Science & Sensibility

As I wrote about in my January 3rd, 2012 post on the top 10 reasons to join Lamaze International, one of the great benefits of being a Lamaze member is complete access to the Cochrane Collaboration.  The Cochrane Collaboration is an international organization whose purpose is to make available information on the effects of healthcare interventions.  Reports in the form of Cochrane Reviews are current, accurate and made available electronically on the internet and by DVD, and updated monthly.  Systematic reviews are conducted and published on a wide variety of healthcare interventions so that people can make informed decisions. This is stored in the Cochrane Library.

The Cochrane Collaboration was founded by Archie Cochrane, who was a British medical researcher.  Mr. Cochrane is best known for his article Effectiveness and Efficiency: Random Reflections on Health Services written in 1972.  

The creation of a systematic review of randomised controlled trials (RCT’s) of care during pregnancy and childbirth is “a real milestone in the history of randomised trials and in the evaluation of care.” Professor Archibald Leman Cochrane, CBE FRCP FFCM, (1909 – 1988)

The Cochrane Collaboration is celebrating their 20th anniversary this year, 2013 and will be sharing a series of 24 short videos over the course of the anniversary year, focusing on the ideas, achievements and people that have been part of the history of this international and well-respected organization.  I am sharing the first in this series, so you can learn a bit more about how this organization came to be recognized as the gold standard in evidence-based health care.

The United States Cochrane Center has created and made available free of charge, an online tutorial, “Understanding Evidence-based Healthcare: A Foundation for Action, that can help you to learn how to best navigate and understand the resources contained in the Cochrane Library.

Lamaze International’s Healthy Birth Practice Tools is completely based on evidence based information and was created so that consumers could understand and advocate for the best care for themselves and their babies.  Lamaze recognizes the importance of educators and others having access to up to date information and therefore is pleased to offer access to the Cochrane Library as a member benefit.   To access the Cochrane Library as a Lamaze member, first login to Lamaze International’s Member Center and then follow the drop down box to the Cochrane Library. You will be redirected to the library, with full access.

I rely on and use this member benefit constantly, and appreciate it being made available to me by Lamaze.  Won’t you share in the comments section how you use the Cochrane Library?  How has it helped you?  Do you find what you need?  Do you share information and studies with your students, clients and patients?  Let us know, please.

References 

Cochrane AL. Effectiveness and Efficiency. Random Reflections on Health Services. London: Nuffield Provincial Hospitals Trust, 1972. (Reprinted in 1989 in association with the BMJ, Reprinted in 1999 for Nuffield Trust by the Royal Society of Medicine Press, London (ISBN 1-85315-394-X)

Sharon Muza Childbirth Education, Continuing Education, Evidence Based Medicine, Healthy Birth Practices, Healthy Care Practices, informed Consent, Lamaze International, Maternal Quality Improvement, Maternity Care, Medical Interventions, New Research, Practice Guidelines, Research, Systematic Review Childbirth Education, Cochrane Collaboration, Evidence Based Medicine, Healthy Birth Practices, interventions, Lamaze International, maternity care systems, research, Sharon Muza, Systematic Review

Science is simply common sense at its best.  ~Thomas Huxley

Science.  Sensibility.  Science and sensibility are good words.  I gravitate to these words naturally.  These words offer me security, comfort and a feeling of order in the world.  I am delighted and honored to be the new Community Manager for Lamaze International’s Science and Sensibility blog and every time I think of the name of the blog I smile, because it feels like coming home.  It defines what I think is important in the work that I do as a childbirth educator and doula.

Science and sensibility is the crux of why I became a Lamaze certified childbirth educator.  The foundation of Lamaze and the principles that guide the work of this blog and of the entire Lamaze organization are built on quality research.  I am proud when I teach The Six Lamaze Healthy Birth Practices in my own classes and I can share the citations that support each practice.  This is the kind of information that should guide informed decision-making by the families that we work with and research that should guide protocols and practice by the health care providers who families trust to care for them during the childbearing year.

I just finished teaching a three day Passion for Birth childbirth educator workshop working with men and women who are on the path to becoming Lamaze certified childbirth educators.  During the workshop, we dedicate time to discuss research.  What makes a good study?  What are reliable sources for information?  How to understand the research?  Vocabulary words like “peer reviewed” and “randomized controlled trial” and other terms are discussed.  We want new educators to feel comfortable looking at research, understanding research and being able to apply current information in their classes as they work with new families.  The workshop attendees often state that they are intimidated, scared and confused about interpreting a research study.  They are not sure how to jump in or what to look for.  Here’s where this blog, Science and Sensibility, can really shine!  Science and Sensibility can help take the mystery out of reading the current research and help new educators, experienced educators, other professionals and interested parents to feel confident about understanding articles and research that impacts new families.

