Why is induction recommended over age 35?

What is induction?

Induction is using medical means to start a labor that hasn’t started on its own. (Learn more about methods of medical induction.)

Induction may be recommended if: the baby is not growing well or thriving in utero, the parent has an illness that is worsening (such as diabetes or hypertension), the baby is overdue, or the bag of water broke and labor hasn’t started on its own. There is also a category called elective induction, which is being induced for non-medical reasons, such as wanting to control the timing of the birth or being tired of being pregnant.

As with all medical interventions, induction has benefits and risks. If there is a clear medical indication that delivering the baby sooner rather than later would have more benefits than the risks of induction, then induction is recommended.

How Common is Induction

Induction rates rose steadily from 1990 to 2010 ((source for chart), then somewhat plateaued, following some active campaigns to reduce elective induction, such as AWHONN’s “Don’t Rush Me – Go the Full 40” about the physiologic benefits of full-term pregnancy, and an editorial in American Family Physician about stopping elective induction before 39 weeks to reduce unintended harms to babies not yet ready for birth.

In 2014, ACOG’s recommendation was to induce at 41 weeks.

That changed after the results of the ARRIVE trial were published in 2018. The ARRIVE trial was considered a high quality randomized controlled clinical study (although ACNM did caution against over-generalizing the results, this article addresses methodology concerns, and this infographic addresses how the results might not apply to all people.)

The results of that trial (and other trials) were that elective induction decreased the risk of cesarean. (Rates were 18.6% in the induction group versus 22.2% in those assigned to the wait for labor to begin group.) The induction group was also less likely to have gestational hypertension / preeclampsia (9% vs 14%).

ACOG (the American College of Obstetrics and Gynecology) issued guidance in response, and a joint statement from ACOG and SMFM (Society for Maternal Fetal Medicine) said ““ACOG and SMFM have … determined that it is reasonable for obstetric care providers to offer an induction of labor to … Women who are planning their first delivery, are healthy and have no medical or obstetrical complications… who are 39 weeks pregnant and had an ultrasound performed early in the pregnancy to confirm dating.”

In other words, elective induction at 39 weeks is back on the table as an option after 2018. In 2016, 24.5% of US births were induced. In 2021, 32% were.

There was not universal agreement with this recommendation: WHO says there’s insufficient evidence to recommend elective induction before 41 weeks and NICE says induction should be offered at 41 weeks. SOGC (Society of Obstetricians and Gynaecologists of Canada) said we shouldn’t recommend induction just to reduce cesarean risk, ACNM (American College of Nurse Midwives) said there are benefits of spontaneous labor and risks of induction and other effective ways to reduce the risk of cesarean (e.g. doulas, midwifery care, movement during labor)

Is induction recommended for parents over age 35?

In a 2022 consensus statement on Pregnancy after Age 35, ACOG made a more explicit move to recommend induction for older moms: “We recommend proceeding with delivery in well-dated pregnancies at 39 0/7–39 6/7 weeks of gestation for individuals with anticipated delivery at age 40 years or older due to increasing rates of neonatal morbidity and stillbirth beyond this gestational age.” A randomized trial of induction at 39 weeks for women over 35 also indicated no increased risk of cesarean and no short-term adverse effects on mothers or babies.

Stillbirth Risk

How high is the risk of stillbirth for mothers over age 35? How much higher is it if the pregnancy continues past 39 weeks?

This chart (source) compares the risk of stillbirth per 10,000 pregnancies during each week of pregnancy for pregnant people under age 35 vs. for people 35 years or older. It is clear that the risk does increase each week, and that it is much higher after age 35.

Weeks	<35 yrs	>35 years
39	3.9	5.0
40	6.8	10.0
41	8.5	15.4
42	28.2	32.5

[Note: if you’re a pregnant person reading this, I know that numbers like this can be frightening. Take a deep breath, and flip the numbers: even a rate like 32.5 per 10,000 means that 9,967 out of 10,000 will NOT have a stillbirth in week 42.]

Benefits and Risks of Induction

So, the research cited above indicates that inducing at week 39 may reduce the risk of stillbirth, possibly reduce the risk of cesarean, and can reduce the chance of hypertension or diabetes worsening.

