Category Archives: Theory of CBE

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.

Simple Guide to Having a Baby 2016

Simple Guide 2016

The 2016 edition of Simple Guide to Having a Baby has gone to print, and will be available to the public at the end of July. (We’re hoping to have copies for sale at the DONA conference in Bellevue, WA) It will be available from Amazon, Barnes and Noble, Walmart, and probably Target.

Simple Guide covers essential information about pre-conception, pregnancy, birth, breastfeeding and newborn care at a 6th grade reading level, in a short, accessible format. It is written by the authors of Pregnancy, Childbirth, and the Newborn. Although we are writing at a different literacy level, we do our best to incorporate the same foundation of current, research-based information and our practical experience of working with thousands of birthing parents over many decades.

What’s new in 2016: increased cultural diversity and sensitivity in photographs and writing, incorporation of the visual aid “The Road Map of Labor“, more links to online resources for more information, and more details on baby care. We have also extensively updated all the medical information. I have an extensive post on all the updates we did to Pregnancy, Childbirth and the Newborn – we weren’t able to incorporate all of these details into Simple Guide, but they certainly did inform our revision of this shorter work.

If you would like to write a review of Simple Guide, I do have galley proofs available. Contact me and jdurham at parenttrust dot org, and tell me about yourself and where you publish reviews, and we can make arrangements to get a proof to you.

Pregnancy and Disability

Janelle 32 wks

Someone recently asked me to share my perspectives on how perinatal professionals can provide sensitive, supportive care for people with disabilities. Here are some initial thoughts on that question.

First, a caveat to any advice I offer below: I can only speak to my own experience. The needs of each person are unique and depend on such things as:

  • What is the disability?
  • How long have they had it and how experienced are they at working around it?
  • What is their self-image / identity – if they think of themselves as “disabled” they are likely to have more worries about the perinatal period than someone who doesn’t see their disability as a primary part of their identity or life experience

My experience: I had bone cancer when I was 15 years old, and had my leg amputated above the knee. I wore an artificial leg for a few years, but discovered I can move around faster and easier on crutches than with an artificial leg. I don’t really think of myself as “handicapped” because there’s little I can’t do. I can’t “run” very fast. But, I can ski, swim, roller-blade, ice skate, and ride a tandem bike. I can carry things while walking on crutches, take care of all my household chores, drive, work full-time, and so on.

When I became pregnant with my first, I’d already been an amputee for 11 years, so I was very used to making the physical adaptations I needed to make. So, throughout my pregnancy, I never questioned my ability to handle pregnancy, birth, and caring for a baby. I didn’t know all the exact details of how I would adapt everything, but I had complete confidence I would figure it out. And I did… I’ve now birthed and cared for 3 children – I don’t actually find it that difficult.  (OK, honestly, we all find parenting difficult! I’m just saying that having one leg did not make it particularly more challenging.)

My care providers vs. others:  During my pregnancies, I don’t remember my disability being a big issue for anyone. My care providers never implied that there would be anything especially challenging about my case, which I appreciated.

But that’s not always the case. Once a public health nurse called and asked me to doula for someone delivering at Valley. I told her I didn’t travel that far. But then she told me why she’d called me specifically. The client was a double amputee who used a wheelchair. She had been told that she would need to deliver by cesarean because she was an amputee. I was dumbfounded! It’s not like you need legs to have a vaginal birth. I ended up not assisting that mother because of timing, but I did meet with her and talk to her about her options, and she did end up planning and having a vaginal birth.

What care providers can do:

