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.

Advertisements

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.

 

Big Changes in Maternity Care 2010-15

I am a co-author of the book Pregnancy, Childbirth, and the Newborn. (We call it PCN for short.) We have been working on a revision – the 5th edition of PCN will be released in March 2016. You can pre-order it here (affiliate link.)

This post is a summary of all the changes we have made to the book. It is not really meant to be a stand-alone post for someone who is not a birth professional and who hasn’t read PCN. However, if you ARE a birth professional (especially a childbirth educator) and HAVE read PCN, this summarizes what we think are the most important changes in maternity care and birthing culture since 2010 when our last edition came out. I have highlighted with ***asterisks*** the ones that I believe are essential for childbirth educators to be aware of and essential to incorporate these ideas into their classes.

Here you go… all the changes… Note, when I say we’ve “made a change to the website”, that will be upcoming changes to our companion website http://www.pcnguide.com – those will appear live online after March.

Throughout the book:

  • Gender: Have made the language more inclusive of gender-non-normative families. Have changed many incidences of “pregnant woman” or “women” to “pregnant person” or “people” or “expectant parent.” Where we could, we re-phrased the sentence to avoid pronouns, but when pronouns are needed, we use she or her to refer to the pregnant person. As always, partners are gender neutral, and for babies we alternate male and female by section.
  • Microbiome: Added a section to the cesarean chapter discussing the microbiome in detail (also added an even more detailed discussion to the website.) Included references to this information in pregnancy complications chapter (when discussing antibiotics for GBS) and in the newborn care chapter when discussing diarrhea and again when discussing colic. See this blog post to learn more
  • Chapter Order and Division: In this document, I refer to chapters by their chapter number in the old edition. For new edition, the breastfeeding chapter will be divided into two, the pain medication information will be made a separate chapter from Labor Pain and Options, and chapters in the birth section will switch order to:
    • When and How Labor Begins (chapter 9); What Childbirth is Really Like (formerly chapter 12); Labor Pain and Options (formerly first half of chapter 10); Comfort Techs for Labor (11); Pain Medications (formerly second half of chapter 10), When Childbirth Becomes Complicated (13)

Intro: Added some notes about “how to use the book” that address some of the concerns that Amazon reviewers have expressed about the book. Added a note at the end about gender-inclusive language.

Chapter 1 – You’re Having a Baby: no major changes

Chapter 2 – So Many Choices: Updated health insurance info to reflect Affordable Care Act (see details on health insurance). Included notes about ACOG/SMFM levels of care recommendations, which include birth centers and then define level 1 – 4 hospitals. Also added brief note defining “high risk” pregnancy vs. low risk, saying that a high risk mother should choose a high level of care (OB and level 3 – 4 hospital) vs. a low risk mother can choose anything.

Moved the lists of questions to ask (at a birthplace, of your caregiver, etc.) to website.

Chapter 3 – Common Changes of Pregnancy:

  • Added a recommendation to subscribe to an email newsletter like Lamaze or Baby Center’s if they want detailed week-to-week information (“this week your baby is as big as a kumquat”)
  • Made changes to ***how we talk about “the 41st week and beyond”*** given ACOG’s 2014 statement on Preventing the Primary Cesarean, where they recommend that all women be induced at week 41 because of the increasing risk of stillbirth beyond that point and the fact that cesarean rates increase for prolonged pregnancies. We state that some caregivers will recommend that pregnancy continue, with some extra monitoring to ensure that placenta/baby continue to do well, and some will recommend induction at week 41.
  • Updated section on pregnancy after age 35. (Trivia note: when PCN first came out in early 80’s, average age of mothers having their first births was 22.7, and just under 4% of all births were to women 35 and older. In 2013, the average age at first birth was 25.8. 15% of births were to women 35 and older. 22% of those were the first baby born to the mother.)
  • Added a section on “If you’re transgender or genderqueer” that gives resources for finding a supportive caregiver and suggests preparing a detailed birth plan to explain things like preferred pronouns and family terms (e.g. pregnant father)

