Decision-Making: Teaching Informed Choice

In my last post, I talked about 4 steps of teaching informed decision-making: Values Clarification, Communicating Values with Birth Plan, Key Questions to Ask, and Informed Decision Making. This post is all about that last step.

Note: we prefer the term Informed Decision Making to Informed Choice for a few reasons: 1) Choice sounds like there was a clear black and white list of options, and we check a box… decision-making is often murkier than that. 2) Choice sounds a little entitled (my four-year-old likes to shout “It’s my choice so I get to do this!” I tell him that’s not really the case…)  Decision-making sounds more like a discussion between the parents and the caregiver and a careful evaluation of the options.

So, how do we teach informed decision-making?

Teaching Method 1: The Five Finger Method
I say “Before your caregiver made the recommendation to you, they already did a risk-benefit analysis. They already thought of what the options were, and thought about the balance between which would be most effective and which would be lowest risk. Let’s say they considered 5 options. [Hold up one hand, five fingers spread.] This option [touch pinkie] would definitely work – it’s very effective, but it’s too high risk – your health situation is not dire enough to need that level of intervention. This option [touch thumb] is really low risk, but it’s not clear if would be effective… it’s benefits are not good enough to offer. This option [touch middle finger] is the best compromise – that’s why your caregiver offered it. But remember, it’s the best compromise for any non-specific person in your situation. That doesn’t mean that it’s the best compromise for you! When you look at those options, you might find that this one [touch index finger] feels like the best answer to you. You understand it might not be effective, and that you might then have to escalate to one of these, but you’d like to try it first. Or, you might be exhausted and done with labor, and ask to do this one [touch ring finger] because you just want to do something you KNOW will work to solve the problem.”

I then give an example: I start with a non-birth-related example. I want to take them out of the realm of birth (where some may feel like this is all complicated and only experts understand it) into some different field where they feel like they have all the info they need.

Two examples I have used: the air conditioner and the loose shelf. I kind of like the air conditioner example better because it brings up the idea that maybe before we ask an expert for an intervention, we should think about whether something is really a problem. But if I’m working with mostly low income clients, it could come from a place of privilege to be able to consider all five options there…

The air conditioner example. “So, the air conditioner broke in my friend’s car last August. Now she knows even before she asks someone what her options are likely to be – she could do nothing and just live with it [touch thumb]- after all, this is Seattle – how many days do you need A/C?  she could repair it [touch middle finger], or she could replace it [touch pinkie]. Now, if she goes to the mechanic and says ‘what should I do’, is the mechanic going to offer ‘do nothing’ [thumb]?? No! He figures that if you came to him asking for help, you want him to do something! He might say ‘well, I could repair it. That’s cheaper than replacing (lower cost = lower “risk”) but it might break again. Or I could replace it. Higher cost, but we know it’s effective.
“So, she’s asked her key questions. She’s gathered all the data from the mechanic’s point of view. Now she needs to look at her values and also at her budget, which the mechanic knows nothing about. If she’s trying to save money for something that’s much more important to her, she may decide either never to fix the A/C [thumb] or to tough it out through August, and save money between now and next summer to repair it then [index finger]. If she’s tight for money but can afford it she may start with a low level repair [middle finger]. If she can afford it and she REALLY hates being hot she might try a more comprehensive repair [ring finger.] If she’s got plenty of money, she might go straight to replacement so she doesn’t have to deal with it again.”

The loose shelf example: I won’t detail it here, because i include it as the example in the quadrants tool I describe below.

Now that I’ve taught the five finger theory and given a quick example, now I want to apply this to birth. AND I want them to practice decision-making. I present a scenario, and tell them they have to ask me questions about benefits, risks, and what other options I considered. Then they have to think about their own values and priorities and what choice they would make

Slow Labor Progress example (you’re past 6 cm, but have gone 4 hours with no progress). Recommendation: Try Pitocin and position changes for an hour or two to see if we can speed it up. [Point to your middle finger to show that is the middle-of-the road recommendation that caregiver made. Note: it’s important that you hold up all five fingers and point to the middle one. Don’t just hold up your middle finger. 🙂 ]  Parents can ask: what are the other options: pinkie – we could do a cesarean now – that would get the baby out, but there’s risks to a cesarean, and your situation is not that big of a problem. Ring finger – could also break your bag of water. Index – could start with really low dose Pit. Thumb – Could just try position changes and maybe some nipple stimulation, but I’m not convinced that’s going to do anything. So, now parents have all the info. They need to reflect on their goals and values. Let’s imagine one family who had originally planned a home birth and wanted as low of interventions as possible. They might say to the caregiver: “Thank you for all that information. We understand that your recommendation is the most likely to be effective with the least risks. But, our original hope was to be as low intervention as possible, so let’s start with a low dose Pit [index finger] and see if that’s enough.” Another family, who has always been open to whatever interventions were needed to help labor progress well, and who are now very tired and just wanting to hold their baby might say “Let’s move this along – let’s do the Pitocin and break my bag of waters… I’m ready to rock.”

Teaching Method 2: The Quadrants
In this PDF: Decision Making Quadrants, I describe the full process of this method. But basically, you’re asking people first to consider their

  • intervention style: are they quick to intervene or are they willing to let something be a problem for a while before they intervene?
  • Self-Help or Expert Help: Do they like to solve things with their own skills, or do they prefer to turn it over to an expert?
  • Benefits vs. Risk: Do they choose the most effective thing even if it comes with more possible risks? Or are they very cautious about risks and more likely to try lots of less effective options first?
  • In a particular decision-making moment, how do they balance their normal decision-making style with the urgency/severity of the current situation while taking their values into account.
  • Examples include: the loose shelf, pain medication preferences

Teaching Method 3: The Values Clarification / Decision-Making worksheet

Can be done in class or as a take-home assignment. Check out the details on how it’s used here and find the worksheet here: Values Clarification.

Teaching Method 4: Help Students Learn More about their Decision Making Style

Check out this post on Medical Mindsets, and this worksheet, which gets into both medical mindset and other decision-making styles.

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Big Changes in Maternity Care 2010-15

I am a co-author of the book Pregnancy, Childbirth, and the Newborn. (We call it PCN for short.) We have been working on a revision – the 5th edition of PCN will be released in March 2016. You can pre-order it here (affiliate link.)

