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Elective Induction at 40 Weeks? “Decision-Based Evidence Making” Strikes Again

July 14th, 2015 by avatar

Today on Science & Sensibility, contributor Henci Goer takes a look at a systematic review released in spring that examined the impact of elective inductions on the cesarean rate.  Sound analysis or a house of cards?  Looking closer at the studies reviewed provides insight into how the conclusions reached by the investigators might need to be examined more closely.  Henci does that in this review.  Have you read this new systematic review?  Did you come to the same conclusions?  I invite you to share your thoughts in our comments section below. – Sharon Muza, Community Manager, Science & Sensibility.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340  CC licensed.

flickr photo by catharticflux http://flickr.com/photos/catharticflux/2710057340 CC licensed.

Yet another systematic review has surfaced “Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials”  in which reviewers claim that electively inducing healthy women, this time at 40, not 41 weeks, offers benefits and doesn’t increase the cesarean surgery rate (Saccone 2015).

Let’s take a closer look.

Reviewers included five trials: three of them conducted in the 1970s (Cole 1975; Martin 1978; Tylleskar 1979), the fourth published in 2005 (Nielsen 2005), and the fifth in 2014 (Miller 2014). Already we have a problem. Induction management in the 1970s is sufficiently different from management today that results are unlikely to apply to contemporary care, but let’s get down to specifics. Two of the 1970s trials were deemed inadequate for inclusion in the Cochrane review of elective induction (Gulmezoglu 2012), and Miller 2014 is published only as an abstract. Quality systematic reviews exclude abstracts because they don’t provide enough information to evaluate the study. For these reasons, these three trials should be taken off the table..

That leaves us with the other two. Nielsen 2005 states in the title “Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial” that it is confined to women with favorable Bishop scores. Anyone familiar with elective induction research should know that inducing when the cervix is ready to go won’t increase the cesarean rate compared with spontaneous onset, but inducing with an unripe cervix is a different story even when using cervical ripening agents (Dunne 2009; Jonsson 2013; Le Ray 2007; Macer 1992; Prysak 1998; Thorsell 2011; Vahratian 2005). As you move the induction date earlier and earlier, more and more women will have an unfavorable cervix, so including a trial limited to women with a ripe one will tilt the playing field in favor of induction. Furthermore, half the participants were multiparous women (113/226). Women with prior vaginal births will go on having vaginal births pretty much no matter what you do to them, which raises another point: inducing earlier means a higher percentage of the inductees will be first-time mothers because first time mothers tend to run longer pregnancies (Mittendorf 1990). Nulliparous women are much more vulnerable to anything that pushes them in the direction of a cesarean. That’s not all: The authors tell us that their hospital has a 7% cesarean rate for dystocia in women at term. If a hospital has a cesarean rate much higher than that—and many do—then results can’t be generalized to it, although, frankly, if the doctors are performing cesareans left and right, induction or spontaneous onset may not make much difference. In short, Nielsen (2005) doesn’t make a compelling argument for 40-week elective induction.

flickr photo by Selbe <3 http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

flickr photo by Selbe < http://flickr.com/photos/stacylynn/11944718954 shared under a Creative Commons (BY-NC-ND) license

This brings us to the last trial, Cole (1975). Investigators allocated healthy women either to induction at 40 weeks (111 women) or 41 weeks (117 women). As with Nielsen, half the women had prior vaginal births. Despite being healthy, 22 women were induced for “obstetric complications” (undefined) in the 41-week induction group before reaching 41 weeks. If their doctors induced labor because they had concerns, then this would likely put the women at heightened risk for cesarean. Another 32 women were induced for exceeding 41 weeks. This means that overall, nearly half (46%) of the comparison group didn’t begin labor spontaneously, which would mask any association between induction and cesarean. Leaving the induction vs. spontaneous onset issue aside, the U.S. cesarean rate in the early 1970s was around 5%, which means it was a rare woman who would have one regardless of circumstances. Again, not exactly a strong case for inducing at 40 weeks.

