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Advocacy: Lamaze International Leaders on Capitol Hill

April 7th, 2015 by avatar

By John Richardson, Director, Government Relations, Lamaze International

I am proud of being both a member of Lamaze International and a Lamaze Certified Childbirth Educator for many reasons.  Today’s post by John Richardson, Lamaze International’s Director of Government Relations is just one reason why I am happy to pay my membership dues and be a part of the Lamaze organization.  Lamaze is actively working in both the private sector and with public/governmental leaders to help every family to have access to the resources to have a safe and healthy birth.  Today on the blog, we share about how our Board of Directors met with Congressmen and Congresswomen to share the importance of an evidence based childbirth education class being available to all families.  My certifying organization works hard for me and the families I teach every day.  – Sharon Muza, Science & Sensibility Community Manager.

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Lamaze BoD on Capitol Hill, 2015

Advocacy is a foundational element of the Lamaze International mission to advance safe and healthy pregnancy, birth and early parenting through evidence-based education and advocacy. Assisting women and their families to make informed decisions for childbearing and acting as an advocate to promote, support, and protect safe and healthy birth are two core competencies of a Lamaze Certified Childbirth Educator.

Advocacy comes in many different forms. The new Lamaze Strategic Framework specifically calls for taking advocacy efforts to the next level, focusing on government and legislative advocacy — leveraging strategic partnerships to advocate for perinatal/childbirth education coverage under the Affordable Care Act (ACA) and partnering with insurance companies, including the Centers for Medicaid and Medicare Services (CMS), to become part of the “bundled care” system. (Bundled care payment programs refer to the concept of grouping together the multiple services associated with a certain health “episode” versus the current fee for service system where each service associated with a condition is charged separately, and is one of the ACA’s many attempts to incentivize health care providers to be more cost efficient.)

BoD President Robin Elise Weiss and BOD Christine Morton

BoD President Robin Elise Weiss and BOD Christine Morton

Over the years, Lamaze has been involved in a variety of coalition and advocacy efforts related to improving access to high-quality maternity care that includes evidence based childbirth education by qualified educators and the promotion of breastfeeding within the health care industry. These efforts will continue with Lamaze taking its message directly to Capitol Hill to have a stronger voice with federal policymakers on behalf of the organization, its members, and the women and families that Lamaze serves. We want to let Congress know that Lamaze International provides gold standard childbirth education which can play an important role in promoting healthier outcomes for mother and baby and reducing healthcare costs and burdens on the healthcare system.

What does advocacy look like?

Advocacy campaigns at the federal level in the United States are typically a set of actions targeted to create support for a specific policy or proposal. The goals of an advocacy campaign may include drafting and passing a new law, drafting and passing amendments to existing laws, commenting on regulation, or influencing public perception and awareness of a particular issue.

Why is advocacy important for Lamaze?

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Board member Alice Turner

The delivery of health care is one of the most regulated industries in the United States. State and federal regulations often define whether services are covered by insurance, which practitioners are allowed to deliver services, the manner in which services are delivered, and how much individual practitioners and health care organizations are reimbursed. Naturally, there are a lot of people and organizations invested in steering and influencing these policies. There are literally thousands of issues and groups vying for policymakers’ attention. For Lamaze, it is critical to engage directly in advocacy activities so that policymakers become aware of the issues that are important to our organization and make them priorities.

There have been several recent successful advocacy initiatives to improve care for pregnant and postpartum women. For example, Lamaze has worked in collaboration with other organizations and lawmakers to improve breastfeeding services under the Affordable Care Act. As a result, there are several benefits now available to women who receive coverage through the Health Insurance Marketplaces (exchanges) and private non-grandfathered plans. Benefits such as lactation support and counseling by trained professionals are now covered without co-pay or co-insurance. Breast pumps are also covered at no charge and most employers must provide access to clean and private locations to pump for women who are hourly employees.

These victories are impressive and it is important to note that they did not occur in a vacuum. Advocates flooded the halls of Congress for years to ensure that policymakers appreciated the importance of breastfeeding. A key component of the success of these advocacy efforts was that they were based on research, focused on higher quality health outcomes, and provided fiscal benefits to the health care system and the federal government.

