Wednesday, June 29, 2011

The 43 Year Active Management of Labor Project: What have we learned?

The concept of active management of labor is familiar to most maternity care professionals.  This concept was first demonstrated  at the National Maternity Hospital in Dublin Ireland in the late 1960s.

Defined, active management of labor includes two major components.  The first component is the Organizational Component, which many have stated is the most critical of the two.  The Organizational Component includes prenatal education (which includes patient/family education about the birth process and working with labor), daily physician assessment (assessing labor progress, supportive to patient throughout labor and during the postpartum period), bedside support (emotional and educational support at the bedside by staff), and peer reviews of outcomes (evaluate the effectiveness of the approach and possible process improvement).  The other component, the Medical Component, includes a rigid inclusion criteria (ensure only term, umcomplicated nulliparas are actively managed), strict diagnosis of labor (prevent hospital admission in early labor, decrease cesarean rate), early amniotomy (to assess volume and presence of meconium), frequent cervical exams (detect early dystocia and adequate process), and high-dose oxytocin (to correct dystocia with more effective contractions).  All of this with twelve hours believed to be the maximum safe duration of spontaneous labor.

Interestingly, epidural anesthesia is not a component of the active management of labor routine.  To compound this, there is some conflicting research as to the effect of epidural anesthesia on length of labor, depending on the source.  Over all,  it is well known in the literature that women who have inductions have longer labors and higher cesarean rates.

Taking a look at the state of US maternity care today, with pregnancy outcomes (specifically maternal morbidity/mortality and infant morbidity/mortality) not improving (in fact worsening) and the cesarean rate rising significantly since 1968, it is important to assess use of active management of labor prior to its efficacy.  Many birthing facilities and care providers use some of the components of active management of labor, however several items tend to be overlooked or forgotten in the implementation of the process ~ specifically, prenatal education, bedside emotional and physical support and rigid inclusion criteria.  Therefore, with these vital components not being included, any assessment of the efficacy of active management of labor would be incongruent.   Thus, active management of labor may be misunderstood by care providers and misapplied.

One only has to look as far as the Cochrane Database to obtain a summary of RCTs and evidence-based care.  No longer do we have an excuse that evidence-based maternity care continuing education opportunities are beyond reach.  And in this case, ignorance is not bliss.  Nor is it professional.  Expectant parents look to care providers to do just that ~ give care.  Our organizations charge us with providing best practice and quality care.  Conversations, albeit heated ones, exist about the best practice vs best price conundrum.  How dare we, as a society or as a country, put currency before the health of our women and children.  How can our conscience survive knowing that we compromise care, blaming it on "that's the way we've always done it", "that's what our policy says" or more acidic comments such as "if you don't do this, your baby will die" (when in fact, the baby will not die).

Our maternity care practices in the past 43 years have not yielded better results.  The outcry of those pleading for revolutionary change in maternity care are not those who are aggressive, uneducated radicals uncomfortable with 43 years of rituals.  Many are, in fact,  physicians, midwives, nurses, childbirth educators and doulas.  They are authors, speakers, researchers, university professors.

And they all are asking the same question: What have we learned?


Listening to Mothers I & II

Boylan, P.C. Active management of labor: results in Dublin, Houston, London, New Brunswick, Singapore and Valparaiso.  Birth 1989 16: 114-9.

Declercq, E. Macdorman M., Menacker F. Recent trends and patterns in cesarean and vaginal birth after cesarean (VBAC) Deliveries in the US.  Clinical Perinatology 2011 June 38(2) 179-92.

Declercq, E. Macdorman M. Zhang J. Obstetrical intervention and the singleton preterm birth rate in the US 1991-2006. American Journal of Public Health 2010 Nov 100(11) 2241-7.

Declercq, E. Macdorman M., Menacker F. Neonatal mortality risk for repeat cesarean compared to VBAC in the US 1998-2002 birth cohorts.  Maternal and Child Health Journal 2010 Mar 14(2) 147-54.

