Category Archives: Uncategorized

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

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 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

Update on Transgender Families

[Note: this post was originally written in 2015, updated in 2019.]

In 2015, we did an updated edition of Pregnancy, Childbirth, and the Newborn: The Complete Guide. We added a few paragraphs on transgender people who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. We switched most of the language in the book to be gender neutral, but it is not perfectly so. In the process of making those changes and many other things I have learned since then, I’ve found several resources that are helpful for birth educators and doulas.

To any transgender or genderqueer folks who read this… I am still learning. If I mis-state anything here, feel free to comment on how I could do better.

Understanding Gender Identity

First, if you know your knowledge of transgender issues is limited, a great place to begin is “Guide to Being a Trans Ally“. It’s long, but well worth the read. (Many people also find the Genderbread Person to be a helpful tool for understanding these ideas.) For example, it defines sex, sexual orientation, gender, gender identity and gender expression, and all the ways terms are used. It also talks about how all these things can be a spectrum. (A side note: If you think biological sex is totally binary, not a spectrum, you’ll find this a fascinating post about in-utero development of sexual characteristics.)

For example, I am a cisgender woman, because I was assigned female at birth, and I identify as female, and my gender expression is female though not exactly “extremely feminine” (you’ll never see me in high heels or makeup!) And I am heterosexual.

A transgender man is someone who was assigned female at birth because of their biological sex characteristics, but internally identifies as male. Some transgender men are not “out of the closet” and don’t disclose their transgender status in their public life – they think of themselves as male and may ask those close to them to refer to them as male, but their gender expression in public is female or sometimes androgynous. Some transgender men express themselves as male – they dress in “male” clothing, may use mannerisms and speech patterns associated with men, and may have a male name but will openly define themselves as trans-male. Some express themselves as completely male and will never disclose any other identity – as the Guide says, they “just want to be seen as their gender-affirmed selves.” In your practice, although you wouldn’t have known it, you may have encountered these men as partners to a female-identified expectant mother.

Estimates on what percentage of the popular is gender variant range widely. The Williams Institute says 0.6% of Americans are transgender. The Transgender Law and Policy Institute says 2 – 5% of the population experience some gender dysphoria (an emotional / mental health condition that arises when someone’s gender expression and how other people refer to them and react to them does not align with their internal sense of who they are.)

It is very likely that younger people are more likely to identify as transgender than older people. When asked whether they identify as lesbian, gay, bi or transgender, 1.4% of those over 75 say yes, but 8.2% of those 20 – 39 do. (Source) This is likely not due to a change in actual incidence of homosexual orientation or transgender identity but more on social attitudes that make it more acceptable to acknowledge those feelings. This will mean that in the future, you will be more likely to knowingly encounter gender variant families than you were in the past.

Transgender people in America (especially transgender women of color) experience very high rates of harassment, discrimination, and assault. They have high rates of homelessness, unemployment, and lack of health insurance. (see http://www.transgenderlaw.org/resources/transfactsheet.pdf and Gender Not Listed Here.)

Transgender Men and Pregnancy

A pregnant father would be someone who was assigned female at birth (and has a uterus, ovaries, and so on) but his internal sense of gender identity is male. There are also non-binary people and other people across the gender spectrum who carry and birth babies.

Some of those expectant parents will have an outward gender expression that is obvious to birth professionals, and they may also have a conversation with the professional about their gender identity, pronouns, and preferred terms (e.g. “I am the baby’s father, and you should refer to me as he / him”). Other transgender people may be more hesitant to reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments – such as presenting more feminine than they otherwise might and not correcting the caregiver if they use female pronouns. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, and having your caregiver use ‘she’, ‘her’, ‘mother’ and other gendered terms frequently can increase that.

When birth professionals encounter clients who express themselves as gender variant, we  need to know how to treat them with respect and honor their identity. And, because we will also quite possibly encounter other gender non-conforming people without knowing it, we should work on adapting our language at all times to welcome them in. And even if everyone in the room is cisgender, using gender-inclusive language helps to increase the visibility of transgender people and their rights for respectful language. And that includes language on websites and advertising where potential clients may look before coming in to determine whether they would be welcomed by your practice.