 The purpose of this blog, since it’s inception, has been to highlight current research on pregnancy, maternity care, birth, parenting and breastfeeding topics.  To share important studies, to break them down, provide a common-sense approach to the material, which is often covered in rather technical terms.  And this…this, is what really makes me feel good.  This mission is what makes me absolutely thrilled to be in the role of Community Manager.  To follow in the footsteps of the previous Community Managers, Amy Romano and Kimmelin Hull, who have worked hard to bring you the research, to highlight important studies and to demonstrate how Lamaze supports and incorporates this information and makes it available to educators, parents and the community at large in the work that it does as a leader in the childbirth education arena promoting normal birth.

My goals for this blog are to:

• Continue to profile current research.
• Present research in a matter of fact way with resources for when you want more information.
• Bring you guest bloggers who are experts in their field, inviting them to share their expertise.
• Reach out to the investigators themselves, in order to get the inside scoop on the research.
• Help you to learn more about the leaders and organizations that are on the front lines of improving care for mothers and their babies.
• Recognize that issues of pregnancy, birth and parenting are global in nature.
• Follow the science and make it understandable and relevant to you.
• Do all of this in entertaining, enjoyable ways.

I invite you to participate with me on this journey. I call on you to share your thoughts, ask your questions, and suggest topics to be explored.  Consider contributing your own ideas by becoming a guest blogger. Let me know who you want to hear from and what you want to know more about.  This blog belongs to all of us and requires the participation of many to make it as rich and successful as it has been and can continue to be.  I am excited about the possibilities and opportunities that await me and all of us.  Together, we can be sure that the science is understandable and that future educators embrace the opportunity to comprehend important research, discuss with others and share with families.

Let’s begin!

 

 

 

Sharon Muza Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternity Care, Practice Guidelines, Research, Science & Sensibility, Systematic Review Childbirth Education, community, lamaze, Lamaze International, Lamaze Six Healthy Birth Practices, maternity care research, New Community Manager, Sharon Muza, Systematic Review

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

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

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

A summary of the study is below.

Background

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

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

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

312 Studies Reviewed

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

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

13 Outcomes Identified for Inclusion

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

Effects of interventions

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

Safety of interventions

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

15 Childbirth Management Methods Identified

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

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

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

Results: Non-pharmacological Studies

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

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

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

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

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

Results: Pharmacological Studies

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

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

Comparative Pain Relief & Side Effects

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

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

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

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

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

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

Limitations Found in the Studies

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

Conclusions

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

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

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

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

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

References

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

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

On February 15^th, the Cochrane Library published a new review comparing cardiotocography (CTG) to intermittent auscultation of fetal heart rate on admission to the labor ward for assessment of fetal well-being (1). The results of the review support current recommendations from healthcare providers worldwide. How well are these recommendations being following in hospitals today? Read on…

What is an admission cardiotocograph?

When it was introduced to the maternity ward, the electronic fetal monitoring (EFM) machine was seen as a superior alternative to intermittent auscultation for the assessment of fetal well-being. Today, many women entering the labor ward with signs of labor are monitored for about 20 minutes using an EFM machine. This 20-minute screening test, which measures fetal heart rate and uterine activity, is called an admission cardiotocograph (CTG) or “admission strip”.  The test is performed to identify fetuses with a high risk of adverse perinatal outcomes.

Results from Devane et al.

Four studies, including 11,338 low-risk women, were reviewed (1). Admission CTG, when compared to intermittent auscultation, increased the risk of cesarean section (RR 1.20, 95% CI of 1.00 to 1.44).  Women allocated to admission CTG also had an increased risk of continuous EFM during labor (RR 1.30, 95% CI 1.14 to 1.48) and increased risk of fetal blood sampling (RR 1.28, 95% CI 1.13-1.45).  Admission CTG did not have an effect on amniotomy, oxytocin augmentation, epidural, instrumental vaginal birth, APGAR score less than 7 at 5 minutes, hypoxic ischaemic encephalopathy, admission to NICU, length of stay in NICU, neonatal seizures, and fetal multi-organ compromise within the first 24 hours after birth.  From these results, the reviewers concluded that the use of the admission CTG for low-risk women had no benefit and increased risk of cesarean birth and continuous EFM.

