Benefits of Babywearing

It’s International Babywearing Week!

Jennifer Taylor from MomTricks.com shared this great infographic with me. As a mom with a handicap (I have one leg and use crutches) I would add the benefit that babywearing made it FAR easier for me to carry all three of my kids. (Hurray for the
New Native Baby Carrier!  When I got my first one and put my child in it, I danced around the living room I was so happy to have found a solution that worked for me!)

BabywearingInfographic_1

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How are you teaching “6 is the new 4”

ACOG’s 2014 bulletin on “The Safe Prevention of the Primary Cesarean” summarized research into when in the typical labor process labor usually speeds up, and offered new guidelines on what should (and should not) be considered an arrest of labor. A key point it makes is that

… cesarean delivery for active phase arrest … should be reserved for women at or beyond 6 cm of dilation with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity, or at least 6 hours of oxytocin administration with inadequate uterine activity and no cervical change.

I worked with some of my colleagues from the Great Starts’ program at Parent Trust for Washington Children on an article about how childbirth educators should incorporate these new guidelines. Read our article at: www.scienceandsensibility.org/blog/teaching-6-is-the-new-4

Resource for Deaf and Hard of Hearing parents

A sign language interpreter just attended my childbirth educator training. She recommends the DVD series Your Pregnancy, What to Expect. It is signed in ASL with voiceover and subtitles.

There are more details on it at https://www.audiopaccom.com/your-pregnancy-what-to-expect#.VvwJQo-cGM8

It covers prenatal care, prenatal development, exercise, stages of labor, cesareans, interview with pregnant deaf women about their experiences, and info on how to access interpreters.

Phantom Pain Doulas

After a recent experience with phantom pain, I was thinking about how helpful it could be to have phantom pain doulas.

What is phantom pain? Phantom limb sensation is something that is experienced by amputees where it feels like the missing limb is still there.

It can be just sensation. For example, any time I talk about or write about phantom pain or about my missing leg, I feel a tingling throughout my “right leg”, even though my right leg was amputated 35 years ago – back in 1982. The tingling is similar to what you feel if your leg falls _really_ asleep, then you change position and you get that tingling / stinging sensation as the blood flow returns. It is very defined as to its location in the “limb”. I can feel the outline of all 5 toes, my heel, my calf and so on, as if my leg was still there.

Sometimes it’s discomfort – maybe in one very specific place – like the outside of “my pinkie toe”, or “my Achilles tendon”, might feel like someone’s pricking it with pins or thumbtacks.

It can also be pain. From mild to awful. Like someone is taking a sharp knife and stabbing it into my knee over and over again.

You may see articles that compare levels of pain, and they typically say that childbirth and phantom pain are at the top of the list, above broken bones, kidney stones, and tooth abscess. Having had three babies, I can definitely say that the intensity of phantom pain can be as overwhelming as labor pain.

It’s usually not that bad! For me, I’d say it only gets that bad maybe once or twice a year. (Usually when I have a fever.) But, I do have times, maybe once a month or every other month, where it’s bad enough that I have a hard time concentrating on my work or enjoying my leisure, or getting to sleep.

But, that frequency (once a month of needing attention, once a year of being overwhelming) is what I experience after 35 years as an amputee. It has become much less frequent over the years. For a NEW amputee, they can experience this pain far more often. It could be a huge help for them to have doula style support managing that pain.

What could a doula or other support person do to help with phantom pain?

Validation: Like with labor pain, one of the first steps is validation – “I hear that you’re hurting. I know it’s hard. I know you feel like you should be able to cope with it on your own, but I know it’s challenging and I’d like to help.”

