Thursday, October 30, 2014

Has the Focus of Birth Professionals Changed?

In my humble opinion: 

Many people wonder why birth professionals (childbirth educators, doulas, midwives, nurses, lactation consultants) are so passionate about their profession.  Unlike other professions, childbirth (and breastfeeding) evoke great emotion and energy in many workers.  What is the underlying cause of this emotional energy and has it changed over the years?

I think it is safe to say that in the 1970s when I began teaching became a nurse and subsequently also became involved in childbirth education, the push of childbirth education was
to come along side women who desired less interventions and a more natural (or physiologic/non-interventive) childbirth.  Educators taught women that their gut feelings about physiologic birth were not wrong, what the evidence said, and gave them the tools to achieve that goal.  The empowerment of women in the 70s enabled educators to thrive and achieve those goals.

Somewhere in the mid-1980s, childbirth education relaxed the emotional energy expended and reaped the benefits of the past.  But in sitting back, this allowed a more interventive style of childbirth to emerge and then we were looking at the 1990s with an increase in epidurals, assistive deliveries (forceps and the miti-vacuum extractor), and an increase in cesarean rates.  By the 2000s, we tried to catch up and began movements such as “evidence based information” in childbirth education and later, in social media, but it was too late.  The perception that “drive thru” deliveries that were scheduled, induced, medicated and sometime surgical became the optimum.  Few were mindful of what all of this was doing to moms, babies and future generations.  Women just wanted the uncomfortable last 3 weeks of pregnancy to end, to hold their babies after little/no pain, and to get back to work.

Questions began to arise in 2010.  Why is the cesarean rate so high?  If women are designed physically to give birth, what is the reason for the 32.8%+ cesarean rate?  Why are only 33% of women attending childbirth education class?  What is the medication given during labor/birth doing to our mothers and babies?  Can we curb elective early birth – why don’t we wait the full 40 weeks?  Are future generations going to be affected by birth practices now?  Will women lose their gut instincts about labor and birth? Will women lose their physical ability to give birth (epigenetics)?

Many birth organizations such as AWHONN, ACNM, MANA, APPPAH, Lamaze and ICEA began asking these questions.  Forward thinkers such as Marsden Wagner and Michel Odent wrote landmark books explaining the research and forecasting the future.  Videos and movies such as “The Business of Being Born”, “Pregnant in America”, “Laboring Under An Illusion” and “Birth by the Numbers” allowed the public to be exposed to the questions we birth professionals were also asking.  And this year, “Microbirth”, put it all in perspective: if how we are born affects how our health manifests itself, we must take that as a mandate to let birth alone and allow humans to reach the potential for which they are destined.

The answer then, is yes – the focus of birth professional has changed.  We have gone from “freedom fighter” to someone “sounding the alarm”.  Birth is much more than having a mother choose her position during labor.  How we treat mothers and babies during pregnancy, labor, birth and the postpartum will forever change us as human beings.  It can be a change for the positive or the negative.  Right now, we are on a slippery slope to the negative. 

It is time for a change.

It is time for those of us who know the research, the facts, the truth – whatever you want to call it – to come together in one strong voice.  Does that mean we become the protectors of future generations?


Become informed.  You be the judge.

Friday, October 10, 2014

Conquering Tocophobia with Haptotherapy

Tocophobia or severe fear of childbirth is rising in frequency.  More than 6% of women, and some men, experience tocophobia during pregnancy.  This leads to an increase in obstetric interventions including preterm birth, emergency cesarean section, or cesarean section at maternal request.  Severe postpartum fear of childbirth and trauma anxiety has also been reported.

Studies, primarily in Europe, over the past decade demonstrate an increase in evidence that Haptotherapy might be effective in reducing fear of childbirth in pregnancy women.  What is Haptotherapy and is there a way childbirth educators can incorporate aspects into their classes?