How this Cochrane review compares to current knowledge

The last systematic review comparing admission CTG to intermittent auscultation was published in 2007 in the International Journal of Nursing Studies (2). This review by Gourounti and Sandall included three of the four studies reviewed by Devane (3-5). Gourounti and Sandall concluded that admission CTG resulted in increased risk for cesarean birth (RR 1.2 95% CI 1.00–1.41) and instrumental vaginal birth (RR 1.1 95% CI 1.00–1.18).  With the addition of Mitchell’s 2008 randomized controlled trial, Devane’s 2012 review did not measure a significant difference in rates of instrumental vaginal birth (6).

Current recommendations for admission cardiotocography in low-risk women

Admission CTG is currently not recommended for low-risk women at term in labor by several organizations, including the Society of Obstetricians and Gynecologists of Canada and the Royal College of Obstetricians and Gynecologists (7-8). The American College of Obstetricians and Gynecologists does not explicitly discuss admission CTG in their most recent clinical practice guidelines of intrapartum fetal heart rate monitoring (9). Instead, they state that either EFM or intermittent auscultation may be used in labour for healthy women with no complications.

Recommendations from Lamaze

Admission fetal heart monitoring is addressed in Lamaze Healthy Birth Practice #4: Avoid Interventions That Are Not Medically Necessary:

“Like continuous EFM, admission EFM became widespread before any studies were conducted to show clinical effectiveness. Also, like continuous EFM, admission EFM does not produce anticipated benefits and, instead, increases harm (increased operative deliveries). (10)”

Lamaze recommends that all expectant women talk with their health-care providers about using auscultation or EFM. There are specific medical complications and interventions where EFM is necessary. Otherwise, it is safer and healthier to have intermittent auscultation.

The current reality of admission CTG

Despite the fact that admission CTG has no benefits when compared to intermittent auscultation, the majority of hospitals require all laboring women to undergo an admission CTG upon arrival. The most recent numbers available show admission CTG was used by approximately 79% of maternity units in the UK, by 96% of units in Ireland, by 76% of Canadian hospitals and 100% of labour units in Sweden (1).

Now to you, the reader. Where do we go from here? Your thoughts, as always, are very welcome!

 

 

References

1. Devane D, Lalor JG, Daly S, McGuire W, Smith V. Cardiotocography versus intermittent auscultation of fetal heart on admission to labour ward for assessment of fetal wellbeing. Cochrane Database of Systematic Reviews 2012, Issue 2. Art. No.: CD005122. DOI: 10.1002/14651858.CD005122.pub4.

2. Gourounti, K., & Sandall, J. (2007). Admission cardiotocography versus intermittent auscultation of fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumental delivery—A systematic review. International Journal of Nursing Studies, 44(6), 1029–1035.

3. Cheyne H, Dunlop A, Shields N, Mathers AM. A randomised controlled trial of admission electronic fetal monitoring in normal labour. Midwifery 2003;19:221-9.

4. Impey L, Reynolds M, MacQuillan K, Gates S, Murphy J, Sheil O. Admission cardiotocography: a randomised controlled trial. Lancet 2003;361(9356):465-70.

5. Mires G, Williams F, Howie P. Randomised controlled trial of cardiotocography versus doppler auscultation of fetal heart at admission in labour in low risk obstetric population. BMJ 2001;322:1457-60.

6. Mitchell K. The effect of the labour electronic fetal monitoring admission test on operative delivery in low-risk women: a randomised controlled trial. Evidence Based Midwifery 2008;6(1):18-26.

7. Liston R, Sawchuck D, Young D. Fetal health surveillance: antepartum and intrapartum consensus guideline. Journal of Obstetrics & Gynaecology Canada: JOGC 2007;29(9 Suppl 4):S3-S56.

8. Royal College of Obstetricians and Gynaecologists. The use of electronic fetal monitoring: the use and interpretation of cardiotocography in intrapartum fetal surveillance. Evidence-based Clinical Guideline Number 8. London: Royal College of Obstetricians and Gynaecologists, 2001.

9. The American College of Obstetricians and Gynecologists. Practice Bulletin Number 106. Obstetrics and Gynecology. 2009;114:192-202.

10. Lothian, J.  Healthy Birth Practices from Lamaze International #4: Avoid interventions that are not medically necessary. 2009.