Health Care Experiences of Transgender People

Many transgender people have a history of bad encounters with health care providers: As many as one-fourth of gender variant people avoid health care services due to concerns about discrimination and harassment. (Source)  “FTM youth said they frequently encountered verbal abuse and condescension from frontline health care staff such as receptionists: ‘I can’t even make it through the front door without staff staring at me, laughing at me, or whispering about my gender presentation.’ In the FTM youth group, all participants agreed that they did not feel safe receiving health care.” (Source) “One FTM youth found experiences with gynecological care especially upsetting:’There is a lack of sensitivity… The doctor was not sensitive to the fact that I experience myself as male and that this experience was overwhelming for me.’ Said one FTM adult,“I think for me it is respect and a willingness to respect your pronoun. I found that to be a huge problem. As somebody that hasn’t done any body alterations,it’s hard for people to switch pronouns and accept the pronoun [that I prefer].” (Source)

This page http://transequality.org/Issues/health.html offers brief, but helpful, recommendations for trans* people about accessing effective health care in general, and things they should consider, and talk to a supportive caregiver about.

Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association) has an excellent resource for health care providers on Guidelines for Care of LGBT Patients. It talks about how LGBT clients might “scan” a practice to see how friendly it is: they might look for gender-neutral language (pregnant parent, partner, and so on – not mother and father), non-discrimination statements, gender-neutral restroom signs, pride flags, intake forms that ask for relationship status not marital status, offer a check box for transgender, a line for preferred pronoun, and so on. Check it out for ideas that might apply to your practice.

Birth Professionals and Gender Variant Families

The Science and Sensibility blog hosted a post by Simon Adriane Ellis on Working with Gender Variant (Transgendered) Families which is an excellent summary for birth professionals (OB’s, midwives, doulas, childbirth educators, and so on) about how to work with gender variant people successfully. Some tips are:

  • Offer accommodations such as one-on-one classes, appointments at the beginning or end of the day, if you need to refer to another provider, you call ahead to provide the patient’s background.
  • Plan to offer additional emotional support – they may feel very isolated and may be struggling with gender dysphoria. [Note: Ellis also co-authored a journal article titled “Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family” which explores this parenting experience and says the over-arching theme was loneliness.]
  • Use sensitive language. It’s important to ask them what name, pronoun, and parenting term they would like to be addressed by.
  • “Don’t let your curiosity get the best of you” – it may be tempting to ask the whole history of their gender identity… only ask what you need to know to care for them
  • I think a really important sentence from the article is “The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s well-being. But the truth is: with very few exceptions, there is no one with more experience.”

ACNM has a position statement on Transgender/Transsexual/Gender Variant Health Care which includes some pointers to additional research.

Inclusive Language in Childbirth Classes

I attended an in-service by Kristin Kali, from Maia Midwifery on how language matters for LGBT students in childbirth classes. Here are some of my takeaway notes from that:

  • Using very gendered language like “mom” and “dad” can be very alienating for many families: single parents, gay or lesbian couples, surrogates, donor fathers, polyamorous families where there will be more than two parents, or a transgendered dad who is carrying the baby.
  • On intros, could ask “who is in this baby’s family?” Or “who will support you in birth and in the early weeks as a parent?” “Who is in your family? You and your child? You and a partner and child? Uncles and aunties?”
  • In class, refer to pregnant parent rather than “mom”, people in labor rather than “women in labor”, the uterus rather than “her uterus”, parents instead of “mothers.”
  • Don’t wait till you have someone in class who you know is transgender before you adapt your language. It’s hard to remember it in that one class! Consider just changing your language  long-term for ALL classes to be as inclusive as possible so that it flows naturally when you do have that parent

You can also talk about chest-feeding as well as breastfeeding. Kelly Mom has a great collection of information on transgender parents and chestfeeding.

If you have single stall bathrooms, instead of having “men” and “women” signs, have signs that just say “restroom” or “all gender restroom”.

Science and Sensibility features a blog post by Sharon Muza on Using Gender Neutral Language in Birth Classes.

Resources for Finding Supportive Caregivers

Here are some directories that may aid a gender variant expectant parent in finding a caregiver:

Updates on Cesarean Birth

As we update Pregnancy, Childbirth and the Newborn, I will post here about major updates in each section since our 2010 edition. Here’s what’s new in thoughts about cesarean.

