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Jazz It Up! Using Haiku Deck to Create Snappy Image-Based Presentations

March 3rd, 2015 by avatar

By Jocelyn Alt, CD(ToLabor), MBA

 My favorite way to teach is using interactive, engaging activities that get my families building community with each other, interacting with class members, actively partipating rather than passive listening and often up and out of their seats.  Sometimes, it does become necessary to use a presentation format to present a topic.  Alternately, using such a format can help reinforce one of the activities you are doing in class.  Today on Science & Sensibility, CBE and doula Jocelyn Alt shares a tool, Haiku Deck, that she uses to create interesting presentations to use in her childbirth classes.  Jocelyn reviews it here and shares some of her recent presentations. – Sharon Muza, Science & Sensibility Community Manager.

Some of my most rewarding moments as a childbirth educator are times when former participants share stories about using skills or information during their births that they learned in class. It might be a squatting position we practiced, the benefits and risks of narcotics as pain relief that we teach using an interactive game, or the BRAIN acronym for making informed decisions (see below if you are unfamiliar with this rubric.) My team of educators and I are always looking for new ways to make our classes more engaging and memorable so that our students will have a higher likelihood of recalling the information when they need it most – during labor.

Haiku Deck – reinforcing learning

It’s been known for eons that using images reinforces learning (it’s been said so often, the adage is hackneyed: “A picture is worth a thousand words.” But it’s often true!) So I was excited when I recently found out about a tool that allows you to create beautiful image-based slide presentations in a snap. It’s called Haiku Deck. Presentations created with this program can be used in conjunction with interactive activities as an introduction or backdrop, or alongside lecture components of class.

© Jocelyn Alt

© Jocelyn Alt

Here is an example of a presentation created with Haiku Deck: Top Five Tips for New Moms. If you click on the deck and view it on the Haiku Deck site, you can also see the notes that accompany each slide. After looking at the presentation, try testing its effectiveness on yourself. How many images do you remember from it? How many of the messages do you remember? How many do you think you would have remembered if you had simply seen them presented as text in a bulleted list?

Here’s another Haiku Deck for the acronym BRAIN: Five Essential Questions for Decision-Making in Labor, which I use to teach informed decision making. Each letter of the Screenshot 2015-03-02 16.22.22acronym stands for a question laboring parents can ask themselves and their care providers when faced with a decision in labor – or at any other time for that matter. One dad said that he found it so useful, he started using it as a decision-making tool at work! The acronym stands for Benefits, Risks, Alternatives, Intuition, and Need Time. Acronyms themselves can help with recall, and reinforcing them with images can make them even more sticky.

What I like about Haiku Deck

Ease of Use – The interface is elegant and simple to use.  One great feature is the huge library of images.  You just type in a word that relates to your content, and dozens of photos come up for your use.  With one click, you can add them to your presentation.

Effectiveness – The structure of Haiku Deck forces you to be concise with your words and use images to communicate much of your message. The result is presentations that connect to people.  Many of the most popular slide decks on the large presentation posting site SlideShare were made with Haiku Deck because they draw people in and are memorable.

Accessibility – You can use Haiku Deck to make presentations in a browser on your computer or through the iPad app. Presentations are all backed up on the Haiku Deck site and can be embedded into websites and social media, so you can easily make them available to your participants to reference outside of class.

Just for fun, here’s one last Haiku Deck on the Six Signs of Labor Progression.

Screenshot 2015-03-02 16.32.49

If you try Haiku Deck in your classes, I’d love to see any presentations you develop. Drop the links in the comments section below and let us know if you found the program easy or difficult to use and a bit about your experience.

Resources

Defetyer, M. A., Russo, R., McPartlin, P. L. (2009). The picture superiority effect in recognition memory: a developmental study using the response signal procedure.Cognitive Development, 24, 265-273. doi: 10.1016/j.cogdev.2009.05.002

Foos, P.W., & Goolkasian, P. (2005). Presentation formats in working memory: The role of attention. Memory & Cognition, 33(3), 499-513.

Shepard, R.N. (1967). Recognition memory for words, sentences, and pictures. Journal of Learning and Verbal Behavior, 6, 156-163.

About Jocelyn Alt

© Jocelyn Alt

© Jocelyn Alt

Jocelyn Alt, CD, MBA, is a childbirth educator and birth doula who has been working with expecting and new parents since 2006. Jocelyn is the Founder and Director of Ohana, a birth and parenting services company with locations in Chicago and Seattle that offers childbirth classes, prenatal yoga, doulas, new parent groups, and maternity concierge services. The word ohana means “family” in Hawaiian and refers to one’s inner circle of both family and close friends. In addition to helping parents-to-be transition to parenthood, Jocelyn enjoys hiking, cycling, and hosting dinner parties. She lives in Seattle, WA.  Reach Jocelyn through her website  www.OhanaParents.com.

