Friday, February 28, 2014

ACOG Announces Obstetric Care Consensus: Safe Prevention of Primary Cesarean Delivery

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

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:

  1. Romano, A. and Goer, H. (2012) Optimal Care in Childbirth: The Case for a Physiological Approach. Classic Day Publishing.
  2. 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:

Lowers stress.  A person not only feels less stressed but also decreases levels of the stress hormone cortisol.

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!


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:

  1. ACNM (2009) Fact Sheet: Stripping Membranes. Journal of Midwifery and Womens Health.
  2. 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
  3. 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.
  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. 
  5. 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.