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Sarah Buckley’s “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” – A Review for Birth Educators and Doulas

January 13th, 2015 by avatar

by Penny Simkin, PT, CD(DONA)

Today, a long awaited report written by Dr. Sarah Buckley, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care” is being released by Childbirth Connection. In this valuable report, Dr. Buckley gathers the most current research and provides the definitive guide for the role of hormones in normal, natural birth.  Esteemed childbirth educator, doula and author/filmmaker Penny Simkin has reviewed Dr. Buckley’s latest offering and shares today on Science & Sensibility how childbirth educators, doulas and other birth professionals can use this information to inform parents on how best to support the physiological process of childbirth.  In coordination with this research report, Dr. Buckley and Childbirth Connection are releasing a consumer booklet geared for families and consumers as well as other material, including infographics in support of this report.  On Thursday, Lamaze International Past President Michele Ondeck will share her interview with Dr. Buckley. In that interview,  S&S readers can get the full story directly from Dr. Buckley, on just what it took to create this remarkable tome. – Sharon Muza, Community Manager, Science & Sensibility.

© Childbirth Connection

© Childbirth Connection

Introduction

For many of us who work in the maternity field, Sarah Buckley’s fine work is well-known. Her book, “Gentle Birth, Gentle Mothering” (Buckley, 2009) has provided scholarly and enlightening guidance on natural childbirth and early parenting for many years. Her 16 page paper, “Ecstatic Birth,” (Buckley, 2010) guides educators and doula trainers, who rely heavily on her explanations of hormonal physiology in childbearing, for teaching about labor physiology and psychology and the impact of care practices.

Her newest publication, “Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies, and Maternity Care,” (Buckley, 2015) is a gift to us all. It represents a massive scholarly effort, a review of all the related scientific literature on the topic. With 1141 references, most of which were published in recent years, Dr. Buckley’s overview provides the transparency to allow readers to trace her statements to the evidence on which they are based. She exercises caution in drawing concrete conclusions when the evidence is insufficient; she presents such information as theory (rather than fact), and points out when more research is necessary for concrete conclusions. The “theory” that undisturbed birth is safest and healthiest for most mothers and babies most of the time is impressively supported by her exhaustive review, as stated in the conclusion (Buckley, 2015):

“According to the evidence summarized in this report, the innate hormonal physiology of mothers and babies – when promoted, supported, and protected – has significant benefits for both during the critical transitions of labor, birth, and the early postpartum and newborn periods, likely extending into the future by optimizing breastfeeding and attachment. While beneficial in selected circumstances, maternity care interventions may disrupt these beneficial processes. Because of the possibility of enduring effects, including via epigenetics, the Precautionary Principle suggests caution in deviating from these healthy physiologic processes in childbearing.”

The Precautionary Principle, to which she refers, has been stated as follows:

“When an activity raises threats of harm to human health or the environment, precautionary measures should be taken even if some cause and effect relationships are not fully established scientifically. In this context the proponent of an activity, rather than the public, should bear the burden of proof. . . . It (the activity) must also involve an examination of the full range of alternatives, including no action.” (Science and Environmental Health Network, 1998).

In other words, when applied to maternity care, The Precautionary Principle states that when a practice, action, or policy may raise threats of harm to mother, baby, or family, the burden of proof that it will result in more good than harm falls on those who wish to adopt it – the policy maker, caregiver, or administrator, not on the pregnant person.

© Sarah Buckley

© Sarah Buckley

What’s new in this document and how might you use it and apply it in your classroom or practice?

This document represents the “State of the Science” regarding hormonal physiology of childbirth (HPOC). It should be the starting point for consideration of proposed changes in maternity care management and education. The question, “How might this policy, practice, or new information impact the HPOC and subsequent outcomes for mother and/or baby?” should be asked and answered about both existing and proposed interventions.

Sarah Buckley has asked and answered this question, and reveals the unintended consequences of numerous widespread practices, including scheduled birth – induced labor or planned cesarean; disturbance and excessive stress during labor; synthetic oxytocin (Pitocin); opioids and epidural analgesia for labor pain; early separation of mother from infant or wrapping the infant in a blanket to be held (i.e., no skin-to-skin contact); breastmilk substitutes, and many more. All of these practices cause more harm than good, except in unusual or abnormal circumstances.

One of the greatest contributions of this book is showing that hormonal physiology is affected by virtually every intervention –major and minor — and understanding this is the key to appropriate maternity care. The topic is complex and not nearly fully understood, but Sarah Buckley has pulled together just about everything that is now known on this topic. If you’re a maternity care practitioner or student, who wants to approach the care you give from a physiological perspective, or want information on the impact of common interventions on the physiological process, it’s all here. If you’re a researcher interested in studying some aspect of HPOC, your literature search has already been done for you and you can discover the many areas that have been insufficiently studied and plan where to go from there.

If you’re a childbirth educator seeking to give accurate information to expectant parents about how normal childbirth unfolds and how it can be altered (for better or worse) with common procedures and medications, you can learn it here. If you’re a doula who wants to understand how your presence and actions may contribute to normalcy, you can learn it here. If you’re an expectant parent who wants to make choices that maintain or improve the pregnant person and infant’s well-being, you can learn it here or access the consumer guide.

Organization of the Chapters

This book, with its numerous references, sheer number of pages, level of detail and broad scope, may seem daunting at first. However, if you take some time to familiarize yourself with the layout of the book before plunging in, you will find that the material in each chapter is arranged so that readers can explore each topic at varying levels of detail.