 

 

 

Childbirth Education, Guest Posts , ,

Henci Goer – Fact Checking the New York Times Home Birth Debate

February 26th, 2015 by avatar
home birth

© HoboMama

An article in The New York Times Opinion Pages – Room for Debate was released on February 24th, 2015.  As customary in this style of article, the NYT asks a variety of experts to provide essays on the topic at hand, in this case, the safety of home birth. Henci Goer, author and international speaker on maternity care, and an occasional contributor to our blog, takes a look at the facts on home birth and evaluates how they line up with some of the essay statements. Read Henci’s analysis below.  – Sharon Muza, Science & Sensibility Community Manager

As one would predict, three of the four obstetricians participating in the NY Times debate “Is Home Birth Ever a Safe Choice?“assert that home birth is unacceptably risky. Equally predictably, the evidentiary support for their position is less than compelling.

John Jennings, MD president of the American Congress of Obstetricians & Gynecologists, in his response- “Emergency Care Can Be Too Urgently Needed,” cites a 2010 meta-analysis by Wax and colleagues that has been thoroughly debunked. Here is but one of the many commentaries, Meta-Analysis: The Wrong Tool Wielded Improperly, pointing out its weaknesses. In a nutshell, the meta-analysis includes studies in its newborn mortality calculation that were not confined to low-risk women having planned home births with a qualified home birth attendant while omitting a well-conducted Dutch home birth study that dwarfed the others in size and reported equivalent newborn death rates in low-risk women beginning labor at home and similar women laboring in the hospital (de Jonge 2009).

The other naysayers, Grunebaum and Chervenak, in their response – “Home Birth Is Not Safe“, source their support to an earlier NY Times blog post that, in turn, cites a study conducted by the two commentators (and others) (Grunebaum 2014). Their study uses U.S. birth certificate data from 2006 to 2009 to compare newborn mortality (day 1 to day 28) rates at home births attended by a midwife, regardless of qualifications, with births attended by a hospital-based midwife, who almost certainly would be a certified nurse midwife (CNM) in babies free of congenital anomalies, weighing 2500 g or more, and who had reached 37 weeks gestation. The newborn mortality rate with home birth midwives was 126 per 10,000 versus 32 per 10,000 among the hospital midwives, nearly a 4-fold difference. However, as an American College of Nurse-Midwives commentary on the abstract for the Society for Maternal-Fetal Medicine presentation that preceded the study’s publication observed, vital statistics data aren’t reliably accurate, don’t permit confident determination of intended place of birth, and don’t follow transfers of care during labor.

As it happens, we have a study that is accurate and allows us to do both those things. The Midwives Alliance of North America study reports on almost 17,000 planned home births taking place between 2004 and 2009 (Cheyney 2014b), and therefore overlapping Grunebaum and Chervenak’s analysis, in which all but 1000 births (6%) were attended by certified or licensed home birth midwives. According to the MANA stats, the newborn death rate in women who had never had a cesarean and who were carrying one, head-down baby, free of lethal congenital anomalies was 53 per 10,000, NOT 126 per 10,000. This is less than half the rate in the Grunebaum and Chervenak analysis. (As a side note, let me forestall a critique of the MANA study, which is that midwives simply don’t submit births with bad outcomes to the MANA database. In point of fact, midwives register women in the database in pregnancy [Cheyney 2014a], before, obviously, labor outcome could be known. Once enrolled, data are logged throughout pregnancy, labor and birth, and the postpartum, so once in the system, women can’t fall off the radar screen.)

We’re not done. Grunebaum and Chervenak’s analysis suffers from another glaring flaw as well. Using hospital based midwives as the comparison group would seem to make sense at first glance, but unlike the MANA stats, which recorded outcomes regardless of where women ultimately gave birth or who attended them, hospital-based midwives would transfer care to an obstetrician when complications arose. This would remove labors at higher risk of newborn death from their statistics because the obstetrician would be listed on the birth certificate as the attendant, not the midwife. For this reason, the hospital midwife rate of 32 per 10,000 is almost certainly artificially low. So Grunebaum and Chervenak’s difference of 94 per 10,000 has become 21 per 10,000 at most and probably much less than that, a difference that I’d be willing to bet isn’t statistically significant, meaning unlikely to be due to chance. On the other hand, studies consistently find that, even attended by midwives, several more low-risk women per 100 will end up with cesarean surgery—more if they’re first-time mothers—then compared with women planning home births (Romano, 2012).

Hopefully, I’ve helped to provide a defense for those who may find themselves under attack as a result of the NY Times article. I’m not sanguine, though. As can be seen by Jennings, Grunebaum, and Chervenak, people against home birth often fall into the category of “My mind is made up; don’t confuse me with the facts.”

photo source: creative commons licensed (BY-NC-SA) flickr photo by HoboMama: http://flickr.com/photos/44068064@N04/8586579077

References

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014). Development and validation of a national data registry for midwife-led births: the Midwives Alliance of North America Statistics Project 2.0 dataset. J Midwifery Womens Health, 59(1), 8-16. doi: 10.1111/jmwh.12165 http://www.ncbi.nlm.nih.gov/pubmed/24479670

Cheyney, M., Bovbjerg, M., Everson, C., Gordon, W., Hannibal, D., & Vedam, S. (2014b). Outcomes of care for 16,924 planned home births in the United States: the midwives alliance of north america statistics project, 2004 to 2009. J Midwifery Womens Health, 59(1), 17-27. doi: 10.1111/jmwh.12172 http://www.ncbi.nlm.nih.gov/pubmed/24479690

