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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 , , , , ,

Care Model Innovations – Changing The Way Maternity Care Is Provided

February 17th, 2015 by avatar
© Serena O'Dwyer

© Serena O’Dwyer

Amy Romano was the original community manager, editor and writer of Science & Sensibility back when this blog was first established by Lamaze International in 2009.  After a healthy stint in that role, Amy has since moved on to other positions and most recently can be found in the position of Vice President of Health Ecosystems at Maternity Neighborhood, a technology company providing digital tools and apps to maternity health care providers around the world.  Additionally, Amy has been focused on finishing up her MBA at the same time.  (Talk about multitasking!)

While moving on to other things, Amy has not stopped blogging and I have been enjoying her most recent series on care model innovation in maternity care in particular and healthcare in general.  The series started in October of 2014, and Amy just published the seventh post in her ten post series. The entire series is part of Amy’s school work toward receiving her MBA.  That is a great blend of combining her degree program with her work, with her passion and interest.

Amy decided to look at four care models in particular: Nurse-Family Partnership, community-based doulas, midwife-led maternity services, and CenteringPregnancy. In talking with Amy, she shared that one of the things that really struck her is that these evidence-based care models are all very much relationship-based. She is more convinced than ever that trusting relationships are the “secret sauce” of good birth outcomes.

The posts available in the series so far include:

  1. What is care model innovation?
  2. The case for care model innovation in U.S. maternity care
  3. Care models that work: Nurse-Family Partnership
  4. Care models that work: Doulas as community health workers
  5. Care models that work: Midwife-led maternity services
  6. Care models that work: Group Prenatal Care
  7. Early examples of payment innovation in maternity care

And those posts yet to come:

8.  More mature payment reform models: An overview
9.  Driving community-based care through payment reform
10. The data infrastructure required for care model transformation

Particularly helpful are the references and learning resources that Amy includes in each of her posts, where the reader can go for more information and to dig deeper into the programs and research that Amy used to substantiate her research.

Changing the maternity care model currently in place is a critical piece for helping to improve the current status of both maternal morbidity and mortality as well as neonatal morbidity and mortality in the USA, which despite our abundance of resources, still has our world ranking in these categories shamefully at the bottom of the list.

According to Amy:

We’re in the midst of a “perfect storm” right now, with implementation of health care reform and lots of forces changing healthcare to be more patient-centered and integrated with community services. If ever there was a time when midwifery care, doulas, physiologic birth practices, etc., were going to take hold, that time is now.

As I have been reading Amy’s series, I have been struck by how some of her posts have reinforced the Lamaze Six Healthy Birth Practices themes, in particular #3 – Bring a friend, loved one or doula for continuous support, and #4 – Avoid interventions that are not medically necessary.

I asked Amy to share what her thoughts on what the role of the childbirth educator was in this time of transition.  Her response:

I think childbirth educators have lots of opportunities in the new healthcare landscape, but it will require a shift in thinking for some. New payment models will reward team-based care and CBEs have an important potential role as valued members of these teams, helping to implement shared decision making, help with care navigation/coordination, and extending educational offerings to postpartum/parenting, special conditions (e.g. gestational diabetes), etc. 

Amy Romano

Amy Romano

We need innovative ideas, forward thinking, and the ability to examine what we are currently doing with a critical eye, if we are to design and implement maternity care programs that improve outcomes and utilize resources more effectively to help mothers and babies.  As Amy highlights, there are existing programs that have shown great results and deserve the opportunity to be implemented on a wider scale.

Take some time to read the seven posts and come back to the Maternity Neighborhood blog to catch the final three when they become available.  Share your thoughts about what Amy is discussing as she rolls out the entire series.  And, consider what your role will be in the changing landscape of care that women receive during their childbearing year.

Babies, Childbirth Education, Doula Care, Healthcare Reform, Healthy Birth Practices, Maternal Mortality, Maternal Quality Improvement, Maternity Care, Midwifery, New Research, Newborns, Research , , , , , , ,

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 , , , , ,

Thank You Midwives! join Lamaze in Celebrating National Midwifery Week!

October 7th, 2014 by avatar

midwifery week poster 2014Please join Lamaze International and Science & Sensibility as we celebrate National Midwifery Week.  Midwives can and should play an integral part of healthy and safe birth practices here in the United States and around the world. Maternal infant health organizations and consumers alike are now aware that we have reached a tipping point.  Our cesarean rate is too high, the availability of VBAC supportive providers is dismal, the rate of inductions, particularly before 39 weeks is cause for concern, labor augmentations are commonplace and infant mortality – particularly amongst babies of color, in our country puts the United States ranking at an embarrassing 56 amongst all the other countries.