Key resources to be aware of

Barber, et al. Indications Contributing to the Increasing Cesarean Delivery Rate. OBGYN VOL. 118, NO. 1, JULY 2011. Reviews records of over 32,000 births at Yale-New Haven hospital between 2003 and 2009, when the cesarean rate increased from 26% to 36.5%. Factors that contributed the most to the increase were, in order:

  • An increase in the diagnosis of nonreassuring fetal heart rates and failure to progress in labor. [Note: These are somewhat subjective diagnoses. It is possible that the rates of problems did not change much, but that caregivers began to lower the threshold at which they would decide cesarean was indicated.]
  • Multiple gestation. The rate of twins increased slightly, but it also became more common to do a cesarean for multiples rather than attempting a vaginal delivery.
  • Suspected macrosomia. Although more cesareans were done because it was thought the baby was too big, the actual size of babies delivered did not increase.
  • Preeclampsia. The average age of mothers has increased, and more women are obese prior to pregnancy, and this has led to an increase in gestational hypertension. Also, caregivers are becoming more likely to use cesarean rather than induction for women with preeclampsia.
  • Maternal request. A very small (less than 1%), but increasing, percentage of women requested a cesarean.

A 2011 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US summarizes current trends. Some of the data from this article figured strongly in the ACOG / SMFM statement discussed below.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request, 2013. They estimate 2.5% of all U.S. births are elective cesareans without medical indication. Their summary recommendation was: ” in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. In cases in which cesarean delivery on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.”

Consensus statement from ACOG and Society for Maternal-Fetal Medicine. Safe Prevention of the Primary Cesarean Delivery. 2014. This statement has the potential of a huge impact on maternity care practices and should be read by all childbirth educators and other birth professionals. From the abstract, with my emphasis added: “The rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Read a response to this statement on Lamaze’s blog, Science and Sensibility. And Penny Simkin’s presentation on the statement and its implications. Or my reflections on it.

What does this all mean?

It can take a long time for practice recommendations to become wide-spread practice in the “real world” of obstetrics. They will likely be adopted more quickly in university teaching hospitals in major urban areas than in rural hospitals.

I think these are the messages we give our students about cesarean:

For a parent who has not had a previous cesarean, your chance of having a cesarean with this birth is about 23%. It is much higher if you are carrying twins (47%), if you are older, obese (44% at BMI of 35+), or if your labor is induced (about twice as likely). Rates vary greatly by hospital, so it’s good to research your options.

If you are carrying multiples, and the first baby is head-down when it is time for the birth, vaginal birth is better than cesarean.

If your baby is breech at 35 weeks, try chiropractic, acupuncture / moxibustion and other techniques to turn baby. Ask for a version at week 37.

If a care provider tells you your baby is looking big, and recommends an ultrasound in late pregnancy to assess size, or recommends induction / cesarean to treat: know that a) late-term ultrasounds are not a precise way to measure size, b) macrosomia is not considered a reason for induction, and c) macrosomia should only be considered an indication for cesarean if baby is believed to be at least 5000 grams (11 pounds) in a woman without diabetes, and at least 4500 grams (9 pounds, 14.7 ounces) in a woman with diabetes.

The most common reasons for cesarean are repeat cesareans, failure to progress in labor and concerns about baby’s heart rate that arise during labor.

For most women with prior cesareans, VBAC is a safe option and should be pursued.

Failure to progress in labor. See my post on what should be considered prolonged labor. Also, talk to your clients about all the ways that we promote labor progress.

For baby’s heart rate: If there are concerns, ask how concerning it is – does it warrant immediate intervention, or is it possible to try other things. Some options are: changing mom’s position, IV fluids or oxygen for mom, amnioinfusion for baby, turning down Pitocin, letting narcotics wear off, giving tocolytics to gentle the contractions. She can also request that they use fetal scalp stimulation to check baby’s response.

