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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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.

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

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.

 

Partner and Family Support for Breastfeeding

Today, I did a presentation on Partner and Family Support for Breastfeeding. Here’s a brief re-cap – and be sure to check out the handout linked from the bottom of the page!!

Research on how Partners and Family Members influence choices about whether to initiate breastfeeding and how long the baby is breastfed

  • 2/3 of women have decided before pregnancy that they plan to breastfeed due to the influence of family, friends, health care providers and the media.
  • 1/3 make the decision during pregnancy, and their strongest influences are: 1) care providers, 2) partners, 3) books and classes, 4) other key friends / family.
  • A few months down the road when making decisions about how long to breastfeed, their partner, family and friends are much stronger influences than professionals
  • An expectant parent is more likely to decide to breastfeed and to continue nursing if she believes that key people in her life are supportive of breastfeeding.
  • The presence of a partner / father increases chance she will initiate BF. But if he then gets very involved in day-to-day baby care, her BF duration can actually go down, because he ends up taking over some of the feeds.
  • Having an involved grandma sadly reduces the duration of breastfeeding, and can reduce initiation, especially if grandma didn’t breastfeed herself.
  • However, research shows we can turn this around. If we engage in conversations with partners, and offer written materials targeted at partners and family and classes for them (especially peer led classes) which focus on the importance of breastfeeding, then it is more likely that she will initiate and continue breastfeeding.
  • If those conversations / classes / materials ALSO include information telling the partner or family member that they play a huge role in her choices about breastfeeding, it is more likely she will initiate and continue.
  • If those conversations / classes / materials ALSO give concrete ideas to the partner or family member about how to help support the breastfeeding relationship, she will nurse and nurse for even longer.

To read a whole powerpoint on the evidence surrounding influences on breastfeeding (and how we can influence them), click here  Influence Of Family On BF Choices.

Teaching Partners and Family Members how to effectively support a nursing parent to increase duration of breastfeeding:

Here are five key areas we can focus on:

  • Increase Knowledge: Offer relevant, targeted, accessible info about the process of breastfeeding, with an emphasis on how to help with BF and concrete information about how to prevent, recognize, and treat BF challenges.
  • Enhance Positive Attitude: Teach them all the benefits of BF – for baby, mom, the family, and the world. The more excited they are about breastfeeding, the harder they’ll work to make it happen. Openly and honestly address worries. Encourage family commitment to BF.
  • Involve Them in Decision Making: Welcome their questions and input. Encourage them to help the breastfeeding parent do research and strategize.
  • Encourage Practical Support: Teach them all the skills to care for everything baby needs (other than feeding) and to take care of baby’s things (pack diaper bag, do laundry, etc.). Encourage them to take care of the breastfeeding parent (feeding the mom so she can feed the baby), maintain the house (groceries, cleaning, cooking), and manage outside duties (pay bills, plan, make appointments, etc.)
  • Encourage Emotional Support: Acknowledge partner’s emotional challenges. Encourage them to offer the breastfeeding parent their presence, appreciation, encouragement, affection.

To read a full powerpoint fleshing out these 5 key areas of breastfeeding support, click here: Teaching Family Support for Breastfeeding

Handout You Can Use:

One of the key points in much of the research is that nobody talks to partners about breastfeeding, and that it helps a lot if they are given targeted information that focuses on what the partner needs to know about: benefits of breastfeeding, how it works, how they can help if there are breastfeeding problems and how they can help in general. So, I’ve designed a handout for partners. It is yours to use, free of charge. You can print it, copy and distribute to partners. You can give clients links to it. Anything to help get partners the information they need to be effective supporters of the breastfeeding relationship.

Here’s the PDF of the color version, and here’s the black and white version .

 

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.

Nitrous Oxide for Labor Pain

Nitrous oxide (also called “laughing gas” or “gas and air”) has long been in common use for labor pain in other countries, being used by more than half of laboring women in such countries as England, Finland, Sweden, and Canada. It has not been common in the United States in recent decades (it was only available at 5 hospitals in 2012); however, its popularity is now increasing as equipment becomes more widely available, and may soon be seen in more hospitals and out of hospital birth centers. This online article is intended as a supplement to chapter 13 of the 2016 edition of Pregnancy, Childbirth, and the Newborn which does not cover nitrous oxide.

How Administered

Nitrous oxide is a gas. It is mixed 50/50 with oxygen, and inhaled through a mask. (Note: If you’ve had nitrous at the dentist, that’s a 70/30 or 80/20 mixture. So the dose given in labor is lower than the dose at dental procedures, and has a milder effect.) The laboring mother holds the mask to her face whenever she wants a dose. The gas only flows when she inhales. When she moves the mask away, the medication stops. (To see what the equipment looks like in use, do an online image search for “nitrous oxide in labor.”)

The peak pain relief effect kicks in about 50 seconds after you start inhaling. But the peak intensity of contraction pain tends to be 25 – 45 seconds into a contraction. That means you need to start inhaling 30 seconds BEFORE the next contraction is expected so the gas is in full effect when the contraction pain peaks. It can be tricky to get timing just right.