The book begins with a very helpful 10 page executive summary of the contents. There are then two chapters introducing concepts relevant to HPOC, and on the physiologic vs. scheduled onset of birth (induction and planned cesarean birth). The 7 chapters are organized with topics and subtopics. The first paragraph beneath the headings for each topic or sub-topic briefly and clearly summarizes the information in that section in italics, so that you can skim each topic by reading only the italicized summary. If you wish to investigate some subtopics more deeply, you can read everything included on those topics. Each chapter also ends with a summary of the entire chapter. Chapters 3, 4, 5, and 6 (Chapter 3 — “Oxytocin;” 4 —“Beta-Endorphins;” 5 —“Epinephrine-Norepinephrine and Related Stress Hormones;” ; and 6 —“Prolactin”) follow the same outline of topics and subtopics.

Using Chapter 6 (“Prolactin”) as an example, here is the outline:

  • 6.1 Normal physiology of prolactin
    • 6.1.1 Introduction: Prolactin
    • 6.1.2 Prolactin in pregnancy
    • 6.1.3 Prolactin in labor and birth
    • 6.1.4 Prolactin after birth
  • 6.2 Maternity care practices that may impact the physiology of prolactin
    • 6.2.1 Possible impacts of maternity care provider and birth environment on prolactin
    • 6.2.2 Prostaglandins for cervical ripening and labor induction: possible impacts on prolactin
    • 6.2.3 Synthetic Oxytocin in labor for induction, augmentation, and postpartum care: possible impacts on prolactin
    • 6.2.4 Opioid analgesic drugs: possible impacts on physiology of prolactin
    • 6.2.5 Epidural analgesia: possible impacts on physiology of prolactin
    • 6.2.6 Cesarean section: possible impacts on physiology of prolactin
    • 6.2.7 Early separation of healthy mothers and newborns: possible impact on physiology of prolactin
  • 6.3 Summary of all findings on prolactin

For childbirth educators: how might we use this information to benefit our students?

I especially appreciate that Dr. Buckley begins every section with a description of the relevant physiology. In order to be truly effective, we educators should do the same in our classes, to ensure that our students understand how and when their care is consistent with physiological childbearing and when (and why) it is not. “’Physiological childbearing’ refers to childbearing conforming to healthy biological processes,” (Buckley, 2015, page 11) as opposed to what many might refer to as “medicalized childbearing,” in which the physiologic process is altered or replaced with interventions and medications.

© Childbirth Connection

© Childbirth Connection

Childbirth education should be designed to allay the pregnant person’s anxiety, not by avoiding mention of potentially troubling labor situations, or minimizing concerns mentioned by the students, but rather by giving realistic portrayals of birth, encouraging expression of feelings, and dealing with them by informing, reframing, desensitizing, and strategizing ways to handle troubling situations. Following is an example of how an educator might include hormonal physiology of childbearing to teach about one critical topic – Physiologic Onset of Labor, which is Lamaze International’s First Healthy Birth Practice.

Let labor begin on its own: How to teach from the standpoint of HPOC

Chapter 2 in HPOC , “Physiologic Onset of Labor and Scheduled Birth,” details the ‘highly complex orchestrated events that lead to full readiness for labor, birth and the critical postpartum transitions of mother and baby.” (Buckley, 2015). As educators, we should try to convey this information, in simplified form, to help our students appreciate the beauty and connectedness of the whole mother-baby dyad. They need to understand the consequences of interrupting the chain of events that usually result in optimal timing of birth. Most parents (and many caregivers as well) have no idea that the fetus determines the onset of labor. Nor do they know that fetal readiness for labor (including protection against hypoxia and readiness for newborn transitions after birth) is coordinated with preparation of the mother’s body for labor, breastfeeding and mother-infant attachment. Once students have some grasp of these processes, they appreciate and want to protect them from interruption or replacement by medical means. As we know, most inductions and many planned cesareans are done without medical reason (ACOG, 2014). Out of ignorance and/or misinformation from their caregivers, parents often agree or even ask for these procedures.

While many educators know and teach about the risks and benefits of induction and planned cesarean, they often don’t convey the physiology on which the benefits and risks are based. It’s all here in HPOC, and this information may inspire parents to question, seek alternatives or decline these procedures.

Over the years, I have wrestled with the challenge of conveying this information fairly simply and concisely, and now, with the help of Katie Rohs, developed a new animated PowerPoint slide, “The Events of Late Pregnancy” (Simkin, 2013) that I use in class. You may access this animated slide and accompanying discussion points/teacher guide here.© Penny Simkin

© Penny Simkin

This is just one example of how we may shift our focus as teachers to incorporate basic hormonal physiology as a starting point. Dr. Buckley gives us a solid understanding of what is known about the key role the endocrine system plays in orchestrating the whole childbearing process, and why we shouldn’t disrupt this elegant process without clear medical reasons. If we teachers and other birth workers incorporate this information in our practices and in our teaching, outcomes will improve.

“Hormonal Physiology of Childbearing” is surely the most extensive search ever done on this topic, and is a solid guide to learning this crucial information. Encyclopedic in its scope, and multi-layered in its depth, this book will be most useful as a reference text, rather than a book to read straight through. It is pretty dense reading, but when you have a question relating to reproductive physiology or the effects of interventions, you can search for well-explained answers. The evidence-based conclusions that Sarah Buckley has synthesized from an abundance of research (1141 references!) are authoritative and must be made accessible. This is truly “State of the Science” on Hormonal Physiology of Childbearing.

Conclusion

Typical maternity care today has departed so far from physiology that in many cases it causes more harm than good, as borne out by Dr. Buckley’s discussions throughout the book of the impact (i.e., unintended consequences) of common maternity care practices on hormonal physiology and mother-baby outcomes. Our job is to inform expectant parents of these things and help them translate information into preparedness and confident participation in their care. If we do our job well, our students will want to support, protect, and participate in the physiological process, which has yet to be improved upon. Parents and their babies will benefit! Our thanks should go out to Sarah Buckley and to Childbirth Connection for bringing this gift to us.