 

 

 

 

Consensus Statements and Real-World Implications

2014 ACOG / SNFM statement

In March, ACOG and SMFM released a consensus statement on prevention of primary cesareans. It made several significant recommendations, such as:

  • A prolonged latent phase (eg, greater than 20 hours in nulliparous women and greater than 14 hours in multiparous women) should not be an indication for cesarean delivery.
  • Cervical dilation of 6 cm should be considered the threshold for the active phase of most women in labor….
  • Before 41 0/7 weeks of gestation, induction of labor generally should be performed based on maternal and fetal medical indications. Inductions at 41 0/7 weeks.. should be performed to reduce the risk of cesarean delivery… perinatal morbidity and mortality.
  • Cesarean delivery to avoid potential birth trauma should be limited to estimated fetal weights of at least 5,000 g… [Note: that’s 11 pounds]

All potential game changers, right? And there’s more! If you haven’t read the statement yet, do. All childbirth educators would benefit from the info on typical length of pregnancy, length of labor, etc.

But, I find myself wondering. Will it be a game changer?

How much effect does a consensus statement (even a major one like this) have on actual practice and how long does it take for that effect to appear?

2010 VBAC Consensus Statement

So, let’s look back at another major consensus statement: Vaginal Birth after Cesarean, an NIH consensus statement from March 2010.

First, the context for the NIH consensus panel: This was at a time when VBAC rates had been dropping steadily since 1997. One factor in these dropping rates was availability of VBAC as an option. In 1999, ACOG released a practice guideline that trial of labor should only occur in hospitals where physicians and anesthesiologists are “immediately available” 24 hours a day to perform emergency cesareans. A joint statement from ACOG and ASA in 2008 re-affirmed this.  Surveys found that 30% of hospitals (especially smaller hospitals and rural facilities) stopped offering trial of labor because they could not provide immediate surgical and anesthesia services.

The NIH recommendations in 2010 included:

  • Given the available evidence, trial of labor is a reasonable option for many pregnant women with one prior low transverse uterine incision.
  • When trial of labor and elective repeat cesarean delivery are medically equivalent options, a shared decision-making process should be adopted and, whenever possible, the woman’s preference should be honored.
  • We are concerned about the barriers that women face in gaining access to … trial of labor. Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel… we recommend [ACOG and ASA] reassess…

What effect did this NIH statement have on ACOG?

ACOG did update their clinical guidelines on VBAC in August of that year. There was some positive progress toward VBAC access there, such as the statement “Most women with one previous cesarean delivery with a low transverse incision are candidates for and should be counseled about vaginal birth after cesarean delivery (VBAC) and offered a trial of labor after previous cesarean delivery (TOLAC).” However, despite the NIH recommendation to reassess this requirement, they retained the wording “TOLAC [should] be undertaken in facilities with staff immediately available to provide emergency care”

What effect did the NIH statement have on VBAC rates?

In 2009, VBAC rate was 8.4%. The NIH statement was released in March of 2010. The 2010 rate was 9.2%, 2011 was 9.7%, and 2012 was 10.2%. [Data is not yet available for 2013.]

So, we have seen some improvement since the consensus statement, which is good news for VBAC advocates.

However, we are nowhere near the rates seen in the mid-1990’s before ACOG recommended “immediate access” requirement for hospitals allowing VBAC.

VBAC rate

Obviously, there are many factors at play in the VBAC rate, beyond the NIH recommendations and the ACOG Guidelines, such as financial reimbursements for procedures, liability concerns and more. Plus, practitioners may be slow to change their practice.

I suspect that some of the new guidelines from the 2014 ACOG / SMFM statement will become standard practice quickly, others are already being viewed as controversial, and are less likely to become standard practice.

Birth Plan for Hospital Transfer

Someone requested a sample birth plan for hospital transfer.

This is probably longer than ideal, but is an example of what one could look like.

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Birth Plan, in case of Hospital Transfer

Hello,

My name is X, my husband is Y. Our first child was born by cesarean 10 years ago, and our second was a VBAC 7 years ago. With this birth, we had planned a home birth with no pain medication and few interventions. However, the fact that we are now at the hospital indicates that I need additional monitoring and/or medical procedures, and we are grateful for your assistance in providing this needed care to usher our third child into the world.

This birth plan expresses some of my preferences, so they can be taken into account and balanced with medical necessity. The ones I feel most strongly about are related to how our baby is cared for in the first hour of life.