Haptonomy is a typical Dutch form of therapeutic assistance therapy discovered by Dutch physiotherapist Frans Veldman, and first used in oncology.  Haptotherapy is the field of application of Haptonomy.  Haptonomy is being in connection with someone in a non-judgmental way.  Practitioners work to establish an environment of acceptance and calm, peace and tranquility so that the client can let go and begin trusting their own inner wisdom.  It involves listening, accepting, sharing.  In some instances, touch relaxation or simply holding hands leads to the calming of the client and activating their inner resources. The goal is for the client to develop inner security, self-awareness and self-confidence.

The most recent Dutch study is examining a standard haptotherapeutical treatment for pregnant women (and their partners)  with severe fear of childbirth, implies teaching a combination of skills in eight one hour sessions. The internet group follows an eight-week internet course containing information about pregnancy and childbirth comparable to childbirth classes. The control group has care as usual according to the standards of the Royal Dutch Organisation of Midwives and the Dutch Organization of Obstetrics and Gynaecology.


Included are singleton pregnant women with severe fear of childbirth, age >= 18 year, randomised into three arms: (1) treatment with haptotherapy, (2) internet psycho-education or (3) care as usual. The main study outcome is fear of childbirth. Measurements are taken at baseline in gestation week 20-24, directly after the intervention is completed in gestation week 36, six weeks postpartum and six months postpartum. Secondary study outcomes are distress, general anxiety, depression, somatization, social support, mother-child bonding, pregnancy and delivery complications, traumatic anxiety symptoms, duration of delivery, birth weight, and care satisfaction.

Sessions include a getting to know each other opportunity, awareness and presence in pregnancy, identification of cause of fear of childbirth,  desensitization of body anatomy as well as hospital procedures through education, practicing correct pushing techniques, working with contractions and dealing with labor pain, labor rehearsals, and finally introduction to birth of the placenta and first days postpartum.

Haptotherapy has dynamic similarities to childbirth education classes.  One might even call them “old school” childbirth education where educators had the time to take the time to listen to the clients and their partners and confront fears one by one.


They say you cannot go home again, but it looks like we are….with a different name.

Tuesday, September 30, 2014

Nitrous Oxide in Labor: Don’t Start Laughing Quite Yet


What do Australia, Canada, Finland, Sweden and the UK all have in common? 

They all have been using nitrous oxide N2O as a labor analgesia for years.  The results have been highly effective and safe.  

Why is it just arriving in the US for use in labor?

How N2O Works
Nitrous oxide works chemically to increase the release of endogenous opioid polypeptide compounds (also known as endorphins), corticotropins and dopamine in the mother’s brain.

The Pros

  • Nitrous oxide can be administered and discontinued easily.  The effects of the nitrous oxide are completely gone within five minutes.
  • Nitrous oxide is safe to use throughout labor and the Second Stage.  Studies are showing little or no adverse effects on the progress of labor, maternal health or fetal health.
  • Nitrous oxide is self-administered  (about 30-60 seconds prior to each contraction) which allows the laboring mother to decide when and how much she uses.
  • Lower cost and less invasive than epidural anesthesia or narcotic analgesia.
  • Positioning is not limited, except by length of hose that is attached to supply source.
  • Monitoring and anesthesia related interventions (such as bladder catheterization) not necessary.
  • Does not require the presence of an anesthesiologist for administration/monitoring.

The Cons

  • Nitrous oxide may cause some minor side effects such as nausea, drowsiness and dizziness.
  • Questionable risk of repeated occupational exposure by health care providers.
  • Room ventilation systems and scavenging systems must be in place to remove waste gases.
  • Insufficient data exists that focus on women’s satisfaction, route of birth, other maternal/infant side effects and health system factors affecting use.
  • Potential for increased problems with sedation and decreased maternal blood oxygen levels if used in combination with injected narcotics.
  • Concerns exist regarding immature fetal brains exposure to high doses of N2O. Unknown effects on alertness of newborns and their ability to interact with the new environment.
  • Hypothesis exists that children exposed to N2O during birth are more likely to become addicted to amphetamine drugs as adults.