In conclusion, Sarah Buckley’s “Hormonal Physiology of Childbearing” is an impressive exploration of the major hormonal influences underlying all aspects of the labor and birth process. As we understand and incorporate the knowledge included in the book, the birth process will become safer, with effects lasting over the life span.

References 

American College of Obstetricians and Gynecologists and Society of Maternal-Fetal Medicine, 2014. Safe Prevention of the Primary Cesarean Delivery. Obstetric Care Consensus Number 1. Obstet Gynecol ;123:693–711.

Buckley S. Ecstatic Birth. Nature’s Hormonal Blueprint for Labor. 2010. www.sarahbuckley.com

Buckley S. 2009, Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and Gentle Early Parenting Choices. Celestial Arts, Berkeley

Buckley S. 2015. Hormonal Physiology of Childbearing: Evidence and Implications for Women, Babies and Maternity Care. Childbirth Connection, New York

Science & Environmental Health Network. 1998. Wingspread Conference on the Precautionary Principle. Accessed Jan. 8, 2015, https://www.google.com/search?q=The+Precautionary+Principle&ie=utf-8&oe=utf-8.

Simkin P. 2013, Events of Late Pregnancy. Childbirth Education Handout and Slide Penny Simkin, Inc. Seattle. https://www.pennysimkin.com/events-powerpoint

About Penny Simkin

penny_simkinPenny Simkin is a physical therapist who has specialized in childbirth education and labor support since 1968. She estimates she has prepared over 13,000 women, couples and siblings for childbirth, and has assisted hundreds of women or couples through childbirth as a doula. She has produced several birth-related films and is the author of many books and articles on birth for both parents and professionals. Her books include The Labor Progress Handbook (2011), with Ruth Ancheta, The Birth Partner (2013), and When Survivors Give Birth: Understanding and Healing the Effects of Early Sexual Abuse of Childbearing Women (2004), with Phyllis Klaus. Penny and her husband have four adult children and eight grandchildren. Penny can be reached through her website.

 

Babies, Breastfeeding, Cesarean Birth, Childbirth Education, Guest Posts, Healthy Birth Practices, Infant Attachment, Maternity Care, Medical Interventions, New Research, Newborns, Uncategorized , , , , ,

New Series: “BABE”- Brilliant Activities for Birth Educators! “Got Oxytocin?”

January 9th, 2015 by avatar

By Kyndal May, MFA, LMP, CD(DONA), BDT(DONA), LCCE

Today on Science & Sensibility, we start a new series on teaching ideas and techniques for you to use in your birth classes. The BABE series (Brilliant Activities for Birth Educators) will bring you exciting and innovative methods to teach the topics normally covered in a Lamaze CBE series. We will be highlighting a variety of childbirth educators as they share some of their favorite activities from their classes.  Today, we welcome Kyndal May, a childbirth educator in Boise, ID, as she shares how she covers the hormones of birth, and the role of oxytocin.  Do you have a creative method of teaching a CB topic?  Let me know via email, and we can connect about sharing in a future BABE blog post!  Everyone loves to learn new ideas and refresh their class activities.  I would love to hear from you.- Sharon Muza, Community Manager, Science & Sensibility.

© Kyndal May

© Kyndal May

This past September, I was among many doulas and childbirth educators lucky to attend Sarah Buckley’s session on The Hormonal Physiology of Childbearing at the Lamaze International/DONA International Confluence in Kansas City, MO. Following Dr. Buckley’s U.S. tour of her Undisturbing Birth Workshops, I suspect many childbirth educators may be revisiting the way we approach and explore the topic of the hormones of labor in our classes.  After viewing her DVD, Undisturbed Birth: the Science and the Wisdom, I am currently working to adapt both my childbirth classes and my birth doula workshops to incorporate this information in a new way.

While I play with what that will look like and how best to make that learning both powerful and playful, I’ll share how I have long taught about the hormones of labor –with a focus on oxytocin and a few activities (both past and present) that make it meaningful and fun.

Like everything in my classes, both content and my facilitation style is constantly changing based on what I am reading at the time, what I am witnessing in births, and the dynamics of the group. My students’ interactions and participation bring so much to the experience that they unknowingly contribute (often month to month) to what stays and what gets tossed.

I doubt that I am that different from other passionate childbirth educators who tend to see life through a “birth lens” if you will, meaning that very often, what I see, hear, and experience goes through the “how does this relate to birth?” or “could I tweak this to be a teaching tool?” filter in my brain. So, in 2009, when I saw t-shirts with messages like “I love my midwife” and “My midwife helped me out,” I immediately starting thinking of a t-shirt message I could use in my class and quickly put in a custom order for my “Got Oxytocin?” t-shirt.

© Kyndal May

© Kyndal May

I wore this t-shirt under another shirt through the first half of class one but I wait to show it to the class until we have explored the role of oxytocin in relation to birth. For example, oxytocin as a smooth muscle contractor – the perfect lead-in to discovering the unique structure of the myometrial musculature and watching as moms and their partners come to appreciate the uterine muscle and its work in labor in a new and meaningful way; oxytocin as ejection reflex initiator – the perfect lead-in to discussing oxytocin’s role both in the second stage and in orgasm and watching the connections made by each couple as they realize the essential environmental commonalities between the two and the need for a safe, private space for both.

At this point, orgasm becomes the perfect lead-in for understanding the role of beta-endorphins — as pain-suppressant and pleasure/transcendence producer — through a brief lesson on the etymology of the word (sometimes using smart phones).