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed?term=1177%5Bpage%5D+AND+2009%5Bpdat%5D+AND+de+jonge%5Bauthor%5D&cmd=detailssearch

Grunebaum, A., McCullough, L. B., Sapra, K. J., Brent, R. L., Levene, M. I., Arabin, B., & Chervenak, F. A. (2014). Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol, 211(4), 390 e391-397. doi: 10.1016/j.ajog.2014.03.047 http://www.ajog.org/article/S0002-9378(14)00275-0/abstract

Romano, A. (2012). The place of birth: home births. In Goer H. & Romano A. (Eds.), Optimal Care in Childbirth: The Case for a Physiologic Approach. Seattle, WA: Classic Day Publishing.

Wax, J. R., Lucas, F. L., Lamont, M., Pinette, M. G., Cartin, A., & Blackstone, J. (2010). Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 203(3), 243.e241-e248. http://www.ajog.org/article/S0002-9378%2810%2900671-X/abstract

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

 

 

Babies, Evidence Based Medicine, Guest Posts, Home Birth, Maternal Quality Improvement, Maternity Care, Midwifery , , , , ,

BABE Series: Putting the “Tee” in Teaching Fetal Positions

February 12th, 2015 by avatar

Today, in our monthly series, “Brilliant Activities for Birth Educators” (BABE), regular contributor and LCCE Andrea Lythgoe shares a fantastic, interactive idea for helping families to better understand the different positions their baby can be in and the abbreviations used to refer to these positions.  If you have a great BABE idea that you would like to share with Science & Sensibility readers, please contact me and I will be in touch with you. – Sharon Muza, Community Manager, Science & Sensibility

Why I made it

With the increasing popularity of websites discussing good positioning for the baby late in pregnancy and during labor, I found that I started fielding a fairly large number of questions in my classes like “What does it mean if my baby is ROA?” or “My sister said she hopes my baby isn’t OP. What’s that?” I also noticed more care providers talking about positioning when I would attend births as a doula, and quite often I had to interpret those conversations for my clients.

TeachingTeeWithBabyOne day such a question came up in class, and in order to best answer it, I grabbed a stack of nearby sticky notes, wrote letters on them, and stuck them on my body. It worked! I could see people grasping the concept. I did it a time or two more and then began to make it a regular part of my class.

But the sticky notes had their own problems. Sometimes, they wouldn’t stick well to whatever I was wearing that day. Sometimes they stuck too well and there was that incident where I stopped at the grocery store on the way home, not realizing I still had several sticky notes all over my body, until someone pointed it out. I started thinking about other options.

How I made it

I bought an oversized cotton T-shirt that is large enough to wear over my regular clothing. I found iron-on letters at a craft store and just followed the package directions to place the letters like this:

“A” on the front of the shirt, a few inches above the hem.

“P” on the back of the shirt, a few inches above the hem

“T” on either side of the shirt, a few inches above the hem and just in front of the side seam

“R” on the right side, near the T

“L” on the left side, near the T

How I use it

I use this in the fourth night of my seven week series, just before we discuss posterior babies and the variations that position can cause during the labor process. It might also work in a discussion of the basic physiology of birth, or any time the question comes up from your students.

© Andrea Lythgoe

© Andrea Lythgoe

To prepare, I generally put the shirt on over my regular clothes before class or after the break. I also put a label on the back of the baby’s head, using masking tape and a sharpie.

First, I show the baby and point out the “O for Occipital bone” on the baby’s head. I discuss how this spot is used as a marker to identify the baby’s position, and refers to how the baby’s occiput is positioned in relation to the mother’s body.

Then I point out the letters on the shirt, explaining what each one means. I take a minute to clarify the difference between a transverse LIE and the occipital bone pointing to transverse, reminding them if they are ever confused which transverse it is, they should ask for clarification from their doctor or midwife.

I then show them the most common positions for baby to be in when labor begins and review the normal motions baby does to move through the pelvis.

I write three spaces on the board (as if we are playing hangman) and tell the class that when health care providers talk about the baby’s position as the baby moves through the pelvis, they typically use two or three letters.

The middle one is almost always “O” with a head down baby, so I fill in the middle slot with the O.

I then tell them that the last one is where the baby’s occiput (or “O”)  is relative to the pelvis. I hold the baby in an OA position and ask them which letter from my shirt would explain where the O is pointed. They easily get it and I write the A in the last space.

Then I shift the baby slightly to my left and add the modifier L to the front.

Draw another set of three blank spaces, and move the baby to LOT, and repeat the process much faster. By this point, there is usually someone in the room who is eager to fill in the blanks.

Ask for a volunteer to come up – anyone can do this. I hand the baby to the volunteer and ask them to show me the OA position on themselves. Then I ask them to show me another position, maybe ROA. If the volunteer has caught on and has the right personality for it, I’ll give them other positions to do rapid fire until they laugh.