This post is a summary of all the changes we have made to the book. It is not really meant to be a stand-alone post for someone who is not a birth professional and who hasn’t read PCN. However, if you ARE a birth professional (especially a childbirth educator) and HAVE read PCN, this summarizes what we think are the most important changes in maternity care and birthing culture since 2010 when our last edition came out. I have highlighted with ***asterisks*** the ones that I believe are essential for childbirth educators to be aware of and essential to incorporate these ideas into their classes.

Here you go… all the changes… Note, when I say we’ve “made a change to the website”, that will be upcoming changes to our companion website http://www.pcnguide.com – those will appear live online after March.

Throughout the book:

  • Gender: Have made the language more inclusive of gender-non-normative families. Have changed many incidences of “pregnant woman” or “women” to “pregnant person” or “people” or “expectant parent.” Where we could, we re-phrased the sentence to avoid pronouns, but when pronouns are needed, we use she or her to refer to the pregnant person. As always, partners are gender neutral, and for babies we alternate male and female by section.
  • Microbiome: Added a section to the cesarean chapter discussing the microbiome in detail (also added an even more detailed discussion to the website.) Included references to this information in pregnancy complications chapter (when discussing antibiotics for GBS) and in the newborn care chapter when discussing diarrhea and again when discussing colic. See this blog post to learn more
  • Chapter Order and Division: In this document, I refer to chapters by their chapter number in the old edition. For new edition, the breastfeeding chapter will be divided into two, the pain medication information will be made a separate chapter from Labor Pain and Options, and chapters in the birth section will switch order to:
    • When and How Labor Begins (chapter 9); What Childbirth is Really Like (formerly chapter 12); Labor Pain and Options (formerly first half of chapter 10); Comfort Techs for Labor (11); Pain Medications (formerly second half of chapter 10), When Childbirth Becomes Complicated (13)

Intro: Added some notes about “how to use the book” that address some of the concerns that Amazon reviewers have expressed about the book. Added a note at the end about gender-inclusive language.

Chapter 1 – You’re Having a Baby: no major changes

Chapter 2 – So Many Choices: Updated health insurance info to reflect Affordable Care Act (see details on health insurance). Included notes about ACOG/SMFM levels of care recommendations, which include birth centers and then define level 1 – 4 hospitals. Also added brief note defining “high risk” pregnancy vs. low risk, saying that a high risk mother should choose a high level of care (OB and level 3 – 4 hospital) vs. a low risk mother can choose anything.

Moved the lists of questions to ask (at a birthplace, of your caregiver, etc.) to website.

Chapter 3 – Common Changes of Pregnancy:

  • Added a recommendation to subscribe to an email newsletter like Lamaze or Baby Center’s if they want detailed week-to-week information (“this week your baby is as big as a kumquat”)
  • Made changes to ***how we talk about “the 41st week and beyond”*** given ACOG’s 2014 statement on Preventing the Primary Cesarean, where they recommend that all women be induced at week 41 because of the increasing risk of stillbirth beyond that point and the fact that cesarean rates increase for prolonged pregnancies. We state that some caregivers will recommend that pregnancy continue, with some extra monitoring to ensure that placenta/baby continue to do well, and some will recommend induction at week 41.
  • Updated section on pregnancy after age 35. (Trivia note: when PCN first came out in early 80’s, average age of mothers having their first births was 22.7, and just under 4% of all births were to women 35 and older. In 2013, the average age at first birth was 25.8. 15% of births were to women 35 and older. 22% of those were the first baby born to the mother.)
  • Added a section on “If you’re transgender or genderqueer” that gives resources for finding a supportive caregiver and suggests preparing a detailed birth plan to explain things like preferred pronouns and family terms (e.g. pregnant father)

Chapter 4 – Having a Healthy Pregnancy

  • Added a new section on prenatal screening for birth defects, which includes: first and second trimester blood tests, nuchal translucency screen, second trimester ultrasound, and cell-free fetal DNA testing. Explains that these are all screening tests and none are 100% accurate, so shouldn’t be used as the sole basis for irreversible decisions like termination. If screening tests reveal high risk of birth defects, diagnostic tests (CVS or amniocentesis) are recommended. Although we don’t cover these topics in birth classes, it would be good for all educators to be familiar with the newer testing options. (See my blog for more)
  • Added signs of prenatal depression to pregnancy warning signs
  • Added new resource on effects of infections, substances, and environmental hazards: Mother to Baby website, from the Organization of Teratology Information Specialists. http://www.mothertobaby.org/otis-fact-sheets-s13037
  • Addressed e-cigarettes: Effects on pregnancy has not been studied. MAY be safer because fewer chemicals and no smoke, but still contain nicotine, which is harmful to babies.
  • Addressed marijuana since some states have legalized recreational marijuana use and several have legalized marijuana for medicinal purposes. (It is still illegal at the federal level and this may come into play in child abuse or neglect rulings in those states.)Some studies show that marijuana use in pregnancy does not increase the risk of birth defects. Others indicate that babies born to mothers who regularly used marijuana had a higher risk of premature birth, low birth weight, small head circumference, and cognitive and attention deficits. These studies were generally done when marijuana use was illegal, and thus difficult to get accurate reporting on. Plus the women who regularly used illegal marijuana were also more likely to use alcohol, tobacco and other drugs, and less likely to access prenatal care, so that may influence these outcomes. Until more research is done, it is wise to avoid recreational marijuana use, and only use it medicinally with the supervision of a caregiver.

Chapter 5 – Feeling good and staying fit: Made changes to ***pelvic floor exercises***, saying there’s not a one-size-fits-all recommendation. Recommend they check strength of pelvic floor muscles (by stopping flow of urine or by tightening around two fingers or partner’s penis.) If they seem weak, then do kegels (note: 10 second kegels are best). On the other hand, these symptoms may suggest the muscles are overly tense: pain in vagina, rectum, tailbone, straining with bowel movements, pain during intercourse, urinary issues such as hesitancy, incomplete emptying or pain. In this case, instead of kegels, she could do pelvic bulging, conscious relaxation, or perineal massage to release tension.

