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

Update on Transgender Families

I’m working now on an update of Pregnancy, Childbirth, and the Newborn: The Complete Guide. It was originally not intended to be a full revision – it was just intended to be a limited update on new trends in maternity care, current statistics, and updated medical guidelines. But, I wanted to add in something to acknowledge parents who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. It started as inserting a few paragraphs on the topic, but I’m now also working to make more of the language in the book gender-neutral. It will not be fully gender-neutral, nor will it fully reflect the experience of these parents, because that level of change is simply beyond the scope of what I can do at this time with our publisher’s deadlines days away. But, I’m glad we’re making baby steps, and hope I don’t make too many mis-steps along the way.

In this process, people have kindly shared resources with me. I will share them here for reference by other birth professionals. If I mis-state anything here, feel free to comment – but be nice, OK? I’m still learning…

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” on straightforequality.org. It’s long, but well worth the read. 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!)

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 may disclose their history and transgender status. Some express themselves as completely male – as the Guide says, they “just want to be seen as their gender-affirmed selves (sometimes referred to as being stealth or private)” In your practice, 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 0.3% 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, 1.9% of those over 65 say yes, but 6.4% of those 18 – 29 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 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 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, preferred pronouns, and preferred terms (e.g. father vs. mother). Other transgender people might not reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, but 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 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.

Resources for Finding Supportive Caregivers

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