What else does the research show us about the risks and benefits of induction? A Cochrane review, which mostly looked at induction at 41 weeks vs. continuing to the 42nd week, showed:

• fewer perinatal deaths / stillbirths
• better Apgar scores at birth, and fewer NICU admissions
• little to no difference for: perineal tears, postpartum hemorrhage, breastfeeding at discharge

But, induction is not innocuous. What are the risks or tradeoffs of induction?

• Medicalization: An induced birth is inherently more medicalized than waiting for labor to begin spontaneously – continuous fetal monitoring is required, IV fluids are common – these two factors can also reduce the birthing parent’s ability to move around and use natural coping techniques. Plus they may not be allowed to eat solid foods. ACNM summarizes this as “Based on US practices, induction may not be a desirable option for those persons who prioritize a… low-intervention birth experience.”
• Not waiting for baby to trigger labor: In the final weeks of pregnancy, babies are gaining immunities, gaining weight, increasing their brain development and maturing their lungs. When the baby’s lungs are mature, that triggers hormones that trigger labor. If we induce labor before that happens, there is a chance that baby is not as ready for birth as they would be if labor started spontaneously. At 39 weeks, many babies are totally ready to go, but not all.
• Longer labor / hospital stay: In late pregnancy, prostaglandins cause the cervix to ripen and thin. If we jumpstart labor, the body may not have made these preparations for labor. So, with an induction, it can take a while to get labor started. It might take 12 – 24 hours, or longer if cervical ripening is needed. If an induction takes too long, cesarean may be recommended.
• Changes to the hormonal dance of labor. Typically, in late pregnancy, the uterus becomes more sensitive to the oxytocin hormone which causes labor contractions. During labor, as the cervix stretches, pain receptors in your brain release endorphins, a natural painkiller more effective than morphine. When labor is induced with Pitocin (synthetic oxytocin), your body does not produce as much natural oxytocin and does not produce as much endorphins, so you miss out on that natural pain relief. (Learn more about the hormonal differences.)
• More Pain? I have not been able to find any research comparing average pain levels in an induced labor versus a spontaneous labor. (Nor much on maternal satisfaction, although it seems to me that both of these things are important factors that we should be researching.) Anecdotally, many people seem to experience more pain in an induced labor. That may be partially due to the fact that a natural labor builds intensity gradually, allowing you to adapt and find coping techniques thar work for you. With a Pitocin induced labor you jump straight into long, strong contractions. (3 – 4 contractions in ten minutes, each lasting 40 – 60 seconds.)
• Induction can cause variations in the baby’s heart rate, which can lead to additional interventions.

Questions to Ask

If your care provider has offered induction at 39 weeks, here are some questions you can ask yourself or them to decide if it’s right for you:

• Are there other ways to reduce risk of stillbirth or monitor for other problems with my baby?
  • Learn about fetal movement tracking – paying attention to your baby’s kicks can reassure you that all is well.
  • Ask about tests to monitor baby’s well-being, such as the non-stress test, biophysical profile
• Are there other ways to reduce the chance of cesarean birth? There are: having continuous labor support (especially from a doula), upright positions and movement during labor and birth, choosing a midwife rather than an OB as your care provider and waiting until 6 cm dilation before being admitted to the hospital are just a few. (Learn more.)
• Are there non-medical ways to get labor started? Possibly sexual intercourse, definitely breast / nipple stimulation, possibly acupuncture, herbs, or castor oil. If the need to start labor is urgent, your care provider may tell you these aren’t effective enough. But, if you have some time, they may say these are options you could try.
• How likely is induction to be successful? If you’re almost ready to go into labor on your own, induction will be faster and more effective than if you’re not. So, learn about the Bishop score which measures ripening and effacement of the cervix and ask your caregiver what your score is. Starting Pitocin only when you have a Bishop score of 4 increases the chance of cesarean. Waiting for your cervix to get ready naturally, or using cervical ripening methods to get your Bishop score up to 8 or higher (if it’s your first baby, 6 or higher if you’ve given birth before) will increase the chance of a successful induction. (Learn more about this and other factors here.)

How to have the best possible induction?