Chapter 6 – Eating Well

  • Added info on gluten free options
  • Changed discussion of non-fat dairy items. Research actually shows that people who consume full-fat dairy are less likely to be obese than those who consume non-fat dairy.
  • Starting with a 2011 medical update of the 2010 edition, we have updated discussion from the Food Pyramid to the new “My Plate” guidelines: http://www.choosemyplate.gov.
  • Added recommendation for 600 IU per day of vitamin D in pregnancy
  • Added a section under special circumstances on “Pregnant and Considered Obese” which encourages them to learn more at http://www.wellroundedmama.blogspot.com or by reading the series “Maternal Obesity: A View from All Sides” on http://www.scienceandsensibility.org

Chapter 7 – When Pregnancy Becomes Complicated

  • Updated miscarriage statistic – it did say 10 – 15%, increased to 15 – 20%. As more women learn about the pregnancy earlier in pregnancy, there has been an increase in recognized miscarriages. Also added a few more details on how a miscarriage is treated (observation, medication, or D&C)
  • Moved the chart on impact of infections out of the chapter and on to website.
  • Updated incidence of gestational diabetes. Was 3 – 5%, now 4 – 9%. Included note that in the days prior to (and day of) a glucose challenge test, mother should be well-rested and eat healthy, non-sugary foods to decrease her chance of a false positive.
  • Updated section on gestational hypertension and preeclampsia. Proteinuria is no longer required for a diagnosis of preeclampsia – if mom has high blood pressure plus either lowered platelets or impaired liver or kidney function that is sufficient. Mild gestational hypertension (BP 140/90) is treated with: reduced activity / stress, daily kick counts, weekly appointments for blood tests and possibly fetal monitoring. ***For those with mild hypertension or preeclampsia, delivery at 37 weeks is recommended.*** For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures. If baby is past 34 weeks, they will deliver baby as soon as she is stabilized. If baby is under 34 weeks, amniocentesis to check for lung maturity and corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable. http://www.slideshare.net/lcmurillo/hypertension-in-pregnancy-acog-2013
  • Added a very brief section on perinatal mood disorders to point out that depression in pregnancy is quite common (estimates range up to 20%, or 30% in women of low SES.) Amongst parents with postpartum mood disorders, a significant portion (up to a third) say symptoms began during pregnancy. (Interestingly, anxiety and panic attacks decrease during pregnancy due to soothing effects of hormones.) ***This info should be covered in childbirth education classes, and parents can be referred for more information to sources that address PPMD.***
  • Moved info on breech babies from “When Childbirth is complicated” chapter to here.

Chapter 8 – Planning for Birth and Postpartum

No major changes, except moved “What to pack for the hospital” list from chapter 9 to 8.

Chapter 9 – When and How Labor Begins

  • Replaced the old Events of Late Pregnancy “arrow” with a new graphic.

Chapter 10 – Labor Pain and Options for Relief

  • Divided into two chapters: Labor Pain Options and Pain Medications for Labor
  • In the section on Pain versus Suffering, added in ***the concept of “working with labor pain” ***(see Leap and Newburn. (2010) Working with pain in labour: An overview of evidence. New Digest 2010; 49:22–6.) Also added a brief note about it in the chart comparing pain relief options. If parents believe that comfort techniques are designed to take away their pain, they’ll be disappointed in labor. If they understand that the goal of comfort techniques is to make pain more manageable and help them feel like the pain is something that they can work with rather than something they are suffering through, they may be more satisfied with the experience.
  • In the last edition, under “Effectiveness of Pain Relief Options” we had cited mother’s experiences from the Listening to Mothers survey. We have kept that, but added info on research into the effectiveness of various methods. In the book, we summarize Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801
    • Gate control, defined as adding pleasant stimuli to the painful area. Users were less likely to use epidurals or Pitocin and had lower pain scores
    • ***Counter-irritation***, defined as creating pain or discomfort elsewhere on the body (with TENS, ice, birth combs) to cause the release of endorphins. Users less likely to use epidurals, had lower pain scores, and more satisfied with birth.
    • Central Nervous system control (attention focus, prenatal education, relaxation, hypnosis, continuous labor support). Less likely to use epidurals and Pitocin, less likely to need instrumental delivery or cesarean, higher satisfaction
    • Most effective is a combination of continuous support with other techniques
  • Added to website a chart comparing Cochrane summaries on individual non-drug techniques.
  • See blog at transitiontoparenthood.wordpress.com for more discussion of ‘working with pain’, counter-irritation, and research into the effectiveness of techniques

Chapter 10 B – Pain Medications

Chapter 11 – Comfort Techniques

  • Lots of minor updates to wording and references
  • Added a section on counter-irritation: when the laboring person causes an uncomfortable sensation somewhere to distract her from pain (e.g. bites her lip, digs her fingernails into her palm, pulls her hair). Explained to partners that if this is helpful to her and not harming her, we reinforce it as her ritual. If it might be harmful to her, we substitute – like giving her a washcloth to squeeze in her hands. Addressed birth combs, TENS, sterile water injections as good options
  • Added peanut balls as a comfort item / item to aid labor progress, particularly in late labor for a mom with an epidural (she lies on her side with the ball between her legs – the pelvic opening gives baby room to descend)
  • Re-did some of the diagrams of breathing techniques, particularly light breathing – diagram shows fast breaths every second. Re-drawn as a breath every 2 seconds, with a brief pause between each breath. Slide breathing diagram had 5 or 6 exhales per inhale. Should be 3 – 4.

Chapter 12 – What Childbirth is Really Like

  • In the past, we had described early labor as lasting to 4 cm. ***Shifting to saying early labor lasts till 6***. We describe a “getting into active labor” phase from 4 – 6 cm to acknowledge that labor often intensifies there, and mom needs more support than she did before, but cervical dilation does not really speed up till after 6 cm
  • Added a sidebar about the 2014 ACOG/SMFM consensus paper as the source for that change, and the perspective of “***6 is the new 4***” (American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine. “Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery.” Obstetrics and Gynecology 2014; 123:6093-711.)
  • Made even clearer our statement that prolonged early labor is not a complication. (But, of course, mom does need support with it, and we do give ideas for how to improve progress.)
  • Changed words used to describe fetal heart rate issues. New terms are ***normal, indeterminate, and abnormal***. Outdated terms include fetal distress, non-reassuring heart rate, and fetal intolerance of labor. http://www.ncbi.nlm.nih.gov/pubmed/19546798
  • Fetal scalp sampling removed (apparently there’s not an FDA approved kit for doing it) But do recommend fetal scalp stimulation (scratching baby’s head) as a tool for evaluating an indeterminate heart rate – if you scratch baby’s head and heart rate speeds up, good sign
  • Added more on delayed cord clamping. (to learn more about it, see Penny’s video here: https://www.youtube.com/watch?v=W3RywNup2CM) Note: cord blood CAN be collected for storage or donation after delayed clamping – it is collected from the placenta.
  • Added more on hormones of labor and on hormonal interaction during fourth stage. Included reference to ‘Pathway to a Healthy Birth’ by Sarah Buckley, available at childbirthconnection.org.
  • We are adding Penny’s Road Map of Labor (newly revised) to the back of the book, so have brought references to it into this chapter and chapter 13.