The Lamaze Board of Directors’ “Hill Day”

cbe graphicBearing all this in mind and in conjunction with their in-person meeting in Washington, DC, members of the Lamaze Board of Directors took to Capitol Hill on March 19, 2015 to meet with their Representatives and Senators about the excellent childbirth education that Lamaze provides and its potential to reduce costs and improve outcomes. The members of the Board met with a total of 23 Congressional offices, the majority of whom sit on committees with jurisdiction over health policy.

Our advocacy efforts on Capitol Hill centered on the following core messages:

  1. Promoting greater utilization of evidence-based childbirth education is a critical element in closing quality outcomes gaps and reducing unnecessary costs. In the face of high rates of cesarean sections, early inductions, and maternal/infant mortality, there is an increasing imperative for women to be informed and in charge of their maternity care to improve birth outcomes.

Maternal or neonatal hospital stays make up the greatest proportion of hospitalizations among infants, younger adults and patients covered by private insurance and Medicaid, which is why improvements in care are a major opportunity to reduce overall healthcare spending. Increasing quality outcomes by reducing the rates of unnecessary interventions, such as early induction of labor and cesarean section, are critical to reduce healthcare spending, particularly with Medicaid.

  1. The ACA has provided an opportunity for millions of uninsured Americans to access health care coverage through the creation of the exchanges. For those that do not enroll in a plan during the “open” enrollment period, there are qualifying “life events” that trigger special enrollment periods. One of those life events is when a woman gives birth. After the birth, the mother can sign herself and her infant up for coverage.

Lamaze believes, along with many others, that pregnancy, rather than birth, should be the life event that triggers the special enrollment period. Recently, 37 Senators and 55 Representatives sent a letter to U.S. Health & Human Services Secretary Sylvia Mathews Burwell  requesting this change. It appears Secretary Burwell can make this change administratively, as it does not require an act of Congress. Lamaze will join a chorus of other organizations that are making this request directly to the Secretary. Lamaze will also emphasize the importance of ensuring that ACA and state Medicaid plans include childbirth education as a covered service under maternity care benefits.

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Hill Day meetings

While meeting and communicating with legislators and staff on Capitol Hill may seem intimidating, it is actually very easy. Legislators are elected (and re-elected) by their constituents (you) so they have an obligation to listen to their constituents (you). That is a very important dynamic to remember. They are naturally inclined to help address the issues raised by their constituents.

However, advocates should always be well-prepared, a task that proved to be almost second nature for the Lamaze Board members as they met with Congressional offices. As experts in the field and natural educators, Lamaze leadership did a fantastic job representing the views of childbirth educators and establishing a rapport with the officials and staffers they met – the most important accomplishment of any first meeting on Capitol Hill.

Check out all the pictures of our Board of Directors on the “Hill” last month here.

Getting Involved

If you want to get involved and contact or meet with Congressional offices in your state, the most important action is to convey who you are, what you do, how you do it, and why it is important. Then, continue a dialogue of how specific policies might be improved for safer, higher quality, lower cost birth outcomes. In preparation for the first Lamaze “Hill Day,” several key documents were developed, including a policy paper and supporting documents to convey Lamaze’s core message in meetings with Congressional offices. By following this link, you can access and use these documents for advocacy efforts with your state’s representatives and in your local communities with insurers, health care providers, and hospitals.

Providing Lamaze’s unique perspective on the state and national level is extremely important and we can only be successful with the help of our members and supporters. In the coming months, we will provide a webinar on how to become an effective advocate and what Lamaze is doing to have an impact on access to high-quality childbirth education. Stay tuned!  If you are already an advocate in your community, on the county or state level or even nationally, share what you are doing to help families receive good care and improve outcomes in our comments section.

About John Richardson

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© John Richardson

John Richardson joined SmithBucklin, Lamaze International’s management company, in 2001 as Director of Government Relations, Healthcare Practice Group. He guides the policy efforts of healthcare organizations whose members include healthcare administrators; allied health professionals; physicians and hospitals. His experience provides his clients with a deep understanding of policy and politics and their effects on the healthcare system.

John lobbies Congress and government agencies at the federal level and also develops strategy for state lobbying efforts. He also has experience pursuing client objectives such as the development of practice guidelines, CPT codes, evidence based research, and technologies that promote efficiencies within healthcare administration.

Prior to joining SmithBucklin, John served as an Associate to the House Committee on Appropriations for a former member of the committee. Preceding his work of 5 years on the Hill, John acquired extensive political and grassroots experience working as a campaign aide to congressional and presidential campaigns.