Preferences:

  • Coping Techniques: As much as possible, we would like to continue to cope with the labor as we would have at home: with minimal interruptions, freedom to move around and continue whatever coping rituals we have developed. If there are decisions that need to be made, please talk with Y about them first. It will be helpful to me to stay in my “birth zone” – an instinctive, emotional space; but if I am asked a lot of questions, I will slip into my academic brain, which tends to block my pain coping skills and labor progress.
  • Routine Interventions
    • Monitoring: I understand that continuous fetal monitoring is standard with VBAC. I would prefer external to internal monitoring.
    • Food and water: At minimum, I would like to consume clear liquids in labor, as is per guidelines from the American Society of Anesthesiologists.
    • IV: I have often been told that my veins are small and tend to roll, so are difficult to insert an IV into. If an IV becomes necessary, I would ask that you pick a staff member who is particularly skilled at insertion.
  • Augmentation
    • Pitocin: fine. No prostaglandins or misoprostol, due to increased risk of rupture.
    • Amniotomy: would prefer to delay till baby is well positioned (OA)
    • Epidural: If pain-related tension is delaying progress, it may be a reasonable tool
  • Pain Medication
    • IV narcotics: are not effective for me; I feel mentally out of control, and don’t gain sufficient pain relief
    • Epidural: If I request it, I would like to start with a low level dose of medication to enable as much mobility as possible; if PCEA is available, this would be ideal
  • Second Stage management
    • I would like to be able to use positions other than semi-sitting (side lying, or hands and knees), especially if my baby is suspected to be large. If I have epidural anesthesia, I may need support getting into and maintaining a position.
    • If possible, I would like to use spontaneous pushing, following my own urge to push and own instincts rather than directed pushing. If I do not have an urge to push, I would prefer to labor down (passive descent), unless time is of the essence
  • Cesarean. I understand that an emergent situation, such as a uterine rupture, could lead to the need for cesarean under general anesthesia. However, if a cesarean is needed but not emergency, here are my preferences for the procedure:
    • Y will accompany me in the O.R. (And my midwife, if possible.)
    • If possible, I would appreciate that baby be delivered slowly through the incision, allowing for a more gradual adaptation, as described in Smith, Plaat, and Fisk, “The Natural Cesarean”, 2008 July; 115(8): 1037–1042 http://tinyurl.com/la83t2; however, this isn’t a high priority for me.
    • I would prefer that the screen be lowered during delivery so I can see the baby.
    • I would prefer internal repair and double-layer suturing.
    • Should I become shaky or nauseous, I would like to handle that with natural coping techniques. I do not want to be given any medication that will make me fall asleep, or cause any amnesia effects during that first hour with my baby.
    • I want skin-to-skin contact with baby as soon as possible, preferably with breastfeeding initiation in the O.R. during repair (with support from Y)
  • Care of the Baby in the First Hour (Highest priority for me)
    • Would like to delay cord clamping and cutting till cord has stopped pulsing
    • Whether baby is born vaginally, or by cesarean, I would like as much of its first hour as possible spent skin-to-skin on my chest. If, for whatever reason, baby cannot be skin-to-skin with me, then it should be skin-to-skin with Y.
    • As much as possible all newborn procedures should be conducted with baby in parents’ arms. Bath, weighing, and measuring can be delayed till after initial breastfeeding.
    • Breastfeeding to be initiated in the first hour after birth, ideally by allowing baby the time to self-attach.
    • Routine procedures
      • Eye ointment should be given as late as possible (one to two hours, as per state requirements) after vaginal birth; but as early as possible after cesarean
      • Vitamin K and Hepatitis B: Can be given per standard protocol
    • Care of the Baby Until Discharge
      • As long as baby is well, baby is to remain in-room with parents at all times, with family providing care, and minimal disruption
      • If baby needs special care, then a parent or family member will accompany the baby at all times, holding the baby skin-to-skin as much as possible
      • No formula or other supplements to be given without express written approval from a parent, and supplementation to be given by spoon, cup, or SNS, not bottle.

Thank you for your time and attention to my preferences, and thank you for the care you are providing to our family.

X and Y