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New Electronic Fetal Monitoring Infographic Along with Printables of All Infographics!

February 19th, 2015 by avatar

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Lamaze International has released a new infographic; “Can Good Intentions Backfire in Labor? A closer look at continuous electronic fetal monitoring (EFM). This infographic is suitable for childbirth educators, doulas and birth professionals to use and share with clients and students.

Many birthing people and their families feel that monitoring in the form of continuous EFM (CEFM) during labor means a safer outcome for both the pregnant person and baby.  But as the infographic clearly states, (and as the research shows) since the invention of the continuous EFM, more than 60 years ago, newborn outcomes have not improved and in fact worsened.  CEFM used on normal, healthy, low risk labors does not make things better and can often create a situation that requires action (such as a cesarean birth) when the reality is that all was fine.

EFMInfographic_FINALAs educators, we have a responsibility to the families we work with to share what the evidence shows about continuous fetal monitoring.  Families may be surprised to learn that CEFM is not necessary for a spontaneous labor that is progressing normally and with a baby who is tolerating labor well.  Many of us may cover this topic when we talk about the 4th Healthy Birth Practice – Avoid Interventions that are Not Medically Necessary.  CEFM during a low risk, spontaneous labor is not medically necessary.  Helping families to understand this information and setting them up to have conversations with their health care providers about when CEFM might become necessary is an important discussion to have in childbirth class. Now there is this Lamaze International infographic on CEFM to help you facilitate conversations with your clients and students.

Lamaze International has also listened to the needs of educators and in addition to having the infographics available on a web page, all of the infographics are available as printable 8 1/2″ x 11″ handouts that you can share with families.  Alternately, for versions to laminate or hang in your classroom or office, you can choose to print the jpg versions in the original format. And of course, they will also reside on the Lamaze International Professional website.  Hop on over to check out all the infographics on a variety of topics.

Parents can find the EFM infographic as part of the educational material on the EFM information page on the parent website.

How do you cover the topic of continuous electronic fetal monitoring in your classes?  Will you be likely to use this new infographic as part of your curriculum?  Let us know in the comments section below.

Childbirth Education, Evidence Based Medicine, Fetal Monitoring, Healthy Birth Practices, Lamaze International, Maternal Quality Improvement, Medical Interventions, Push for Your Baby, Uncategorized , , , , , ,

ACOG & SMFM Standardize Levels of Maternal Care to Improve Maternal Morbidity & Mortality

February 5th, 2015 by avatar

obThe American College of Obstetricians and Gynecologists and the Society for Maternal Fetal Medicine released their second joint consensus statement on January 22nd, 2015. This consensus statement, Levels of Maternal Care is published in the February 2015 issue of Obstetrics and Gynecology (Green Journal).

What are the objectives of this statement?

The objectives of the statement, Levels of Maternal Care, is fourfold:

  1. To introduce uniform designations for levels of maternal care that are complementary but distinct from levels of neonatal care and that address maternal health needs, thereby reducing maternal morbidity and mortality in the United States
  2. To develop standardized definitions and nomenclature for facilities that provide each level of maternal care
  3. To provide consistent guidelines according to level of maternal care for use in quality improvement and health promotion
  4. To foster the development and equitable geographic distribution of full-service maternal care facilities and systems that promote proactive integration of risk-appropriate antepartum, intrapartum, and postpartum services

With a system in place that defines the levels of care, it will be clear when a transfer of care is deemed necessary to a facility that is better able to provide risk appropriate care to those women who need a higher level of maternity care.  This will improve maternal outcomes and reduce maternal morbidity and mortality.

Our goal for these consensus recommendations is to create a system for maternal care that complements and supplements the current neonatal framework in order to reduce maternal morbidity and mortality across the country. – Sarah J. Kilpatrick, MD/PhD, Lead Author

The USA ranks 60th in maternal mortality worldwide (Kassebaum NJ, 2014) and while some states  have established programs for a striated system of maternity care separate from the needs of the newborn, designations of what level of maternal care center will best serve the mother is not consistent and and creates confusion with a lack of uniform terms and definitions. Data supports better outcomes for mothers when certain maternal complications are handled in a facility deemed most appropriate for that condition.

Many years ago, thanks to the efforts of the March of Dimes, a similar system of levels of neonatal care was designated for the newborn, with each level having clear definitions of the type of services they were best able to provide, how they should be staffed and when a baby was to be transferred to a higher level facility based on newborn health conditions.  This newborn level of care system improved outcomes for babies in the USA, as they were assigned to a location that could best meet their medical needs. The levels of maternal care compliment the levels of care for the neonate, but should be viewed independently from the neonatal designations.