Chapter 13 – When Childbirth Becomes Complicated

  • Changed the order of the sections. In the past, they were roughly in order from most common to least common. But that didn’t lead to a logical flow of topics. New order:
    • complications of pregnancy that affect labor: multiples,  gestational hypertension
    • issues with transition from pregnancy to labor: premature birth, rapid birth, induction
    • challenges that arise in labor: prolonged labor, concerns about well-being
    • prolonged second stage
    • issues after the birth: third stage complications; premature or seriously ill newborns; infant death
    • Note: breech birth moved to chapter 7. Preterm labor divided up as follows: chapter 7 – warning signs and what to do if you think you may be in preterm labor; chapter 13 – when labor can’t be stopped and birth is inevitable
  • Induction – cite recommendations from ACOG that ***elective induction not be done before 39 weeks (and ideally not before 41). However, also mention ACOG recommendation that all women consider induction at 41 weeks.*** acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
    • Shortened section on misoprostol, as current protocols do not appear to cause the severe health complications that happened when it was first used as an induction agent
  • Changed discussion of prolonged labor to match current ACOG recommendations. Prolonged labor should not be diagnosed before 6 centimeters dilation. After 6 cm, it still shouldn’t be diagnosed until she’s had not progress for 4 to 6 hours, even with AROM and Pitocin.
    • Note: ***this is a very significant change for childbirth educators to be aware of***. If more care providers start following these guidelines, labor will become longer on average, and students need to have expectations set appropriately! We need to talk more about not getting excited too early in prelabor, conserving energy in early labor, ways to aid progress in active labor but also not stress over a long labor. (e.g. it may take 5 – 7 hours to progress from 4 to 6 cm even if you’ve got contractions in the 5-1-1 pattern)
  • Childbirth educators used to talk about prolonged labor / back pain being mostly due to OP babies. Ultrasound studies have shown that isn’t always true (see Simkin 2010 – Fetal OP Position: state of the science), and that babies change position more in labor than we had thought. We can say that if you have any of these issues: slow labor progress, irregular or coupling contractions, back pain, or very severe pain, then there is something dysfunctional (“not quite right”) about your labor that needs to be corrected. It may be baby’s position, it may be something else. But whatever the cause, the things we’ve always recommended for slow labor and for back pain can help (e.g. positions and movement, counter-pressure and hip squeeze, addressing mom’s fears, hydration, etc.)
  • Prolonged second stage. Again, the ACOG recommendations have changed! There is no absolute maximum amount of time for pushing. ***Arrest of descent should not be diagnosed unless the mother has pushed at least 3 hours (2 hours if multip). Longer may be appropriate: for example, allowing one hour more if the mother has an epidural or if baby is malpositioned.***
    • Before instrumental deliveries are done, manual rotation of baby’s head should be considered. Before a cesarean is done, vacuum or forceps should be considered.
  • Previous edition said postpartum hemorrhage occurs in 20%. This was a typo. 😦 Should have said 2-5%. Updated this to say “about 5%” based on WHO and ACOG.

Chapter 14 – All About Cesarean

  • Updated “cesarean trends” section to address that rates have increased for all women across the board, and to address practice variations between birth places and how that influences cesarean rates at individual hospitals. Talk about the ACOG statement on need to reduce c-s.
  • Updated info on elective cesarean to reflect 2013 ACOG saying that if there are not medical reasons for cesarean, then vaginal delivery should be recommended. If elective is done, should be after 39 weeks.
  • Updated info on what counts as prolonged labor in need of cesarean (see chapter 13 notes)

Chapter 15 – What Life is Like for a New Mother Parent

  • Changed the order of topics for more logical flow
  • Replaced section on breast self-exams with new recommendations for long-term reproductive health care: Pap smear every 3 – 5 years. Under 40, clinical breast exam every 3 years. Over 40, may recommend annual breast exams and annual mammograms, or they may follow the USPFTF research-based recommendations for biennial mammograms starting at age 50

Chapter 16 – When Postpartum Becomes Complicated

  • Added brief info on PTSD after birth; noted that 5% of new dads experience PPMD; briefly address placental encapsulation (while noting research on its efficacy and safety is limited)

Chapter 17 – Caring for Your Baby

  • Tightened up some medical details to make room for some practical stuff like “how to hold a baby”, “dressing your baby”, “when and how to change a diaper” and typical wake-sleep patterns at 2 weeks, 4-6 months, and 2 years
  • Newborn procedures – removed silver nitrate and tetracycline from eye ointment options, leaving just erythromycin which is what is in current use. Changed hearing screening to note that it is now recommended for all babies. Added the pulse oximetry test. (learn more about this test: http://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html)
  • ***Updated circumcision.*** New AAP guidelines say medical benefits outweigh risks, but not enough to recommend routine circ. http://pediatrics.aappublications.org/content/130/3/585.full; New CDC guidelines say circumcision reduces risk of HIV and 2 other STI’s, and given concerns over the spread of HIV we should do all we can to prevent, and it’s safer to circumcise a baby boy than an older boy or man http://www.cdc.gov/nchhstp/newsroom/docs/MC-factsheet-508.pdf. However, AAP says parents need to weigh benefits and risks, and CDC says delaying circ allows child to participate in decision-making. Note: there is a chair that can be used during the procedure rather than strapping baby to a board on his back – this leads to less distress for baby
  • Increased information about newborn cues, particularly disengagement cues, and overstimulation as a culprit in colicky behavior. Cited research that probiotics may help colic.
  • Updated vaccinations. Old edition didn’t really talk about the benefits, just all the reasons people might choose not to. Update covers benefits to child and community. Says the CDC believes that for the population as a whole, the benefits outweigh the risks, but some parents may have concerns about the risks. States that research does not show a connection between vaccines and autism. Suggests that if they want to opt out of vaccines or adjust timing they should do so only after research into benefits and risks and consultation with caregiver.