The midwifery model of care offers women and babies care by qualified, skilled health care providers who are experts at normal physiologic birth and meeting the needs of healthy, low risk, pregnant women.  The midwifery model of care respects the shared decision making process between the mother and her health care provider, the importance of the mother’s emotional health as well as her physical health and recognizes pregnancy and birth as part of a woman’s normal lifecycle, rather than an illness or pathological condition.  There is respect for the normal physiological process of birth, and the recognition that when things deviate from normal, collaboration and referral to obstetricians and other specialists is appropriate.  When midwives have the opportunity to care for more healthy low risk women, the United States might start to see some of the dismal statistics reverse, and women and babies will benefit from the new trend.

The American College of Nurse Midwives has created a consumer website, Our Moment of Truth, where women can learn more about midwifery, increase awareness and understanding of the different care options available, make informed choices about the type of care they would like to receive and even find a midwife in their area.  There is also a brochure available – “Normal Healthy Childbirth for Women and Families: What You Need to Know” to download in English and Spanish and share with your students and clients. This document and the ACNM program “Our Moment of Truth” was supported and endorsed by Lamaze International along with many other maternal infant health organizations.

The ACNM has a very nice “Essential Facts about Midwives” info sheet that contains some great statistics and information about Certified Nurse Midwives and Certified Midwives.  Midwives can catch babies in hospitals, birth centers and at home and Medicaid reimbursement is mandated for CNMS/CMs in all 50 states.  In 2012, CNMs/CMs attended over 300,000 births in the U.S.  When you add in Certified Professional Midwives/Licensed Midwives who also attend births at birth centers and homes, the number of midwife attended births goes up even further.

ACNM has created a fun video highlighting midwives and the care they provide.  I have also collected of a few of my favorite videos about midwives that you might enjoy viewing and sharing.

Mother of Many from emma lazenby on Vimeo.

What are you doing to celebrate and honor midwives this week?  Do you talk about the midwifery model of care in your childbirth classes and with your doula clients?  What resources do you like using to help your students understand the scope of practice and benefits of working with midwives?  Share with others in our comments below.

Babies, Childbirth Education, Healthy Birth Practices, Home Birth, Midwifery, Newborns , , , , , , ,

The Red/Purple Line: An Alternate Method For Assessing Cervical Dilation Using Visual Cues

July 3rd, 2014 by avatar

By Mindy Cockeram, LCCE

Today’s blog post is a repost of one of the most popular posts ever shared on our blog. It is written by Mindy Cockeram, LCCE.  Mindy explores the “mystical” red/purple line that has been observed to provide information about cervical dilation without the need for a vaginal exam. Have you seen such a line.  Do you have other ways of identifying dilation that do not involve cervical exams?  Please share in the comments- Sharon Muza, Science & Sensibility Community Manager.

When couples in my classes are learning techniques for coping in labor, such as the Sacral Rub (sacrum counterpressure), Double Hip Squeeze and Bladder32 accupressure points,  I always talk about the great position the partner is in for spotting the red, purple or dark line (depending on skin color) that creeps up between the laboring woman’s buttocks and how – by ‘reading’ that line – he or she may be able to assess more accurately the woman’s cervical progress than the health care providers!  This empowering thought is often met with smiles and laughter especially when I translate ‘natal cleft’ into more recognizable words like ‘butt cleavage’.  Strangely, I’ve never had anyone in class mention having heard of this ‘thermometer’ for accessing cervical dilation by sight and I find this interesting considering the number of medical professionals that come through my classes.

Photo CC http://www.flickr.com/photos/alexyra/214829536/

I first came across this body of research as an Antenatal Student Teacher with the National Childbirth Trust in London.  The article I was reading was in Practising Midwife and was a ‘look back’ at the original article (Hobbs, 1998) published in the same magazine.  The original Practising Midwife article was based on a letter referencing a small study by Byrne DL & Edmonds DK published in The Lancet in 1990.

In the 1990 letter to The Lancet, Byrne and Edmonds outlined and graphed 102 observations from eighteen midwifes on 48 laboring women. It states “The red line was seen on 91 (89%) occasions, and was completely absent in five (10.4%) women and initially absent in three (6.25%).”  The report then goes on to talk about the “significant correlation between the station of the fetal head and the red line length.”  Later the authors write: “To our knowledge, this is the first report of this red line.  We believe that it represents a clinical sign which is easy to recognize and which may offer valuable information in obstetric management.”