Endorphin

With a consensus regarding the pleasure of orgasm and the pulsating rhythm of labor, everyone would very much like to know how to avoid inhibiting that process. So, epinephrine and norepinephrine become the perfect lead-in to receptors and …a short detour actually, to the brain, where we acknowledge the differences between a “typical male” and “typical female” brain through the perspective of the adolescent brain, in particular. Here, we compare the fight or flight response to ‘tending and befriending’ and what that can look like in different settings.

Throughout this process, we pause so that each couple can answer a few questions together and privately identify their own unique styles of co-creating an oxytocin-rich environment in their day-to-day living and connect it to their mutual vision of a safe birthing space.

Sound complex? It is – as complex as the interactions of these hormones, but just as rewarding and very fun. At this point, we take a break and when we come back together, I am sporting my “got oxytocin?” t-shirt for all the class to see.

As we turn our attention to how oxytocin and its partnering hormones set up both mother and baby for a thriving start together in the postpartum period, I pass out plain, white baby t-shirts to each couple. I invite them to take them home and design their own “Got Oxytocin?” baby t-shirt. I ask them to create it as if the baby was asking the question of everyone who comes into the birthing space.

© Kyndal May

© Kyndal May

My intention is to have them continue to think about oxytocin’s value in labor; to remember how it interacts with and is inhibited by the other hormones and how they might best co-create a space that supports the free-flow of the hormone. And most of all, because their canvas is the baby t-shirt, they are mindful how it benefits not only the mother but also the baby.

Each time I have used this activity, the response has been very positive. The first time, it was met with surprising enthusiasm and every couple chose to participate. Two weeks later, they returned with their amazingly creative t-shirts using everything from paint, to iron-on transfers, crochet to tie-die. One couple even reconstructed their t-shirt into a bowling shirt complete with buttons, color panels, collar and nametag. It was clear all of them not only enjoyed the activity, they enjoyed doing it together as a couple. A few commented that the activity provoked them to imagine their baby’s personality.

At least one couple took their baby t-shirt to their birth as a reminder to everyone who entered to support their efforts to create a safe and private birth space. Many couples commented how meaningful it was to them to have the t-shirt as a memento from the class in their baby book.

It has been a while since I have done this kind of an activity in class, but a new idea came to me last year. As we approached the holiday season, it seemed the perfect time of year to try it out.

© Kyndal May

© Kyndal May

At the end of class one, I handed each couple 2 clear plastic tree ornaments – one round and one in the shape of a heart. These ornaments can be opened and filled with paint, confetti or, in the case of the photo here, a piece of paper with some writing on it. I asked each couple to think of some way they might represent oxytocin or what oxytocin means to them and put it into the ornament. The objective is to work together to identify what is especially oxytocin producing for them. Once they do that, they’ll find a creative way to represent it and put it in the ornament that will then become their personal “mistletoe”.

They are invited to hang their “oxytocin ornament” and each time they walk under it, it will remind them to stop and spend a little time in an embrace — which we know, if they will hold for 10 seconds or more and do it 8 times a day, is a wonderful way to increase their own oxytocin levels.

Ornament music

© Kyndal May

This first group brought their oxytocin ornaments back and I had just a moment to photograph just a couple at the break. The first one is filled with berries that represent gooseberries for the couple who met a health store called “Gooseberries.”
Another couple filled theirs with sheet music as each of them is very musical and plan to use music as a comfort measure in their birth. One couple filled their ornament with small birthday candles to represent candlelit moments and another filled theirs with layers of colored cake decorations – each color representing something about their relationship. Overall, the project was met with positive interest and one couple said they enjoyed it so much they found themselves giggling through the process which became a very playful experience them.

Early in my teaching career one of the moms in class brought a gift to give everyone at the closing class of the session.   She told us all, “The way Kyndal talked about oxytocin, I just felt it was a ‘wonder-product’. It can contract the uterus and bring milk down, it can bond people to each other and more…maybe even get stains out of the carpet. So, I thought everyone should have their own bottle of oxytocin.” She passed out massage oil in tiny bottles with a label claiming the contents to be “oxytocin” and thus began an long tradition of sending each couple home with their own personal bottle of “oxytocin”.

I have since shifted my parting gifts but I revisit that one now and again as it was a long-running favorite. You can see more of the “Got Oxytocin” baby t-shirts by visiting my site.

Maybe you would like to incorporate some of the ideas listed here in your childbirth classes as you cover the hormones of labor.  If you do, please consider coming back to Science & Sensibility and sharing how it goes.  We’d love to hear from you. – SM

About Kyndal May 

© Kyndal May

© Kyndal May

Kyndal May, MFA, LMP, CD(DONA), BDT(DONA), LCCE, is a storyteller and facilitator; a confidence and commUnity builder for expectant parents, doulas and childbirth educators. She has been an active, private practice childbirth professional since 1995. Teaching her own curriculum, first in Seattle, WA and now in Boise, ID, she has well over 2000 hours of teaching experience and has attended nearly 300 births. A Licensed Massage Practitioner, she incorporates her background in bodywork and movement into her classes to facilitate awareness and help her students discover their own way to labor and birth. She refers to her Confident Birthing Childbirth Class as an ‘informed choice’ class and her unique education platform is used by educators in the United States and abroad.

She is a Lamaze Certified Childbirth Educator, a DONA Certified Birth Doula and Birth Doula Trainer offering advanced doula trainings in loss and communication. She serves as the consumer member of the Idaho State Board of Midwifery and on the DONA International Board of Directors as the Western Pacific US Regional Director.

