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

July 11th, 2013 by avatar

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

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© www.momaroo.com

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

References:

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

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

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

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

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

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

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

ACOG, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Push for Your Baby, Uncategorized , , , , , ,

EMDR Part Two: Clinical Opinions Regarding the Safety of using EMDR to Process Traumatic Material During a Subsequent Pregnancy to Treat PTSD (childbirth onset)

October 4th, 2012 by avatar

Today, Kathy Morelli shares the second part of her series on EMDR, and exams clinical opinions  on the safety of EMDR as a treatment modality.  You can find part one of Kathy’s post on EMDR here. –  SM

There is a lack of specific empirical research to support the safety or lack of safety about incorporating EMDR into a trauma treatment plan for a pregnant woman.

However, there are many experienced trauma clinicians who work weekly in their practices with pregnant women. I gathered clinical information about this issue from several experienced and distinguished trauma clinicians who work with women, pregnancy and trauma and use EMDR.

Background Research about Maternal Stress and the Uborn

The mom and unborn baby (I will henceforth use the term, uborn, borrowed from Michelle LeClaire O’Neill) are connected via stress hormones, which reach the uborn via the placenta.

There are many studies about the effects of stress hormones on the uborn. In general, the research draws a distinct difference between the impact of moderate amounts of stress and the impact of long-term chronic stress. (For a more detailed discussion of this, see How Much Stress is Too Much Stress in Pregnancy?)

Creative Commons Image: Pamela Machado

Chronic and extreme stress is characterized as famine, poverty, major natural disasters, domestic violence and other extreme life stressors. Studies show the release of excessive amounts of maternal stress hormones may impact the uborn’s brain development (Johnson, 2012; Mulder et al, 2002). In addition, there may be changes in the blood flow to the uborn and this may impact the development of other organs. The research also indicates there are individualized, mitigating factors on the effects of extreme stress, such as social supports and individual resilience (Johnson, 2012; Mulder et al, 2002).

While there isn’t much specific research about the effects of using Eye Movement Desensitization and reprocessing (EMDR) to treat PSTD (childbirth onset) in the pregnant population, there is a lot of research about using EMDR to treat PTSD in the general population.

What are clinicians’ experiences regarding the safety of using EMDR during a subsequent pregnancy to treat PTSD (onset childbirth)?

In my interviews of clinicians regarding the processing of traumatic material with pregnant women, several guidelines emerged:

  •  Little or no empirical research on this issue exists
  • Clinician must be experienced in trauma work
  • Clinician must use good clinical judgment, as it is not always appropriate to go forward
  • Treatment must be tailored to the individual woman and her needs
  • Recommend consultation with her physician if there are existing physical issues or if she is in her third trimester
  • Processing traumatic material during pregnancy generally does more good than harm

Benefits cited:

  • processing attachment trauma (abuse) promotes healthy attachment & bonding behaviors
  • enhances enjoyment of pregnancy,
  • enhances confidence in healthy birth
  • can be used to reinforce positivity about the birth, including what was learned in childbirth classes, such as the Lamaze methods

Julia Wood, M.D., a psychiatrist specializing in women’s issues, has a special focus on trauma and borderline personality disorder. She is Medical Director of Brookhaven Recovery Retreat for Women. Her past position was at the Massachusetts General Hospital Center of Women’s Health. She began by saying, when working with traumatic material with pregnant women, in the absence of empirical research indicative of either benefit or harm to the developing fetus, one must use good clinical judgment.

While at Massachusetts General Hospital’s Center for Women’s Health, she worked with a disenfranchised population: pregnant women under chronic stress due to domestic violence and poverty. Although she believes caution should be used when treating traumatic material with a pregnant woman, she said her overall clinical experiences indicated it was beneficial for her patients to be treated for their psychological trauma during pregnancy.

Dr. Wood stated the mental health support helped her patients process their personal traumatic experiences, be more confident about pregnancy and birth, form a more positive attachment with their babies and learn positive coping skills.

Dr. Wood said she does not favor any particular trauma treatment modality, but stressed that the value of clinical experience when treating trauma is key and good clinical judgment is a necessary component of compassionate and successful treatment.

Heidi Koss, LCSW, Executive Director of Postpartum Support International of Washington State, and an expert clinician in childbirth trauma, says she uses an integrative approach with pregnant clients. She creates an individualized treatment plan, incorporating EMDR and other modalities such as interpersonal therapy, mindfulness and somatic experiencing to help her clients process traumatic material. When using EMDR, she says “….I don’t have them recall all the details of their previous traumatic birth, just enough to access the neural pathways we are targeting in order to calm, to lessen any spikes in cortisol that might impact the fetus.”