Benefits

Nitrous oxide stimulates the brain to release endorphins and dopamine, hormones that help to reduce pain. Nitrous oxide does not completely relieve labor pain, but women are less bothered by the pain. It reduces anxiety, and can cause a mildly euphoric feeling. Women describe themselves as feeling relaxed and calm while using it. Women report that they liked the fact that they had control over the administration. (To learn more about the laboring person’s experience of nitrous, watch this video from Vanderbilt at https://www.youtube.com/watch?v=lPyuerAoKg8)

Other benefits are that it’s inexpensive (at some hospitals, there’s no extra charge – it’s included in room cost), it takes effect quickly, and if you stop using it, the effects fade quickly (it has a half-life of 3 minutes) rather than remaining in your system for a long time. That means that if you decide nitrous does not provide enough pain relief, it’s easy to move on to other options, such as epidural analgesia.

Effectiveness

One study (Pasha, 2012) found that 92% of women had less pain with nitrous than without. They were also less likely to have severe pain. On nitrous, 41% reported severe pain and 10% reported very severe pain. In the no-nitrous group, 55% had severe pain and 27% had very severe pain.

It’s important to note that nitrous oxide is a mild pain reliever. You should not expect it to take away all your pain. An epidural is much more effective at that; however, an epidural also has more tradeoffs and side effects, so you may choose to start with nitrous and see if that offers enough relief. Some nurses describe the choice to have nitrous as “why not try it and see if it helps.”

Rather than thinking of nitrous as pain relief, it may help to think of it as a ‘coping boost.’ One study showed that it did not reduce the intensity of pain much (as measured on a visual analog pain scale), but after the study period, when given the option to stop using it, women wanted to continue using it anyway. (Carstinou, 1994) The unpleasantness of the pain was reduced, and seemed more manageable. Another study found that 98% of users were satisfied with the experience of using nitrous oxide. (Pasha, 2012) Studies also show that women say they would use it again in a subsequent labor.

Tradeoffs

Unlike epidural analgesia, nitrous does not require extra procedures or extra monitoring. You will not need an IV or continuous fetal monitoring. You are also able to stand, move, and change positions. (If the oxygen comes from a portable tank, you can move around with it, but if the oxygen is piped in from the wall, you’ll need to stay near the bed.)

Possible Side Effects

Side effects on mother and baby are minimal, and less than those experienced with epidural analgesia and with IV / IM narcotics. They can include nausea, dizziness, drowsiness and a hazy memory of events. There is a small chance you could lose consciousness, but if you do, you drop the mask away from your face, and quickly recover. Nitrous does not slow labor and does not affect your ability to push. It does not appear to affect baby at birth. The portable pump is loud, but nurses report this does not seem to bother the user.

Nitrous is contra-indicated if you have persistent anemia / vitamin b12 deficiency.

Timing in Labor

Can be used at any time in labor, except you cannot have nitrous if you have had narcotics in the past two hours. You must wait for them to wear off.

Some cases where it might be especially helpful: during transition, during anxiety provoking procedures (such as vaginal exams, IV starts, stitches for a tear), for women who arrive at the hospital in heavy labor and need quick relief, and at any time by someone who wants to delay getting an epidural. Birth center midwives also report using it when a mom is considering a transfer to the hospital for pain medication. Anecdotally, they say that about half the time it has allowed the client to remain at the birth center.

Comparison to Other Methods

On page 211 – 212 of the book, we offer a chart called “Nonmedicated Labor versus Medicated Labor” that compares what labor is like if no pain medications are used, or if IV narcotics or epidural analgesia are used. Here is that same information for nitrous oxide, so you can easily compare and contrast to the other options.

Pain-Relief Option Used Nitrous Oxide
How it affects your experience of pain Increases pain-relieving endorphins, eases anxiety or fear, and enhances your mood. Small decrease in pain intensity, but makes pain less unpleasant. Can boost your ability to cope.
Feedback from women who used it “Labor was still intense, but it took my fear away and helped me calm down. It made it seem like coping with the pain was doable.”
How it affects your mental state You’re relaxed, calm, may be drowsy or light-headed.
How it affects your mobility You can walk, move around and change positions. If the equipment is hooked up to the wall (rather than being on a mobile cart), you will have to stay close to the bed.
What you’ll need from your support people You’ll still be experiencing pain (though you’ll be less distressed by it). You’ll still want support with comfort techniques and emotional support. Also, they can tell you when a contraction is about to start so you can begin inhaling. (Nitrous oxide is most effective if you start 30 seconds before the contraction.)
Equipment and precautions required You’ll hold the mask that dispenses the nitrous, inhaling from it as desired. Some women need an oxygen sensor on their fingers.
Impact on labor progress Does not affect labor progress.
Timing Can be used at any time, especially during anxiety provoking times in labor.
Availability Very limited availability in the U.S.
Possible risks to you Minimal. (See above.)
Possible risks to baby No apparent risks
Cost Inexpensive
Best option for you if… You just need a little boost to your ability to cope, or need to reduce your anxiety.

For more information:

Source for study data cited: Pasha, et al. Maternal expectations and experiences of labor analgesia with nitrous oxide. Iran Red Crescent Medical Journal, 2012. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3587869/