A New Hampshire native, he graduated with a B.A. in Political Science from Roger Williams University in Bristol, R.I, and currently resides in Bowie, MD with his wife Kristin and sons Garrett and Holden.

 

Childbirth Education, Evidence Based Medicine, Guest Posts, Healthcare Reform, Healthy Birth Practices, Lamaze International, Lamaze News, Maternal Quality Improvement, Push for Your Baby, Research for Advocacy , , , , , ,

Maternity Care On the National Agenda – New Opportunities for Educators and Advocates

January 17th, 2013 by avatar

Today, Amy Romano, CNM, MSN, Associate Director of Programs for Childbirth Connection (and former Community Manager for this blog) follows up last Thursday’s post, Have You Made the Connection with Childbirth Connection? Three Reports You Don’t Want to Miss with her professional suggestions for educators and advocates to consider using the data and information contained in these reports and offering your students, clients and patients the consumer materials that accompany them.- Sharon Muza, Community Manager.

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As we begin 2013, it is clear from my vantage point at the Transforming Maternity Care Partnership that the transformation is underway. In Childbirth Connection’s nearly century-long history, we’ve never seen so much political will from leaders, so much passion from grassroots advocates, and so much collaboration among clinicians and other stakeholders. This new landscape presents many new opportunities for educators and advocates.

One area of maternity care that has garnered increasing attention is the overuse of cesarean section, especially in low-risk women. Last year, the multi-stakeholder Maternity Action Team at the National Priorities Partnership set goals for the U.S. health care system and identified promising strategies to reach these goals. One of the goals was to reduce the cesarean section rate in low-risk women to 15% or less. This work served as the impetus for Childbirth Connection to revisit and update our Cesarean Alert Initiative. We undertook a best evidence review to compare outcomes of cesarean delivery with those of vaginal birth. Based on the results, we also updated and redesigned our consumer booklet, What Every Pregnant Woman Needs to Know About Cesarean Section. These are powerful new tools to help educators and advocates push for safer care, support shared decision making, and inform and empower women.

Two of the biggest obstacles to change have been persistent liability concerns and the current payment system that rewards care that is fragmented and procedure-intensive. Efforts to make maternity care more evidence-based or woman-centered often run up against policies and attitudes rooted in fear of lawsuits or increasing malpractice premiums, or against the reality that clinicians can not get easily reimbursed for doing the right thing. But these barriers are shifting, 

Recently the literature has provided example after example of programs that reduced harm and saw rapid and dramatic drops in liability costs as a result. That’s right – one of the best ways to decrease liability costs is to provide safer care. Rigorous quality and safety programs are the most effective prevention strategy among the ten substantive solutions identified in Childbirth Connections new report, Maternity Care and Liability. The report pulls together the best available evidence and holds potential liability solutions up to a framework that addresses the diverse aims of a high-functioning liability system that serves childbearing women and newborns, maternity care clinicians, and payers.  

The evidence and analysis show that some of the most widely advocated reforms do not stand up to the framework, while quality improvement programs, shared decision making, and medication safety programs, among other interventions, all have potential to be win-win-win solutions for women and newborns, clinicians, and payers. If we are to find our way out of the intractable situation where liability concerns block progress, we must learn to effectively advocate for such win-win-win solutions.  Advocates and educators can better understand these solutions by accessing the 10 fact sheets and other related resources on our Maternity Care and Liability page.

Evidence also shows that improving the quality of care reduces costs to payers. As payment reforms roll out, there will be many more opportunities to realize these cost savings. To predict potential cost savings, however, it is necessary to know how much payers are currently paying for maternity care. Surprising, this information has been largely unavailable, and as a result we have had to settle for using facility charges as a proxy. This is a poor proxy because payers negotiate large discounts, and because charges data do not capture professional fees, lab and ultrasound costs, and other services. Childbirth Connection, along with our partners at Catalyst for Payment Reform and the Center for Healthcare Quality and Payment Reform, recently commissioned the most comprehensive available analysis of maternity care costs. The report, The Cost of Having a Baby in the United States shows wide variation across states, high costs for cesarean deliveries, and rapid growth in costs in the last decade. It also shows the sky-high costs uninsured women must pay – costs that can easily bankrupt a growing family. Even insured women face significant out-of-pocket costs that have increased nearly four-fold over six years. Fortunately, health care reform legislation has made out-of-pocket costs for maternity care more transparent by requiring a simple cost sample to each person choosing an individual or employer-sponsored health plan.