 

 

 

Lisa Baker Systematic Review Healthy Birth Practices, interventions, Systematic Review

Systemic reviews are generally considered to be at the top of the evidence pyramid, providing one of the best sources of information. But just like any other type of research, a systemic review is only as good as the work and data that goes into it. A systemic review carefully looks at all of the evidence using a rigorous, predefined system of methods, and draws conclusions based on the information gathered. That rigorous, predefined system of methods is critical to a good systemic review. The researchers go through several steps:

• Select a specific, well-defined question
• Lay out their criteria for searching and selecting the evidence
• Conduct a very thorough search of all the available literature
• Evaluate the studies, rejecting the studies that are of poor quality
• Review the studies that make the cut
• Make a recommendation for practice

A systemic review differs from a general review of the literature in the methodology used. A systemic review starts by formulating specific criteria that will be used to judge which studies will be included and which will be excluded. The criteria are set before any of the studies are reviewed; ideally this will prevent bias and make for a stronger, more valid result.

Some systemic reviews include a meta-analysis, where statistical techniques are used to combine the results of the included studies and use the larger sample size to draw a stronger conclusion. But don’t assume that all meta-analyses use the systemic review process! It’s entirely possible to conduct a meta-analysis of a group of studies chosen in an incomplete or biased manner. The questions below can help you identify which meta-analyses use the systemic review process.

When reading a systemic review or meta-analysis, here are some questions to consider:

1. How well is the question defined? There should be a clear statement of what the review would like to show. Then double check the results to make sure that question actually got answered.

2. Is it the right question? If two things are being compared, is the comparison appropriate? Do all the studies included use the same comparison/control?

3. Do the authors describe their search? Was it thorough? Authors should discuss how they went about searching for the articles they evaluated. A thorough researcher will look at multiple databases, use variations of the key words, and include studies published in other languages.  Limiting to studies published in English is convenient, but you may miss valuable research. Unpublished studies are also sometimes included, as it can be difficult to get a study published if your results showed no dramatic differences. This can help avoid publication bias, but unpublished studies should still be thoroughly checked for quality. The search and selection methods should be so clearly outlined that someone could duplicate them.

The Cochrane Collaboration is best known for conducting systemic reviews. In the Cochrane organization, reviewers publish their protocols before conducting the review. (If you are a Lamaze member, you can access these protocols on the Cochrane site by logging in through the Lamaze Member Center.) This is not generally done elsewhere, but in the published paper, the reviewers should explain their protocol. Any potential conflicts of interest should also be addressed.

4. Did the authors evaluate the quality of the studies reviewed? Not all studies are of equal quality, though sometimes studies with quality issues can still provide useful information. One example of this is the Cochrane Review on skin-to-skin, which included some studies that did not have completely random groupings if it appeared that the groups were otherwise equal.  For this reason, many systemic reviews will rate the quality, size and applicability of the studies as they evaluate them, and assign them a weight so that the most appropriate studies are more heavily represented in the results.

5. Are there any biases in the inclusion/exclusion criteria? Read through them very carefully and evaluate this aspect. Easier when you’re already familiar with the studies out there, or if the excluded studies are listed for your viewing. Overly restrictive criteria lead to smaller sample sizes and less reliable results.

6. Were the outcome measures clearly defined? What are the benefits or risks the researchers were looking at? Are outcomes lumped into groupings of debatable usefulness? Do they matter? As Amy Romano recently pointed out sometimes the outcomes have little or no real life importance.

7. Are there biases in how subgroups are analyzed? In one interesting study researchers created random data with the roll of the dice. The studies used dice that were identical other than color, and each time a 6 was rolled, it was counted as a patient death. The researchers then manipulated subgroup analysis to show that red dice had significantly higher death rates than other colors!

Don’t assume that the general inclusion/exclusion criteria were applied to each subgroup. As we learned with the Wax meta-analysis on home birth, selective subgroup analysis does happen.

Bias in subgroup analysis is less likely if the subgroups were defined before the reviewers selected the included studies. Cochrane systematic reviews generally are conducted this way.

8. How old is it? As new research is done, even systematic reviews become outdated. It’s hard to give a specific age that is “too old”, though, since some topics will have many new studies each year, and might be outdated at 18 months old while others rarely get anything new, and might still be relevant three years after publication.

9. How can I apply this? Again, this is always your last, but very important, consideration. Is this information that is applicable to your practice? To the population you serve? How can you best use this information?

Systemic reviews are among the best types of evidence out there, but only if they are done well. Read carefully, and consider the quality of the analysis as well as the quality of the included studies.

Next up: A roundup of other types of articles you may encounter in journals.

Andrea Lythgoe Uncategorized becoming a critical reader, meta-analysis, Systematic Review, Understanding Research