Monday, October 17, 2011

Dystocia: is there a gene for that?

On every birth professional's reading list should be Penny Simkin and Ruth Ancheta's updated and 3rd edition of The Labor Progress Handbook.

This new edition comes with even more information on the simplicity of birth, and common sense non-invasive methods to prevent or facilitate dystocia. Heavily referenced (new references have been added and others have been updated), this edition is a must have for childbirth educators who practice in the community or in a hospital setting!  Retaining the hallmark features of previous editions and meeting the needs of all types of learners, this book uses charts and  illustrations showing position, movements, and techniques and is logically organized to facilitate ease of use.  Two new chapters are included in this 3rd edition and include research based information on third and fourth stage labor facilitation, including low-technology interventions, a complete analysis of directed versus spontaneous pushing, and additional information on massage techniques. Information on delayed cord clamping, the Gaskin Maneuver and so much more.

And new research indicates that dystocia may be in a woman's genes.

In a new study just published (Indentification of a Myometrial Molecular Profile for Dystocic Labor BMC Pregnancy and Childbirth 2011 11:74), researchers Brennan et al suggest an underlying molecular basis for dystocia in nulliparous women in spontaneous labor.  Myometrial biopsies were obtained from the upper incisional margins of nulliparous women undergoing lower segment cesareans for dystocia.  These women were in spontaneous (non-induced) labor but had received intrapartum oxytocin to accelerate labor.

This new finding suggest an important role for the immune response in dystocic labor and could provide indicators for new diagnosis and therapies for helping with dystocia.

In light of this new study, we need to be as prepared as possible to assist women with any event that needs assistance during labor and birth.  The Labor Progress Handbook is one important tool to have!

Tuesday, October 11, 2011

A Few Reasons Why Occupying a Hospital Won't Change Policies & Procedures

Several days ago I posted this on my Facebook page:

"What if we 'occupied' hospital parking lots?  Would that facilitate policy and procedure change?"

Several people, within just a few minutes, were ready to paint signs and begin the sit-in.  I was very surprised at the response, yet have since realized that it is through the frustration of years of "telling the truth" that this must have been a visceral response.

Occupying any location in a hospital or near a hospital for the purpose of facilitating policy and procedural change would be folly.  Why?  If you have ever worked in any type of business and tried to facilitate change, then you already know that change does not happen because someone is protesting or beating the door while yelling "you must change because we said so".

As with most change, it happens sssslllooowwwlllyyy.  It happens because more and more become educated that the "way we've always done it" is no longer desirable, gets the desired responses or is no longer useful.  It is difficult because we are creatures of habit and typically multitask - so habit enables multitaking.

Change also happens from the top of the pile.  Hospitally speaking, it happens when nurse managers, directors of nurses, administrators and the finance people all realize that this change will impact their numbers.  Yes, it is a numbers issue.  And who impacts the numbers most of all?  THE CONSUMER.

But unlike when this happened back in the 1970s, the consumer cannot take the larger responsibility of informing the professional that excessive intervention rates and unfathomable cesarean rates hurt mothers and babies rather than help them.  Exposing the facts from the CDC and World Health Organization about the maternal morbidity/mortality rates and infant morbidity/mortality rates is paramount in bringing about change.  Getting this information to the top, to those nurse managers, directors of nurses, administrators and yes, even the finance people is paramount.  While the the finance people may see early preterm births as revenue from the added intervention (cost) and admission into the NICU (cost) as a benefit, we need to also inform the consumer that professional who pay the bills on the very backs of the healthy consumers must be informed and educated.  And ultimately, stopped.

In a state of economy as this country (the US) is currently experiencing, all are conscious about keeping their jobs.  L/D nurses and childbirth educators are not excluded.  But it is beyond my personal thinking that especially these two groups of which I am a part of both, can continue to protect their jobs and not tell the absolute truth about the hazards of induction/medication for labor and the risks/benefits about intervention (especially cesareans).  This is called teaching informed consent and I thought it was the foundation of every childbirth education certification program.

But perhaps, as childbirth educators and nurses, need to go back and look at why we chose this profession?  At least for myself as a nurse, I chose nursing to take care of people and get them (in obstetrics) from one state of health to the next.  As a childbirth educator, the choice was similar but instead of me caring for them, I wanted them to become active in their own health care and make the choices that are best for them.

So what is the answer?  If we advocate for change from the "top" (directors/administrators) as well as from the "bottom" (parents), just as we did in the 70s, then there will be an educational squeeze play and change will occur.  Rational behavior with a side order of evidence based information, referenced to the hilt is the order of the day.  Every professional organization should talk about it.  We must insist that The Joint Commission and Magnet Recognition change/add to their definitions of quality by insisting on evidence-based best practice.

And as childbirth educators, we need to present information in the complete risk/benefit style that we all know is best practice.  We need to be bold, be true and be educated ourselves.  Our classes can still be exciting and enriching without being overly humorous (portraying to parents that childbirth is something funny) or aggressive.

This is serious business.  And we are only contributing to the statistical nightmare if we don't ramp up best practice now.

Thursday, October 06, 2011

Dear Dr. Lisa, Thank you for helping!

After viewing the segment on waterbirth with Barbara Harper yesterday on the daytime talk show The Doctors, I just want to say thank you to Dr. Lisa!

The Doctors asked Barbara on their show to talk about waterbirth. After all, she is the expert and travels world-wide to educate professionals as well as parents about the gentleness and benefits and the precautions surrounding waterbirth.  She has written books.  She has created DVDs.  She has an evidence-based website with all of the evidence-based research data.  As Barbara said in a text message to me on 10/5/11 about the show: "They edited it so much and moved things around.  The taping was far worse and longer.  I actually think it was good for our side.  The truth prevails!!"