  • First and foremost: Assume she is capable of pregnancy, birth and baby care. (You may be one of the few who treat her this way.)
  • If you see accommodations that you think could be made, ask her if she would like your help brainstorming how to handle something. If she’s had her handicap for more than a few months, she probably knows a great deal more about her needs than you do. Respect that.
    • For example, I happened to have a dad who was an arm amputee attend a newborn care class I was teaching. I approached him on break, and said “I am wondering if you have any specific questions that are unique to your situation. I don’t know anything about having one arm, but I know a lot about baby care, so if you have things you’re wondering about, maybe you and I can put our knowledge and experience together and brainstorm some kind of solution together.”
    • Once when I attended a prenatal yoga class, the instructor approached me before class, and said “let me know if there’s anything I can do to help you with the exercises.” I told her: “I can usually do a better job than you can of figuring out how to adapt things, but it helps me to know what my goals are. So, when you teach a position, if you can tell me whether the goal is to stretch my hamstring, or stretch my calf muscles, or strengthen my glutes or whatever, that helps me adapt the exercise in a way that reaches that goal.”
  • Don’t “other” someone.  Don’t do things that imply that they are a weird aberration from a normal human being. Examples from my experience:
    • When a caregiver is going to a pelvic exam on me, they always pull out both stirrups as per their usual habit. I like it if they then calmly put one away instead of getting all flustered and awkward when they realize that I don’t have a foot to put in the right side stirrup.
    • When a nurse opened a package of non-slippy socks, I liked that she calmly set one aside on the table, saying “here’s an extra for later”
    • If you make a “mistake”, calmly apologize and move on. Don’t make a big deal of it.
    • If someone gushes over me like “wow! You’re so brave to take this on. If I were handicapped, I would be too afraid to try this,” they may think that’s supportive, but it’s easy for that to come off as “something’s wrong with you. You’re less capable of parenting than other people are.”
  • Be sensitive about their “appliances”. Their wheelchair, hearing aids, glasses – whatever – should be treated with the same respect with which you treat their body.
    • My crutches may seem like inanimate objects to you, but they are an essential part of my independence and mobility. It is VERY important to me that no one take my crutches and move them across the room without my permission. Although I can hop short distances, I can feel “trapped” in place the second my crutches are out of my reach, which can be anxiety inducing.
    • I also wear glasses as I am very near-sighted. I need to know where they are at all times, because when I don’t have them on, I can’t find them! And I feel mentally competent with my glasses on, and severely limited without them.
  • A person with a disability also often has a long history with health care providers and medical institutions. Her experiences may be positive, negative, or a very complex mix.
    • If you sense any defensiveness or animosity toward you, or if she “over-reacts” to a situation, realize there may be a very good reason for her reaction.
    • Respect that she may have some expertise that a non-disabled layperson might not have. For example, I can tell you that I’ve had many I.V’s in my life, and been told by many health care providers that my veins are tiny and tend to roll, and it’s hard to get an I.V. into me. If a patient tells you something like that, respect that. I appreciate when care providers have said “Oh, thanks for letting me know. I’m actually going to ask X to come in and start this I.V. because she’s a wizard at finding a vein.”
    • Ask her: “I’m guessing you’ve had some experience with medical care – tell me what kinds of things you find most helpful or let me know if what I’m doing is not helpful.”
  • Don’t assume that their handicap defines them. Although the fact that I have one leg is certainly the first thing people notice about me, it is only a very small part of all the things that I am.
    • Someone once asked me: “Wouldn’t you have loved to take a childbirth class that was specifically aimed at people with disabilities and that could really focus on your unique needs?” I answered “not really.” Not that I have anything against the idea, but it also didn’t feel like something I needed. When I was pregnant for the first time, my disability was old news. I didn’t need peer support with it. Becoming a parent for the first time was new… I needed support from other expectant parents. Whether they had a disability like me, or liked Broadway musicals like I do, or enjoy Indian food like I do didn’t matter. The key was that they were other first-time parents like me.
    • If there are support services in the community that are unique to specific populations, learn about them! When you have a client that fits that demographic, let them know the resource is out there. But also tell them about all the other support services that might be a good match for them. Don’t assume you know which are the best match. Let them choose the support services that they feel best meet their needs.

 

Decision-Making Values Clarification

In teaching informed decision-making, it’s not just about teaching birth plans, or just teaching key questions. There need to be at least four steps:

  1. Figure out your goals and preferences first (values clarification)
    1a. Choose the care provider and birth place that are most in alignment with your goals, preferences, and unique health needs (caregiver choices)
  2. Articulate those priorities for care providers (birth plan)
  3. Then if an intervention is proposed that is outside your birth plan, gather data on it (key questions).
  4. Then take that information and weigh it against your values to make the decision that is right for you. (informed decision-making)

And teaching these things is not just about Theory – we also have to Practice!

A quick note about step 1a: Ideally, this would always be the process. If I was talking to someone in early pregnancy who hadn’t yet chosen, I would absolutely cover that step. But, in childbirth classes, when I’m speaking to people in their third trimester, that choice was made long ago. So I won’t cover 1a. (But some of the other steps may lead students to question for themselves whether the caregiver choice they made was the right one.)

Let’s look at options for teaching each of those.

1. Values Clarification: The goal is to talk about what they want their birth to look like – what kind of labor support do they want, what are their views on interventions and pain medications, how involved they want to be in decision-making, and generally: what would help this birth be satisfying for them. There are many ways you could do this. I created a worksheet that could be used in class, or as a homework assignment, that would be one way of exploring these questions. The pregnant parent fills out one form with their values, the partner fills out a slightly different form with their values. Then they compare their answers and discuss them. How do they come to have a common vision of their goals and priorities? (And if they can’t, with birth, the pregnant parent’s priorities need to win in the end, so they may need to agree to that.) They can also discuss here whether their caregiver and birthplace share those values. Here’s the Values Clarification worksheet.