Kathleen Reay, Ph.D., who has been teaching EMDR for 12 years, has worked extensively with traumatic material with pregnancy clients. Dr. Reay stresses that good clinical judgment must always be used.

Dr. Reay says she’s never come across any safety issues in her work with pregnant clients and she believes there are extensive benefits to working through traumatic material while pregnant. However, Dr. Reay says that when the mother has a pre-existing medical or physical issue, or if she is in her third trimester, she discusses her work with her client’s physician, before beginning any treatment with EMDR, in order to ensure safety. She also says it’s important to discuss the treatment with the mom, too, assuring her she may stop the session(s) at any time.

Dr. Reay believes the benefits to processing traumatic material during pregnancy are twofold. One, it helps the mom work out her own traumatic attachment issues (perhaps related to abuse) and addresses pervasive emotional dysregulation, thus promoting self-regulation, appropriate regulation of her baby and a secure attachment with her uborn and newborn.

Two, EMDR can be used to strengthen the mom’s own resources and positive attitudes about her upcoming birth, such as positive beliefs that she will be able to get the support shes needs, and EMDR can be used to reinforce whatever birth practice the mom chooses to use, including Lamaze’s Healthy Birth Practices.

Julie Greene is an EMDR trainer with extensive experience with pregnancy and trauma. She has been practicing EMDR since 1998 and teaching since 2005. Ms. Greene says as a trainer as well as a clinician, she stresses caution and safety first. She has extensive experience with using EMDR during pregnancy, and has an integrative approach, using mindfulness in her practice as well.

Like Dr. Reay, Ms. Greene uses EMDR to do resource development with any pregnant client, in order to strengthen inner feelings of self-efficacy and emotional flexibility.

Also like Dr. Reay, her cautionary clinical signals are if the mom was either in her third trimester or experiencing physical difficulties, she first speaks to her client’s physician, in order to assess whether or not to proceed with the trauma treatment.

Generally, her thoughts are the benefits to the baby are usually higher than the risk. Ms. Greene says the best reasons to do EMDR trauma work during pregnancy are when there are issues stuck in the mom’s bodymind related to pregnancy and birth. For example, she says, if the mom is terrified and stressed the entire pregnancy, there is a benefit to the current pregnancy to clear this out of the mother’s system using EMDR.

Or, if the client has traumatic history, such as sexual abuse, locked in her body, this can cause a lot of mental and emotional difficulty during pregnancy. There may be a lot of shame and negative thoughts and feelings about her body, the pregnancy, and fears of becoming a parent. Ms. Greene says EMDR is a good way to release this.

Like Dr. Reay, Ms. Greene uses EMDR to help her clients access and strengthen their internal resources, so they feel and believe they made good decisions that are right for them for their personal birth and parenting experience.

To sum up, when processing traumatic material with EMDR with pregnant women, these clinicians used caution and followed good clinical guidelines, tailoring the treatment to the individual woman, and generally believed the benefits regarding birthing and parenting confidence outweighed the harm.

References

EMDR Institute, Inc. (2012). Research Overview. Retrieved July 29, 2012 from http://www.emdr.com/general-information/research-overview.html

Johnson, K. (2012). The effects of maternal stress and anxiety during pregnancy. Retrieved September 25, 2012 from http://bit.ly/QhNyIq 

LeClaire, Michell O’Neill (2000). HypnoBirthing- the original method. Chicago: Papyrus Press.

Mulder, E.J.H., Robles de Medina, P.G., Huiznik, A.C., Van den Burgh, B.R.H. & Buitelaar, J.K., &Visser, G.H.A., (2002). Prenatal maternal stress: effects on pregnancy and the (unborn) child. Early Human Development, 70, 3-14.

Parnell, L. (2007). A therapist’s guide to EMDR: Tools and techniques for successful treatment. New York: W.W. Norton & Co.