There may still be research to do before we see N2O routinely in US hospitals.  But as far as analgesia/anesthesia goes, it is the most promising so far.

Video of Blender of N2O and oxygen:





References:


  1. ACNM Position Statement, Nitrous Oxide for Labor Analgesia.http://www.midwife.org/acnm/files/acnmlibrarydata/uploadfilename/000000000080/nitrous_oxide_12_09.pdf
  2. ACNM (2013) Nitrous Oxide for Pain Relief in Labor. Journal of Midwifery and Womens Health. 58(6): 727-728.http://onlinelibrary.wiley.com/doi/10.1111/jmwh.12103/pdf
  3. Agency for Healthcare Research and Quality Clearinghouse (2012) Nitrous Oxide for the Management of Labor Pain: Comparative Effectiveness Review Executive Summary No. 67.http://effectivehealthcare.ahrq.gov/ehc/products/260/1230/CER67_NitrousOxide_ExecutiveSummary_20120817.pdf

    Baysinger, C. American Society of Anesthesiologists: Nitrous Oxide for Labor Analgesia.https://www.asahq.org/For-Members/Clinical-Information/Nitrous-Oxide.aspx  
  4. Childbirth Connection. Labor Pain: Nitrous Oxide.http://www.childbirthconnection.org/article.asp?ck=10188
  5. Dammer, U. et al. (2014) Introduction of Inhaled Nitrous Oxide and Oxygen for Pain Management during Labour – Evaluation of Patients’ and Midwives’ Satisfaction. Geburtshilfe Frauenheilkd. 74(7): 656-660.  Free article: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4119100/?report=printable
  6. Rooks, J.P. (2011) Safety and risks of nitrous oxide labor analgesia: a review. Journal of Midwifery and Womens Health. Nov-Dec; 56(6): 557-65.
  7. Zuck, D. et al. (2012) Nitrous Oxide: Are you having a laugh? Royal Society of Chemistry: Education in Chemistry. March.http://www.rsc.org/images/Nitrous-oxide_tcm18-214047.pdf

Monday, September 29, 2014

Examining the Lack of Communication Regarding Evidence Based Information in Childbearing Women and their Care Providers.

A Facebook friend recently posted this question:

“What questions would you have of ACOG?”

It really caused my brain to begin working – what would I want them to know?  What would I ask them? Limit it to just a few, hard-hitting questions.  Don’t whine or play the victim.  Act like what I am, their colleague.  Sadly, the four questions that came to mind were the same questions I’ve been asking on this blog since its inception in 2007.  The first, however, was fueled by a situation experienced recently at a local hospital.

Question one:

Do you really believe that 40-70% of American women are unable to go into labor without dangerous medications such as Cytotec?

According to birth researcher Henci Goer, 40% (or more) American women are unable to go into labor without induction.  Or so the statistics would have us believe.  In many other communities, the rate of induction is higher than 40% and in some cases, nurses working labor/delivery have never cared for a mother who is having her baby without induction or augmentation.  All too frequently, physicians also have never cared for a mother who is having her baby without induction or augmentation.

Question two:

What is the cause of the rise in induction and augmentation? 

Childbirth Connection offers one explanation:
“A surprising number of women don't have accurate information about when it is safe for a baby to be born, if there is not a clear medical reason. When we asked women who had recently given birth in our national Listening to Mothers III survey, just 21% chose 39 weeks or beyond; 35% identified 37 or 38 weeks, considered an early term birth with known risks to babies. And 44% chose earlier weeks, considered to be preterm births.
Childbirth education classes that teach specific information about the risks, benefits, and appropriate uses of labor induction reduce the number of women having induced labor. However, attendance at childbirth education classes appears to be decreasing in the United States, and childbirth education classes are getting shorter, leaving less time to address this important topic.”

