surgical births. Clearly it is critical that we reduce the risks of surgery and this recommendation needs to be heeded. We need to make surgical births as safe as possible. However, if we eliminated the overuse of cesarean sections we would eliminate even more deaths and injuries. Based on publicly released data, the increase of cesarean surgical intervention is related to where a woman gives birth.

Debra Bingham, DrPH, RN, LCCE

Indeed there is often as much as a three-fold variation in the number of surgical births performed at different hospitals even after adjusting for the woman’s age and risk factors. Reining in practice variation has been a focus of efforts to improve care in other healthcare specialties, yet wide and unwarranted practice variation remains a serious problem in maternity care.

So why are there so many more surgical births and such wide variation in rates of cesarean sections? Well one clear factor at work is variation in how women are treated in labor. For example, some hospitals keep women who present in early labor while other hospitals are more likely to offer supportive care to these women and encourage that they remain at home until active labor. Why is being in a hospital in early labor a problem? When a woman is in a hospital in early labor she is put in a bed, her movements are restricted, and she is tethered to a fetal monitor. None of these interventions has been shown by research to improve maternal or infant outcomes, and in fact they all have documented harms. In addition, it is normal and expected for early labor to start and stop for several days. However, if a woman is admitted to a hospital in early labor and her labor stops then she is likely to have an unnecessary induction of labor. Overuse of inductions lead to more cesarean sections. This becomes the beginning of a cascade of events that all too often leads to a surgical intervention.

Let’s move to the hemorrhage recommendations as another example. Hemorrhage remains a leading cause of death and severe morbidity despite more efforts over recent years to control blood loss at birth. Why haven’t these efforts succeeded? One reason is that as the cesarean rate rises, more pregnant women have uterine scars. The uterine scar increases a woman’s risk for abnormal placenta implantation when they get pregnant again. These abnormal placenta implantations are called percretas, accretas and previas. When a woman has placenta accreta or percreta this can lead to internal organ damage and permanent damage to her uterus because the placenta literally grows into the uterine muscle or even into her bowel and bladder and cannot detach from these organs after the baby is born. This abnormal implantation leads to hemorrhage and also often necessitates the removal of her uterus to save her life. Abnormal placenta implantations used to be very rare emergencies; they are becoming common now due to the overuse of cesarean sections. This is a trend that is frightening to me because based on the current rates of cesarean sections the number of women affected will only increase. Things are going to get much worse.

Lamaze International has issued our own “Sentinel Alert” on how to prevent maternal deaths. Lamaze’s recommendations are called the Six Healthy Birth Practices. Following these key practices will prevent women from being thrown in the river and needing to be rescued.

The critical behaviors that Lamaze recommends to improve health and safety are to let labor start on it’s own, encourage freedom of movement, offer labor support rather than labor management, avoid all routine interventions not supported by evidence, avoid interfering with a woman’s freedom to push in an upright position or any position of her choice, and keep the baby with the mother after birth.

Hospitals can help achieve the Joint Commission goal of reducing preventable maternal deaths while also making progress toward Joint Commission core measures by training staff in these practices. Lamaze International offers an Evidence-Based Nursing Care Workshop to do just that. Registration is currently open for our March workshop in Hollywood, Florida.

Debra Bingham, DrPH, RH, LCCE is President-Elect for Lamaze International, Executive Director of the California Maternal Quality Care Collaborative (CMQCC), a member of the California Pregnancy-Associated Maternal Mortality Review Committee and a lead researcher for determining how to prevent maternal deaths.

Debra Bingham Uncategorized cesarean, complications, hospitals, induction, interventions, Joint Commission, practice variation, safety