SAMHSA National Registry of Evidence-Based Programs & Practices (NREPP) (2012). Eye movement desensitization and reprocessing. Retrieved July 29, 2012 from http://nrepp.samhsa.gov/ViewIntervention.aspx?id=199

Wood, J. PTSD and Childbirth. Retrieved July 29, 2012 from http://www.womensmentalhealth.org/posts/ptsd-and-pregnancy/

 

Birth Trauma, Cesarean Birth, Depression, EMDR, Guest Posts, Infant Attachment, Kathy Morelli, Maternal Mental Health, Parenting an Infant, Postpartum Depression, PTSD, Trauma work , , , , , , ,

Blog Carnival Round-Up: Stories of Success from the Field

January 28th, 2011 by avatar

It really is a joy and, I believe, imperative to spend time sharing childbirth success stories amongst those of us who dedicate our professional lives to improving childbirth experiences and outcomes for women all around the globe.  This year’s first blog carnival is about just that:  celebrating success while illuminating some ways in which Lamaze’s Six Healthy Birth Practices can and have been implemented in the process of realizing these successes.

Lisa, at Journey Through Lamaze, shared with us a lovely story of one of her recent clients who allowed labor to start on its own, and labored at home long enough before checking into the hospital to find herself fully dilated and ready to begin pushing shortly after admission.  Having begun with Healthy Birth Practice #1, this mama progressed through a non-medicated birth which Lisa describes as, “…the calmest birth I’ve ever been at.”  (Read Lisa’s post to find examples of other Healthy Birth Practices exemplified during this baby’s birth.)

Childbirth Educator, Judith, from Dance While You Cook relates how she incorporates teaching the importance of walking, moving around and changing positions throughout labor (Healthy Birth Practice #2) into her childbirth preparation classes.  Beyond “typical” teaching strategies, Judith shows her students how movement in labor can be effective by demonstration through a labor and birth dramatization. Read her post, and I guarantee you, you will pick up on the renewed energy and empowerment Judith gains each time she conducts this portion of her curriculum.

Many of our carnival contributors wrote about experiencing childbirth from a doula’s point of view.  Wendy from Mom and Little Me wrote about her strong belief in extending Healthy Birth Practice #3 into the prenatal period as much as possible.  It is during the prenatal visits that some of her most effective doula support takes place.  (Follow the link to Wendy’s post to also read about her ambitions for educating “a younger generation on natural childbirth and breastfeeding.”)  Hillary at Infinitely Learning shares with us a lovely anecdote about the birth of one of her doula clients that showed her the importance of holding space and bearing witness to the great journey of another human being, as she describes below:

She was a really independent birther and mostly needed the midwives and me (the doula) there for reassurance during some strong moments, but mostly I just stood Witness. A couple of times I doubted that I was even needed and became self-conscious that I wasn’t doing enough, but when I checked in internally to be guided I heard, “Witness”.

Kate, at Two Bee Birth Services shared the story, as written by the mother, of a successful, un-medicated VBAC.  With a history of multiple medical interventions during previous birth experiences plus some other recent pregnancy-related complications, this mama pursued a vaginal birth in the safest way possible, considering a present and extenuating medical circumstance.  In order to do this, she dedicated herself to avoiding interventions that were not medically necessary (Healthy Birth Practice #4) and succeeded in achieving the VBAC she hoped for.

Providing a fantastic success story that illustrated all six Healthy Birth Practices, in the setting of one birth, “Anthro Doula” Emily at Doula Ambitions simply and beautifully describes the end of one of her first birth experiences as a doula:

Once in the labor and delivery room she crawled up onto the bed on all fours, following her instinct and her urges to push on her own. She changed positions to a squat, leaning against the back of the raised bed, so that she would be able to catch her own baby. (Healthy Birth Practice 5: Avoid giving birth on your back and follow your body’s urges to push!)

This is my favorite part of the story, and my favorite part of any birth so far…
While the baby’s head was crowning, she reached down and felt his head, and she looked up with a face full of wonderment and said, “His head is coming out and then going back in a little!” She was so calm and intrigued, fully experiencing the birth of her first child. Then she pushed out her baby and pulled him up onto her stomach, all the while calm and grinning like mad!

The husband had tears streaming down his face, and the new mother was immensely pleased with herself. Mama and baby stayed together, skin-to-skin, and began to initiate breastfeeding, for the whole first hour.
(Healthy Birth Practice 6: Keep mother and baby together - It’s best for mother, baby and breastfeeding)

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Thank you to all blog carnival contributors for your thoughtful words and illustrative stories which collectively remind us that safe, healthy, fulfilling birth experiences are not an anomaly, but an achievable reality!
**Don’t forget to swing on over to Giving Birth With Confidence to read additional results of this blog carnival!

Posted By:  Kimmelin Hull, PA, LCCE

Blog Carnivals, Doula Care, Healthy Care Practices, Practice Guidelines, Vaginal Birth After Cesarean (VBAC) , , , , , , , , , , , ,