If you do decide that induction is the best answer for you, here’s how to increase your satisfaction:

• Ask your care provider what method(s) will be used, and learn more about them.
• Be prepared for a long process. Pack some entertainment options and plenty of patience. Consider having an extra support person so they can swap off or take breaks.
• Eat before your induction begins, as you may not be able to eat after it begins.
• Create an environment that is as calm and soothing as possible: perhaps dim light, music playing, favorite items to wear or look at or hold.
• Try to be as mobile as possible (this helps baby rotate and descend which helps labor to progress.) For example, try sitting on a birth ball or in a rocking chair rather than lying in bed.

Learn more about interventions in maternity care and making informed choices in episode 8 of the Transition to Parenthood Podcast, or by reading Pregnancy, Childbirth, and the Newborn: The Complete Guide.

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Changes in Lactation Advice

If, like me, you’ve been teaching birth education for many years, it’s important to keep up on how advice changes or evolves as new information is learned. There have been huge shifts in lactation advice over the past 10 or so years, so I will summarize those here to the best of my understanding. I am not a lactation consultant and never have been, so IBCLC folks, please let me know if I’ve got anything wrong or am mis-interpreting the data.

I have created a PowerPoint curriculum for a breastfeeding class that you can download, which reflects this updated advice.

Antenatal Milk Expression

We once advised parents against a lot of nipple stimulation during pregnancy, concerned that it might start labor. That’s changed. It is now reasonable to recommend hand expressing colostrum started at week 36 of pregnancy unless care provider considers someone high risk for preterm labor. It can help milk volume increase sooner after birth. Those who might want to express: people with diabetes (any type), PCOS, high blood pressure, obesity, breast hypoplasia, history of low supply or previous breast surgeries. It may also be helpful if they are expecting multiples, or a baby with a cleft lip, palate, IUGR, Down Syndrome or other complications that might lead to them needing special care after birth and increase the chance that formula or supplemental feeding would be recommended. It can also be helpful for any expectant parent to help them feel more confident about breastfeeding.

I also do feel that overall, we are seeing more attention on hand expression than in the past. There are helpful videos showing how to do hand expression at: https://med.stanford.edu/newborns/professional-education/breastfeeding/hand-expressing-milk.html  and https://www.unicef.org.uk/babyfriendly/baby-friendly-resources/breastfeeding-resources/hand-expression-video/.

Learn more:

• Patient Education: University of Washington Medical Center Lactation Services, “Expressing Milk Before Giving Birth,” University of Washington Medical Center. (2019) https://healthonline.washington.edu/sites/default/files/record_pdfs/Expressing-Milk-Before-Giving-Birth.pdf
• Research showing no risk to antenatal milk expression: Della Forster, et al, “Advising women with diabetes in pregnancy to express breastmilk in late pregnancy (Diabetes and Antenatal Milk Expressing [DAME])” Lancet, 389: 10085 (2017). https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)31373-9/fulltext

Laid Back Position

When I first trained 20+ years ago, we were teaching cradle, cross-cradle, football and side-lying positions. About 10 years ago, I started hearing more about sitting up / straddle hold and more about the laid-back position. (Laid-back is a semi-reclined position, like resting on a deck chair by the pool.) Now, most research and practice seems to be leaning toward this (combined with infant-led latch) as the best option.

Colson describes the Biological Nurturing approach: “Mothers lean back and place the baby on top so that every part of the baby’s body is facing, touching, and closely applied to one of the mother’s curves… Nursing in a laid-back position… promotes neonatal locomotion by releasing up to 20 primitive neonatal reflexes which act as breastfeeding stimulants. BN is quick and easy to do; there is no lining up of body parts and no “correct” breastfeeding procedures…” Note: in this position, the parent does not support her breast, and gravity holds baby in place, so it can free up one or both hands.

You can find videos with more information about how to use the laid-back position and baby led latch at Laid-Back Breastfeeding: https://www.biologicalnurturing.com/sample-of-biological-nurturing/ and https://raisingchildren.net.au/newborns/breastfeeding-bottle-feeding/how-to-breastfeed/attachment-techniques

This approach significantly reduces cracked and sore nipples. (Milinco, Wang.)

