Dated March 2014, the American College of Obstetricians and Gynecologists has announced a new document developed jointly by the American College of Obstetricians and Gynecologists (the College) and the Society for Maternal-Fetal Medicine with the assistance of Aaron B. Caughey, MD, PhD; Alison G. Cahill, MD, MSCI; Jeanne-Marie Guise, MD, MPH; and Dwight J. Rouse, MD, MSPH. The information reflects emerging clinical and scientific advances as of the date issued, is subject to change, and should not be construed as dictating an exclusive course of treatment or procedure. Variations in practice may be warranted based on the needs of the individual patient, resources, and limitations unique to the institution or type of practice.
To read more about the Consensus Document, click here.
PDF Format
Friday, February 28, 2014
Wednesday, February 26, 2014
Becoming a Childbirth Educator in Three "Easy" Steps
I became a childbirth educator in 1980. And to this day, I love what I do. I have expanded my role from childbirth
educator for expectant parents, to educating via social media, educating those
new to the childbirth profession, and as a leader in childbirth educator
organizations. For three + decades, I
have devoted my professional life to sharing and encouraging the embrace of the
evidence and facilitating informed decision-making.
And it only took three “easy” steps.
Step one was to decide that this passion was also a career
choice. It is one thing to be excited
about something shortly after the birth of one’s child. It is quite another to take the proverbial
bull by the horns and see it through the good times and the challenging times. Some of my most fierce challenges included
completing my certification through Lamaze (which included typing my six week
curriculum on a portable typewriter with carbon paper), seeing the ramped used
of epidurals in the late 1990s, and too-early elective induction/cesareans
which necessitated the need for more NICU space. Some of my peers quit during any one of these
challenges. I knew there was a proper
way for birth – a physiologic way for birth to happen – and my passion kept me
going.
“Cesarean surgery is
the quintessential issue that distinguishes the medical and physiologic models
of care.”1
Stepping into social media and the “computerized age” seemed
daunting however, I embraced Step Two - always educating.
Always loving gadgets and how things worked, everything from cell phones
(remember the bricks?) to my first Apple IIc computer became a way to extend my
passion. Oddly, what seemed so
daunting
back then has now become my most used educational tool. Via my cell phone, I can log onto Facebook,
Twitter, LinkedIn or be available for a client/peer with a question. Via my computer or iPad, I can research new
evidence, update my blog or website, or get answers to those with
questions. While books and magazines certainly
do play a vital part of my research life, I cannot imagine how my research, educating or
marketing would be without the internet, computers, cell phone, or other smart
device.
Through all of the certifications, recertifications,
continuing education, conferences, organizational
politicalness and perceived hiding of the evidence surrounding physiologic
birth, I never lost the focus (Step Three) that physiologic birth is best for
mother and baby. Many authors have
studied it, written about it and shown the evidence to be there – if we clean
up our maternity care act, our maternal/infant morbidity and mortality rates
with improve. As we saw an increase in
chemical pain relief, we also saw a decrease in breastfeeding rates.
Anesthetics cross the placenta and reach the infant quickly and also target the
mother’s sensory nerve tissue. Early
induction predicates cesarean sections, with associated risks. Yet knowing all
of this, we still hesitate to do skin-to-skin during the immediate postpartum
because it may interfere with continuing medical procedures; ignoring the fact
that skin-to-skin supports normal thermal stability, stabilizes newborn blood
sugars, releases milk to the newborn, and promotes gastrointestinal motility
and digestion in the newborn (just to name a few of the benefits)2.
Clearly we do not focus on the evidence which
leads to physiologic birth which leads to optimum labor/birth outcomes.
But I digress.
Yes, the three easy steps of becoming a childbirth educator:
passionate career choice; embracing
technological change to find and promote research; and staying focused on the evidence for positive outcomes. To be called to this profession is a humble privilege. To sustain in this profession, takes a
passionate focus.
It is indeed my pleasure.
References:
- Romano, A. and Goer, H. (2012) Optimal Care in Childbirth: The Case for a Physiological Approach. Classic Day Publishing.
- Smith, L. (2010) Impact of Birthing Practices on Breastfeeding, 2nd Edition. Jones & Bartlett Publishing.
Tuesday, February 25, 2014
When a Professional Gets Burnt Out: Rediscovering What We Preach Part 2
Meditation
and relaxation go hand in hand, however they are learned arts. In our hectic world, many of us feel stressed
out and over worked. Meditation gives
the mind a break and makes thoughts calmer and better focused. Spending quiet time in meditation also
teaches about overcoming stress and finding inner peace and balance. Many individuals overcome negative thoughts
through meditation and also, some individuals also utilize prayer during quiet
time or meditation.
In
a 2013 Huffington Post article, author Amanda Chan identified many benefits of
meditation. The benefits include:
Lets us know our true selves by having the time to objectively analyze ourselves.
Promotes better focus ~ with working adults as well as students, cognitive function is improved.
Allows for better performance, better ability to handle and recover from stress.
Changes the brain in a protective way – for more positive thoughts.