What about the benefits? The best reviewers can come up with are a clinically meaningless reduction in mean blood loss (-58 ml); a lower rate of meconium-stained amniotic fluid (4% vs. 14%), not, mind you, a reduction in meconium aspiration, and therefore clinically meaningless as well; and an equally meaningless reduction in mean birth weight of -136 g (5 oz). If they had found something more impressive, surely they would have reported it.

Really? This merited a pre-publication media blast? Because it amounts to a textbook example of “garbage in, garbage out.” I can see only three possibilities to explain it: either 1) the authors and peer reviewers at the American Journal of Obstetrics and Gynecology (AJOG) don’t know as much as they should about what constitutes a quality systematic review, 2) they are so steeped in medical model thinking—“How early can we get the baby out of that treacherous maternal environment?”—that their judgment is compromised, or 3) we have a “pay no attention to what’s behind the curtain” effort to promote elective induction. I don’t know which is the more troubling, but if it’s the last one, the sad thing is that because it’s got the magic words “systematic review,” “meta-analysis,” and “randomized controlled trials” in the title, it’s likely to succeed.

References

Cole, R. A., Howie, P. W., & Macnaughton, M. C. (1975). Elective induction of labour. A randomised prospective trial. Lancet, 1(7910), 767-770.

Dunne, C., Da Silva, O., Schmidt, G., & Natale, R. (2009). Outcomes of elective labour induction and elective caesarean section in low-risk pregnancies between 37 and 41 weeks’ gestation. J Obstet Gynaecol Can, 31(12), 1124-1130.

Gulmezoglu, A. M., Crowther, C. A., Middleton, P., & Heatley, E. (2012). Induction of labour for improving birth outcomes for women at or beyond term. Cochrane Database Syst Rev, 6, CD004945.

Jonsson, M., Cnattingius, S., & Wikstrom, A. K. (2013). Elective induction of labor and the risk of cesarean section in low-risk parous women: a cohort study. Acta Obstet Gynecol Scand, 92(2), 198-203. doi: 10.1111/aogs.12043

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: a retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Martin, D. H., Thompson, W., Pinkerton, J. H., & Watson, J. D. (1978). A randomized controlled trial of selective planned delivery. Br J Obstet Gynaecol, 85(2), 109-113.

Miller, N., Cypher, R., Pates, J., & Nielsen, P. E. (2014). Elective induction of nulliparous labor at 39 weeks of gestation: a randomized clinical trial. Obstet Gynecol,132(Suppl 1):72S.

Mittendorf, R., Williams, M. A., Berkey, C. S., & Cotter, P. F. (1990). The length of uncomplicated human gestation. Obstet Gynecol, 75(6), 929-932.

Nielsen, P. E., Howard, B. C., Hill, C. C., Larson, P. L., Holland, R. H., & Smith, P. N. (2005). Comparison of elective induction of labor with favorable Bishop scores versus expectant management: a randomized clinical trial. J Matern Fetal Neontal Med, 18:59-64.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: a case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Saccone, G., & Berghella, V. (2015). Induction of labor at full term in uncomplicated singleton gestations: a systematic review and metaanalysis of randomized controlled trials. American journal of obstetrics and gynecology.

Thorsell, M., Lyrenas, S., Andolf, E., & Kaijser, M. (2011). Induction of labor and the risk for emergency cesarean section in nulliparous and multiparous women. Acta Obstet Gynecol Scand, 90(10), 1094-1099. doi: 10.1111/j.1600-0412.2011.01213.x

Tylleskar, J., Finnstrom, O., Leijon, I, et al. (1979). Spontaneous labor and elective induction – a prospective randomized study. Effects on mother and fetus. Acta Obstet Gynaecol Scand, 58:513-518.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.out

About 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.

 

ACOG, Cesarean Birth, Childbirth Education, Do No Harm, Evidence Based Medicine, Guest Posts, Medical Interventions, New Research, Research , , , , , ,

Webinar – “Childbirth Class for Students Who Want An Epidural” – Today! Register Now.