Learn more:

• Suzanne Colson, “Biological Nurturing: the laid-back breastfeeding revolution,” Midwifery Today 101: 9-11. (2012) https://www.midwiferytoday.com/mt-articles/biological-nurturing/
• Zhi Wang, et al, “The effectiveness of the laid-back position on lactation-related nipple problems and comfort: a meta-analysis,” BMC Pregnancy Childbirth, 21(1): 248. (2021) https://pubmed.ncbi.nlm.nih.gov/33761882/
• Mariarosa Milinco, “Effectiveness of biological nurturing on early breastfeeding problems,” International Breastfeeding Journal, 15:21. (2020)  https://internationalbreastfeedingjournal.biomedcentral.com/articles/10.1186/s13006-020-00261-4

Baby-Led Latch / Symmetry?

There is also an increased emphasis on letting the baby take the lead in latching on. This increases duration of exclusive breastfeeding, decreases nipple pain. (Baby-Led Latch: Caixin Yin, et al. “Effect of Baby-Led Self-Attachment Breastfeeding Technique in the Postpartum on Breastfeeding Rates,” Breastfeeding Medicine, 16:9. (2021) https://pubmed.ncbi.nlm.nih.gov/33913745/). This video illustrates an infant led latch. https://www.breastfeeding.asn.au/resources/baby-led-attachment

There is a lot less talk about the old method (using U-holds and C-holds to shape the breast like a sandwich before latching, tickling baby’s lip till mouth is open wide, then rapid arm movement to get them to latch on). It’s more about just bringing baby’s nose near the nipple, touching the nose or upper lip with the nipple so the baby tilts up, opening mouth wide and taking a big mouthful of nipple.

Jack Newman describes the ideal latch as asymmetrical, where more areola is covered by the bottom lip than the top, and where the chin indents the breast, but the nose never quite touches the breast. (When Baby is Latching Well: Jack Newman and the International Breastfeeding Center. “Latching and Feeding Management”, 2021. https://ibconline.ca/information-sheets/latching-and-feeding/)

Conversely, Pamela Douglas has a very different view based on her reading of ultrasound images of latch. She prioritizes a symmetrical face-bury, where the nose is against the breast. She also says there should be no visible lips, because if you can see lips, there is drag on the nipple which causes pain. (This idea of neutral lips is different than the flanged / “fish lips” I was once taught.) She has a video at https://possumsonline.com/video/how-babies-breastfeed that highlights her concept of gestalt breastfeeding. (Pamela Douglas, “A brief gestalt intervention changes ultrasound measures of tongue movement during breastfeeding,” BMC Pregnancy Childbirth, 22:94. (2022) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8808964/ see additional file 1 in that article for details on gestalt method.)

Nipple Soreness

Of course, a good position and good latch continue to be key to reducing nipple soreness. Where I used to see recommendations that if the latch isn’t good, you should break suction and try again, more recommendations now say that most latch issues can be fixed by: tucking baby in closer to the parent so there’s no gap between them and making sure baby is aligned (ears, shoulders and hips in a line.) “Adjust the body, adjust the breast, adjust the baby” – microadjustments in each can fix the latch.

Yeast Infection?

Some breastfeeding parents with persistent nipple pain during and between feeds also may have shiny pink nipples with white flakes of skin. In the past, this was often diagnosed as a yeast infection and treated with antifungal medications. But there’s no evidence that candida causes the nipple pain, and antifungal treatments are no more effective at treating it than doing nothing.

• Pamela Douglas, “Overdiagnosis and overtreatment of nipple and breast candidiasis,” Women’s Health, 17. (2021) https://pubmed.ncbi.nlm.nih.gov/34269140/.
• Esther Jimenez, et al “Mammary candidiasis: a medical condition without scientific evidence?” PLoS One, 12:7. (2017) https://pubmed.ncbi.nlm.nih.gov/28704470.
• Ryan Colton Betts, et al. “It’s Not Yeast: Retrospective Cohort Study of Lactating Women with Persistent Nipple and Breast Pain,” Breastfeeding Medicine, 16:4. (2021) https://pubmed.ncbi.nlm.nih.gov/33305975/

Ointments?

In the past, I have been told to recommend lanolin, hydrogel dressings and other moist wound healing approaches. Current research indicates that hydrogel, lanolin, antifungal creams, Vaseline, expressed breast milk and all-purpose nipple ointment are no more effective at reducing nipple pain than it is to do no treatment at all, and some may actually delay healing due to moisture related damage.

Most nipple pain reduces to mild levels by 7 to 10 days postpartum no matter what you do or don’t do.