1a. Choose the caregivers that match that. (Check out the quiz at the beginning of the Great Starts Guide for one approach to this step.)

2. Articulate those priorities in a birth plan – learn more about what to teach about developing a birth plan. (Or see Pregnancy, Childbirth, and the Newborn for more details on our approach to birth plans.)

3. Key Questions. Here’s what we teach:
Whenever a test or procedure is offered, first ask how urgent / severe the situation is and whether you have time to ask questions, discuss options, and consider the information you’ve learned. Then, ask:

  • Benefits: What’s the problem we’re trying to identify, prevent, or fix? How is the test or procedure done? Will it work?
  • Risks: What are the possible tradeoffs, side effects, or risks for my baby or me? How are they handled?
  • Alternatives: What other options are available? What if I wait? Or do nothing?
  • Next steps: If the procedure doesn’t identify or solve the problem, what will we need to do next?

It would be all too easy to stop with the key questions, thinking we’ve done our job, but we just missed they key point of decision making: MAKING THE DECISION!

We need to remind them that although their caregiver is an expert source of information and advice on benefits and risks, that only they can take into account all their goals and priorities and make the choice that is best for them. We also need to acknowledge that sometimes the choice we need to make is NOT something we wanted. But we want parents to feel in retrospect, that the choice they made DID line up with their values, and WAS the best decision available at the time.

4.Teaching Informed Decision-Making. Check out my next post for this one… https://transitiontoparenthood.wordpress.com/2015/07/31/teaching-informed-choice/

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

table

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (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) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

  • Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
  • Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity. (Birth combs also fit in this category although they were not included in the research.)
  • Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

  • Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
  • Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
  • Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.

New Ways to Talk about Labor Pain III: Diffuse Noxious Inhibitory Control

Diffuse Noxious Inhibitory Control (DNIC) is one of the mechanisms we can use for managing pain. That name is a mouthful, so I call these counter-irritants. (Read my post on birth combs as a DNIC tool here.) The principle is that if a laboring mom adds a pain or discomfort on her body during a contraction (like biting her lip, pressing her fingernails into her palm, or putting ice on her back), that helps to distract her brain from the pain. TENS, sterile water injections, acupressure, and birth combs are all DNIC tools for labor.

One theory for why these are effective is that the pain from these sensations causes a release of endorphins, endogenous opiates that help to reduce our perception of pain.

Another has to do with how the brain processes stimuli coming in on various pathways. (This is similar to the Gate Control mechanism of pain, which says that when we provide stimuli on fast-moving nerve pathways – like through sound, smell, touch with our sensitive fingers and toes – then those block some of the pain coming in on slower pathways – like labor pain.)

Chaillet, et al says that DNIC primarily reduce the intensity of pain. I believe that they can also help to reduce the unpleasantness of the pain. (see my post here for the difference between the intensity of pain and the unpleasantness of pain.) If mom is in control of the counter-irritant, it may give her more of a sense of control over the labor pain. She may feel like she can’t escape the labor pain (it’s highly “unpleasant”) but that she could stop biting her lip anytime she wants… being in control of something is better than feeling totally out of control. It’s one way of “working with labor pain.”

In childbirth classes, we can talk about counter-irritants by suggesting options to the pregnant parent (ice, squeezing something, TENS). We can use the concept to better explain sterile water injections (some parents are mis-educated in advance, and think that the injections themselves relieve pain… they’re shocked at how much the injections hurt! So, we want to explain in advance that they do hurt… like a bee sting… and that’s the idea, because they trigger an endorphin release.

In classes, we can also let the support person know that some people in labor develop a spontaneous ritual where they are causing pain to themselves (like pulling their hair)… help the partner understand that the person in labor is looking for counter-irritant – an uncomfortable sensation to distract her from the pain, and they can help her find one that gives that counter-stimulation but doesn’t harm her (like squeezing birth combs).

In the Bonapace method (I’ll post on that tomorrow), the DNIC mechanism that is taught is for the partner to do painful pressure on acupuncture trigger points. I personally prefer using only counter-irritant techniques that the person in labor applies and controls. I personally don’t like to teach partners to do anything painful to a woman, even if it might have benefit for labor pain. (A licensed massage therapist who has been clearly trained in safe high pressure massage I have no concerns about.) If I were to teach this in a class, I would set clear expectations that the laboring woman controls this firm massage – she asks for it to be done, and if she doesn’t like it, she tells her partner to stop, and her partner should stop.