© Andrea Lythgoe

© Andrea Lythgoe

I always end with the volunteer showing the OP position. I then transition into talking about OP babies and how some babies will spend part of labor rotating around to a position that facilitates moving down through the pelvis easier, and the discussion continues. At some point in that discussion, I turn around and hold the O on the baby’s head next to the P on the shirt, so it reads OP and reinforces visually what that means.

How Parents Receive It

Most of the time, the families start grasping the concept as I write the letters on the board in the first example, and by the time I have a parent volunteer up at the front they are all on board chiming in with answers. My favorite is when we do the rapid fire positions, and everyone is verbally helping the partner like something out of “The Price is Right.” It doesn’t always get there, but I love it when it does.

I find that as we move on to our next topics, that the parents will use the letter abbreviations to ask questions and clarify their understanding. I’m confident that they will be able to remember and understand the terms through their third trimester and into labor and have more clarity when their provider mentions the baby’s position.

Do you think that you might use this “BABE” idea in your classroom?  How would you use it?  Would you make any modifications?  How do you teach this topic in your classes? Share your thoughts in our comments section. – SM

Babies, Childbirth Education, Guest Posts, Series: BABE - Brilliant Activities for Birth Educators , , , ,

Congenital Heart Defect Awareness Week – Are You Up to Date?

February 10th, 2015 by avatar

 By Elias Kass, ND, CPM, LM

© Tammi Johnson

© Tammi Johnson

This week is Congenital Heart Defect Awareness week.  Critical Congenital Heart Defect screening can help identify and save the lives of newborns born with previously undetected but serious malformations of the heart that can significantly impact them as they transition to life on the outside.  Families can learn about the simple screening procedure in a childbirth education class and be prepared to discuss the screening with their health care providers.  Dr. Elias Kass, naturopath and midwife, shares 2015 information and updates on screening, stats on the incidence of CCHDs and how you can help spread the word on the importance of all newborns being screened. – Sharon Muza, Community Manager, Science & Sensibility 

There’s a new newborn screening being implemented in many birth settings – critical congenital heart defect screening, or CCHD. What is this screening? What does it look for, and how can you educate and prepare your childbirth education students for the screening and possible results?

Critical congenital heart defects refer to heart defects that babies are born with and that require surgical intervention within the first month (or year, depending on the defining organization). About 1 in 100 babies have heart defects (1%), and about 1 in 4 of those with a heart defect have a defect so severe that it needs to be corrected immediately (0.25% of all babies) Only some of these defects will be picked up by prenatal ultrasound, and they may not show up on exam before the baby goes home (or the midwife leaves in the case of a home birth). Depending on the defect, some babies may be able to compensate with structures that were in place during the fetal period but begin to go away after the baby is born.

Fetal circulation and changes after birth

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

By KellyPhD (Own work) [CC-BY-SA-3.0], via Wikimedia Commons

Because a fetus receives oxygen through the placenta and umbilical cord, there’s no need for him to send a significant amount of blood to the lungs, so a fetus has very different heart and lung circulation than they will after making the transition to life on the outside. One of the big differences (simplified for this article) is the ductus arteriosis – this is a bypass that takes blood from the pulmonary artery and provides a shortcut to the aorta, instead of continuing on to the lungs. Another big difference is the foramen ovale – this is an oval-shaped window between the right atrium and left atrium, which allows blood to bypass being pumped out to the lungs entirely. After birth, pressure changes cause massive changes in flow. Pressure increases in the left atrium cause a flap to slam shut across the foramen ovale. Blood also finds it easier to flow to the lungs, so less blood flows through the ductus arteriosus. Over the course of days and weeks, the foramen ovale seals shut and the ductus arteriosus starts to shrivel.

Typically blood being pumped out to the body is loaded with oxygen. If there are structural problems, it’s possible that this blood would be a mix of oxygenated and deoxygenated blood – there would be less oxygen available in this blood, but at least it’s getting out to the body. Sometimes those fetal structures are what allows that mixed blood to circulate. So what if the baby was really depending on those shortcuts and bypasses? And then the shortcuts and bypasses go away? These babies may look well and do fine, until the fetal structures start to go away.

This March of Dimes article describes seven conditions considered to be part of CCHD:

  1. Hypoplastic left heart syndrome (also called HLHS)
  2. Pulmonary atresia (also called PA)
  3. Tetralogy of Fallot (also called TOF)
  4. Total anomalous pulmonary venous return (also called TAPV or TAPVR)
  5. Transposition of the great arteries (also called TGA)
  6. Tricuspid atresia (also called TA)
  7. Truncus arteriosis

See page for author [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

Circulation after birth [GFDL or CC-BY-SA-3.0], via Wikimedia Commons

CCHD screening of the newborn is intended to catch babies who might need intervention, before they decompensate and their heart defects are made obvious.

The screening process

CCHD screening involves using a pulse oximeter at two locations — the right hand (or wrist), and either foot. The right arm receives its blood supply before the ductus arteriosus enters the aorta, so it’s known as “pre-ductal.” The left hand and the lower body receive “post-ductal” blood.