• Nipple Pain section: Pamela Douglas, “Re-thinking lactation-related nipple pain and damage” Women’s Health, 18. (2022) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8966064/
• Nipple pain ointments: Cindy-Lee Dennis, et al, “Interventions for treating painful nipples amongst breastfeeding women”, Cochrane Database. (2014) https://pubmed.ncbi.nlm.nih.gov/25506813/

Anatomy / Engorgement / Mastitis

We have a new understanding of breast anatomy based on ultrasound imaging vs. cadaver study as past models were based on. A summary is here: “Anatomy of the Lactating Breast,” Medela. https://www.medela.com.au/breastfeeding-professionals/research/breast-anatomy. And the research: D. T. Ramsay et al., “Anatomy of the Lactating Human Breast Redefined with Ultrasound Imaging,” Journal of Anatomy 206, no. 6 (2005): 525–34. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1571528/

Here is an image from the Ramsay article with an artist’s impression of breast anatomy – note how this differs from older illustrations showing “bunches of grapes” in the alveoli and lactiferous reservoirs.

We have learned there are not sinuses / reservoirs that store milk in the breast. Only about 1 – 10 ml can be expressed before a let-down. So, getting a good latch so you get a good letdown is essential.

Plugged Ducts?

We used to teach about plugged ducts, saying that milk was clogging a duct, and we had all sorts of advice for placing baby’s mouth so it lined up with the lump, and massaging as the baby nursed, or using a vibrating device like an electric toothbrush to relieve that. Based on new learnings about breast anatomy, clogged ducts are not actually possible. “Ducts in the breast are innumerable and interlacing and it is not physiologically or anatomically possible for a single duct to become obstructed with a macroscopic milk ‘‘plug.’” (Mitchell, et al) And deep tissue massage to relieve a clogged duct can worsen edema, inflammation and pain.

Parents should be taught that slightly lumpy breasts are normal, and that localized inflammation is just that, and can be treated similar to how we treat engorgement.

Engorgement

For engorgement, ice and ibuprofen to reduce pain and inflammation are recommended. Cabbage leaves are no more effective than ice. Heat (e.g. warm compresses and showers) may provide comfort but can also worsen symptoms. If using hand expression or pumping to treat engorgement, express only enough milk for comfort and/or to help baby latch on. Over-pumping can worsen engorgement.

Mastitis

If the symptoms are pain, redness and a short-duration fever, that is considered inflammatory mastitis, and likely not an infection. It can resolve on its own with continued breastfeeding, rest and plenty of fluids.

If the fever, pain and inflammation continue for more than 24 hours, it could be bacterial mastitis, an infection. They should check with a lactation consultant or care provider – antibiotics may be recommended at that point.

To learn more about all the topics in this section, read: Katrina Mitchell, et al, “Academy of Breastfeeding Medicine Clinical Protocol #36, The Mastitis Spectrum,” Breastfeeding Medicine, 17:5. (2022) https://www.bfmed.org/assets/ABM%20Protocol%20%2336.pdf

Paced Bottle Feeding

When giving a bottle to any baby, but especially one who is primarily breast-fed, we can use a method called Paced Bottle Feeding. Many parents hold the baby horizontal on their back and the bottle vertical, so the nipple is filled with milk. Baby takes in a lot of milk really fast this way, which might seem efficient, but can lead to over-feeding or increased spit up. It also teaches a baby to expect this fast flow and “flow preference” might be the true “nipple confusion” as baby gets used to fast flow. With paced bottle feeding, instead we hold the baby vertical and the bottle horizontal so they’re taking milk in more slowly. When they pause a bit in sucking (as they would at a breast), you can tilt the bottle completely horizontal to give a rest. When they resume sucking, you tilt it up just a bit so they get more milk. Check out these videos: https://www.youtube.com/watch?v=OGPm5SpLxXY and https://www.youtube.com/watch?v=TuZXD1hIW8Q.

Comments

If you have comments on anything you read here – about any surprises you see, or any misinterpretations you want to clarify, please comment below!

Incorporating Video into PowerPoint

I know many educators use videos from YouTube or elsewhere on the internet during classes. I always want to have my videos downloaded so that I don’t have to count on the internet working when I want to show the video. I also like to trim them to show exactly the clip that I want my students to see. Here’s how to set up a PowerPoint so all your videos are ready to go.