Knowing about self-help techniques that help with phantom pain

  • Counter-irritants: One thing amputees may do to manage the phantom limb pain is to cause another pain somewhere “real” to distract them from this pain. This might be biting their lip, pounding their fist on the remaining limb, or squeezing their fingernails into their hands. Counter-irritants can be helpful for many pain sources, but especially for phantom pain, it can give the sufferer a sense of being in control of that pain even though they can’t control the phantom pain. An effective tool for creating this discomfort that doesn’t harm them is reflexology combs. Learn more about them and counter-irritants here. Learn more about the theory of diffuse noxious inhibitory control here.
  • Heat and massage: I find often, but not always, the cause of my phantom pain in my leg is actually tight muscles in my lower back, near my sacrum. (This usually happens when I’ve had some days of bad posture – like sitting on a soft bed and reading, which is hard on my sacral muscles.) So, heating pads and a good sacral massage can often relieve the phantom pain.
  • Other amputees find other self-help techniques helpful, such as acupressure, exercise, putting pressure on the stump – I discuss them in this post I wrote years ago: www.transitiontoparenthood.com/janelle/energy/PhantomPain.htm
  • Many of the other coping techniques doulas use in labor, such as breathing, attention focus, movement, baths, and so on can help. Phantom pain is often intermittent, coming in waves (like contractions), so support could look like labor support in early labor: sitting and watching TV or playing games for ten minutes, then helping the amputee manage a 30 second surge of pain, then returning to the movie / game.

Knowing about alternative medicine that can help with phantom pain

Knowing about medication

In MY EXPERIENCE (others may vary), here are things that didn’t help with phantom pain: Tylenol on its own, Tylenol with codeine, ibuprofen on its own, other NSAID’s, and alcohol. None of it did anything, really, so the self-help, acupressure, and energy medicine were essential to me for years.

What does help? What’s my best magic cure for phantom pain? One Tylenol and one Ibuprofen. Taken together. It’s gotta be both, or it doesn’t work. But together, it’s fabulous. No matter how bad my pain is, it’s gone in 15 minutes after I take this.

I LOVE that I discovered this about ten years ago. It gives me so much more of a sense of control over my phantom pain. I don’t take medication for mild pain – I want to go easy on my liver and taking large amounts of medication is NOT good for your liver. But it helps to know that whenever it gets too much to handle, or when I need to go to sleep or need to be at my best to teach, all I need to do is take a Tylenol and ibuprofen and it will be better in about 15 minutes and will stay better for about 6 hours. I never travel without my emergency stash of one of each pill (ever since that day in Disneyland where I had to buy one whole bottle of each at theme park prices!)

What you could do

As a doula, you know a lot about pain coping in general, and how to sit with someone who is in pain, and now I’ve given you some tips specific to phantom pain. For an “old amputee” like me, we’ve learned coping techniques that work, and we can take the occasional Tylenol/ibuprofen cocktail to manage it.

But a new amputee needs to learn those coping techniques, and they can’t be popping medications every day (because of impact on liver), so they need extra support. If you know any new amputees who are struggling with phantom pain, consider offering your support, even just a conversation about things that might help.

 

 

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. (See Pregnancy, Childbirth, and the Newborn for 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…

Decision Making Style

Recently I posted about tools to help students / client’s understand their medical mindset and how it affects the decisions you make. I’ve since decided it doesn’t capture some of the other key components that affect our decision-making in labor: how much information we need to make a decision, how much time we need to make a decision, and whether we prefer to make our own decisions or just follow the recommendations of a trusted caregiver. So, I’ve added a second page to that worksheet which explores decision-making in more depth. Find it here.

Screening for Gestational Diabetes

In this post, I compare guidelines for testing for gestational diabetes. 4 – 9 % of pregnant people have gestational diabetes. Women with GDM are at a higher risk for gestational hypertension and cesarean. Their babies are at higher risk of macrosomia (being > 9.9 pounds), hypoglycemia, jaundice, cesarean delivery, and shoulder dystocia.

Types of Tests Used

GCT = A glucose challenge test is a screening test, where an expectant parent drinks 50 g of a sugary beverage (or eats a prescribed sugary snack such as white toast with honey), and then one hour later blood is drawn to test her blood glucose levels. If they are high (above the threshold listed below), she will then have a GTT.

GTT = A glucose tolerance test is a diagnostic test. After fasting for 8 hours, a woman drinks either 75 g or 100 g of a sugary beverage, and then has her blood drawn at 1 hour, 2 hours, and 3 hours. If her blood glucose levels are high, then gestational diabetes is diagnosed.