The pulse oximeter senses oxygen saturation by shining light through the skin. Red blood cells that are loaded with oxygen deflect light differently than red blood cells without oxygen. The opposite sensor collects the light and calculates how much was lost. By using multiple wavelengths of light, the unit can isolate arterial flow and disregard venous flow (veins return blood to the heart after the tissues have ‘used’ the oxygen the blood was carrying). For babies, an adhesive probe is typically wrapped around the hand or wrist, and then around a foot. The thin strip might be covered with a foam band to help block out the room light. Some facilities use reusable probes that are more like clips. Not all pulse oximeters are well suited for this purpose – they need to be able to sense low saturations and not be confused by an infant’s constant motion.

There are three possible results from the screening – pass, fail, and an in between, or “try again.”

If a baby’s oxygen saturation is ≥ 95% in the right hand or foot, and there is less than a 3% difference between the two readings, then she passes the screening.

For a baby whose saturations are between 90-95%, or has a greater than 3% difference between the right hand and foot, the screening test is repeated in an hour. If she still doesn’t pass or fail, she can have one more chance. If she still doesn’t pass after three tries (one initial and two retries), that’s considered a fail, and she should be evaluated.

If a baby’s oxygen saturation is under 90% in either the right hand or foot, or she didn’t pass in three tries, this is considered a fail, or a positive screening. This baby should be referred to a pediatric cardiologist who can assess her and do an echocardiogram (ultrasound of the heart), and/or other workup. Depending on her health at the time, that might mean an immediate consult, or it might mean having her scheduled for a visit soon.

In Washington state, Seattle Children’s Hospital and the other regional pediatric cardiology groups are available to talk with the clinician who has a patient with a problematic screening and help figure out when and where the baby should be seen. If there is no local pediatric cardiology group, some cardiology groups can do telemetry or read studies remotely. Before implementing screening in their practice or facility, there should be a clear process for how to obtain consultation and referral (who should be called, how to contact them, how to transmit images if able, etc). Evaluation should be arranged before the baby is discharged because a baby’s condition can deteriorate rapidly.

There are tools available to help with this algorithm. The Center for Disease Control and Prevention (CDC) has a flow chart to help guide the screening process, and Children’s Health Care of Atlanta has a web site and Pulse Ox Tool app to help guide providers.

When should the screening be done?

The screening should be done between 24-48 hours after birth. Before 24 hours, there is an increased incidence of false positives, but a baby who passes before 24 hours is still considered to have passed (i.e., it still “counts”). If a baby is being discharged before 24 hours, the recommendation is to do it as close to discharge as possible. For babies born at home, this screening should be done at the 24-48 hour home visit, along with the metabolic screening. For the screening to be most accurate, baby should be awake and calm, but not feeding. (Feeding causes some decrease in oxygen saturation even in normal term newborns.)

What about a failed screen?

It’s helpful to know that not all babies with a failed screen have a critical congenital heart defect. Like all screening tools, this screening has false positives. The false positive rate overall is about 1/200 (0.5%), but it falls to 1/2000 (.05%) when the screening is performed after 24 hours of age according to the FAQ on the Seattle Children’s Hospital Pulse Oximetry Screening for Newborns resource page for providers. About a quarter of the babies who fail the screening truly have a Critical Congenital Heart Defect(true positive), while half have condition that causes low blood oxygen, like pneumonia and sepsis, and a quarter are well (false positive).

Who should be screened?

All babies should be screened, unless the baby is already known to have a critical congenital heart defect, identified during ultrasounds done during the pregnancy or immediately after birth. Most states mandate screening, either by legislation or regulatory guidance. One state has an executive order. Several states, including Washington, have introduced legislation that is currently being voted on. In states without mandated screenings, most birth settings have adopted the screening, but not all. For some settings there are logistical challenges in terms of purchasing equipment (particularly independent midwives who might not have other use for the pulse oximeter, although since it was recommended to be used as part of neonatal resuscitation that has begun to change), arranging for consultation (particularly in rural areas or regions without adequate pediatric cardiology support), or logistical challenges in terms of who will do the screening and when. The Secretary of Health and Human Services (HHS) has recommended that CCHD screening be added to the newborn screening panel (like metabolic screening and hearing screening). The American Academy of Pediatrics also supports the universal adoption of this screening.

Cost can be a barrier in offering this screening. There is currently no procedure (CPT) code for this screening, and insurance companies are generally bundling it into the general newborn care (and not reimbursing for it as a separate service), though there are groups working to change this, since there is significant up-front investment and on-going costs in terms of probes and staff time to provide the screening. Most appropriate pulse oximeters start at $500 and the disposable probes around $3-5. Using reusable probes can decrease the cost of providing this screening.

If the hospital or midwife doesn’t provide this screening, parents can ask their pediatric provider to perform the screening at the baby’s first office visit. The goal is to catch these conditions as quickly as possible, ideally before the baby’s condition decompensates. Getting a screening a little later is better than not getting it at all.The screening is no less accurate later on.