Works as the brain’s volume knob, keeping negativity at a minimum.
Improves focus on music by improving focus.
Promotes sleep through relaxation.
Lowers depression
Boosts health by reducing the expression of genes linked with inflammation.
Meditation
needs only to last 10 – 15 minutes to be effective. Sitting in a comfortable position to meditate
is best, although there is no prescribed position. While
being quiet in meditation, don’t try to eliminate thoughts or resist them. Let them come and go freely. You may
experience a dream-like state during meditation and not be conscious of noises
or sounds. Some people fall asleep while
meditating, while others experience strong emotions. Should you experience any strong thoughts or
emotions, try to come back to breathing and focus on that.
The
Cleveland Clinic has a unique take on mindfulness and meditation. Code Lavender is a holistic care response
serving both patients and providers in need of emotional or spiritual
support. Through
the program, a provider who summons emotional support is met by a team of
holistic nurses within 30 minutes of a call. The team provides Reiki* and
massage, health snacks and water, and lavender arm bands to remind the
individual to relax for the rest of the day. The Holistic Services Team also
offers a variety of other methods, including spiritual support, mindfulness
training, counseling and yoga. According to the Huffington Post, the
Cleveland Clinic is one of a growing number of hospitals and health systems
that are integrating holistic therapies into their services. A 2011 American
Hospital Association report found that 42% of hospitals surveyed offer one
or more Complementary and Alternative Medicine therapies, including
acupuncture, homeotherapy, and herbal medicine—up from 37% in 2007.
I have included a sample meditation from Meditation
Oasis. It is an eight minute Mandela
Meditation, with beautiful music and mandalas.
*Reiki is a Japanese technique for stress reduction,
relaxation and promoting healing. It is
a method of “laying on of hands” and is based on the idea that an unseen life
energy force flows through us and is what causes to be alive. If the life
energy force is low, a person is more likely to feel ill, stressed or unhappy.
References:
Ainsworth, B. et al. (2013) The effect of focused attention
and open monitiroing meditation on attention network function in healthy
volunteers. Psychiatry Research, 210(3):1226-31.
Foureur, M. et al. (2013)
Enhancing the resilience of nurses and
midwives: pilot of a mindfulness-based program for increased health, sense of
coherence and decreased depression, anxiety and stress. Contemporary
Nurse, 45(1):114-25.
Goyal, M. et al. (2014) Meditation programs for psychological
stress and well-being: A systematic review and meta-analysis. JAMA
Internal Medicine, Jan 6.
Singh, Y. et al. (2012) Immediate and long-term effects of
meditation on acute stress reactivity, cognitive funcitions and
intelligence. Alternative Therapies in Health and Medicine. 18(6): 46-53.
Thursday, February 13, 2014
The Evidence Says: Stripping the membranes not consistently effective but consistently uncomfortable.
Frequently, I am asked to address traditional maternity care procedures and shine the light of evidence on these procedures. Today, in response to a midwife's request, The Evidence Says presents the most current findings regarding stripping membranes.
Do you have a topic that you would like addressed by Childbirth Today? If so, email me at birthguru@birthsource.com!
Do you have a topic that you would like addressed by Childbirth Today? If so, email me at birthguru@birthsource.com!
Induction
of labor is a highly controversial topic and one that requires careful
consideration.
Stripping or sweeping of
membranes (the amniotic sac near the opening of the cervix) is one method care
providers often use.
How is it done ?
During
a vaginal exam, the care provider places a gloved finger into the cervical
os. The closer edge of the membranes is
detached from the lower uterine segment in a circular motion – not unlike
peeling an orange.
Why is it done?
Stripping
the membranes may begin labor by increasing local production of prostaglandins
(hormone that will soften the cervix) by stretching of the cervix. This intervention may shorten pregnancies of
women who are at term (41-42 weeks) and may also reduce the need for induction. However, some studies refute this finding3.
What the evidence
indicates:
According
to the most prestigious research database, the Cochrane database, stripping of
membranes, while possibly shortening pregnancy by initiating cervical softening
and irritating the uterine muscle, does not reduce cesarean rates in any
population (nulliparous or multiparous women).
There was also no significant difference in maternal or neonatal
infections. It may not be the most
effective means of inducing labor when there are medical indications.
Routine use of
sweeping of membranes from 38 weeks of pregnancy onwards does not seem to
produce clinically important benefits. When used as a means for induction of
labor, the reduction in the use of more formal methods of induction needs to be
balanced against women's discomfort and other adverse effects.
Discomfort associated with
stripping membranes includes irregular contractions, spotting/bleeding, cramping
and general discomfort – all of which may last for up to 24 hours.
Reasons You Would Not Want Your Membranes
Stripped:
According to the
American College of Nurse-Midwives (ACNM) Fact Sheet on Stripping Membranes1,
there are five reasons why an expectant mother may not want her membranes
stripped. They include:
- You have been told that it is not safe to have your infant vaginally.
- You have had unexplained vaginal bleeding during your pregnancy.
- You have been told that you need to have your infant urgently and it would be safest to have your labor induced by using medication.