Chapter 4 – Having a Healthy Pregnancy

  • Added a new section on prenatal screening for birth defects, which includes: first and second trimester blood tests, nuchal translucency screen, second trimester ultrasound, and cell-free fetal DNA testing. Explains that these are all screening tests and none are 100% accurate, so shouldn’t be used as the sole basis for irreversible decisions like termination. If screening tests reveal high risk of birth defects, diagnostic tests (CVS or amniocentesis) are recommended. Although we don’t cover these topics in birth classes, it would be good for all educators to be familiar with the newer testing options. (See my blog for more)
  • Added signs of prenatal depression to pregnancy warning signs
  • Added new resource on effects of infections, substances, and environmental hazards: Mother to Baby website, from the Organization of Teratology Information Specialists. http://www.mothertobaby.org/otis-fact-sheets-s13037
  • Addressed e-cigarettes: Effects on pregnancy has not been studied. MAY be safer because fewer chemicals and no smoke, but still contain nicotine, which is harmful to babies.
  • Addressed marijuana since some states have legalized recreational marijuana use and several have legalized marijuana for medicinal purposes. (It is still illegal at the federal level and this may come into play in child abuse or neglect rulings in those states.)Some studies show that marijuana use in pregnancy does not increase the risk of birth defects. Others indicate that babies born to mothers who regularly used marijuana had a higher risk of premature birth, low birth weight, small head circumference, and cognitive and attention deficits. These studies were generally done when marijuana use was illegal, and thus difficult to get accurate reporting on. Plus the women who regularly used illegal marijuana were also more likely to use alcohol, tobacco and other drugs, and less likely to access prenatal care, so that may influence these outcomes. Until more research is done, it is wise to avoid recreational marijuana use, and only use it medicinally with the supervision of a caregiver.

Chapter 5 – Feeling good and staying fit: Made changes to ***pelvic floor exercises***, saying there’s not a one-size-fits-all recommendation. Recommend they check strength of pelvic floor muscles (by stopping flow of urine or by tightening around two fingers or partner’s penis.) If they seem weak, then do kegels (note: 10 second kegels are best). On the other hand, these symptoms may suggest the muscles are overly tense: pain in vagina, rectum, tailbone, straining with bowel movements, pain during intercourse, urinary issues such as hesitancy, incomplete emptying or pain. In this case, instead of kegels, she could do pelvic bulging, conscious relaxation, or perineal massage to release tension.

Chapter 6 – Eating Well

  • Added info on gluten free options
  • Changed discussion of non-fat dairy items. Research actually shows that people who consume full-fat dairy are less likely to be obese than those who consume non-fat dairy.
  • Starting with a 2011 medical update of the 2010 edition, we have updated discussion from the Food Pyramid to the new “My Plate” guidelines: http://www.choosemyplate.gov.
  • Added recommendation for 600 IU per day of vitamin D in pregnancy
  • Added a section under special circumstances on “Pregnant and Considered Obese” which encourages them to learn more at http://www.wellroundedmama.blogspot.com or by reading the series “Maternal Obesity: A View from All Sides” on http://www.scienceandsensibility.org

Chapter 7 – When Pregnancy Becomes Complicated

  • Updated miscarriage statistic – it did say 10 – 15%, increased to 15 – 20%. As more women learn about the pregnancy earlier in pregnancy, there has been an increase in recognized miscarriages. Also added a few more details on how a miscarriage is treated (observation, medication, or D&C)
  • Moved the chart on impact of infections out of the chapter and on to website.
  • Updated incidence of gestational diabetes. Was 3 – 5%, now 4 – 9%. Included note that in the days prior to (and day of) a glucose challenge test, mother should be well-rested and eat healthy, non-sugary foods to decrease her chance of a false positive.
  • Updated section on gestational hypertension and preeclampsia. Proteinuria is no longer required for a diagnosis of preeclampsia – if mom has high blood pressure plus either lowered platelets or impaired liver or kidney function that is sufficient. Mild gestational hypertension (BP 140/90) is treated with: reduced activity / stress, daily kick counts, weekly appointments for blood tests and possibly fetal monitoring. ***For those with mild hypertension or preeclampsia, delivery at 37 weeks is recommended.*** For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures. If baby is past 34 weeks, they will deliver baby as soon as she is stabilized. If baby is under 34 weeks, amniocentesis to check for lung maturity and corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable. http://www.slideshare.net/lcmurillo/hypertension-in-pregnancy-acog-2013
  • Added a very brief section on perinatal mood disorders to point out that depression in pregnancy is quite common (estimates range up to 20%, or 30% in women of low SES.) Amongst parents with postpartum mood disorders, a significant portion (up to a third) say symptoms began during pregnancy. (Interestingly, anxiety and panic attacks decrease during pregnancy due to soothing effects of hormones.) ***This info should be covered in childbirth education classes, and parents can be referred for more information to sources that address PPMD.***
  • Moved info on breech babies from “When Childbirth is complicated” chapter to here.