Kyndal’s photography has been published in The Essential Homebirth Guide, Birth Ambassadors: Doulas and the Re-emergence of Woman Supported Childbirth in the United StatesA frequent speaker at professional conferences, her session, The Doula’s Field Guide to Birth Photography is available online through DONA International’s webinar series. To view more of her birth photography, visit her website at: www.kyndalmay.com

Babies, Childbirth Education, Guest Posts, Infant Attachment, Newborns, Series: BABE - Brilliant Activities for Birth Educators, Uncategorized , , , , , , ,

Series: On the “Independent Track” to Becoming a Lamaze Trainer

December 2nd, 2014 by avatar

By Jessica English, LCCE, FACCE, CD/BDT(DONA)

Last month, LCCE Jessica English began the path to become an independent trainer with Lamaze International, as part of the just opened “Independent Track”  trainer program.  This new program helps qualified individuals become Lamaze trainers – able to offer Lamaze childbirth educator trainings which is one step on the path for LCCE certification.  She’s agreed to share her trainer journey with us in a series of blog posts; “On the Independent Track to Becoming a Lamaze Trainer”, offering insights at key milestones in the process. If this is a program you are interested in, look for information in 2015 on how to apply for the 2015 cohort.- Sharon Muza, Science & Sensibility Community Manager.

When I first saw the invitation to apply to become an independent trainer with Lamaze International, my heart leapt! As a doula trainer, I’d long wanted to extend my training work to include childbirth educators but I’d heard the process to become a Lamaze trainer was complicated. The announcement that landed in my inbox said that there was a new, simplified pathway to becoming an independent Lamaze trainer. As I prepared to launch a new business venture that included many facets of my skill set: DONA birth doula trainings, childbirth classes, business training/coaching sessions and more, it seemed so clear that becoming a Lamaze trainer fit right in with my path. Yes! Count me in!

© Tanya Strusberg

© Tanya Strusberg

I was “in” wholeheartedly, but I still needed to apply and be approved. The application asked about our qualifications and our vision for a Lamaze program. Several days before the application deadline, Laura Ruth in the Lamaze office told me that they’d already received a lot of applications. My nerves set it! The closer the deadline came, the surer I was that becoming a Lamaze trainer was the right path for me; I hoped the review committee would agree.

The wait to hear back was blessedly short. Less than a week after I submitted my application, I heard back from Lamaze International that I’d been approved as part of the first cohort of independent track trainers. How exciting! I immediately started laying plans to travel to Washington, D.C. for the “train the trainer” session, praying that my November doula clients would either have their babies before I left or wait for my return. I also needed a sub to teach my own Thursday night childbirth class.

Thankfully, three babies came in nine days, I found a fantastic sub, and I headed to D.C. with a clear calendar. (Thank you for aligning, birthy stars!) I arrived Wednesday night and met my roommate, Trena Gallant from Halifax, Nova Scotia. Before our official training ever began, our informal education started with the opportunity to share stories and techniques as experienced educators and (doula) trainers. My LCCE heart was already bursting!

I’d been curious from the beginning about who would be in the training, and it was fun to watch the room fill Thursday morning. Several of my fellow DONA-approved birth doula trainers were in the group, there were a handful of other folks whose names I recognized, and I saw a few new faces. The 12 of us hailed from the United States, Canada and even Australia. Everyone participating in the training was an experienced educator, and we had several accomplished Lamaze trainers and leaders in the room to help guide us as well. I was excited know we’d have the chance to connect throughout the weekend.

The morning began with ice breakers and climate setters with our experienced facilitator, Tom Leonhardt. Once we all felt comfortable together, we dove into the science of adult learning. Even as an experienced educator and trainer, I enjoyed the chance to reanalyze how adults learn. One of the things that I love about Lamaze International is its emphasis on evidence-based information, and this training was no different. There’s great science on adult learning, and Lamaze ensures that your trainers understand how to use that science to help new educators create great classes. I appreciated that the training itself was highly interactive – implementing the same proven techniques we were discussing. I picked up some new ideas and other information was reinforced. I was able to explore my own teaching style and its strengths and weaknesses. An expert facilitator, Tom guided us and brought us back to task when we ventured just a little too far down an occasional rabbit hole.

Saturday was spent on additional teaching analysis and introduction of the primary objectives for our Lamaze curricula. Another reason I adore Lamaze is that they lay down core objectives for educators and then allow each LCCE to teach in his or her own way. I discovered that the trainer process was similar. Each trainer will complete a needs assessment for her community, region or country. We are tasked with using a planning table to detail content for each objective, then listing our teaching techniques and evidence-based resources. In part because all Lamaze International training seminars qualify for nursing contact hours, the process of getting your training program accredited is rigorous – just another reason that Lamaze is the gold standard in our field! I could see the work ahead.

On Saturday afternoon we broke into pairs and developed an assigned training module. Each team delivered its 20-minute teaching session beginning Sunday morning. My partner and I volunteered to present first, which allowed us to fully enjoy the rest of the presentations without any thoughts about our own session. What a delight to watch so many incredible educators work their magic! I think we all picked up techniques and language from one another. We reminded ourselves again and again that we were training educators and not parents. That was an interesting shift, as we’ve all been teaching families for years or even decades. We glowed with the praise from our peers and humbled ourselves to received constructive feedback on what could have gone better. What an excellent model for us to follow as we prepare others to teach!

Saturday ended with an exploration of best practices in dealing with challenging participants. I love that Lamaze International wants us to explore these issues with new instructors! Being a great childbirth educator is about so much more than just understanding birth. The science and art of teaching are critically important to our work and Lamaze International is devoted to helping to build truly great teachers around the world.

As I said goodbye to my new colleagues Monday afternoon and wound my way through a weather-challenged journey home, my thoughts turned to next steps. As my new venture- Heart | Soul | Business ramps up, I’m carving out time to work on my Lamaze curriculum. Branding and marketing are on my mind as I solidify plans to combine birth doula workshops, childbirth educator seminars and advanced business trainings to help other birth workers thrive in this heart-centered work. My background is in marketing, public relations and business administration, so that trifecta of trainings feels like the perfect combination!