Downloading what you need

If you want to download videos from YouTube or elsewhere on the internet, YTD downloader is a free software program that enables you to do that easily. (You could also check out 4K Video Downloader as an option.) Please be aware of copyright law and consider whether you are legally able to use that content for your purposes.

Gathering Recordings in one place

Make  sure that you have saved all the video you will use in a presentation IN THE SAME FOLDER as where you’ve saved the presentation.  We will only put a LINK to the video in the slide deck. If we insert the whole video in the slide deck, the PowerPoint becomes a massive file and has problems loading. Having the video in the same folder makes it more likely the link to the video will work as you intend.

If you’ll upload your work to google drive for someone else to use, make sure that when you upload the PowerPoint, you also upload all the videos  to the SAME FOLDER as the presentation they’re associated with and that they know they’ll need to access both the slide deck and the videos for the presentation.

Inserting video recordings – .mp4, .mov

Go to the slide where you want the video, then choose the insert menu, then choose “insert media” (on the right hand side of the screen) then choose video, then choose video on my PC. Find the file you want, select it, and then in the bottom right where it says “insert”, click on that little triangle to get the drop-down menu. Choose “insert link to file” instead of “insert” video. This will help keep your PowerPoint a manageable size – if you insert the whole video, the PowerPoint is huge, and that can cause problems with it running smoothly or being easy to upload.

Now click on the video image on the slide, and the playback menu will appear at the top. In the playback menu, choose “start automatically”. Set the volume to medium. (You’ll absolutely want to test the volume later to see how it sounds to your meeting participants, especially if you’ll use it on Zoom. Sometimes what sounds quiet to you will blast them.)

You’ll often want to choose “play full screen” but not always (like if you want to type lyrics on the slide to appear with the video of a song) and you may want to “hide while not playing” – that’s up to you.

If you want to show just a portion of the video, then click on “trim”. It will let you choose to start exactly where you want them to start, and end where you want to end.

When you’re done, run through the slide show to make sure it performs as you expect it to. I usually insert a slide before the video that has an image from the video and properly credits it. This gives me a chance to set up the video – what will we see, what should you pay particular attention to, why am I showing it. Then, when I’m ready I advance to the next slide and the video begins.

Key Research and Guidelines 2015-19

At the 2019 Lamaze Conference, Deborah Amis presented a Research Update. I watched it today – it is available at that link for $20. It is an excellent review of the most important research and research-based guidelines issued between 2015 and 2019. I will list here some of the items she covered, with links and a few notes, but I’d encourage you to watch the recording for all the details.

Here are the key research and guidelines you should be aware of – just listed in the order she covered them in her presentation.

WHO Statement on Cesarean Section Rates (2015) – “at a population level, caesarean section rates higher than 10% are not associated with reductions in maternal newborn mortality rates.” Here is a companion FAQ.

California Maternal Quality Care Collaborative (CMQCC) Toolkits. Each includes best practice tools and articles, care guidelines, and implementation guides. Toolkits include: Substance Exposure; Maternal Sepsis; Venous Thromboembolism, Cardiovascular Disease in Pregnancy, Obstetric Hemorrhage, Preeclampsia, Reducing Elective Deliveries before 39 weeks, and Toolkit to Support Vaginal Birth and Reduce Primary Cesareans and Implementation Guide, 2016

AJOG April 2019 – Safety Assessment of a Large Scale Improvement collaborative to reduce nulliparous cesarean delivery rates. Study of CMQCC efforts to reduce primary cesareans. Data from 119,000 births. NTSV cesarean rate fell 29.3 to 25% between 2015 and 2017, with no increase in poor maternal or neonatal outcomes.

AIM – Alliance for Innovation on Maternal Health – Patient Safety Bundles – “… a small, straightforward set of evidence-based practices … proven to improve patient outcomes.” Not new ideas, but a standardized approach for delivering well-established, evidence-based practices to be implemented for every patient, every time. Topics include: Safe Reduction of Primary Cesarean; Reduction of racial disparities; Obstetric Hemorrhage, Severe Hypertension in Pregnancy, Obstetric Care for Women with Opioid Use Disorder, Cardiac Conditions; Postpartum Discharge Transition, and more.

Lancet: Optimizing Caesarean Section Use – 2018 series. Reviews the global epidemiology and disparities in caesarean section use, as well as the health effects for women and children, and lays out evidence-based interventions and actions to reduce unnecessary caesarean sections.