The childbirth educator perspective

As a childbirth educator, you can share information about this quick screening test, when you discuss other newborn care procedures. You can encourage your students to ask their midwife or doctor about the screening, or ask on the hospital tour. If the hospital or health care provider hasn’t yet implemented this screening, families can ask why not, and if there’s anyone they can talk to encourage implementation. Facilities and providers should hear from families that they know about this screening and expect it as part of their newborn’s care.  Universal screening will go a long way to identifying those children who were not previously diagnosed with a Critical Congenital Heart Defect and who can begin to receive care for the CCHD as soon as possible by pediatric cardiologists.  Your childbirth class may be the only opportunity for these families to hear about and understand the importance of the CCHD screening test.

Are you already talking about this screening test for CCHD in your classes? If not, might you begin to share this information as a result of what you learned today?  Are providers and facilities in your area already offering this test as part of normal newborn screening? Do you know any families who have had this screening and their baby was diagnosed with an heart defect? Share your experiences in our comments and let’s discuss.- SM

References and Resources

March of Dimes, with general information about CCHD screening targeted towards families
American Academy of Pediatrics – detailed information about screening and implementation, targeted towards providers and facilities
Dr. Amy Schultz (a pediatric cardiologist at Seattle Children’s) frequently presents on CCHD screening – this presentation, with detailed information about critical congenital heart defects and screening, was recorded and can be streamed online

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, focusing on pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Childbirth Education, Evidence Based Medicine, Guest Posts, Neonatology, Newborns , , , ,

Epidurals: Do They or Don’t They Increase Cesareans?

January 27th, 2015 by avatar

By Henci Goer

In October, Author Henci Goer wrote an article for Science & Sensibility, Epidural Anesthesia: To Delay or Not To Delay – That is the Question – examining the impact of the timing of an epidural on labor and birth.  Today Henci looks at some new research, Epidural analgesia in labour and risk of caesarean delivery which seeks to determine whether receiving an epidural at all impacts the likelihood of a cesarean delivery.  Lamaze International has a great infographic on epidurals that you also may find very helpful. – Sharon Muza, Community Manager, Science & Sensibility.

© J. Wasikowski, provided by Birthtastic

© J. Wasikowski, provided by Birthtastic

Let’s start with a bit of background for those of you who didn’t personally live through the early controversy over whether epidurals increased the cesarean rate. As epidurals began to achieve popularity in the late 1970s and 1980s, one researcher sounded the alarm when he and his group published a study of 714 first-time mothers showing that even after excluding women with big babies and women whose labor pattern was abnormal prior to having an epidural, epidurals remained a potent factor in cesarean rates for delayed progress (Thorp 1989). Everyone pooh-poohed his finding on grounds that observational studies can’t truly determine whether epidurals lead to more cesareans or women experiencing more prolonged, painful labors, and therefore at higher risk for cesarean, were more likely to want epidurals. The “chicken versus egg” question, they argued, couldn’t be resolved without a randomized controlled trial (RCT), and it wasn’t likely that women would agree to be assigned by chance to have an epidural or not. In point of fact, that same year saw publication of a small Danish RCT (107 women, 104 of them first-time mothers) (Philipsen 1989). It reported that having an epidural nearly tripled the cesarean rate (16% vs. 6%) for “cephalopelvic disproportion” despite no clinical evidence of CPD being a requirement for inclusion. The investigators ignored this, however, concluding only that instrumental vaginal delivery rates were similar, and epidurals provided better pain relief. In any case, the anesthetic dose was much higher than was already becoming the norm, so it could be reasonably argued that the trial’s findings wouldn’t apply to modern-day practice.

Thorp, meanwhile, took up the RCT challenge. He and his colleagues carried out an epidural versus no epidural trial in 93 first-time mothers and found that epidurals did, in fact, lead to cesareans (25% vs. 2%), not vice versa (Thorp 1993). That bit of unwelcome news precipitated a stampede to perform more RCTs, and when enough of those had accumulated, to a series of systematic reviews pooling their data (meta-analysis), of which the Cochrane review, Anim-Somuah et al. (2011), is the latest. These reached the more comfortable conclusion that epidurals didn’t increase likelihood of cesarean, and pro-epiduralists breathed a collective sigh of relief and went back, if they had ever stopped, to unreservedly recommending epidurals. (This rather sweeps under the rug the other problems epidurals can cause, but that’s a topic for another day.)

Weaknesses of the “Epidural” vs. “No Epidural” Trials

Epidural

By User:Ravedave (Own work) [GFDL (http://www.gnu.org/copyleft/fdl.html)

The finding that epidurals don’t increase cesareans is puzzling because they increase likelihood of factors associated with them (Anim-Somuah 2011). For one thing, they increase use of oxytocin to augment labor, which implies they slow labor. For another, more women run fevers, and it stands to reason that a woman progressing slowly who starts running a fever is a likely candidate for cesarean. For a third, the difference in fetal malposition (occiput posterior) rates at delivery comes close to achieving statistical significance, meaning the difference is unlikely to be due to chance. Persistent OP is strongly associated with cesarean delivery (Cheng 2006; Fitzpatrick 2001; Phipps 2014; Ponkey 2003; Senecal 2005; Sizer 2000). Epidurals even increase cesareans for fetal distress by 40%, although the absolute difference didn’t amount to much (1 more per 100 women). Could a difference exist and meta-analysis of RCTs fail to detect it?