A variety of questions remain for me. Which cities need childbirth educator, doula and business trainings? How can I help to even further distinguish the Lamaze name in an increasingly crowded marketplace? What are the pieces of a kick-butt curriculum that will help grow strong, confident educators who can make a difference in diverse communities and in their own unique styles? What will it be like to work on that curriculum with Lamaze International’s amazing lead nurse planner, Susan Givens? I’m strongly committed to continuing to teach families and attend births in my home community, but how will those commitments balance with an increased travel schedule?

Stay tuned, friends. I’m diving in and I’m excited to have you along for the journey.

About Jessica English

jessica english head shotJessica English, LCCE, FACCE, CD/BDT(DONA), is the founder of Heart | Soul | Business. A former marketing and PR executive, she owns Birth Kalamazoo, a thriving doula and childbirth education agency in Southwest Michigan. Jessica trains birth doulas and (soon!) Lamaze childbirth educators, as well as offering heart-centered business-building workshops for all birth professionals.

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Exclusive Q&A with Rebecca Dekker on Evidence for Inducing Labor if the Water Breaks (PROM)

November 20th, 2014 by avatar

Today on Evidence Based Birth, occasional contributor Rebecca Dekker, Phd, RN, APRN, provides a comprehensive research review – What is the Evidence for Inducing Labor if Your Water Breaks at Term?  When membranes are released at term, before a woman is in labor, this is referred to as premature rupture of membranes, or “PROM”.  There does not seem to be a consistent agreement amongst doctors and midwives on what is the appropriate protocol for women who experience PROM.  Rebecca examines the research and helps us (and the families we work with) to understand what might be acceptable options when PROM occurs.  I had a chance to preview the article and ask Rebecca some additional questions that I had.  Her review article along with the questions/answers here can help you to provide the families you work with an update of the most accurate information available. What are you currently sharing with patients, clients and students about best practice around PROM?  What are you seeing in your communities?  Will this information change what you are saying? – Sharon Muza, Science & Sensibility Community Manager.

CLOSEDSharon Muza: What approach do you suggest women and families take in discussing this scenario (PROM) with their health care providers both prenatally and in the moment if PROM should occur?  How can they assure themselves that they will receive evidence based care in either situation?

Rebecca Dekker: Given that one in ten women who give birth at term will experience premature rupture of membranes (PROM), it is important to talk with your health care provider ahead of time about what their recommendation is for PROM that happens at term.

Evidence suggests that in women who meet certain criteria, both waiting for labor to start on its own and inducing labor immediately are evidence-based options. If you hear things like, “You must” do this or “You’re not allowed” to do this in relation to PROM, and those recommendations don’t line up with the evidence, then you may want to seek a second opinion before you go into labor!

Similarly, if you find out that your birth setting has strict requirements for giving birth after PROM (for example, you MUST give birth within 24 hours or you’re required to have a Cesarean, or we NEVER induce for PROM even if it takes you a week to go into labor), then you may want to look into a different birth setting.

The best-laid birth plans are often sidelined by PROM. If you are facing strict rules—either by your provider or hospital—that do not take into account your individual clinical situation, preferences, values, and goals, then you might face pressure to conform to their policies, procedures, or standard practices.

On the other hand, if you know you have a trustworthy care provider and birth setting who will provide you with accurate, evidence-based information about your options, and actively elicit and respect your preferences, then experiencing PROM does not have to be a bad thing!

SM:  Women are often told that a “sterile speculum exam” does not increase their risk of infection after PROM.  What would you say to this?

RD: We found limited evidence that a “sterile speculum exam” does not introduce extra bacteria to the cervix. In one small research study, five women had two sterile speculum exams, and their cervixes were swabbed to check for bacteria after each exam. There was no increase in bacteria on the cervix after the second speculum exam (Imseis et al., 1999).

In contrast, when they swabbed the cervix before and after a digital vaginal exam done with sterile gloves, they found a doubling in the number of types of bacteria on the cervix after the exam. There was also an increase in the growth of bacteria when they cultured the post-exam swab.

So for some reason, vaginal exams using sterile gloves are more harmful than exams using a sterile speculum. The researchers did not say why this might be, but my guess is that perhaps it has to do with the fact that the speculum is made out of a material that does not easily transfer bacteria.

Here’s a funny story for you—when our Evidence Based Birth retreat team was working on the literature search for PROM, we were talking through the whole problem with vaginal exams and the increased risk for infection. One of the clinicians on our team wisely pointed out that it’s not that the gloves are dirty (they’re supposed to be sterile)—it’s that the sterile gloved hand is touching the outside of the vagina and then those germs are delivered by the glove to the cervix. One of us called it the “hostile vagina” syndrome. That term made us laugh really hard.

But in the end, we decided that women’s vaginas aren’t really hostile (and we’re tired of people blaming childbirth problems on women’s bodies!)—it’s that clinicians are using their sterile gloved hands to push bacteria from the lower vagina up to the cervix. Instead of calling it a hostile vagina problem, let’s call it a hostile exam problem!

SM: While conducting your research, did you come across any information that mothers with malpositioned babies were more likely to experience PROM?  How about more PROM during a storm with an extremely low barometric pressure in place?

RD: After an extensive search, we could not find any research that directly looked at the relationship between posterior-positioned babies and the risk of PROM. I did find this book written by Johns Hopkins Medical Center in 1916, where they mentioned anecdotes about posterior babies and PROM. There was also one paper published in 1994 that found 21% of mothers with persistent posterior-positioned babies started labor with PROM. But we have very little evidence to go on here, so not sure if we can say with any certainty whether there is a relationship or not.