What are the levels of maternal care?

The statement defines five levels of care – Birth Center, Level I (Basic Care), Level II (Specialty Care), Level III (Subspecialty Care) and Level IV (Regional Perinatal Health Care Centers).

For each level, there is a definition, a list of capabilities that each facility should have, the types of health care providers that are assumed to be competent to work there and examples of appropriate patients.

Each level requires meeting the capabilities of the previous level(s) plus the ability to serve even more complicated situations until you reach Level IV, suitable for the most complicated, high populations.

The risk appropriate patient deemed suitable for each level takes into account the skills and training of the midwives or doctors who staff that facility and the ability of those individuals to initiate appropriate emergency skills and response times for the patient.  As a woman becomes less and less “low risk”, she will need to have her care transferred to the appropriate level.  This transfer may occur prenatally, intrapartum or during the postpartum period.

Recognition of the out of hospital midwife and the birth center

The consensus statement recognizes the credentials of the Certified Midwife (CM), the Certified Professional Midwife (CPM) and the Licensed Midwife (LM) as appropriate health care providers, along with Certified Nurse Midwives, OBs and Family Practice doctors, for low risk women in out of hospital facilities where those individuals are legally recognized as able to practice.  The low risk woman is defined as low-risk women one with an uncomplicated singleton term pregnancy with a vertex presentation who is expected to have an uncomplicated birth.

The statement also officially recognizes the freestanding birth center as an appropriate place to give birth for low risk women, along with supporting the collaboration of birth center midwives with the health care providers at higher level maternal care facilities.

Clear capabilities and requirements

The statement also outlines the type of staffing requirements to be available for services, consultation, or emergency procedures at each type of facility.

The consensus statement acknowledges that the appropriate level of  care for the baby may not align with the appropriate level of care for the mother.  Care guidelines that have been long established and well determined for the newborn should also be followed.

Consensus statement receives strong support

The consensus statement has been reviewed and endorsed by:

American Association of Birth Centers

American College of Nurse-Midwives

Association of Women’s Health, Obstetric and Neonatal Nurses

Commission for the Accreditation of Birth Centers

The American Academy of Pediatrics leadership, the American Society of Anesthesiologists leadership, and the Society for Obstetric Anesthesia and Perinatology leadership have reviewed the opinion and have given their support as well.

Additionally, the Midwives Alliance of North America was pleased to see this consensus statement and read how the role of out of hospital midwives was addressed.

MANA applauds ACOG’s identification of the need for birthing women to have a wide range of birthing options, from out of hospital settings for low-risk women to regional perinatal centers for families experiencing the most complicated pregnancies. As ACOG states, a wide variety of providers can meet the needs of low-risk women, including Certified Professional Midwives, Certified Nurse Midwives, Certified Midwives, and Licensed Midwives. We strongly concur with the need for collaborative relationships between midwives and obstetricians. Treesa McLean, LM, CPM, MANA Director of Public Affairs

What does this mean for the childbirth educator?

I encourage all birth professionals to read the consensus statement (it is easy to read) to understand the specifics of each level of maternal care.  As we teach classes, we can discuss with our families that there may be circumstances during their pregnancy or labor that require their care to be changed or transferred to a facility that offers the level of maternal care appropriate for their condition. Some of us already work in hospitals that are Level IV while others of us might teach elsewhere. We can help families to understand why a transfer might be necessary, and how to ask for and receive the information they need to fully understand the reason for a transfer of care and what all their options might be.  Families that are prepared, even for the events that they hoped to avoid, can feel better about how their labor and birth unfold.

Thank you ACOG and SMFM for working hard to clarify and bring about uniform standards that can be applied across the country that will improve the outcomes for mothers giving birth in the USA.

Photo source: creative commons licensed (BY-NC-SA) flickr photo by Paul Gillin

References

Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, Shackelford KA, Steiner C, Heuton KR, et al. Global, regional, and national levels and causes of maternal mortality during 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013 [published erratum appears in Lancet 2014;384:956]. Lancet 2014;384:980–1004. [PubMed]

Levels of maternal care. Obstetric Care Consensus No. 2. American College of Obstetricians and Gynecologists. Obstet Gynecol 2015;125:502–15.