AWHONN Save your life: get care for these POST BIRTH warning signs. Patient handout.

ARRIVE Trial. Study with 6000+ participants showed elective induction at 39 weeks yielded a cesarean rate of18.6% vs. expectant management rate of 22.2%, a 16% reduction in relative risk. Leads to ACOG Guidelines that “it is reasonable… to offer elective induction of labor to low-risk nulliparous women at 39 weeks gestation.” Also read Rebekka Dekker’s article on this in Evidence Based Birth, which includes a link to a one-page patient handout, which includes other ways to reduce c-s risk: midwifery care, continuous labor support, intermittent auscultation, etc. Dekker also links to responses to the ARRIVE trial and ACOG guidelines from ACNM and CMQCC. Summaries of the AWHONN response and SOGC response are on this Talking Points handout from Amis’ The Family Way.

JAMA 2018 – Effect of Immediate vs Delayed Pushing on Rates of Spontaneous Vaginal Delivery Among Nulliparous Women Receiving Neuraxial Analgesia. Shows no difference in perineal lacerations, endometritis, severe hemorrhage, transfusion, NICU, neonatal morbidity. Immediate pushing group had shorter second stage (mean 102 minutes vs. 134 minutes), decreased chorioamnionitis, decreased hemorrhage, decreased neonatal acidemia, decrease suspected sepsis. Delayed pushing had less 3^rd and 4^th degree tears; active pushing was 75 minutes vs 84. ACOG Committee Feb 2019 – “data support pushing at the start of the second stage of labor for nulliparous women receiving neuraxial analgesia”.

AWHONN’s Second-Stage Labor Practices Reduce Cesarean Births and Newborn Harm (2019) has 13 evidence-based, second-stage labor practices. (Article on Implementing Guidelines.) Provide info about both immediate and delayed, but a key guideline is respecting spontaneous urge to push.

ACOG – Approaches to Limit Intervention During Labor and Birth – 2017 and 2019. Also read Sharon Muza’s follow-up articles on these guidelines: Sharing ACOG’s Guidelines with Clients and her Research Update – ACOG Advises No Longer Laboring Down and Support of Family-Centered Cesareans. Guidelines include: laboring at home till active labor; doulas, intermittent monitoring, reducing AROM, using coping techniques and positions; oral hydration; pushing with urge to push, immediate pushing at 10 cm with epidural, and family-centered cesareans.

Physiologic basis of pain in labour and birth – Bonapace… Buckley. (SOGC) “…scientific literature supports the use of nonpharmacological approaches to pain management … due to benefits for the mother and child, including a reduction in the need for obstetrical interventions, labour augmentation, or Caesarean section.” Addresses Gate Control, Diffuse Noxious Inhibitory Control (counter-irritants), Central Nervous System control, continuous labor support, and the hormones of labor.

International Childbirth Initiative – 12 steps to safe and respectful motherbaby- family maternity care. Includes: affordable care, midwifery model, continuous support, non-pharmacological first option, benefit/risk considerations, and baby-friendly practices. (It’s similar to the Ten Steps of the Mother Friendly Childbirth Initiative from CIMS, from 1996.)

WHO update 2015 – Pregnancy, childbirth, postpartum and newborn care: A guide for essential practice. Includes 56 recommendations for labor and birth. Many are same as 1996 – midwifery, intermittent, food and fluid; mobility & upright positions, following urge to push, skin-to-skin. New: active labor begins at 5 cm; during active, may progress more slowly than 1 cm/hr; no interventions to speed up labor before 5 cm; delay cord clamping at least one minute; delay bath 24 hours.

AIMM study – Vedam et al 2018 – Mapping integration of midwives across the United States: Impact on access, equity, and outcomes. States with a better integration of midwives into the health care system had more spontaneous births, VBACs, breastfeeding and at 6 months; less interventions; less preterm birth, LBW, neonatal deaths.

Consortium for Safe Labor? I didn’t get the full citation on this… but Amis summarized that hospitals with physicians AND midwives had lower rates of induction, augmentation, c-s; had birth at a later gestational age, more NICU admissions; no differences in adverse neonatal outcomes or Apgars.