Educators and advocates have to be able to help women be savvy consumers of health care. That means being informed about their options and also being able to identify and work around barriers to high quality, safe, affordable care. Childbirth Connection produced this trio of reports to provide a well of data and analysis to help all stakeholders work toward a high-quality, high-value maternity care system.

How Childbirth Educators and Consumer Advocates Can Help

 What is the first thing that you are going to do to join this maternity care transformation? Can you share your ideas for using this information in your classroom or with clients or patients.  Can you bring others on board to help with this much needed transformation?- SM

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New Lamaze Campaign: Push For Your Baby! Childbirth Educators Play A Key Role

May 22nd, 2012 by avatar


Lamaze International has released a new campaign, “Push for Your Baby!” that demonstrates the key role that childbirth educators have in providing the tools for mother and families to ask for and receive the best care possible for their pregnancy, labor and birth.

Along with the “Push for Your Baby” campaign, Lamaze International reveals two new websites, Lamaze International for Parents geared for parents and consumers seeking information about classes, best practices and resources to help them connect with a Lamaze Certified Childbirth Educator and have the best birth possible and Lamaze International for the childbirth professional, where you can find professional development opportunities, forums for peer connection, resources for working with families to help them have the safest and healthiest births possible and information on becoming a Lamaze Certified Childbirth Educator.

“With the right information and education, women have the opportunity to be active partners in their care during pregnancy and birth, not just recipients of that care,” said and Lamaze Childbirth Educator Program for the Duke AHEC Program. “This campaign is designed to help women be ‘savvy shoppers’ and prepared to seek out the best care for their babies and themselves.”Lamaze President-elect Tara Owens Shuler, MEd, CD(DONA), LCCE, FACCE, Director of Continuing Education, Special Projects

The key components of the “Push for Your Baby” campaign include;

  • Push for Better!

Women often do not know what questions to ask or how to find out if the recommendations and suggestions provided by care providers are in line with research about what is best for mothers and babies. Childbirth educators play a significant role in preparing parents to have the conversations that matter, when the parents have learned and understand what the current research says about healthy birth practices from attending your classes.

  • Spot the Best Care

Parents often receive an overabundance of information during the childbearing year on the topics of pregnancy, labor, birth, breastfeeding and newborn/infant care. Much of this information, though potentially well meaning, might not be totally accurate. Lamaze provides an easy way for parents to understand the practices that offer the safest care and explains their options and avoid unnecessary interventions. Directing your families to the Six Lamaze Healthy Birth Practices, complete with short videos and downloadable pdfs of research and resources helps simplify the information overload and provides accurate resources to help parents understand how to have the healthiest and safest birth possible.

  • Childbirth Challenges
As labor unfolds, being flexible and adapting to changing circumstances is an absolute necessity for women and their partners. Working in partnership with their care providers to understand interventions and the alternatives that might be available can help families to avoid unintended consequences. Your role as a childbirth educator is critical to giving mothers and partners the tools to face these challenges if they should arise during their labor and birth.

  • Questions to Ask Your Physician or Midwife

10 Questions to Ask When Selecting A Care Provider can help families to identify doctors and midwives who are a good fit for them and who practice in a way that feels good to the mother. Using these well thought out questions can help families decide who is the right person to help them welcome their baby in the safest and healthiest way possible. Women may not do the up front “leg work” to find a provider who shares their vision of pregnancy and birth, but these questions provide a great guide. Using these questions as resources in an early pregnancy class can help your students find the right fit for their pregnancy and birth.

Questions to Ask During Labor and Birth will help mothers and their partners to ask the important questions when faced with decisions during their labor and birth. The unpredictability of certain birth situations will require parents to gather information. These simple questions will help them to organize their thoughts and advocate for their birth and their baby. Taking time to collect this information will allow mothers to feel confident in the decisions they make as they work to birth their baby in the safest and healthiest manner possible.

Childbirth education can help you to push for the best care! In a poignant, and extremely effective eight minute video, meet seven women and hear more about their births, the challenges they faced, their experiences in seeking care that felt good to them and the choices they made. Hear how these women feel about their birth experience. The celebrations and the forks in the road. These stories are a wonderful cross section of the types of experiences that women in our classes may receive, all across the country and around the world. The message in the video is loud and clear that childbirth education helps women to be better positioned to ask the right questions, seek appropriate care and be more prepared to face the challenges that may arise during their labor and birth.