There is very little evidence on the topic of PROM during storms with low barometric pressure. This relationship is theoretically possible, but the evidence is limited. I found two studies that found a correlation between low barometric pressure and PROM—however, both of these studies were limited by retrospective (looking backwards in time) designs (Akutagawa et al., 2007; Polansky et al. 1985).

I’m not sure if the barometric pressure relationship with PROM has any clinical relevance, though—what are we going to tell women? Avoid storms at the end of pregnancy?

SM: You wrote that researchers found that 8-10% of women will have PROM, but anecdotally, many HCPs, doulas, CBEs etc., state that it happens more frequently than that.  Do you think it could be higher than the 10% stated, and why do you think experiences do not align with the research?

RD: The reference that most people point to for the one in ten number comes from a really interesting paper published by Gunn et al. in 1970. In this article, they reviewed all of the previous studies on PROM, and they also looked at the rate of PROM in their own institution. Gunn et al. found that previous researchers reported incidences of 2.7% to 17%, with most incidences falling between 7% and 12%. In their own review of medical records at UCLA during a ten year period (1956-1966), they found an overall PROM rate of 10.7%. This rate included preterm and term births, and they defined PROM as the water spontaneously breaking any time before the start of labor.

In the Evidence Based Birth blog article on PROM, we spent a lot of time discussing the known risk factors for PROM. You have to take into account the fact that this 10% is an average, and it may fluctuate depending on risk factors. For example, if you live in an area where most clinicians are doing weekly prenatal vaginal exams starting at 36-37 weeks and routinely stripping the membranes, then you are probably going to see a higher rate of term PROM.

SM: If you could design a study that wanted to determine the best practice for PROM, how would you go about it?

RD: I actually think that the Hannah (1996) TermPROM study was really well designed (with a few exceptions that would need to be changed), and future researchers can learn a lot of lessons from how they went about looking at induction versus expectant management.

If we were going to conduct another study, it would obviously need to use modern protocols for Group B Strep screening, and a better definition of chorioamnionitis.  We also don’t know what would happen if care providers kept their hands out of the vagina—one-third of women in the Hannah study had vaginal exams right away when they entered the study. So making it part of the study protocol to keep those hands out of the vagina at the beginning would be important.

I would also like to see this topic studied in various settings with both low and high Cesarean rates. The Hannah study took place in countries and hospitals where the C-section rates seemed to be pretty low overall—about 15% for first-time moms—which isn’t great, but it’s much lower than the one in four primary Cesarean rate we have in the U.S. It’s quite possible that the Hannah findings about Cesarean rates are NOT generalizable to the U.S. and other countries where Cesarean rates are very high.

Finally, I would love to see a secondary data analysis from the AABC Birth Center study about outcomes from women who gave birth in U.S. birth centers after experiencing PROM. This would not be a randomized trial of course, but it could give us really great information about the general rate of complications women might experience if they give birth in a low-intervention setting with PROM.

SM: In the research you examined, is there any information about women who had PROM in a previous pregnancy more likely to have it again?  (i.e., is this just how labor starts in general for those women.) 

RD: In the studies that we did review, I did not find  any research about this topic.

SM: Given that the risk of a prolapsed cord is around or less than 1%, (and some risk factors make that more likely: breech baby, SGA, preterm, multiples, polyhydramnios for example) what should women consider when they are told by their HCPs to come in immediately after PROM, even when there are no contractions and labor has not yet started.  (I am assuming that is why they are told to come in immediately, even though prolapsed cord would be an obstetrical emergency, not a “head this way now” thing.)

RD: I would recommend finding out more information about your care provider’s intentions and treatment protocols. Prolapsed cord is really rare (reported range with PROM is 0.3% to 0.6% per Gunn et al.’s 1970 extensive review of the literature) and it’s an immediate, life-threatening emergency for the baby, so if they are saying, “You can take a shower, but then you need come to the hospital,” then that can’t be what they are worried about.

As a mother, I would want to know, “Why do you want me to come in immediately? And what are you going to do when I get there? Are there medical reasons (such as GBS) that I need to come in for right away?” Are they just going to verify that the water is broken with a sterile speculum exam and do a quick check with the monitor to make sure baby is doing okay? Are antibiotics indicated? Will the mother be given the choice of induction versus expectant management, and be told that if she wants to, she can wait for labor to begin either at the hospital or at home? Or are they going to insist that she start the induction process as quickly as possible? This is where it is really helpful to know the standard procedure that is practiced in your birth setting, and how rigid their protocols are.

Looking at the evidence that we have available to us, it seems that waiting 6 to 12, or maybe 24 even hours at home for labor to start is probably not going to be harmful—as long as the mom is GBS negative, the fluid is clear, and she is monitoring her temperature and baby’s movements. It is also certainly evidence-based to go in and get evaluated (after all, that was the protocol in the Hannah and Pintucci studies that have given us evidence on the safety of waiting).

It’s best if you figure this out ahead of time—before you experience PROM. It takes honest and careful communication with your care provider, and that discussion simply has to take into account your own personal situation, risk factors for infection, and preferences. It’s so important to find a care provider you can trust, consult with them, and ask their opinion about any information or research you have uncovered. Have open discussions about the evidence with whomever you have hired to take care of you, but find a trustworthy care provider! I can’t emphasize that enough.

ImprovingBirth.org just launched a really great article about how to find care you can trust, and I highly recommend reading it!

SM: Have you read anything about the amniotic membranes being able to reclose after breaking?  I have heard that sometimes if there is a high leak they will “repair” themselves?