Chapter 8 – Planning for Birth and Postpartum

No major changes, except moved “What to pack for the hospital” list from chapter 9 to 8.

Chapter 9 – When and How Labor Begins

  • Replaced the old Events of Late Pregnancy “arrow” with a new graphic.

Chapter 10 – Labor Pain and Options for Relief

  • Divided into two chapters: Labor Pain Options and Pain Medications for Labor
  • In the section on Pain versus Suffering, added in ***the concept of “working with labor pain” ***(see Leap and Newburn. (2010) Working with pain in labour: An overview of evidence. New Digest 2010; 49:22–6.) Also added a brief note about it in the chart comparing pain relief options. If parents believe that comfort techniques are designed to take away their pain, they’ll be disappointed in labor. If they understand that the goal of comfort techniques is to make pain more manageable and help them feel like the pain is something that they can work with rather than something they are suffering through, they may be more satisfied with the experience.
  • In the last edition, under “Effectiveness of Pain Relief Options” we had cited mother’s experiences from the Listening to Mothers survey. We have kept that, but added info on research into the effectiveness of various methods. In the book, we summarize Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801
    • Gate control, defined as adding pleasant stimuli to the painful area. Users were less likely to use epidurals or Pitocin and had lower pain scores
    • ***Counter-irritation***, defined as creating pain or discomfort elsewhere on the body (with TENS, ice, birth combs) to cause the release of endorphins. Users less likely to use epidurals, had lower pain scores, and more satisfied with birth.
    • Central Nervous system control (attention focus, prenatal education, relaxation, hypnosis, continuous labor support). Less likely to use epidurals and Pitocin, less likely to need instrumental delivery or cesarean, higher satisfaction
    • Most effective is a combination of continuous support with other techniques
  • Added to website a chart comparing Cochrane summaries on individual non-drug techniques.
  • See blog at transitiontoparenthood.wordpress.com for more discussion of ‘working with pain’, counter-irritation, and research into the effectiveness of techniques

Chapter 10 B – Pain Medications

Chapter 11 – Comfort Techniques

  • Lots of minor updates to wording and references
  • Added a section on counter-irritation: when the laboring person causes an uncomfortable sensation somewhere to distract her from pain (e.g. bites her lip, digs her fingernails into her palm, pulls her hair). Explained to partners that if this is helpful to her and not harming her, we reinforce it as her ritual. If it might be harmful to her, we substitute – like giving her a washcloth to squeeze in her hands. Addressed birth combs, TENS, sterile water injections as good options
  • Added peanut balls as a comfort item / item to aid labor progress, particularly in late labor for a mom with an epidural (she lies on her side with the ball between her legs – the pelvic opening gives baby room to descend)
  • Re-did some of the diagrams of breathing techniques, particularly light breathing – diagram shows fast breaths every second. Re-drawn as a breath every 2 seconds, with a brief pause between each breath. Slide breathing diagram had 5 or 6 exhales per inhale. Should be 3 – 4.