Chapter 18 – Feeding Your Baby

  • Split into two chapters. Feeding your baby and When Breastfeeding is Challenging. We did this because of feedback from students that it was overwhelming to see all the complications mixed in with the normal. Throughout the book, we separate typical from Complicated (chapter 7, 13, and 16) so that the complications info is there, but that it’s hopefully less anxiety inducing when it’s clearly labeled as the unusual circumstance.
  • In the past, lots of the information on general feeding practices no matter what they’re fed (when to feed, how much to feed, how to burp, spit-up, etc.) was in the midst of the breastfeeding content, so parents who were bottle-feeding might have skipped much of that important content, and only seen the info on bottles and formula at the end of the chapter. We re-organized the chapter a bit, to be: general feeding info, breastfeeding specific info, bottle-feeding (breast milk or formula) info, then a brief section on formula.
  • “Normal” breastfeeding challenges covered in Feeding Chapter: when your baby doesn’t get enough milk – ways to increase supply; breast fullness and tenderness, sore nipples and leaking
  • Issues covered in the “when breastfeeding is challenging” chapter: persistent sore nipples – causes and treatments; engorgement; plugged ducts; mastitis; persistent low milk supply; and situations that make breastfeeding challenging (cesarean, preemie / ill baby, multiples, nursing while pregnant / tandem nursing; working and nursing.)

Chapter 19 – When You’re Pregnant Again

  • Minor updates, including updated recommendations for books to read to older child.

Appendices

  • We will be moving the chart about pain medications to the website
  • We will add “The Road Map of Labor” graphic to the book, and have updated the “Summary of Normal Labor” chart to incorporate ideas from the road map

The new book will be available in March. We encourage you to check it out! We are also revising the Simple Guide to Having a Baby, which will be out in May 2016. It is similar content to PCN, but whereas PCN is written at a high school / college reading level, Simple Guide is 6th-8th grade reading level. It’s a good match for students with less formal education, for those for whom English is a second language, or those who are too busy to read the much longer PCN.

Medical Mindset Tool

When making choices about medical care, are you a maximalist or a minimalist? A maximalist may use lots of tools to prevent and treat problems. A minimalist may try to use as few tools as possible, letting things run their natural course. What kinds of medical tools do you use? Natural remedies and self-help techniques or medicine and technology? A maximalist naturalist might prepare for birth by attending prenatal yoga, drinking raspberry leaf tea, and frequent love-making to get her oxytocin flowing. A minimalist technologist might choose a hospital birth with an OB, but ask for as few interventions as possible.

Helping your students or clients understand their medical mindset may help them in choosing care providers and birth places, and may also help them explain their decision making in labor to their partners and care givers. There are a few tools you can use to learn more and help your clients to understand this idea.

Jerome Groopman has written a book on Your Medical Mind: How to Decide What is Right for You. (He also wrote How Doctors Think and some other great books.) You can read an article which summarizes it here: http://news.harvard.edu/gazette/story/2012/02/%E2%80%98your-medical-mind%E2%80%99-explored/ or watch a video here that presents the idea to medical professionals: http://practicalbioethics.tv/2012/06/11/jerome-groopman-pamela-hartzband/when-experts-disagree.html

Kim James and Laurie Levy discuss this in their childbirth classes and with doula clients. They designed a worksheet you can find here: http://kimjames.net/Data/Sites/3/groopmanspectrumsforlamaze2012landscape9.24.12.pdf

I liked their idea, but found the worksheet complicated and a little dense on information for my client population, so I made a simplified version of the worksheet. Click here for the PDF. If I were using this in a class, I might give one copy to the pregnant parent, and one to the support person to fill out separately, then compare and discuss.

[Added on 7/28/15: a 2-page version of the handout that looks at more factors that affect decision-making. Find it here.]

Seeding and Feeding a Baby’s Microbiome

What is the microbiome?

The collection of bacteria, viruses, fungi, and other organisms that live in and on the body. We have about 10 trillion human cells in our bodies, and about 100 trillion microbes. We have evolved in tandem with this microbiome for thousands of years. The balance of microbiomes varies throughout our body, and the bacteria found in our mouths is different than on our skin, which is different than in our intestines.

Why does the microbiome matter?

  • A balance of microbes leads to optimal health. An imbalance can lead to disease. For example, a vaginal yeast infection may occur when the healthy bacteria are reduced by antibiotics, allowing yeast to overgrow.
  • Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, and protect against infection.
  • An overgrowth of harmful bacteria can lead to infectious disease.
  • Disruption of the gut microbiota has been linked to inflammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers.
  • Many studies have shown that the presence of absence of specific microbes can cause life-long changes in immunity.

How does a baby’s microbiome develop?

  • During pregnancy
    • In the past, the womb was believed to be a sterile environment. However, microbes are found in the placenta, amniotic fluid, and in meconium. (The waste that accumulates in the fetal bowels.)
    • Maternal fecal microbes have been found in the uterine environment, leading to hypotheses that microbes from throughout the body are transferred through the bloodstream. And from there into the placenta, then the umbilical cord and the amniotic fluid.
    • Placental microbes are similar to the microbes in the mother’s mouth – especially types of bacteria that aid in the metabolism of food.
    • Healthy bacteria may benefit baby. For example, if the mother lived or worked on a farm, that might protect against allergies and asthma.
    • Others worry that unhealthy bacteria may affect baby. For example, obese women tend to have abnormal gut microbiota. This may be transferred to the baby.
    • Maternal diet affects the baby. E. coli bacteria (an unhealthy bacteria) was less common amongst babies whose mothers ate primarily organic foods.
  • At birth
    • During a vaginal birth, a baby is exposed to the microbes in mother’s vagina. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk.
    • When a baby is placed skin-to-skin on a parent, they are exposed to the parent’s skin microbiome. The baby’s skin, mouth, and digestive tract are “seeded” by whatever and whomever they first have contact with.
  • Through feeding
    • Breastmilk exposes the baby to more microbes. Several are gut microbes that influence digestion.
    • Breastmilk contains sugars (oligosaccharides) which are not digestible by babies, and whose role appears to be to nourish / feed a healthy microbiome in baby’s gut. These are also referred to as prebiotics. By helping healthy bacteria to grow, there is less room for unhealthy bacteria.
    • When solid food is introduced, the microbiome begins to evolve to a more adult-like combination of microbes.
  • Through the environment
    • As baby is held by various people, their microbiomes influence it.
    • As the baby starts to explore his world, crawling on the floor, playing outdoors, petting animals, and putting everything in his mouth, his microbiome shifts and evolves, becoming quite diverse by age 3. The “hygiene hypothesis” states that babies who are exposed to more symbiotic organisms have lower risks of asthma and allergies, and stronger immune systems.