RD: Yes, this is possible. In the Gunn et al. (1970) literature review, they referenced studies from the 1950s and 1960s claiming that a break can happen in the membranes in an area above the lower uterine segment. The break can then re-seal itself so that no more fluid loss occurs.

Then in 2006, Devlieger et al. published a review of the literature in the American Journal of Obstetrics and Gynecology on the topic of membrane healing. If you’re interested in this topic, I would recommend reviewing their article, although it mostly focuses on the possibility of resealing the membranes after preterm premature rupture of membranes (not term PROM).

SM: For all the childbirth educators reading this post – what key points should they be sure to cover during class to help their families feel prepared if PROM should happen to them?

RD: Evidence shows that in women who meet certain criteria (single baby, head-first position, clear fluid, no fever or signs of infection in mother or baby, negative Group B Strep test), waiting for labor to start on its own for up to 2-3 days is as safe for the baby as inducing labor right away, although the mother is more likely to get an infection herself. In other words, both inducing labor and waiting for labor are evidence-based options. Families need to know that their preferences and values matter in this situation, and if they are in a setting where the care provider has strict rules that “must” be followed, their preferences might not be honored.

However, you have to keep in mind that as always, there are caveats with the information about the safety of waiting for labor to begin. In the most recent study that we have (Pintucci et al., 2014) showing great outcomes with waiting for labor to begin on its own, women did their waiting in the hospital, and started antibiotics at 24 hours. In the Hannah et al. (1996) TermPROM study, women in the “expectant management” arm of the study came to the hospital first, were assessed and had a non-stress test, and then were given the choice to go home and monitor their temperature there, or stay in the hospital to wait for labor to begin.

Finally, probably the single most important thing that women need to know is to not let people put hands up your vagina after your water breaks! That is the single most important risk factor for infection, and hands need to be kept out as much as possible. A vaginal exam when your water first breaks with PROM is not necessary, and is probably harmful, and can cause infection in you and your baby. Sterile speculum exams are probably okay.

The more vaginal exams you have after PROM, the higher your risk of infection. Keep all hands out!!

SM: Anything else you would like to add or include as a follow up to your informative article?

I want to publicly thank Alicia Breakey, a brilliant PhD candidate from Harvard who is about to graduate very soon (and is looking for a position in maternal health!). Alicia served as first-author on this blog article, and I really couldn’t have published it without her diligent help. I’d also like to thank our clinician expert, Angela Reidner, MSN, CNM, who was also a co-author with us.

Photo source: By Saltanat ebli (Own work) 

References

Akutagawa, O., Nishi, H., & Isaka, K. (2007). Spontaneous delivery is related to barometric pressure. Archives of gynecology and obstetrics275(4), 249-254.

Devlieger, R., Millar, L. K., Bryant-Greenwood, G., Lewi, L., & Deprest, J. A. (2006). Fetal membrane healing after spontaneous and iatrogenic membrane rupture: a review of current evidence. American journal of obstetrics and gynecology195(6), 1512-1520.

Gardberg, M., & Tuppurainen, M. (1994). Persistent occiput posterior presentation-a clinical problem. Acta obstetricia et gynecologica Scandinavica,73(1), 45-47.

Gunn, G. C., Mishell, D. R., & Morton, D. G. (1970). Premature rupture of the fetal membranes. Am J Obstet Gynecol106(3), 469-483.

Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., … & Willan, A. R. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. New England Journal of Medicine334(16), 1005-1010.

Imseis, H. M., Trout, W. C., & Gabbe, S. G. (1999). The microbiologic effect of digital cervical examination. American journal of obstetrics and gynecology,180(3), 578-580.

Pintucci, A., Meregalli, V., Colombo, P., & Fiorilli, A. (2014). Premature rupture of membranes at term in low risk women: how long should we wait in the “latent phase”?. Journal of perinatal medicine42(2), 189-196.

Polansky, G. H., Varner, M. W., & O’Gorman, T. (1985). Premature rupture of the membranes and barometric pressure changes. The Journal of reproductive medicine30(3), 189-191.

Stapleton, S. R., Osborne, C., & Illuzzi, J. (2013). Outcomes of care in birth centers: demonstration of a durable model. Journal of Midwifery & Women’s Health58(1), 3-14.

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Looking Ahead to 2015 Conferences – Is Your Event Listed On Our Conference Calendar?

October 30th, 2014 by avatar
2014 conference

Sharon Muza & Jeanette McCulloch present@ Lamaze/DONA 2014

I just received, via email, my contact hour documentation from my attendance at the Lamaze International/DONA International Confluence that was held in Kansas City, MO this past September.  In addition to conferences being a wonderful place to network with colleagues, participate in engaging learning opportunities and travel and explore a new city, most conferences also offer the opportunity to be awarded the continuing education/contact hours that I need to maintain both my Lamaze certification and my DONA birth doula certification.  Both of these recertifications require renewal every three years, and I am working on my Lamaze recertification now, due by the end of December.

At the same time as I am closing out the 2014 year, I am looking at the available conferences scheduled for 2015, planning out my year, allocating both my financial resources and my available time.  I am going to be sure to plan on attending the Lamaze/ICEA Joint Conference scheduled for September 2015 in Las Vegas, NV.  I am looking for other opportunities as well!

Is your organization offering a conference or workshop that other birth professionals, including childbirth educators, doulas, nurses, midwives, physicians, lactation consultants, counselors, and others involved in maternal infant care would want to know about?  If so, please be sure to submit your organization’s event using our online submission form, so we can get it posted in our maternal health, birth, breastfeeding and postpartum conference schedule.

Take a look at what is listed now, check back regularly for new additions and start to plan what conferences are the ones that you don’t want to miss!  Let us know in the comments section what plans you have made for attending a 2015 conference. What looks exciting to you?

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