- You want to let your pregnancy and labor unfold naturally and there is no medical reason to have your labor induced.
- If you have had a vaginal culture that says you have group B strep (GBS) in your vagina, you may not want to have your membranes stripped; there are no studies that have shown it is safe if you have GBS so this decision should be made with you and your care-provider making the decision together.
When might induction improve health outcomes
of mothers and babies:
According to two
studies4,5, three situations showed small improvements in outcomes
but left many unanswered questions.
These situations included:
- Pregnancy lasting beyond 41 weeks.
- Prelabor rupture of membranes at term.
- Increased blood pressure/preeclampsia at the end of pregnancy.
And a final word on reasons for induction
that are not supported by research:
- Preterm prelabor rupture of membranes.
- Twin pregnancy.
- Gestational Diabetes requiring insulin.
- Intrauterine growth restriction (IUGR) before 37 weeks or at term.
- Oligohydramnios (too little amniotic fluid).
- Concern that the baby will get to big (suspected macrosomia).
Stripping of membranes
and other mechanical methods of labor induction may begin labor but may also
lead to additional interventions and methods of induction (such as Pitocin/
Syntocin) or even Cytotec. It is important
for careproviders to share all information with expectant mothers so that a
well-thought out decision can be made.
References and Resources:
- ACNM (2009) Fact Sheet: Stripping Membranes. Journal of Midwifery and Womens Health.
- Boulvain, M. et al (2005) Cochrane Database: Membrane sweeping for induction. Last accessed 2/13/14 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000451.pub2/abstract;jsessionid=D4F9ECF1A89EEAB8143B5930D810A792.f03t02
- Kashanian, M. et al. (2006) Effect of membrane sweeping at term pregnancy on duration of pregnancy and labor induction: a randomized trial. Gynecologic and Obstetric Investigation. 62(1): 41-4.
- Koopmans CM, Bijlenga D, Groen H, et al. Induction of labour versus expectant monitoring for gestational hypertension or mild pre-eclampsia after 36 weeks' gestation (HYPITAT): A multicentre, open-label randomised controlled trial. Lancet. 2009;374(9694):979-988.
- Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King VJ. Indications for induction of labour: A best-evidence review. British Journal of Obstetrics & Gynecology. 2009;116(5):626-636.
Wednesday, February 12, 2014
When a Professional Gets Burnt Out: Rediscovering What We Preach Part 1
Over the
years, there have been numerous articles about professionals and burn out. The general public is becoming aware of burn
out. And the one modality that can help
both groups deal with stress is mindfulness-based stress reduction or MBSR.
Dr. Jon
Kabat-Zinn first created MBSR in 1979 at the University of Massachusetts
Medical Center. The National Institutes of Health's
National Center for Complementary and Alternative Medicine has provided a
number of grants to research the efficacy of the MBSR program in promoting
healing. Completed studies have found that pain-related drug utilization
was decreased, and activity levels and feelings of self-esteem increased, for a
majority of participants.
For a history of the Center for Mindfulness at UMASS,
click here
Studies of
health care providers who use MBSR suggest that there is a decreased perception
of stress and greater self-compassion. Job burnout and psychological stress
were also decreased.
So just
what is MBSR and how does it work?
MBSR is a
behavioral program that uses the psychological concept of mindfulness to help
with coping skills, reduce pain and increase mental focus. Juliet Adams, founder of mindfulnet.org explains
mindfulness through the ABC’s of Mindfulness:
A. is for
awareness. Becoming more aware of what
you are thinking and doing – what’s going on in your mind and body.
B. is for “just
being” with your experience. Avoiding
the tendency to respond on auto-pilot and feed problems by creating your own
story.
And
C. is for
seeing things and responding more wisely.
By creating a gap between the experience and our reaction, we can make
wiser choices.
MBSR
includes developing a sense of peace, heightened awareness, and tranquility through regular meditation and
relaxation. MBSR helps to cope
emotionally and physically with everyday stress, challenges and demands. It is bringing awareness to the present
moment – while trying to not allow your mind to wander onto other topics past
or future. In his Center, Kabat-Zinn has
seen over 18,000 individuals who have reported a decrease in physical symptoms
of stress, increased ability to relax, reduction in pain levels, greater energy
and enthusiasm for life, and improved self-esteem.
Part of MBSR involves breathing - not unlike Lamaze! Watch Dr. Kabat-Zin here:
References
and resources:
Davis, D.M.
and Hayes, J.A. (2012) What are the
benefits of Mindfulness. American Psychological Association. Vol
45, No 7.
Fjorback,
L.O. (2012) Mindfulness and bodily distress.
Danish Medical Journal.
Goodman,
J.H. et al. (2014) CALM Pregnancy: results of a pilot study of
mindfulness-based cognitive therapy for perinatal anxiety. Archives of Womens Mental Health.
Shapiro, S.
et al. (2005) Mindfulness-based Stress Reduction for Health Care Professionals:
Results from a Randomized Trial. International Journal of Stress Management Vol.
12, No 2. 164-176.
Monday, February 10, 2014
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