Take a look at this video, and think about how you can share these women’s stories with the women and families that you work with. What discussions can grow from the stories in the video?  How are you going to use this learning tool to help prepare the families that you work with to “Push for Your Baby” and receive the care they and their babies deserve? Share your ideas with us here in our comments section and let us know what YOU plan to do?

Lamaze educators around the world are the cornerstone of  good childbirth education preparation for today’s parents. The “Push for Your Baby” campaign recognizes the information that parents learn in your classes helps them to be better prepared, play an active role in advocating for themselves and their babies and asking for care that is backed by research and proven to be safest and healthest for mom and baby.

What you can you do today?

Explore both the Lamaze for Parents and Lamaze International for educators websites and see what is new and exciting

Watch and share the “Push for Your Baby- Parents Share Their Stories” video with your online community

Place the new “Push for Your Baby” Logo, Banner and Button on your blog or website to let the world know you support safe and healthy birth practices

Visit the Lamaze Science & Sensibility Facebook Page and share the “I Help Parents Push for the Best Care” picture to spread the word in your social community about this exciting new campaign and your role in helping parents to “Push for Your Baby.”

Watch the Science & Sensibility blog over the next days and weeks as we explore together all the rich resources available to you as educators on the new and improved websites.

 

Babies, Childbirth Education, Healthy Birth Practices, Healthy Care Practices, Lamaze News, Maternity Care, Medical Interventions, News about Pregnancy, Patient Advocacy, Practice Guidelines, Push for Your Baby, Research for Advocacy, Social Media, Transforming Maternity Care, Uncategorized , , , , , , , ,

New Research Project Looking at Lived Experiences of Pregnant Women in the Work Place

September 21st, 2011 by avatar

[Editor’s note: I was recently contacted by a PhD student at Texas Tech University who is working with a professor at the University of Georgia to research pregnant women’s experiences at work. The research team is seeking to understand how organizations can do a better job at helping pregnant women in the workplace (or at the very least, stop doing things that negatively impact them). They have created a brief, 15 minute survey that involves asking pregnant women how they manage their identity at work.  The research team is looking for ways to spread the news on this project–including using social media as a primary platform for survey distribution.  Will you, after reading the following statement, please consider passing this onto your students/clients/patients?  The more women who complete this survey, the better representation of thoughts, opinions and experiences there will be.  I’m sure all of us can think of one example in which we know a woman could have been better supported by her work environment during her pregnancy.  Won’t you help spread the word on this important research project?]

 

Are you pregnant and working? We need your help!

We are researchers from the University of Georgia and Texas Tech University, studying the attitudes and behaviors of pregnant working women. We are also mothers and understand the struggles pregnant working women feel. We want to help so we are studying ways to improve the workplace experiences of pregnant working women.  To do so, we need pregnant working women who are 18 years of age or older to fill out a short survey. The data obtained in this survey will help us develop a valid instrument so that in the future we may test these experiences and how they relate to organizational outcomes.

PLEASE CLICK THE LINK BELOW TO TAKE THE SURVEY. Also, please forward this link to other pregnant working women.

http://terry.qualtrics.com/SE/?SID=SV_eScAf4xinSkxIkk

You can also click on the links below to learn a little more about the researchers,  You can then click through to the survey by clicking “PREGNANT AND WORKING SURVEY. CLICK HERE”.

Dr. Laura Little – http://www.terry.uga.edu/profiles/?person_id=768

Amanda Hinojosa – http://management.ba.ttu.edu/people/Amandacv.pdf

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

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Positioning During Second Stage of Labor: Dorsal Lithotomy vs. Lateral Lying

March 24th, 2011 by avatar

The final post in this blog series will examine the pros and cons of assuming a lateral lying position during the second stage of labor as compared to dorsal lithotomy position. Anatomical implications, perineal outcomes, and orthopedic concerns will all be addressed.

Anatomical implications
As discussed in earlier posts, dorsal lithotomy puts the birth canal in an “uphill” orientation. Conversely, the lateral lying position places the birth canal in a gravity-eliminated orientation, allowing the laboring mother to have a mechanical advantage during the pushing stage.  Also, when in side lying on the left side, there is optimal blood flow as compression of the inferior vena cava by the uterus is avoided.