Who is at risk (aka categories of risk):

High risk: Risk factors that increase a woman’s risk for developing GDM include obesity (BMI >30), increased maternal age (>35), history of GDM, family history of diabetes, and belonging to an ethnic group with increased risk for type 2 diabetes. [NICE defines high risk as BMI > 30, previous baby over 9.9 pounds, previous GDM, first-degree relative with diabetes, South Asian, black Caribbean, Middle Eastern. PCOS.]

Average risk: not high risk, not low risk.

Low risk: under 25 years, normal BMI before pregnancy, member of ethnic group with low prevalence of GDM, no known diabetes in first degree relatives

When to test:

ADA says screen high risk women as early as possible, and re-test at 24- 28 weeks if first screen was negative. Screen average risk women at 24- 28 weeks. For low risk asymptomatic women, no screening required.

ACOG: Screen all women at 24 – 28 weeks

CDA: Screen all women at 24 – 28 weeks (Optional: Screen higher risk women earlier and again at 24 – 28)

NICE: Do a GTT at 16–18 weeks if prior GDM; at 24–28 weeks if risk factors

USPSTF says there is not sufficient evidence for screening before 24 weeks. Should screen after 24 weeks.

How to test:

ADA – 1 step: 75 g fasting GTT may be cost-effective for high risk patients or populations. Or 2 step: 50 g GCT. Then, if indicated, 100 g GTT

ACOG: 2 step –-50 g GCT, then fasting 100 GTT

CDA: Preferred 2 step – 50 g GCT, then if indicated 75 g GTT. Alternate 1 step: 75 g GTT

NICE: 75 g GTT (but only test if there are risk factors)

On GCT results, what threshold indicates need for GTT diagnostic testing?

ADA / ACOG / CDA: If <140 mg/dl, no further testing is indicated. If > 140, then GTT should be done. ACOG says 135 should be threshold in women at high risk for GDM.

If the threshold was set at 130, then you would catch 90% of cases of GDM, vs. the 80% of cases you catch when setting threshold at 140. However, at 130, there would be many more false positives – women diagnosed and treated for GDM who did not have it. [Note: None of these guidelines share what the false positive rate is.]

On GTT results, what threshold indicates a diagnosis of gestational diabetes?

Fasting 1 hour 2 hour
ADA/CDA 1 step 75 g GTT ≥ 92 mg/dl (5.1 mmol/L) ≥ 180 (10) ≥ 153 (8.5)
ADA / ACOG 2 step 100 g GTT ≥ 95 mg/dl ≥ 180 ≥ 140
CDA 75 g GTT ≥ 95 (5.3) ≥ 190 (10.6) ≥ 153 (9.0)
NICE 75 g GTT ≥ 126 (7.0) ≥ 140 (7.8)

Can an expectant parent do anything to decrease her risk of a false positive result?

About 15 – 20% of expectant parents test positive on GCT. Only 4 – 9% are diagnosed with GDM after a GTT. (Doing only the one-step GTT increases the rate of diagnosis, which likely means there are more false positives with the one step than with the two step method.)

To reduce false positives on a GCT. Eat healthy, non-sugary meals in the days before the test. Be well-rested and relaxed on the day of the test. Eat a small, healthy non-sugary meal one hour before test, then walk around to let your body metabolize it. In the hour between drinking the glucose and having blood taken, do not drink tea, coffee, soda, etc.; eat sugary food, or smoke cigarettes.

Sources

ACOG http://www.medscape.com/viewarticle/808409 2013

ADA, American Diabetes Association, 2003 http://care.diabetesjournals.org/content/26/suppl_1/s103.full

CDA: Canadian Diabetes Association, 2013 http://guidelines.diabetes.ca/fullguidelines/Chapter36

NICE: http://care.diabetesjournals.org/content/33/1/34.full.pdf+html

USPSTF 2014 http://www.uspreventiveservicestaskforce.org/uspstf/uspsgdm.htm