What can interfere with the establishment of a healthy microbiome?

  • During pregnancy and labor
    • Antibiotics given to mom can affect the mix of microbes in the placenta, amniotic fluid and vagina. This disrupted microbiome is inherited by the baby.
  • At birth
    • Babies born by cesarean, and thus not exposed to vaginal bacteria, are at increased risk of asthma, allergies, obesity, diabetes, and celiac disease. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown differences in their gut bacteria as much as seven years after delivery. (Salminen)
    • After cesarean birth, instead of skin-to-skin contact with the parents, the baby’s first exposures are to hospital bacteria and the bacteria of hospital staff. (Babies in NICU were found to be colonized by bacteria from the health care staff, from medical equipment, and from the counter-tops in the NICU. – Brooks)
  • Newborn care
    • After any birth, if baby is wrapped in a blanket, and placed on a clothed parent, rather than skin-to-skin, the transfer of skin microbes is not complete.
    • Early baths remove / reduce protective vernix, vaginal microbiome, and baby’s own newly seeded skin microbiome. Those are replaced by hospital microbes.
    • If baby is given antibiotics, it reduces microbial diversity, and the number of both harmful and helpful bacteria. The impact lasts over 8 weeks. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of antibiotics, or prolonged use, can have long-term side effects, increasing risk of obesity or inflammatory bowel disease in later life.
  • Feeding
    • Formula-fed babies (even those who just had short-term formula feeding in the first few days) had increased harmful bacteria and decreased helpful bacteria.

What can parents and health care providers do to foster a healthy microbiome?

  • During pregnancy:
    • A mother can increase exposure to diverse healthy bacteria. Taking probiotic supplements may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. (Research cited in Collado) You can eat probiotic foods which introduce healthy bacteria, such as fermented foods and foods with live cultures. And you can eat prebiotics – foods with oligosaccharides which feed healthy bacteria – see the list at the end of this article. (Reed)
    • Minimize exposure to unhealthy bacteria, such as food-borne illnesses.
  • During pregnancy and labor: Minimize exposure to antibiotics. If they are needed, consider consuming probiotics or prebiotics after the course of antibiotics is complete.
  • If baby will be delivered by cesarean, a baby’s initial seeding is from hospital bacteria and skin microbes rather than vaginal microbes. You can expose the baby to vaginal bacteria by swabbing. Although swabbing does not colonize the baby as well as vaginal birth, it helps. (Swabbed babies had twice as much maternal bacteria as babies who were born by cesarean but not swabbed. Babies who were born vaginally had six times as much maternal bacteria.) Here’s the process:
    • Sample mom’s vagina: make sure the mother is HIV-negative, strep-B negative, and has an acid, lactobacillus-dominated vagina.
    • Place sterile gauze in the mother’s vagina. Incubate gauze for one hour. Remove prior to surgery.
    • After birth, wipe baby’s mouth, face and hands with the gauze.
    • Note: If the caregiver will not do this procedure, the mother and partner can do it themselves.
  • After birth, baby should go straight onto the mother’s body, skin-to-skin. (Consider bringing a blanket from home to cover baby, rather than using a hospital blanket.)
  • In the first hours, encourage people other than the parents to look but not touch.
  • Wait 24 hours after birth to bathe the baby.
  • Feed baby only breastmilk for as long as possible.
  • If a breastfeeding mother develops mastitis or a yeast infection, ask a lactation consultant about treatment with lactobacillus probiotics.
  • Giving probiotics to a baby can treat antibiotic-induced diarrhea, prevent eczema, reduce colic symptoms, and possibly reduce obesity in later life. (Studies cited in Arrieta and Collado.)
  • Let your child explore their world, with plenty of time outdoors, digging in gardens, and exposure to animals, both pets and animals at petting zoos.
  • Offer your child diverse foods, including: fermented foods and foods with live cultures (Yogurt, buttermilk, sour cream, kefir, sauerkraut and other fermented vegetables, tempeh, miso, soy sauce, kimchi, dosas and sourdough breads, kombucha, etc.) and prebiotic foods that are high in oligosaccharides (onions, garlic, legumes,  asparagus, starchy vegetables like sweet potatoes, squash, turnips, parsnips, beets, and plantains)

Note: While many of those recommendations are supported by scientific research, not all have been adequately researched.

Here is a 2 page handout of this information to share with clients.

Sources:

To learn more about practically any topic related to the perinatal period, check out Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Gestational Hypertension Update

ACOG issued a report on Hypertension in Pregnancy in November 2013. Key points:

Proteinuria is no longer required for a diagnosis of preeclampsia – It can be diagnosed if mom has high blood pressure (gestational or chronic hypertension) plus

  • lowered platelets
  • impaired liver function
  • renal insufficiency
  • pulmonary edema
  • new onset of severe headaches or vision disturbances

Women with a history of early onset preeclampsia and preterm delivery may benefit from daily low-dose aspirin. None of these are recommended to reduce hypertension: low salt intake or vitamin C or E.

Mild gestational hypertension (BP 140/90) and mild preeclampsia is treated with: daily kick counts, twice-weekly blood pressure checks (at home or clinic), weekly blood tests and possibly fetal monitoring. (Note: not hypertensive medication.) Bed rest is not recommended, though some caregivers may recommend reduced activity and reduced stress. Ultrasounds may be done to assess fetal growth, and if IUGR is detected,more testing may be done.