A string of well-conducted observational studies over the years have suggested that they could (Eriksen 2011; Kjaergaard 2008; Lieberman 1996; Nguyen 2010), the most recent of which is a very large, very convincing study published last fall (Bannister-Tyrrell 2014). Its authors point out, as have others before them, the weaknesses of the RCTs, weaknesses serious enough to nullify their results or make them inapplicable to typical community practice (external validity).

To begin with, in most trials, substantial percentages of women allocated to the non-epidural group ended up having epidurals, and some women allocated to the epidural group ended up not having one. Since RCTs analyze results according to group assignment (to do otherwise would negate the point of random assignment, which is to avoid bias), not what actually happened, this diminishes differences between groups. In addition, trials were mostly confined to women with no medical or obstetric complications who were treated according to strict protocols for labor management and indications for cesarean delivery. Neither is the case in most hospitals. To these I would add that many trials lumped together first-time mothers and women with prior births when reporting outcomes. First-time mothers are much more susceptible to factors that impede progress, so including women with prior vaginal births can make it appear that epidurals are less problematic for first-time mothers than they really are. In addition, three of the trials were carried out in a hospital where participants were mostly attended by midwives, and cesarean rates were much lower than is common for women attended by obstetricians.

All of this means that any null results in meta-analyses of the trials can be taken with a grain of salt, any findings of significant differences probably represent a minimal value, and first-time moms may be harder hit than appears. To cite one example, Anim-Somuah (2011) reported that 5 more women per 100 having epidurals had a malpositioned baby at delivery (18% vs. 13%) in the 4 trials reporting this outcome, a difference, as I said, that just missed achieving statistical significance. But when I confined results to the two trials in first-time mothers alone in which 10% or fewer of the women in the “no-epidural” group had an epidural, the gap widened to 9 more per 100 (11% vs. 2%).

Summary of the Bannister-Tyrrell (2014) Analysis

Bannister-Tyrrell and colleagues (2014) drew their population from a database of 210,700 Australian women with no prior cesareans who were laboring at term with a singleton, head-down baby. A strength of the database was that, unlike most, it distinguished epidurals for labor from epidurals for delivery. Using a long list of factors, investigators constructed a propensity score for how likely a woman was to have an epidural, matched women according to their score, and compared results according to whether women with the same score had or didn’t have an epidural. Matched controls were found for 52,600 women who had an epidural and were found across the full range of propensity scores. Women having epidurals were 2.5 times more likely to have a cesarean (20% vs. 8%), or put another way, 12 more women per 100 having epidurals had a cesarean (absolute excess), which amounts to 1 additional cesarean for every 8.5 women having an epidural (number needed to harm). Among first-time mothers, women having epidurals were 2.4 times more likely to have a cesarean. Study authors didn’t provide cesarean rates for this subgroup, but the raw cesarean rates overall were 18% in first-time mothers versus 2% in women with prior births, so the effect on this more vulnerable population could be dire.

But there’s still more. Investigators further adjusted for confounding factors not captured in their database. These included differences in health-care settings (same state but not same city), care provider (women without epidurals are more likely to be attended by midwives), and for confounding interventions more likely with epidurals (continuous fetal monitoring). Relative risk of cesarean with an epidural remained at 2.5. Investigators then adjusted for the association between occiput posterior baby and cesarean by setting estimates of the risk ratio to exceed the strongest associations reported in the literature, and they assumed that the prevalence of severe labor pain was 3 to 4 times higher in women having epidurals. Factoring these into their statistical analysis reduced the risk ratio, but women having epidurals still were 50% more likely to have a cesarean. This means that with a baseline cesarean rate of 8% in women without an epidural, 12% of women with an epidural will have one or 4 more women per 100 or 1 more cesarean for every 25 women.

The Take-Home

At the very least we cannot assure women with confidence that epidurals don’t increase the likelihood of cesarean. For this reason and because of their numerous other drawbacks and considering that comfort measures and other strategies have been shown to be both effective for most women and free of adverse effects (Declercq 2006; Jones 2012), women may want to make epidurals Plan B rather than Plan A. That being said, whatever their choice, women can minimize their chance of cesarean—with or without an epidural—by choosing a midwife or doctor whose policies and practices promote spontaneous vaginal birth http://www.lamaze.org/HealthyBirthPractices.

References

Anim-Somuah, M., Smyth, R. M., & Jones, L. (2011). Epidural versus non-epidural or no analgesia in labour. Cochrane Database Syst Rev(12), CD000331. doi: 10.1002/14651858.CD000331.pub3 http://www.ncbi.nlm.nih.gov/pubmed/22161362

Bannister-Tyrrell, M., Ford, J. B., Morris, J. M., & Roberts, C. L. (2014). Epidural analgesia in labour and risk of caesarean delivery. Paediatr Perinat Epidemiol, 28(5), 400-411. http://www.ncbi.nlm.nih.gov/pubmed/25040829

Cheng, Y. W., Shaffer, B. L., & Caughey, A. B. (2006). Associated factors and outcomes of persistent occiput posterior position: A retrospective cohort study from 1976 to 2001. J Matern Fetal Neonatal Med, 19(9), 563-568. http://www.ncbi.nlm.nih.gov/pubmed/16966125?dopt=Citation