Florence DJ, Palmer, D. "Therapeutic choices for discomforts of labor" Journal of Perinatal and Neonatal Nursing 2003 Oct-Nov 17(4) 238-49

Impey L. Boylan P. Active management of labor revisited.  British Journal of Obstetrics and Gynecology. 1999 106:183-7.

James D.C. "Routine obstetrical interventions: research agenda for the next decade." Journal of Perinatal and Neonatal Nursing.  2011 Apr-Jun 25(2): 148-52

Wednesday, June 22, 2011

Nil Nocere

This post is actually a quote from Dutch professor of obstetrics G. Kloosterman:

Spontaneous labour in a normal woman is an event marked by a number of processes so complicated and so perfectly attuned to each other that any interference will only detract from the optimal character.  The only thing required from the bystanders is that they show respect for this awe-inspiring process by complying with the first rule of medicine - nil nocere [do no harm].

Kloosterman, G. (1982) "The universal aspects of childbirth: Human birth as a socio-psychosomatic paradigm" Journal of Psychosomatic Obstetrics and Gynecology 1(1) 35-41 page 40.

Monday, June 20, 2011

Free New App for Breastfeeding

Hot off the press is the new LactMed App for iPhones and Androids.

LactMed, part of the National Library of Medicine's (NLM) Toxicology Data Network (TOXNET®), is a database of drugs and other chemicals to which breastfeeding mothers may be exposed. It includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives are provided to those drugs where appropriate. 

All data are derived from the scientific literature and fully referenced. Data are organized into substance-specific records, which provide a summary of the pertinent reported information.

To download this App, go to the iTunes App Store or scan the QR code here below to learn more.

Tuesday, June 14, 2011

What if......we substituted Childbirth Educator for the word Anesthesiologist?

There was an article that was written recently about the disparity in understanding between maternity health care providers, focusing on anesthesiologist.  In playing with the word anesthesiologist, I wondered what the article would look like if I substituted the word childbirth educator or education.  Here's how it turned out.  What are your thoughts?


"Childbirth educators are pivotal in so many areas of the hospital, yet their work and expertise are not well understood, especially in labour and delivery settings," said Dr. XXXXXX, XXX Fellow at XXXX  Centre and resident physician at the University of XXXX and lead investigator of the study. "This study is the first-of-its-kind that explores specifically how childbirth educators and their labour and delivery colleagues perceive the childbirth educators role, and the potential impact of these perceptions on interprofessional dynamics and team collaboration in labour and delivery."

The study, co-supervised by Dr. xxx, vice-president of education at St. xxxas Hospital, and Dr. XXXXXXXXXXX  with the XXXXXX  Institute of xxxxx  Hospital and The xxxx Centre, was recently presented at the first International Conference on Faculty Development in the Health Professions in (city)  at  xxxxx  Hospital.

Health providers in the labour and delivery units at two urban teaching hospitals in Toronto were interviewed. Participants (ranging from midwives, nurses and obstetricians, as well as childbirth educators, all with different levels of experience) were asked a series of in-depth questions to determine their understanding of the childbirth educators's role during labour and delivery, the childbirth educators process, and the type and amount of education and training they had received around childbirth education management.

On analysis of the data, a number of important themes emerged: 
  • Lack of understanding of the complexity of the childbirth education process during labour and delivery. While midwives, nurses and obstetricians appreciated the role of their childbirth educator colleagues, particularly in the provision of labour pain relief and anesthetics for C-sections, many reported that their understanding of the actual process of childbirth education was limited.