June 25th, 2015 by avatar
Photo by Patti Ramos Photography

Photo by Patti Ramos Photography

Robin Weiss, PhD, MPH, CPH, ICCE-CPE, ICPFE, CLC, CD(DONA), BDT(DONA), LCCE, FACCE, President of Lamaze International, has an absolutely great webinar scheduled for later today that you definitely don’t want to miss. This 60 minute live webinar, titled “Childbirth Class for Students Who Want an Epidural” will be valuable for both new educators and experienced educators alike at 1 PM EST.

When families enroll in Lamaze classes, some people may be planning to birth without pain medications while others may already have made a different decision and are intending to get an epidural.  Then of course, there are those people who prefer to “see how it goes” and make a decision at during labor.

As a childbirth educator, we won’t necessarily know who falls into which category, and honestly, it simply doesn’t matter.  Our role is to present information that is unbiased, based on evidence and best practice and helps families to make the best decision for themselves. Everyone who takes a childbirth class needs to receive quality information and deserves to have the facts presented in a nonjudgmental manner.

Teaching about epidurals in a Lamaze class allows families to gain knowledge in a safe and welcoming environment.  Whether this topic is covered extensively during your regular classes (which it should be) or you decide to offer a module for those who are positive they want medication, families should have the opportunity to learn what they need to know.

Robin Weiss is the perfect facilitator to lead us through this potentially tricky topic. She has been a childbirth educator, author and trainer of Lamaze educators for many years. She recently completed her Ph.D in Maternal Infant Health at the University of Louisville in KY.

This will be a great check-in to help you evaluate how you are presenting this topic to your students, give you some new ideas and perspective for approaching the subject and possibly even provide the impetus to offer a specialized class.

© Robin Elise Weiss

© Robin Elise Weiss

If you participate in this webinar, you have the option of receiving contact hours for a small additional fee upon completion of a post-webinar evaluation.

Won’t you consider registering now for this webinar that happens today, at 1 PM EST.  After you participate in the webinar, I invite you to come back and share your thoughts, ideas and any learning moments that you have taken away on this topic.

 

Childbirth Education, Epidural Analgesia, Medical Interventions, Webinars , , , , ,

Looking Back in Time: What Women’s Bodies are Telling Us about Modern Maternity Care

June 18th, 2015 by avatar

By Christina Gebel, MPH, LCCE, Birth Doula

Christina Gebel, MPH, LCCE, Doula writes a reflective post examining current birthing conditions to see how today’s practices might be interfering with the the normal hormonal physiology and consequently impacting women’s ability to give birth.  Times have certainly changed and birth has moved from the home to the hospital.  A slow but steady increase in out of hospital births is examined and Christina asks us to consider why women are increasingly choosing to birth outside the hospital – and what do hormones have to do with it? – Sharon Muza, Science & Sensibility Community Manager

“Pregnancy is not a disease, but a beautiful office of nature.” These are the words of Victoria Woodhull, the first female candidate for President of the United States in 1872.

Lajja_gauri ancient birth art

© “Lajja gauri

The world in which pregnant women find themselves today looks a lot different than the time of Woodhull’s campaign run. For instance, hospitals didn’t become the mainstream setting for labor and delivery until the 1930s and 40s. While modern medicine has undoubtedly helped millions of women who may have otherwise died in childbirth, mothers and birth advocates across the nation are beginning to ask if we are paying a price for today’s standard maternity care. With increasing protocols and interventions, pregnancy is viewed less like the office of nature Woodhull spoke of and more like a pathological condition.

The Hormonal Physiology of Childbearing, a recent report by Sarah Buckley, systematically reviews existing research about the impact that common maternity practices may have on innate hormonal physiology in women and fetuses/newborns. The report finds strong evidence to suggest that our maternity care interventions may disturb these processes, reduce their benefits, or even create new challenges. To find out more, read an interview that Science & Sensibility did with Dr. Buckley when her groundbreaking report was released.