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to Mothers II: Report of the Second National U.S. Survey of Women’s Childbearing Experiences. New York: Childbirth Connection. http://childbirthconnection.org/pdfs/LTMII_report.pdf

Eriksen, L. M., Nohr, E. A., & Kjaergaard, H. (2011). Mode of delivery after epidural analgesia in a cohort of low-risk nulliparas. Birth, 38(4), 317-326. http://www.ncbi.nlm.nih.gov/pubmed/22112332

Fitzpatrick, M., McQuillan, K., & O’Herlihy, C. (2001). Influence of persistent occiput posterior position on delivery outcome. Obstet Gynecol, 98(6), 1027-1031. http://www.ncbi.nlm.nih.gov/pubmed/11755548?dopt=Citation

Jones, L., Othman, M., Dowswell, T., Alfirevic, Z., Gates, S., Newburn, M., . . . Neilson, J. P. (2012). Pain management for women in labour: an overview of systematic reviews. Cochrane Database Syst Rev, 3, CD009234. http://www.ncbi.nlm.nih.gov/pubmed/22419342

Kjaergaard, H., Olsen, J., Ottesen, B., Nyberg, P., & Dykes, A. K. (2008). Obstetric risk indicators for labour dystocia in nulliparous women: a multi-centre cohort study. BMC Pregnancy Childbirth, 8, 45. http://www.ncbi.nlm.nih.gov/pubmed/18837972?dopt=Citation

Lieberman, E., Lang, J. M., Cohen, A., D’Agostino, R., Jr., Datta, S., & Frigoletto, F. D., Jr. (1996). Association of epidural analgesia with cesarean delivery in nulliparas. Obstet Gynecol, 88(6), 993-1000. http://www.ncbi.nlm.nih.gov/pubmed/8942841

Nguyen, U. S., Rothman, K. J., Demissie, S., Jackson, D. J., Lang, J. M., & Ecker, J. L. (2010). Epidural analgesia and risks of cesarean and operative vaginal deliveries in nulliparous and multiparous women. Matern Child Health J, 14(5), 705-712. http://www.ncbi.nlm.nih.gov/pubmed/19760498?dopt=Citation

Philipsen, T., & Jensen, N. H. (1989). Epidural block or parenteral pethidine as analgesic in labour; a randomized study concerning progress in labour and instrumental deliveries. Eur J Obstet Gynecol Reprod Biol, 30(1), 27-33. http://www.ncbi.nlm.nih.gov/pubmed/2924990

Phipps, H., Hyett, J. A., Graham, K., Carseldine, W. J., Tooher, J., & de Vries, B. (2014). Is there an association between sonographically determined occipito-transverse position in the second stage of labor and operative delivery? Acta Obstet Gynecol Scand, 93(10), 1018-1024. http://www.ncbi.nlm.nih.gov/pubmed/25060716

Ponkey, S. E., Cohen, A. P., Heffner, L. J., & Lieberman, E. (2003). Persistent fetal occiput posterior position: obstetric outcomes. Obstet Gynecol, 101(5 Pt 1), 915-920. http://www.ncbi.nlm.nih.gov/pubmed/12738150?dopt=Citation

Senecal, J., Xiong, X., Fraser, W. D., & Pushing Early Or Pushing Late with Epidural study, group. (2005). Effect of fetal position on second-stage duration and labor outcome. Obstet Gynecol, 105(4), 763-772. http://www.ncbi.nlm.nih.gov/pubmed/15802403

Sizer, A. R., & Nirmal, D. M. (2000). Occipitoposterior position: associated factors and obstetric outcome in nulliparas. Obstet Gynecol, 96(5 Pt 1), 749-752. http://www.ncbi.nlm.nih.gov/pubmed/11042312?dopt=Citation

Thorp, J. A., Hu, D. H., Albin, R. M., McNitt, J., Meyer, B. A., Cohen, G. R., & Yeast, J. D. (1993). The effect of intrapartum epidural analgesia on nulliparous labor: a randomized, controlled, prospective trial. Am J Obstet Gynecol, 169(4), 851-858. http://www.ncbi.nlm.nih.gov/pubmed/8238138?dopt=Citation

Thorp, J. A., Parisi, V. M., Boylan, P. C., & Johnston, D. A. (1989). The effect of continuous epidural analgesia on cesarean section for dystocia in nulliparous women. Am J Obstet Gynecol, 161(3), 670-675. http://www.ncbi.nlm.nih.gov/pubmed/2782350

About Henci Goer

Henci Goer

Henci Goer

Henci Goer, award-winning medical writer and internationally known speaker, is the author of The Thinking Woman’s Guide to a Better Birth and Optimal Care in Childbirth: The Case for a Physiologic Approach She is the winner of the American College of Nurse-Midwives “Best Book of the Year” award. An independent scholar, she is an acknowledged expert on evidence-based maternity care.  

 

Cesarean Birth, Childbirth Education, Epidural Analgesia, Guest Posts, Healthy Birth Practices, Medical Interventions, New Research, Pain Management, Research , , , , , , ,