Question three:

How do you explain the horrific maternal/infant morbidity/mortality in the US?

American women of childbearing age are stuck in a vicious cycle.  With an increase in the number of interventions for birth and the non-evidence based statements and practices regarding aspects of normal physiologic birth, our rates are deplorable and horrific.  For a country as intelligent as it is, we continue to put our heads in the sand when it comes to the safety of our women and children.  The statistics do not lie.

Question four:

If our outcomes are not improving, why are interventions including cesareans escalating?

Simply, there is no Voice. 
No national Voice for childbearing women, and no national Voice for babies. At the risk of sounding like there is a “we” and “them” situation, there is definitely a power paradigm and the power needs to shift from convenience and finance to the health of mothers and babies. Women do not have their own voice because of lack of information, lack of education and lack of evidence-based information.  Best practice in the U.S., as defined in the research, has not permeated the hospital policies and procedures.  Nor has the best practice found its way into the curriculum of most nursing schools or medical schools.

In summary, we have a plethora of evidence-based information that would reduce NICU admissions, and improve the maternal/infant morbidity/mortality rate BUT no one is being informed of this information – not the childbearing women, not the hospital staff and not the physicians.


We have a huge failure to communicate.

Wednesday, September 24, 2014

The Birth By The Numbers Update!

Join Gene Declercq and the rest of the Birth by the Numbers team to explore how the United States is doing on a number of maternal and child health indicators. Are we doing better? Worse? Tune in to find out this answer and more!

These statistics are updated, as the video came out August 29, 2014.  Not only are the statistics - some good and some worse than 2008, but Declercq's humor is great.


Tuesday, September 23, 2014

2014 ICEA Conference: Post conference Wrapup

ICEA Pres. Nancy Lantz
Jeannette Schwartz's Skype
Interview with Toni Harmon
of "Microbirth"
Asheville North Carolina was the site of the 2014 ICEA Conference.  With the them of "Back to OuRoots", there was an emphasis on the history of childbirth and ICEA as well as a resurgence of importance on tools and techniques to reach all types of learners in all types of environments.

General Session speakers were Dr. Sarah Buckley, Dr. Pec Inman, Kathy Kendall-Tackett, Dr. Rob Strauss and Jeannette Schwartz, past ICEA President.  The breakout sessions were very hard to choose from with such topics as backwards curricula, using social media, eco friendly moms and babies, and techniques for teaching breastfeeding.

Dr. Sarah Buckley
Vonda Gates and ITP
Jenny Kozlow-Rodriguez
Set against the backdrop of the North Carolina hills and the architectural backdrop of the Biltmore Estate, there was no lack of extracurricular things to do.  On Wednesday evening, there was a reception at the hotel for all attendees and speakers.  Thursday evening saw many attendees travel to the Biltmore Estate for a lovely tour and dinner.  Friday evening was the traditional "President's Pajama Party", complete with a chocolate fountain!






Nicette Jukelevics 
Kathy Kendall-Tackett
& Myra Lowrie
Several new elements of ICEA were announced including the new Doula and Childbirth Education Program brochures, the new Early Lactation Care Program, the formation of the International Teaching Partners (ITP) with the first inductees (Sarah Hannibal, Jennifer Kozlow-Rodriguez, Dr. Meei-Ling Gau, and Dr. Chien Huei Kao), and the new VBAC Program (headed by cesarean and VBAC expert Nicette Jukelevics). Also the Online Doula Program, the new Position Papers, the Military Mother's Initiative and the updating of the Childbirth Education Program were highlighted.



ICEA is certainly moving forward, meeting the needs of the membership and looking for new ways to promote evidence based maternity care.  To this end, ICEA will join with Lamaze once again in a joint conference in 2015.  The theme of this joint conference: 
Raising the Stakes for Evidence-based Practices & Education in Childbirth
demonstrates the determination of both organizations for dynamic work towards making 
evidence-based maternity care the gold standard!