  • Lack of training about childbirth education: Many nurses and midwives received little formal training about the childbirth education process in school or during their clinical placements. Similarly, most obstetricians had very little postgraduate exposure to formal childbirth education training. The study also revealed that opportunities for structured communication between all labour and delivery health professionals (ex. to discuss cases or to debrief after an adverse event) were infrequent and therefore, a missed opportunity for team learning and quality improvement. 
  • Childbirth educators’ membership in the labour and delivery 'team': Nurses, midwives, obstetricians and other members of the obstetrical team spend countless hours with the patient throughout the entire labouring process. In comparison, the study found that the childbirth educators had less involvement in decision-making processes, even when they could have had useful and important input into a patient's care. The study found that this misunderstanding and the often peripheral position of the childbirth educators on the team, led to isolation of the childbirth education s in their work, which had implications for effective communication, collaboration and the safe delivery of care. 
  • Imbalances and tensions between health professionals: The study found that some engrained stereotypes and historical tensions were present between different health professions. Instances of hesitation to question other professionals about decisions related to patient care were sometimes borne out of fear, or were due to inadequate training and knowledge. 
    "This study tells us that as
     health professionals, we have an immense amount of work to do in order to build a culture of true interprofessional teamwork and to provide the necessary training and supports to ensure that we deliver the best possible patient care, " .

World Breastfeeding Week 2011!

The theme of this year's World Breastfeeding Week is "Talk to Me! Breastfeeding a 3D Experience".  When we look at breastfeeding support, we tend to see it in two-dimensions: time (from pre-pregnancy to weaning) and place (the home, community, health care system, etc). But neither has much impact without a THIRD dimension – communication!

Every year, breastfeeding advocates and parents celebrate world wide Breastfeeding Week during August 1-7!
Even with global exclusive breastfeeding rates on the rise, the momentum to promote and continue to promote breastfeeding is a wise decision!

Read more.......

Monday, June 13, 2011

Healthy Babies Are Worth the Wait! New from March of Dimes

Another great resource for childbirth educators and doulas: the first educational stop on the pregnancy journey!

The March of Dimes' new campaign, Healthy Babies are Worth the Wait, informs health professionals and the public about the complications and health risks related to inducing a pregnant woman before 39 weeks gestation.

Through this new campaign, the March of Dimes aims to raise awareness among women and medical providers of the importance of having a full-term birth and allowing for natural labor, if possible.  

For more information and resources related the MOD’s 39 weeks campaign, visit:

Food Guide Pyramid --> My Plate!

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Out with the old Food Guide Pyramid and in with the new My Plate!

The USDA has created a more user friendly and easier to comprehend way of looking at our nutrition and have replaced the Food Guide Pyramid with the new My Plate graphic.  Designed to help everyone eat better and be healthier, the USDA have also added some great resources to add to your childbirth education class materials or doula client information!

Check it out ~

Daily Food Plan for Moms
Daily Food Planner/Tracker
Moms with Special Nutritional Needs: Allergies, etc.

While not as Baby Friendly as the Surgeon General would like, there is info on nutrition and breastfeeding:

Breastfeeding Nutrition

What about food safety?  Click here

Need more info about nutrition and pregnancy and breastfeeding?  They have great resources too!

Remember, it is NEVER too late to talk to your expectant clients about the impact of dietary changes on the development of their baby(s)!  Even if you begin interacting in the closing weeks of the third trimester, share the My Plate with them.  It may make a world of difference!

Follow up: FDA oks Birth Pools

The FDA has released birth  pools from "detention" and will continue their investigation. For right now, they are NOT classifying them as Medical Devices, which is best for midwifery community and all women seeking a non-medicated birth. 

~ Waterbirth Solutions

10 Simple Truths About Childbirth ~ #5

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Many people are followers and few are leaders.  This is true both in childbirth related organizations and society as a whole.  Not only does it apply to "politics" but also how birth is viewed.  

Birth is an organic, normal, natural and physiologic process.  Like other body functions, birth typically does not need intervention.  However, occasionally, like other body functions, intervention is fact necessary for positive outcomes.

Whatever your role in the birthing community ~ care provider or care receiver ~ think twice about being a sheeple....that is, following the crowd.  Doing what has always been done because it appears ok.  The reality is, at the end of the day...or at the cliff's edge, it may appear ok, but it may not be ok!  

Oh, and another thought.  Be careful whom you do follow.