Delivery at 37 weeks is recommended for all women with hypertension.

For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures.

If baby is past 34 weeks, they will deliver baby as soon as she is stabilized.

If baby is under 34 weeks, she will be transferred to a hospital with a NICU, given corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable.

Other indications for delivery, even before 34 weeks are: very low platelets, liver enzymes twice the normal value, increasing renal dysfunction, fetal growth restriction (under 5th percentile), very low amniotic fluid (AFI <5 cm).

For women with preeclampsia, cesarean need not be the presumed mode of delivery. Mode of delivery should be determined by gestational age, fetal presentation, cervical status, and maternal and fetal conditions.

Women who continue to have high blood pressure more than 24 hours after birth should avoid non-steroidal anti-inflammatories (e.g. ibuprofen) for pain relief.

Prenatal screening for birth defects

Birth professionals who have been in the field a long time are well acquainted with the diagnostic tests for Down syndrome and other conditions (amniocentesis and CVS) and the challenges of explaining to clients: “Before you have the test, think about what you’ll do if you have a positive result.” Over the past 15 – 20 years, there’s been huge improvements in screening tests for these conditions, and those need to come with their own patient education and precautions about how to respond to a “screen positive” result.

Vocabulary: Before we talk about the tests, let’s talk about some terms:

  • Screening test – assesses how likely it is that baby has the condition being tested for.
  • Diagnostic test – determines whether the baby actually has the condition.
  • False negative is the chance that a test will come up negative when the baby actually DOES have the condition being tested for. This is obviously distressing for parents if they had tests done and were told the baby was fine, and then discover at birth that it’s not as they expected. A test with a detection rate of 90% would catch 90% of the cases, and have a false negative rate of 10%.
  • False positive is the chance that a test will come up positive when the baby does NOT have the condition. This could lead someone to take actions or have procedures that are not necessary. (See below.)
  • Screening threshold or “cut-off” – the answer to a screening test is not really Positive or Negative / Yes or No. It’s really “If we say you’re screen positive, that means you exceed the threshold at which we think it’s a good idea for you to have diagnostic testing to determine for sure whether or not you have that condition. If we say you’re screen negative, that means we don’t think it’s worth having more testing because we don’t think it’s likely you have the problem.” For example, if a test showed you had less than 1 in 50 chance of a problem, then it doesn’t make to have a test that has a 1 in 20 chance of creating a problem.
  • It is helpful to learn from a caregiver not just the screen positive or screen negative answer, but also what are your chances. For example, they might say you’re screen positive for something if the cut-off was that your risk was greater than 1 in 200. But, if your risk is estimated at 1 in 190, the recommended diagnostic test is not that likely to show you have the condition (though it’s probably still a good idea to have it.) If your risk is estimated at 1 in 10, not only will they recommend that diagnostic test, but it’s pretty likely it will turn up positive.
  • Aneuplody. Chromosomal abnormalities, such as trisomy 21 – Down Syndrome and trisomy 18 – Edward syndrome.

Should anyone skip screening tests and go straight to diagnostic tests?

In the past, often the recommendation for amniocentesis was made solely on the basis of the mother’s age (typically, for those over 35). The risk of aneuplodies goes up with age, so caregivers recommended the test when her risk of having a baby with a chromosomal condition was greater than the risk of miscarriage caused by amniocentesis. (At that time 1 in 200 risk.) Age is no longer considered reason enough for diagnostic testing. Most caregivers recommend that first a pregnant person have a non-invasive screening test,and only do a diagnostic test if her risk is higher than the screening threshold.

Some women are considered high enough risk that they could go straight to the diagnostic testing. typically that’s: if the baby was conceived by IVF, if the woman or her partner has a history of a previous pregnancy with a chromosomal abnormality, or if both partners are carriers of a genetic condition that increases the risk of chromosomal birth defects.

What screening tests are available?

(Note: WordPress tables aren’t always easy to read, so here’s a PDF of the tables if you prefer to view that… )

Test Type of test When done What is test screening for? Detection rate and false positive rate for Down syndrome (DS) and neural tube defects (NFD) Turnaround time from testing to results
First trimester blood test Blood test 10 – 13 weeks, ideally at 10 Tests levels for PAPP-A and HcG. Down syndrome, trisomy 13 and 18 Blood test: 69% with a 5% FPR (SOGC)

 

Days
Nuchal translucency screening

(may also assess for presence or absence of nasal bone)

Ultrasound 11 – 14 weeks, ideally at 11 Measures the thickness of a clear space at the back of a fetus’ neck. Babies with chromosomal disorders, such as Down syndrome, accumulate more fluid in this area Ultrasound:

69 – 75%. FPR 5 – 8% (SOGC)

 

When combined with first trimester blood test:

82 – 87% (ACOG) 83%, 5% FPR (SOGC)

Immediate to days
Cell-free fetal DNA testing (e.g. MaterniT 21). Also known as non-invasive prenatal screening (NIPS). Blood test 10 – 13 weeks, ACOG recommends that it be done only if blood test or nuchal translucency showed high risk (there’s a discussion of this here…) Tests for placental DNA in mother’s blood. Screening for Down syndrome, other trisomies, and fetal sex aneuploidies. Also reveals gender and baby’s Rh factor. 99% / FPR 0.2% (Source) 7 – 10 days
Second trimester blood test (quad screen) Blood test 16 – 20 weeks ideally at 16 – 17 Tests levels of alpha-fetoprotein (AFP), estriol, human chorionic gonadostropin (hCG) and inhibin A. Screen for Down and Edwards, plus neural tube defects. 81% (ACOG)

75-80%, FPR 3 – 5% (SOGC)

 

For neural tube defects: 71 – 90% with 1- 3% FPR (SOGC)

7 – 10 days
Second trimester ultrasound Ultrasound scan 18 – 22 weeks Screen for neural tube defects and other anatomical defects For NTD: 68 to 86% for neural tube defects (SOGC2) Immediate to days

Often test results are combined to increase accuracy. Here are some of the common combinations.