Perineal outcomes

Shorten (2002) compared birth positions, Accoucher, and perineal outcomes in almost 2900 births.  It was found that the lateral lying position produced quite favorable results with regards to the health of the perineum.  Below average rates of episiotomy were observed and intact perineums were seen in 66.6% of the women who delivered while lying on their side.  The lateral lying position was, by far, the best choice for decreasing the risk for tears and the need for sutures in their research.

In a study by Soong (2005), the need for perineal sutures was decreased when a lateral lying position was assumed during delivery with epidural anesthesia.  The semi-recumbent position was associated with an increased need for suturing.  If a woman does choose to receive an epidural during her labor, it is important to realize that there are a fewer number of possible positions that she can assume because of the effects of the anesthesia.  However, given the aforementioned study by Soong, a woman should be able to make an informed decision about what position may be the best choice to improve perineal outcomes.

 

Orthopedic concerns
Although the lateral lying position does not have as many advantages as, for example, squatting or quadruped during a “normal” birth, it does have many indications when looking at births that involve a mother with orthopedic issues present.  One example is when a woman is suffering from coccygeal (tailbone)pain. Lateral lying may be the best choice for her to be in as this position does not place any force on this area and also allows the coccyx to move freely and out of the way as the baby descends.  Furthermore, it may be helpful to the woman who has pubic symphysis dysfunction, if careful attention is given to not overly abduct the lower extremities, placing undue stretch to the already separated joint.

In consideration of the spine, the side lying position is beneficial to keep the lumbar spine in a flexed position when spondylolisthesis or spinal stenosis are present.  The amount of flexion may be easily adjusted to maintain or improve maternal comfort during second stage and may improve her ability to recruit the proper musculature to push, if pain due to spine impairments is decreased.

Lastly, the lateral lying position may be optimal if hip joint dysfunction, knee joint dysfunction or superficial/deep vein thrombosis (while lying on unaffected side) is present (Hobel 2004).  Once again, attention must be paid to avoid end ranges of motion to decrease strain on the hip and knee joints and decrease risk for further injury. (See previous posts in this series for further discussion on the above-mentioned orthopedic conditions)

 

Summary
I have covered many advantages and disadvantages over the last three posts when considering second stage labor positions.  It is important to note that further research is needed in this area so we may better understand the implications of each position.  Likewise, additional information will further support  our education of women on optimal second stage positioning.  There are many different individual concerns of every woman, in every circumstance, in every birth.  It is my hope that women everywhere will be empowered to make an informed decision according to what birth outcome is important and specific to them based on the evidence presented in these posts.

picture source: http://www.flickr.com/photos/joygant/1447261129/

References

Gardosi, J., Sylvester, S. and B-Lynch, C. (1989), Alternative positions in the second stage of labour: a randomized controlled trial. BJOG: An International Journal of Obstetrics & Gynaecology, 96: 1290–1296.

Hobel CJ, Chang AB.  “Normal Labor, Delivery, and Postpartum Care:

Anatomic Considerations, Obstetric Analgesia and Anesthesia, and Resuscitation of the Newborn” in Essentials of Obstetrics and Gynecology, 4th Edition, Editors Hacker, Moore, Gambone.  Elsevier Saunders:

Philadelphia.  2004.

Liddell, H. S. and Fisher, P. R. (1985), The Birthing Chair in the Second Stage of Labour. Australian and New Zealand Journal of Obstetrics and Gynaecology, 25: 65–68

Oxorn, Harry MD Human Labor and Birth (University of Ottawa, Ontario, Canada,McGraw-Hill Professional Publishing)1986

Sax TW, Rosenbaum RB.  Neuromuscular disorders in pregnancy.  Muscle Nerve.  2006 Nov; 34(5):559-71

Shorten, A., Donsante, J. and Shorten, B. (2002), Birth Position, Accoucheur, and Perineal Outcomes: Informing Women About Choices for Vaginal Birth. Birth, 29: 18–27.

Snow, R., Neubert, A. Peripartum Pubic Symphysis Separation:  A Case Series and Review of the Literature.  Obstetrical & Gynecological Survey: July 1997 – Volume 52 – Issue 7 – pp 438-443

Soong B, Barnes M.  Maternal position at midwife-attended birth and perineal trauma: is there an association?  Birth.  2002;32(3):164-169.

Posted By:  Amanda Blaz, DPT


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