So how does this line work?  And why does this it appear?  Practising Midwife Magazine presented a graphic which I have attempted to recreate here.  Basically as the baby descends, a red/purplish (or perhaps brown depending on skin color) line creeps up from the anus to the top of the natal cleft in between the bottom cheeks.  When the line reaches the top of the natal cleft, 2nd stage is probably a matter of minutes away.  A line sitting an inch below the natal cleft is probably in transition.  A line just above the anus probably signifies early labor.

Byrne DL & Edmonds DK, the authors of the original study, surmise that the cause of the line is “vasocongestion at the base of the sacrum.” Furthermore, the authors reason that “this congestion possibly occurs because of increasing intrapelvic pressure as the fetal head descends, which would account for the correlation between station of the fetal head and red line length.”  Fascinating and logical!

Interestingly, I came across a 2nd Scottish study from 2010 published by BMC Pregnancy & Childbirth: (Shepherd A, Cheyne H, Kennedy S, McIntosh C, Styles M & Niven C) which aimed to assess the  percentage of women in which a line appeared (76%. ) The study cited only 48-56% accuracy of vaginal examinations to determine cervix diameter and fetal station.  So why aren’t clinicians using this less invasive visual measure – especially considering how much some women may dread vaginal exams in labor??  Wouldn’t the thought of using a methodology to lower infection rate after rupture of membranes has occurred enthuse Health Care Providers instead of using higher risk techniques?  Or how about using the accuracy of the line at the natal cleft to know when a women using epidural should really be coached to push?

My educated guess is that this information has not yet reached Medical Textbooks and non-standard practices can take years to become mainstream (for example. delayed cord clamping) – and then only if or when women request them or media sensation activates them.  In addition, since laboring women are only intermittently attended by Labor & Delivery staff during early and active labor and often encouraged to “stay in bed,” Health Care Providers aren’t necessarily faced with a woman’s buttocks in labor.  Also vaginal examinations are considered “accurate” so staff have no need to peek between a woman’s natal cleft.   However both these studies, paired with the roughly 50% accuracy rate of manual vaginal exams, show that there is potentially a more accurate and less invasive way ahead.

In The Practising Midwife (Jan 2007, Vol 10 no 1, pg 27), Lesley Hobbs writes “Accurate reading would seem to the key to this practice.  I sometimes notice in myself a wish to see the line progressing more quickly than it actually does; when I do this – and check with a vaginal exam – only to find the line is right, I get annoyed with myself and wish I’d trusted my observations.”  Later she goes on to say “I can now envisage a time when I shall feel confident enough to use this as my formal measurement mechanism and abandon intrusive and superfluous vaginal exams.”

Licensed Midwife Karen Baker from Yucaipa, CA commented “The purple line is a curious thing.  It’s definitely not present on everybody but is more prominent on some than others – especially right before pushing.  It tells us when she’s in full swing if we are in a good position to spot it!”

I often urge couples to send me a picture of the so called ‘purple line’ which I promise I will use only for educational purposes but so far a picture is as elusive as the Loch Ness Monster.  So, as I say in class, ‘show me your purple line’!

Are you a midwife, doctor, nurse or doula who has observed this in a client or patient? Partners, have you seen this when your partner was in labor? Has anyone heard of it or witnessed it?  If you are a childbirth educator, do you feel this is something that you might mention in your classes?  Do you think that the families in your classes might be likely to ask for this type of assessment if they knew about it? Please comment and share your experiences.

References

Byrne DL, Edmonds DK. 1990, Clinical method for evaluating progress in first stage labour.Lancet. 1990 Jan 13;335(8681):122.

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term (Protocol). Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.

Hobbs 1998. Assessing cervical dilatation without Vaginal Exams. Watching the purple line. The Practising Midwife 1(11):34-5.

About Mindy Cockeram

Mindy Cockeram is a Lamaze Certified Childbirth Educator teaching for a large network of hospitals in Southern California.  She has a BA in Communications from Villanova University and qualified as an Antenatal Teacher through the United Kingdom’s National Childbirth Trust (NCT) in 2006.  A native of the Philadelphia area, she spent 20 years in London before relocating to Redlands, CA in 2010.

 

 

 

 

Childbirth Education, Guest Posts, Midwifery, New Research , , , , ,