American Academy of Pediatrics, Childbirth Education, Evidence Based Medicine, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Medical Interventions, Midwifery, New Research, Practice Guidelines, Pregnancy Complications , , , , ,

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 , , , , , , ,

“Pathway to a Healthy Birth” – Using Consumer Materials from Hormonal Physiology of Childbearing Report in Your Classes.

January 22nd, 2015 by avatar

Screen Shot 2015-01-21 at 6.01.46 PMLast week, Dr. Sarah Buckley in coordination with Childbirth Connection released a new research report, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care.”  This massive tome gathers in one place, all the current information available on the role of various hormones on pregnancy, labor, birth, breastfeeding and postpartum and provides information on what happens to the processes when interventions are introduced.  Well known childbirth educator Penny Simkin reviewed the report on Science & Sensibility on January 13th and then Michele Ondeck followed up with an exclusive Science & Sensibility interview with Sarah Buckley later in the week.

I think that everyone will acknowledge that this report is a remarkable and valuable piece of work, but at over 400 pages if you take into account all accompanying documents and with a bibliography consisting of over 1100 sources, the typical pregnant woman is hardly going to be keeping a copy on their bedside table for some light reading before drifting off to sleep.  Today on Science & Sensibility, I would like to highlight the resources and tools that Childbirth Connection has thoughtfully provided that are geared specifically for the consumer.  Childbirth educators, doulas and health care providers can access and share these materials with their students, clients and patients.

Pathway to a Healthy Birth – How to Help Your Hormones to Do Their Wonderful Work – consumer booklet

This 17 page colorful consumer booklet is written in easy to comprehend language and illustrated with attractive photographs that show a diverse collection of families.  Families are introduced to the hormones of birth and postpartum; oxytocin, beta-endorphins, catecholamines and endorphins.  Each hormone has a brief description and a short explanation about the role it plays in childbearing.

Families are told that events can interfere with the intended actions of the childbearing hormones.  Birthing women are encourage to think about how activities around them during their labor and birth may interfere with hormones and prevent the hormones from working effectively.

Women learn that hormones prepare her body for an efficient labor and birth.  The booklet addresses how women’s bodies are prepared by some hormones to handle the pain and stress that may accompany labor. They also find out that the hormones help prepare their babies for the newborn transition.  Infant attachment and maternal behaviors are also supported by the role of the hormones.

Follow Angela’s Birth Story

Families are introduced to “Angela” and read about her labor and birth story.  The story shows how the hormones allow the labor and birth to unfold in support of the normal processes and how small things can have a big impact and disrupt the process.  For example, The transition from home to hospital reduces the intensity and frequency of Angela’s contractions as a result of interference with the normal hormonal process.  The story is filled with lots of strategies to encourage and allow the hormonal effects as they are intended to occur.

It is easy to see from Angela’s story, that while labor and birth are hard and do involve pain, with the right support and environment, along with best practices that endorse physiological birth, Angela is able let her body do the work it is designed to do, and have a birth that is very satisfying to her.

“What’s Happening”

Accompanying the story is an easy to read guide that demonstrates exactly what the hormones of childbearing are doing at each particular point in Angela’s story.  Explanations of the role of each hormone as things unfold help families to understand how what happens in their own birth can affect their own birth story and outcome.

What Can You Do

The next portion of the brochure offers steps that families can take to help them identify providers and facilities that support physiologic birth.  Lists of questions to ask, tips for making a hospital room comfortable and private, interview questions for their doctor or midwife, how to pick a childbirth class, find a doula, how to determine if medical procedures are necessary and explore less interventive alternatives and more are all there in an easy to digest format. Included are valuable links in the final section that makes the booklet resource rich.  There are many web links to get more information about all the topics covered above.  This makes the booklet an ideal handout for a childbirth class, doula consultation or meet and greet with potential health care providers.

Infographic

Screen Shot 2015-01-21 at 6.03.49 PMThere is a consumer infographic that can be printed in a size suitable for hanging in a classroom or office, or provided in a smaller format that makes a great accompaniment to the above booklet.  The infographic identifies things that can keep a woman on the “pathway” to a physiological birth and what can steer her away from the pathway.  There is a lot of similarity between the points made in this infographic and the Lamaze Six Healthy Birth Practices.

One teaching idea

After discussing the role of hormones in labor and sharing the infographic as a visual aid, I can easily see how an educator can play a game with her class – making and distributing cards to class members with scenarios on them, and asking families to share if those scenarios and activities are making it easier for the mother to stay on the physiological pathway or what steers her further away and having the students identify which hormones are affected.