Let’s examine something as simple as the environment that a woman gives birth in. In prehistoric times, laboring women faced immediate threats and dangers. They possessed the typical mammalian “fight-or-flight” reaction to these stressors. The hormones epinephrine and norepinephrine caused blood to be diverted away from the baby and uterus to the heart, lungs, and muscles of the mother so that she could flee. This elevation in stress hormones also stalled labor, to give the mother more time to escape. Essentially, she told her body ‘this place is not safe,’ and her body responded appropriately by stopping the labor to protect the mother and her child during a very vulnerable time.

Today, mothers are not fleeing wild animals but rather giving birth in hospitals, the setting for nearly 99% of today’s births, where this innate response may cause their labor to stall. The sometimes frenetic environment or numerous brief encounters with unfamiliar faces may trigger a sense of unease and, consequently, the fight-or-flight response, stalling the mother’s labor. Prolonged labor in a hospital invariably leads to concern and a need to intervene, often by the administration of Pitocin, synthetic oxytocin, to facilitate regular contractions. Arrested labor could lead to further interventions up to and including a cesarean section. The fight-or-flight response may be further reinforced by these interventions, as they potentially come one after the other, in what is often referred to as the “cascade of interventions.”

This is just one example of how a woman’s body’s natural physiology can go from purposeful to working against the labor, the mother and the baby. Epinephrine and norepinephrine are both necessary in labor and delivery. In fact, at appropriate levels, these hormones support vital processes protecting the infant from hypoxia and facilitating neonatal transitions such as optimal breathing, temperature, and glucose regulation, all markers for a healthy infant at birth.

Recent data show that mothers themselves may already think what the Hormonal Physiology of Childbearing report suggests. The series of Listening to Mothers (LtM) studies, a nationally-representative survey of childbearing women, shows a shift in mothers’ attitudes towards normal physiologic birth: In 2012, 58% of mothers agreed somewhat or strongly that giving birth is a process that should not be interfered with unless medically necessary, up from 45% in 2000. According to 2013 national birth data, out-of-hospital (home and birth center) births have increased 55% since 2004, but the overall percentage is still only 1.35% of all births nationwide. While low, this shows that a small core of mothers are voting with their feet and choosing to give birth out of the hospital. Though their choice may seem extreme, they’re not alone. In the LtM data, which only surveys women who have given birth in a US hospital, 29% of mothers said they would definitely want or would consider giving birth at home for a future birth, and 64% said the same of a birth center. All this raises the question: What’s happening in a hospital that is leading mothers to consider other settings for their next birth?

One answer to upholding women’s preferences, autonomy, and the value of normal physiologic birth is a mother’s involvement in shared decision making with her provider, along with increasing access to models of care that support innate physiologic childbearing, like midwives in birth centers. Increasing access to these options may present a challenge, as demand seems to outweigh availability.

Leslie Ludka (MSN, CNM) has been the Director of the Cambridge Health Alliance Birth Center (Cambridge, Mass.) as well as the Director of Midwifery since 2008. Like other birth centers, the center has seen a steady increase in demand each year, with patients coming from all over New England. Ludka sees many barriers to having more birth centers available including finances (the reimbursement for birth not being comparable to an in-hospital birth), “vacuums in institutional comprehension” of the advantages of the birth center model for low-risk women, and the rigorous process to be nationally certified by the Commission for the Accreditation of Birth Centers (CABC), requiring “a great commitment and a lot of support by all involved.” In order to overcome these barriers, Ludka suggests marketing the safety of birth centers to the general public, sharing outcome statistics for women and infants cared for in birth centers, and educating insurers and providers about the overall benefits and financial savings of midwifery and the birth center model. With supportive policy and better understanding on the part of insurers, the public, and healthcare institutions, models like the birth center could become more plentiful, more easily meeting the demand.