Midwifery Care for Low Income Women – fewer small for gestational age; fewer preterm, fewer LBW – “women who are more vulnerable benefit from the care of a midwife.” Study.

Listening to Mothers in California 2018 – survey of 2539 participants. Summarizes survey result data, but also includes quotes from parents who describe their maternity care experiences. Asked about choice of care provider and birthplace, maternity care preferences vs. care received, respectful and disrespectful treatment, and racial disparities. Here are a couple of interesting visuals from Listening to Mothers.

Guide to Zoom

Many childbirth educators are now teaching their classes online. For those who are using Zoom, I wrote up a guide that has several tutorials, from the basic “how to join your first meeting” to becoming a more skilled participant, to hosting meetings, sharing video, playing live music, and more. It also includes lots of ideas for interactive games and learning tools you can use. Find it at: https://janelledurham.com/guide-to-zoom/.

Teaching about Birth Plans

Here are the steps I teach for how to develop a birth plan. I do a brief walk-through of a birth planning process. For each, describe how to do the step, who participates, and the primary goal.

• Birth Plan Checklist – Pregnant Parent and Partner
  • Find a checklist such as http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. The pregnant parent and the primary support person walk through this together, making sure they understand what each of the options are (and if not, learning more), and making sure the support person knows her preferences for each. There is no need to share this detailed checklist with their care providers, it’s just for their own reference – it’s worth tucking it in the bag they’ll take to the hospital in case they would like to refer back to it in labor.
• Top 3 – 5 Priorities – Discuss with Care Provider.
  • While completing the checklist, they can determine what their top priorities are. They should discuss these with their care provider at a prenatal appointment. Will these choices be options for them during their birth process? What can they do to increase the likelihood of reaching those goals? This discussion allows them to develop realistic expectations and increase the chance the expectations will be met. (Note, sometimes this can lead a parent to re-examine whether the caregiver and birthplace choices they have made are the best fit for their goals.)
• Written Birth Plan – To Share with Nurses at the Hospital
  • A birth plan is the primary tool for communicating with nurses about the family’s goals and priorities, and what kind of support from caregivers would be most helpful to them.
  • It should never be more than one page long (in a easily readable format.)
  • One format is to have three sections. The first describes who they are as a family and who will be at the birth and what they have done to prepare for this birth. The second gives the big picture of their preferences for labor support, pain medication, and interventions. The third is optional, and explains any special information that “if the nurse only knew this about me, they could better support me.” This is a good place to address religious or cultural preferences, history of sexual abuse or other personal history that may affect them during the birth process, any particular worries they have about the birth.
  • If parents are planning a home birth, they may not need a written birth plan for their midwife if they’ve been in deep discussion for the whole pregnancy. However, they absolutely should have a written birth plan in case of transfer. In a survey of birth satisfaction, some of the lowest rates were for people who had planned an out-of-hospital birth and transferred. They could increase the chance of a satisfying birth experience by taking time to articulate their wishes.
  • Sample birth plans are available at http://www.pcnguide.com/wp-content/uploads/2016/03/2-Preparing-Your-Birth-Plan.pdf. Feel free to print several examples to share in class to show there’s no one right way to write a birth plan.

Childbirth Educators can support students with figuring out their top 3 – 5 priorities using the Birth Plan Card Sort exercise: https://transitiontoparenthood.files.wordpress.com/2018/10/birth-plan-card-sort.pdf. Instructions are on the last page.

Learn more about the steps of teaching about Informed Decision Making, including Values Clarification, and how to make the decision after gathering information.

Materials Added

Today I spent some time going through my materials, and adding things to the site that I hadn’t yet posted – I added 18 new items to the site today, between the handouts page and the class activities page. Check them out!

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: I prefer the term Informed Decision Making to Informed Choice for a few reasons: Choice focuses on the product – which box would you check on a list of options. Decision-making focuses on the Process of getting to that final choice – it emphasizes 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.

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 41^st 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

• In the last edition, we had a chart at the back of the book summarizing all the details about pain medications. That will be moved to the website. pcnguide.com
• We updated the info on pain meds. A good summary of current research can be found here, so you may want to read that between now and when the 2016 edition is available for you to read: http://www.minnesotamedicine.com/Past-Issues/Past-Issues-2012/March-2012/Safe-and-Individualized-Labor-Analgesia

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.]