We have a responsibility as childbirth educators to share the important role the hormones of childbearing play in supporting healthy mothers, healthy births and healthy babies.  Using the Pathway to a Healthy Birth consumer booklet and accompanying infographic as part of your teaching materials provides a simple to understand but effective tool for conveying this information to the families you interact with.

How do you see yourself using these consumer products in your childbirth classes?  With your doula clients?  Please share your ideas for teaching, discussing and using this material and covering these topics with the families you work with.  I would love to hear your thoughts.

Babies, Breastfeeding, Childbirth Education, Healthy Birth Practices, Infant Attachment, Medical Interventions, Newborns, Research, Transforming Maternity Care , , , , , ,

An Interview with Sarah Buckley: Discussing Her New Report – “Hormonal Physiology of Childbearing”

January 15th, 2015 by avatar

By Michele Ondeck,RN, MEd, IBCLC, LCCE

© Sarah Buckley

© Sarah Buckley

Sarah Buckley is a family doctor, mother of four, and author of the bestselling book Gentle Birth, Gentle Mothering. She has been writing and lecturing about the hormones of birth, among other topics, since 2001. Mothering Magazine published her article “Ecstatic Birth, Nature’s Hormonal Blueprint of Labor” in 2002.  She lives with her family near Brisbane, Australia.  On Tuesday, January 13th, 2015, Dr, Buckley released a comprehensive report entitled “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” in cooperation with Childbirth Connection.  Two days ago, Penny Simkin reviewed the report and shared valuable information on how birth professionals will be able to use this report in their classes or practices.  Today, Lamaze International Past President, Michele Ondeck, shares her recent interview with Dr. Buckley.  In this interview, they discuss Sarah’s thoughts on what this report means for both families and professionals. Sarah speaks to how it we are just beginning to recognize the downstream effects of disturbing the normal hormonal process that occurs during labor, birth and postpartum and what this disturbance might mean for future generations. – Sharon Muza, Community Manager, Science & Sensibility.

Michele Ondeck: Sarah, thank you for the in-depth review of the hormones of labor in the Hormonal Physiology of Childbearing (HPOC) report. I am thankful for the support you received for this project from the Childbirth Connection programs with the National Partnership for Women & Families. As a board member of Lamaze International, I am proud that we were able to also provide some support to make this report possible. How are you celebrating the report’s release?

Sarah Buckley: Finishing the report has been a big milestone, not just for me but also for my family who have been very involved and supportive. We’ll be celebrating with champagne and, as its summer down here, with an Aussie barbeque.

MO: Sarah, I have been sharing orchestration of the hormones of birth: oxytocin, beta endorphins, epinephrine and nor-epinephrine and prolactin from Ecstatic Birth with parents and professionals since its publication. You have expanded, clarified, and synthesized that basic information in your report. I know that you have been working on this report since 2011. What was your inspiration to keep at it? How did you find time to review more than 1,100 publications?

SB: Yes, it’s been a long gestation! What has kept me engaged is the practical relevance of the material for mothers, babies, fathers, and families, and my own lived experiences. For me, its much more than an academic body of knowledge, it’s a paradigm that recognizes the superb design of our female bodies, and describes the smoothest, safest, easiest, and most pleasurable path to parenting. I am also lucky to receive much support and positive feedback about this material, both from maternity care providers, who gain a scientific understanding of what they are seeing every day in the birth room, and from women themselves, who realize that there are positive ways to support their hormones and increase safety, ease, and pleasure for themselves and their babies.

Screen Shot 2015-01-13 at 6.38.16 PMMO: Now with the publication of the Hormonal Physiology of Childbearing, there is the potential to educate so many more professionals in the maternity and newborn care community. How does the timing of the report fit with the changes that you see happening today that can influence professionals?

SB: I have been writing and lecturing about the hormonal physiology for more than 10 years and I have seen a significant shift in receptiveness to this perspective, especially in the last 2 to 3 years. I think we are maturing as birth professionals and beginning to think more widely about the perinatal period. The microbiome paradigm, for example, which looks at the effects of birth on the transfer of healthy bacteria from mother to newborn, is giving us solid evidence that what happens at birth can have long-term consequences.

It is also a very exciting time to launch the report because this material is very much aligned with other initiatives, including ACNM’s Physiologic Birth Initiative and the ACOG/SMFM Safe Prevention of the Primary Cesarean Delivery statement. It’s also a pleasure to me that the Hormonal Physiology of Childbearing supports and extends other current models including the Lamaze Healthy Birth Practices.