Women’s bodies are sending subtle messages that our current healthcare system is, at times, not serving their needs. It’s time to respond to these messages, beginning by viewing childbirth foundationally as a life event and not first as pathology, and adapting our models of care to speak to this viewpoint. If we fail to do so, we run the risk of creating excess risk for women and newborns.

It’s been 143 years since Woodhull ran for president. We’ve made progress in getting much closer to seeing our first woman president, but with childbirth, perhaps our progress now starts with looking back in time.

About Christina Gebel

© Christina Gebel

© Christina Gebel

Christina Gebel holds a Master of Public Health in Maternal and Child Health from the Boston University School of Public Health. She is a birth doula and Certified Lamaze Childbirth Educator as well as a freelance writer, editor, and photographer. She currently resides in Boston working in public health research. You can follow her on Twitter: @ChristinaGebel and contact her through her website duallovedoula.com

Childbirth Education, Guest Posts, Home Birth, Maternity Care, Medical Interventions, Midwifery , , , ,

American Obstetrician Takes Rational Position on Home Birth

June 16th, 2015 by avatar

Neel Shah, Harvard Medical School assistant professor and practicing obstetrician, commenting in the New England Journal of Medicine Perspectives section –  “A NICE Delivery – The Cross-Atlantic Divide over Treatment Intensity in Childbirth“, agrees with new United Kingdom National Institute for Health and Care Excellence (NICE) guidelines concluding that healthy, low-risk women are better off at home or in a midwife-led unit than in a hospital under the supervision of an obstetrician. Citing a table comparing outcomes in low-risk multiparous women from the Birthplace in England data, Shah writes:

The safety argument against physician-led hospital birth is simple and compelling: obstetricians, who are trained to use scalpels and are surrounded by operating rooms, are much more likely than midwives to pick up those scalpels and use them. For women giving birth, the many interventions that have become commonplace during childbirth are unpleasant and may lead to complications . . . .

He quite reasonably adds the caveat that the guidelines apply to low-risk women only and that even these women may develop labor complications without warning, but then, responsible home birth advocates acknowledge those same two points. That being said, I can’t resist adding a couple of caveats of my own.

© Families Upon ThamesFirst, one reason why women with risk factors plan home birth, women with prior cesareans being a common example, is that doctors and hospitals deny them the possibility of vaginal birth (Declercq 2013). With their only hospital alternative being unwanted and unneeded cesarean surgery, planned home birth becomes their least, worst option. This dilemma puts their choice squarely in the lap of the medical system. Another reason is that some women have been so emotionally traumatized by their treatment during a previous birth that they reject planned hospital birth and refuse intrapartum transfer even when this may be the safer option (Boucher 2009; Symon 2010). Again, the failure and its remedy lie with the system, not the woman.

Second, if the hospital lacks 24/7 obstetric, anesthesia, and pediatric coverage and at least a Level 2 nursery, which many do, then a woman is probably no better off in the hospital in an emergency than she would be at home or at a freestanding birth center. Furthermore, most urgent situations—a baby who doesn’t breathe, excessive bleeding, even umbilical cord prolapse—can be managed or stabilized by a properly trained and equipped home birth attendant. In fact, what would be done in the hospital is no different from what would be done at home: neonatal resuscitation, oxygen, medications to stop bleeding, maternal knee-chest position and manually holding the fetal head off the cord until cesarean.

Finally, with admirable frankness, Shah notes that unlike the U.K., and to the detriment of safety, “[A]ccess to obstetric care that is coordinated among homes, birthing centers, and hospitals is both unreliable and uncommon.” And while he doesn’t cast any blame, once more, the fault lies with the system. (Just as an FYI, a model guideline for transfer of care developed by a workgroup that included all stakeholders is publically available.)