Type Combines results from Detection rate and FPR for Down syndrome When are results reported to parents
Integrated screening First trimester blood test, nuchal translucency ultrasound, and second trimester quad screen 94 – 96% (ACOG)

85 – 87% with FPR of 0.8% to 1.5% (SOGC)

92% with 3% FPR (Quest)

Results not reported until after the second trimester results are in
Serum integrated screening First trimester blood test and second trimester quad screen 85 – 88% (ACOG)

88, with 6% FPR (Quest)

Same as above
Sequential integrated screening First trimester blood test and nuchal translucency scan are done.

Then second trimester screening or diagnostic testing, depending on risk level.

95% (ACOG)

92%, with 4% FPR (Quest)

After first trimester tests, if risk is high, diagnostic testing is recommended. Otherwise, second trimester screening is done before results are reported
Stepwise sequential First trimester blood test and nuchal translucency scan.

Then no further testing, second trimester screening, or diagnostic testing, depending on risk level.

95% (ACOG)

92%, with 4% FPR (Quest)

After first trimester tests, results are reported. If high risk, diagnostic testing is recommended. If moderate risk, second trimester screening is recommended as a follow-up. If low risk, no further testing.

Explaining Test Results to Clients

It’s very important for expectant parents to understand the difference between a screening test and a diagnostic test, and important to understand what false positives are.

If a screening test comes up positive, one of the first questions an expectant parent should ask their caregiver is: how certain are we that this test is correct? Are there other tests I could have to confirm this?

They can ask their caregiver to explain the false positive rate – the chance that although they screened positive, the baby does not actually have that defect.There’s two sides to that… 1) what’s the false positive rate for all people tested and 2) amongst people who test positive, what percent of those are false positives and what percent actually have the condition. (This latter number is called the positive predictive value of a test.)

For example, all the advertising for cell-free fetal DNA testing will talk about how it will detect 99% of cases, and has a false positive rate of 0.2%. This is true, and MUCH more accurate than other screening methods. But it’s still not perfect. One study showed that of 1909 patients screened, most people screened negative. 11 screened positive. After diagnostic testing, it turned out that 5 of the 11 babies had Down syndrome and 6 did not. So, for the whole population screened, only 0.3% were false positives. But of those who screened positive, 55% of those were false positives. (Source)

In another study of cell-free fetal DNA testing, of 41 patients who screened positive, 38 were true positives. 3 were false- positives. (Source) Better… but still 7% of the people who screened positive were not.

A parent who has heard the 99% accuracy advertising may not be aware of the subtleties of all this, and may not fully understand what a screen-positive result means.

The rates of false positives with other testing are much higher than that, and even more important for expectant parents to understand in order to interpret what a “screen positive” result means. (Note: screening results should not just be given as “positive” or “negative.” They should also be given in terms of probability. For example,  “you have a 1 in 150 chance of this condition.” The expectant parents can ask for this information if it was not given to them clearly.)

Responses to a False Positive Test

In the case of Down syndrome, some parents might use a positive screening test result as a reason to spend the rest of their pregnancy learning about Down syndrome and lining up resources to help them care for their child. If they found out at birth that the test was a false positive and the baby did not have Down syndrome, it is likely they would be relieved not to need to use those resources.

However, a majority of expectant parents choose to terminate a pregnancy if the baby is diagnosed with Down syndrome.

The Society for Maternal-Fetal Medicine states

all positive cell free DNA screening results require confirmatory diagnosis before an irreversible action, such as pregnancy termination, is undertaken.   (Source)

However, 6 – 17% of those who screen positive with cell-free fetal DNA testing are choosing to terminate the pregnancy based on those results alone without any further testing.

Before getting testing, and definitely before getting results, it is very helpful for expectant parents to understand that a screening test is not absolute, and what their options will be. If they screen positive, they could choose diagnostic testing to confirm the diagnosis – CVS can be done at week 10 – 12, in time for a first trimester termination decision. If for some reason, CVS is not an option for the parents, another option could be additional screening tests. The cell-free fetal DNA testing, first trimester blood tests, and nuchal translucency look at separate factors, and having results from more than one test could be illuminating information to have before making an irreversible decision.

Learn more

An interesting article on this topic is Oversold and Misunderstood.

Or click on any of the links above…

Prolonged Labor: New definitions

A 2010 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US, and a 2014 consensus statement from ACOG and Society for Maternal Fetal Medicine argue for a re-definition of what should be considered prolonged labor, and when intervention should happen.Here is a brief summary:

Phase Definition Friedman / standard practice Consortium on Safe Labor / ACOG & SMFM
Latent When mother perceives regular contractions Prolonged if over 20 hr in nullips, and 14 in multips A prolonged latent phase (e.g. over 20 hours) is not an indication for cesarean. If it is not treated, women may stop contracting or may eventually reach active labor. If treated with AROM and Pitocin, most will enter active labor.
Active When rate of dilation significantly increases. Protracted = slow. Arrest = progress has stopped. Protracted if < 1.2 cm/hr for nullips and < 1.5 for multips. Typical dilation ranged from .5 cm/hr to .7 for nullips, and from .5 to 1.3 for multips. From 4-6 cm, dilation is slower than historically described. After 6 cm, progress speeds up. Protracted labor should not be diagnosed before 6 cm. After 6 cm, protracted labor is not an indication for cesarean as long as there is progress, even if it’s slow.
Arrest if no change in 2 hours (after 4 cm and with adequate contractions) Cesarean for arrest should only be for women who are beyond 6 cm with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity or, for those with inadequate contractions, at least 6 hours on Pitocin.
Second Stage When cervix is fully dilated through delivery. (Note: some researchers argue we should define it as when the mother develops the urge to push) Typical practice has been to limit nullips to three hours, and multips to two, even with epidural. (ACOG) Parity, delayed pushing, use of epidural analgesia, mom’s BMI, birth weight, and OP position affect length of pushing. (e.g. pushing is one hour longer on average with epidural). No absolute maximum length of pushing has been defined. Arrest should not be diagnosed until after 3 hours pushing for a nullip, and 2 for multip – longer if she has an epidural or diagnosed malposition. In case of prolonged second stage or arrest of descent, vacuum, forceps, and manual rotation of the fetus should be considered prior to cesarean.

In an induced labor, latent phase may go 24 hours or longer. It should not be considered a “failed induction” until Pitocin has been administered for at least 12 – 18 hours after AROM.