And Dr. Lisa made a great point (and I am paraphrasing): please read ACOG's opinions and then go to Barbara's website to see the research evidence from medical journals and then let the parents make the decision.  Brilliant.

It was clearly evident by her excessive body language and voice inflection/argumentative tone, that Dr. Lisa felt very threatened by Barbara's presence and the evidence which Barbara brought to the show....or tried to even over the posturing and yelling of Dr. Lisa.  This is, in fact, typical behavior when a person feels as if their territory has been invaded.

However, and let me be historically accurate, it was the midwife or sage femme who began assisting mothers with birth...back in the day...when we all wore fig leaves and lived in caves.  It was the midwife/sage femme who continued to care for the family when other children came along.  Physicians became insanely valuable during difficult births and because they are trained surgeons, when a cesarean became necessary.  However seeing that becoming a mainstay in maternity care meant more financial stability, some physicians formed a trade union called ACOG - the American College of Obstetricians and Gynecologists - and began a movement to move in on and ultimately deter midwifery care.  And more damning is that in a June 2011 story on MSN, this statement appeared:

The rest are based on anecdotal evidence or expert opinion, which is subject to personal biases, they reported.

So if ACOG and obstetricians in general are operating on less than 33% evidence, is it any wonder why Dr. Lisa had to resort to carnival stunts by showing a dirty aquarium with a baby doll sunk in the water?  She simply does not know the evidence.

Oh, wait, this isn't the first time that they have formed a movement against wellness in maternity care.  In the early 1980's, physicians/hospitals co-opted childbirth education from the community to the hospital ("The Politics of Co-optation: strategies for childbirth educators" by Dr. Eugene Declerq. Birth 1983 Fall 167-172) .  As epidurals, inductions and the rising cesarean rate became evident, obstetricians often tell their expectant patients that childbirth education is not necessary.  In other words, don't go.  Hospitals loose revenue, and reduce childbirth education down to a one day, 4 hour class or worse yet, no classes offered at all.  And too, an informed patient/client asks questions, which take time and may cause a deviation away from the set and managed practice guidelines.

In her 2004 book, The Medical Delivery Business, author Barbara Bridgman Perkins states that academia and industry (aka the pharmaceutical company) worked together to develop management of labor - not only an expectant mother's labor but the labor work force in a hospital.  An Upjohn-funded study in Britain concluded that labor induction could save hospitals money by enhancing staffing and efficiencies in their labor and delivery units.

More inductions --> more interventions --> more cesareans = more $$.  And according to Perkins, bowing to (1994) contemporary practice, ACOG softened its stance against elective induction for logistic reasons.

"Production costs" do not allow for nature to be involved.  Long labors cost man-hours, with no added benefit (revenue from induction, interventions such as continuous EFM, epidurals, cesareans).  The one-workday labor is a major incentive for managed care.  Nature not invited.

Dr. Lisa may have very well ignited (or fanned the flames) of re-forming maternity care by reformation.  Similar to what the International Childbirth Education Association published in 1972, Doris Haire's The Cultural Warping of Childbirth (where she documented the inadequate evidence supporting much of the routine technological intervention practiced in birth during the late 60's and 70's).  Sound familiar?

There should be a second edition of The Cultural Warping of Childbirth published.  The re-forming of care, the true identification of best practice, and putting the well-being of mothers and babies above increasing revenue should be paramount.  There needs to be a ROBUST conversation about the state of maternity care.

The question is: can we come TOGETHER to actually have that ROBUST conversation?

I believe the answer is YES!

So yes, thank you Dr. Lisa for reminding us about all of these things! 

Monday, October 03, 2011

Remember the Psychology of Daytime Television: Contact Information

.......and should you be moved to response to the program directly, here is contact information from our friend Jeanne Batacan:

It should prove to be a very interesting program - and according to the guest Barbara Harper may just move you to contact the website:

or contact the Associate Producer 

or write to the program:

The Doctors
5555 Melrose Ave.
Mae West Building, Second floor
Los Angeles, CA 90038

Remember the Psychology of Daytime Television: The Young and the Childbearing!

This Wednesday, October 5 2011, birth advocate and friend Barbara Harper will be on the US daytime talk show, The Doctors.  Filmed a few weeks ago, we have anxiously been waiting on this segment.

As we prepare to gather before our televisions on that day, please try to remember that this show is on daytime television!  Daytime television is the home of ridiculous game shows, shows where half of the US population do not know actual paternity, people dress up like chickens to win prizes and residents of imaginary towns flaunt their dirty laundry. (Wait, am I sure I am talking about DAYTIME television?)

According to Wikipedia, daytime television is  usually designed to be viewed by audiences such as stay-at-home mothers and fathers, and secondarily those viewers who might not usually carry a job, such as the unemployed, senior citizens and in some select cases, college students. For all intents and purposes however the traditional target of daytime television has been demographically 18-49 women, and as such daytime programming is hosted by women and usually pertains to women's issues and other subjects such as child care, minor health care and other issues within a home setting.

I suppose by that definition and judging from the kind of drivel they put on Daytime Television, programming must be mindless and ridiculous for this demographics to be attracted to it.  Keeping with that thought, then, does that imply that The Doctors falls into the category of drivel.

If you are following this logic train, then to be upset with the reception that Barbara is going to receive OR did receive on this daytime television show is also drivel.  However, if you look more closely at the demographics of 18-49 women, these are childbearing women!  This is also OUR target market!  Hence, we cannot ignore this drivel.

So, I propose that the entire cyber birth community begin today to flood the net even more with evidence of best practice of maternity care - statistics, quotes, videos etc.  Yes, even more than normal.

In this way, when The Doctors airs on Wednesday, and stays then forever on You Tube, all will see it as............just drivel.