Shah concludes: “The majority of women with straightforward pregnancies may truly be better off in the United Kingdom.” True that, but it doesn’t have to be that way. Dialing back the overuse of medical intervention and cesarean surgery; respecting the woman’s right to give informed consent and refusal; implementing a culture of care that is kind, compassionate, and respects a woman’s dignity; and ensuring that out-of-hospital birth attendants can consult, collaborate, and transfer care appropriately would have two benefits: it would reduce the number of women refusing hospital birth while minimizing the chance of adverse outcomes in those who continue to prefer to birth at home or in a freestanding birth center. Nonetheless, despite the generally positive responses accompanying Shah’s commentary, rather than inspiring a wave of reform, I would lay odds that the more common reaction to Shah’s piece within the medical community will be to shoot the messenger.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126.

Declercq, E., Sakala, C., Corry, M. P., Applebaum, S., & Herrlich, Ariel. (2013). Listening to Mothers III. Pregnancy and Birth. New York: Childbirth Connection.

Symon, A., Winter, C., Donnan, P. T., & Kirkham, M. (2010). Examining autonomy’s boundaries: a follow-up review of perinatal mortality cases in UK independent midwifery. Birth, 37(4), 280-287.

About 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.

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

BABE Series: Cesarean Section Role Play Helps Prepare Families

April 30th, 2015 by avatar

apron and babyToday, in our monthly series “Brilliant Activities for Birth Educators” (BABE), I would like to share one of the activities that I do in my Lamaze class to help families feel prepared for a cesarean section. Most families in my classes are planning a vaginal birth, but it never hurts to be prepared should plans change.  One in three pregnant people will birth by cesarean in the USA.  April is Cesarean Awareness Month and that is why I am sharing this activity at this time.

Objectives

My objectives for this specific activity are threefold – 1) to share how the procedure is done 2) to offer different options that might be available for the family to request (skin to skin in the OR, delayed newborn procedures, etc., and 3) brainstorm the role of the support person during a cesarean and what kind of support the pregnant person will find comforting and helpful.

This role play is done in the fifth week of a seven week series. We have just covered variations in labor (induction, augmentation, EFM, AROM, pain medications, assisted second stage and more). They have heard about the hard and soft reasons for a cesarean and now I hope that they will understand the procedure and the choices and options they might have at the time.

Supplies for the activity and the setup

  • Cesarean apron
  • surgical masks
  • drape
  • soft baby
  • hair nets
  • scrubs
  • surgical clothing
  • laminated labels for each role
  • optional – IV bag, BP cuff, EKG leads, etc
up close cesarean apron

Up close of four zippers on cesarean apron

My main prop in this activity is a “cesarean apron” handmade by Kris Avery, a fellow LCCE here in Washington State. The apron has breasts, a belly button and some pubic hair painted on it, but what makes it special is a series of zippers that correspond to the different layers of a person’s body that will be cut during the cesarean procedure. Each zipper is sewn into a different layer and opens to reveal the layer underneath. The skin is represented by the apron, and then there is a layer of fat (yellow felt) that zips open, revealing the uterus (red felt). There are no muscles to “open” because as we know, the abdominal muscles are retracted and not cut. Finally, underneath the uterus, is the amniotic sac, represented by a thin white nylon material.

I ask a partner to come with me out of sight of the class and place the cesarean apron on them. All the zippers are closed. I place a soft baby doll (I use the baby from IKEA) underneath the apron with the head positioned right near the inner zipper.  Sometimes I place the baby in the breech position and plan on having the bum be removed first. When the partner is ready, we walk together back into the classroom and I ask them to lay on a table, where I have placed a pillow.