MO: You refer to the growing recognition of the significance of the Developmental Origins of Health and Disease (DOHaD) in the report. Midwives, childbirth educators and doulas among others have long discussed the unintended consequences of interventions in childbirth. Now with more recognition of the importance of the perinatal period as a sensitive period that potentially affects long term health, how do you simply explain this fascinating concept and others like epigenetic programming for childbearing families?

SB: The perspective of Hormonal Physiology is very much aligned with these big-picture models including DOHaD, epigenetics, and Lifecourse Health Development, which is a multi-system model looking at the potential for early events to change the trajectory of long-term health and development.

Epigenetics refers to the biochemical processes that switch genes on or off, which helps organisms to adapt to their environment and circumstances. We know that epigenetic changes give critical adaptations (“programming”) in early life that increase the chance of survival in the environment they have come into.

In relation to DOHaD, it is now scientifically established, and widely accepted — e.g., you read this research in the media and online — that the baby’s exposures in the womb can have long-term health effects. We also know from animal studies (with a growing interest in human research also) that early life events can have long-term programming effects, and we have even identified the associated epigenetic changes in some animal studies.

What the HPOC perspective adds to these models is the possibility that these long-term programming effects may occur not only before and after birth but also during birth, and it provides possible mechanisms for such effects. In other words, changing the hormonal experiences around the time of birth could have far-reaching effects.

In fact, we would expect very significant epigenetic effects at this time, as part of the enormous shifts involved with adapting to life outside the womb and, for the mother, optimally adapting her to the essential tasks of nurturing and nourishing her young. We have substantial animal research showing long-term effects from perinatal hormone exposures, including exposure to high doses of synthetic oxytocin.

MO: When you were doing this in-depth research on the hormones of labor. What finding(s) were most meaningful to you as a mother?

SB: As we describe in the report, this is a “consistent and coherent mosaic coming into view,” so we don’t have all the gaps filled in. However, what strikes me as a mother, and in relation to my own experiences of birth and mothering, is evidence that the hormonal processes of labor and birth, including mother-newborn contact in the first hour after birth, might switch on maternal reward systems in the brain at this powerful time, so that the new mother finds her offspring rewarding into the future. This is a critical mechanism for species survival, and ensures that mammalian mothers give the dedicated care that their newborns need- without going to a prenatal class! And after birth, these systems are reinforced for the mother by rewarding hormones including oxytocin and beta-endorphins released with breastfeeding and also with close infant contact.

© Sarah Buckley

© Sarah Buckley

I wonder if some of the problems we have with parenting in our culture, that it seems like hard work, that we can find caring for our young children boring, are because we can miss all of these sources of rewarding hormones.

MO: The forward to the report was written by leaders in medicine, midwifery, nursing, obstetrics, and pediatrics urging maternity care to support physiologic birth in order to uphold the Precautionary Principle of “do no harm.” What do you want to say to us on where to start in changing the current environment?

SB: I think one of the most powerful things we can do is to share the information in this report, including the knowledge gaps, with professionals and with expectant parents, so that we can shift our cultural understanding towards appreciating how superbly designed women’s bodies are for childbearing, how these hormonal systems can be disrupted, and that we actually don’t know the long-term effects for our children, so we should be applying precaution.

I especially want to reach high-technology settings, so that we can begin to recognize the gap between physiology and current practice and work to bridge it. In situations where interventions are genuinely needed, I want care providers to be asking “How can we safely add more hormonal physiology?” and take actions. This could be as simple as supporting skin-to-skin after cesarean, or promoting doula care for women with pregnancy complications.

I also want this report to get the attention of policy makers and funders. Physiologic childbearing is a low-technology approach that is generally inexpensive compared to our current high-technology models of care. The hormonal physiology perspective also suggests significant longer-term and public health benefits, for example through support for breastfeeding. This could give even greater benefits and cost-effectiveness in the longer-term, making it an excellent investment of health-care funds

About Michele Ondeck

michele ondeck head shot 2015Michele Ondeck,RN, MEd, IBCLC, LCCE serves the Lamaze International Board of Directors as its immediate past president. She was employed by Magee-Womens Hospital of University of Pittsburgh Medical Center for more than thirty years in a number of positions including education and research in the pursuit of improving women’s health and maternity care. She is the mother and grandmother of four. Currently, she is a director of a Lamaze International Accredited Childbirth Educator Program and self-employed as a perinatal education consultant.

 

 

 

 

 

 

 

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