How I conduct the role play

I invite two class members to come up and hold a drape at chest level, just like it might be positioned in the OR.  I hand out laminated cards to all the other class members. Each card has the role of someone who might be in the OR during a cesarean section – surgeon, baby nurse, anesthesiologist, surgical tech, respiratory therapist, and so on.   I ask the pregnant person who is partnered with my “cesarean person” to play the role of “partner.”  I invite the partner to get into the white “moon suit” that is normally provided to family members during a cesarean.  I hand out hair nets, scrubs, face masks, surgical gowns, to all those who will be in the OR and everyone suits up.  I position all the “actors” in the appropriate spot.  Some go by a pretend “baby warmer” and others stand around the birthing person while others go where they might be in the real operating room. I talk about how hard it is to tell who is in the room and what their role is, when everyone is wearing scrubs/gowns/hats/masks and suggest that they ask people to introduce themselves.  I discuss strategies that the birthing person can use if they are temporarily separated from their support person.  I bring the support person over and seat them at the head of the OR table near the “anesthesiologist” and discuss how they cannot see over the drape for both the patient and the partner. The partner can stand up at the time of birth if they wish, or together they could ask for the drape to be dropped at that moment.  I ask the pregnant person how they are feeling as the surgery is about to begin.FullSizeRender

I walk everyone through the procedure step by step and describe what is happening.  I share what noises they might hear, and what sensations the pregnant person might “feel.”  (Tugging, pressure, pulling, but no pain.)  I try and give a sense of how long it takes for each part of the operation, (prep, incision to baby, closure)  I ask the surgeons to begin to open the zippers, and talk about each layer that they come to.  Finally the surgeons are through the amniotic sac and they reach in and remove the baby’s head through the opening. It is a somewhat tight fit and we discuss how that might benefit the baby.

The baby is delivered, shown to the parents and taken over to the “warmer” where the baby team is waiting.  I encourage partner to go over and see the baby, initiate talking to the baby and start sharing information with the birthing person – what the baby looks like, how s/he is doing, and so on.

cesarean apronWe go on to discuss how the partner can facilitate having the baby brought over to the birthing person ASAP, skin-to-skin, what might need to happen if baby is moved to the special care nursery, and more.  Throughout all of this, the class participants are role-playing through all of the likely activities and people are stepping up to help the family to have a positive experience, within the scope of their assigned role.  The surgeons close (zip up) the different layers and close the outer zipper on the skin.

I am leaving out much of the detail, as I am confident that you can fill in the activities that happen when a person is prepped, taken to the OR, has the cesarean surgery and is then taken to recover.  My hope is to have parents aware of some of the major points of the overall procedure.

Processing the activity

The class members take off the “costumes” and return to their seats.  I feel it is very important to debrief this activity.  It can be overwhelming to some. We debrief further, discussing any observations they had, how they felt as our role play was happening. I ask what are the values that are important to them and their family, if a cesarean should be needed.  A discussion also takes place about what a cesarean recovery plan might look like and how the family’s needs might change if they do not have a vaginal birth.

How is this activity received?

IMG_0116During the activity, class members are usually very engaged and creative in answering questions, acting out their “roles” and brainstorming solutions to the situations I present.  The real magic happens when we debrief.  I can see the wheels turning as families articulate what they will want and need should they have a cesarean birth.  They learn that they have a voice and can share what is important with their medical team.

Time and time again, I receive emails and and notes from class members who ended up having a cesarean. They share how “accurate” our role play was and how it helped them to understand the steps involved with their cesarean.  They were able to speak up in regards to their preferences and felt like their class preparation helped to reduce their stress and anxiety.

Summary

This activity takes time and I often wonder if I should replace it with something much shorter that covers the same topic.  But, I continue to do this role play activity because I see how it really helps families to understand how to play an active role in the birth of their baby, even if it is by cesarean section.

Other resources that I share with the class are the following links:

How might you make a “cesarean apron” that you could use for this activity?  Do you have ideas on how you could modify this activity for your classes?  What other things do you do to help your families to be prepared for a cesarean birth?  I would love to learn how you cover this important topic.  Please share your ideas in the comments section below.

Note/Disclaimer: The use of the acronym “BABE” (Brilliant Activities for Birth Educators) is not affiliated with, aligned with or associated with any particular childbirth program or organization.

 

Babies, Cesarean Birth, Childbirth Education, Medical Interventions, Newborns, Push for Your Baby, Series: BABE - Brilliant Activities for Birth Educators , , , ,

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