Chapter 12 – What Childbirth is Really Like

  • In the past, we had described early labor as lasting to 4 cm. ***Shifting to saying early labor lasts till 6***. We describe a “getting into active labor” phase from 4 – 6 cm to acknowledge that labor often intensifies there, and mom needs more support than she did before, but cervical dilation does not really speed up till after 6 cm
  • Added a sidebar about the 2014 ACOG/SMFM consensus paper as the source for that change, and the perspective of “***6 is the new 4***” (American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine. “Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery.” Obstetrics and Gynecology 2014; 123:6093-711.)
  • Made even clearer our statement that prolonged early labor is not a complication. (But, of course, mom does need support with it, and we do give ideas for how to improve progress.)
  • Changed words used to describe fetal heart rate issues. New terms are ***normal, indeterminate, and abnormal***. Outdated terms include fetal distress, non-reassuring heart rate, and fetal intolerance of labor. http://www.ncbi.nlm.nih.gov/pubmed/19546798
  • Fetal scalp sampling removed (apparently there’s not an FDA approved kit for doing it) But do recommend fetal scalp stimulation (scratching baby’s head) as a tool for evaluating an indeterminate heart rate – if you scratch baby’s head and heart rate speeds up, good sign
  • Added more on delayed cord clamping. (to learn more about it, see Penny’s video here: https://www.youtube.com/watch?v=W3RywNup2CM) Note: cord blood CAN be collected for storage or donation after delayed clamping – it is collected from the placenta.
  • Added more on hormones of labor and on hormonal interaction during fourth stage. Included reference to ‘Pathway to a Healthy Birth’ by Sarah Buckley, available at childbirthconnection.org.
  • We are adding Penny’s Road Map of Labor (newly revised) to the back of the book, so have brought references to it into this chapter and chapter 13.

Chapter 13 – When Childbirth Becomes Complicated

  • Changed the order of the sections. In the past, they were roughly in order from most common to least common. But that didn’t lead to a logical flow of topics. New order:
    • complications of pregnancy that affect labor: multiples,  gestational hypertension
    • issues with transition from pregnancy to labor: premature birth, rapid birth, induction
    • challenges that arise in labor: prolonged labor, concerns about well-being
    • prolonged second stage
    • issues after the birth: third stage complications; premature or seriously ill newborns; infant death
    • Note: breech birth moved to chapter 7. Preterm labor divided up as follows: chapter 7 – warning signs and what to do if you think you may be in preterm labor; chapter 13 – when labor can’t be stopped and birth is inevitable
  • Induction – cite recommendations from ACOG that ***elective induction not be done before 39 weeks (and ideally not before 41). However, also mention ACOG recommendation that all women consider induction at 41 weeks.*** acog.org/Resources-And-Publications/Obstetric-Care-Consensus-Series/Safe-Prevention-of-the-Primary-Cesarean-Delivery
    • Shortened section on misoprostol, as current protocols do not appear to cause the severe health complications that happened when it was first used as an induction agent
  • Changed discussion of prolonged labor to match current ACOG recommendations. Prolonged labor should not be diagnosed before 6 centimeters dilation. After 6 cm, it still shouldn’t be diagnosed until she’s had not progress for 4 to 6 hours, even with AROM and Pitocin.
    • Note: ***this is a very significant change for childbirth educators to be aware of***. If more care providers start following these guidelines, labor will become longer on average, and students need to have expectations set appropriately! We need to talk more about not getting excited too early in prelabor, conserving energy in early labor, ways to aid progress in active labor but also not stress over a long labor. (e.g. it may take 5 – 7 hours to progress from 4 to 6 cm even if you’ve got contractions in the 5-1-1 pattern)
  • Childbirth educators used to talk about prolonged labor / back pain being mostly due to OP babies. Ultrasound studies have shown that isn’t always true (see Simkin 2010 – Fetal OP Position: state of the science), and that babies change position more in labor than we had thought. We can say that if you have any of these issues: slow labor progress, irregular or coupling contractions, back pain, or very severe pain, then there is something dysfunctional (“not quite right”) about your labor that needs to be corrected. It may be baby’s position, it may be something else. But whatever the cause, the things we’ve always recommended for slow labor and for back pain can help (e.g. positions and movement, counter-pressure and hip squeeze, addressing mom’s fears, hydration, etc.)
  • Prolonged second stage. Again, the ACOG recommendations have changed! There is no absolute maximum amount of time for pushing. ***Arrest of descent should not be diagnosed unless the mother has pushed at least 3 hours (2 hours if multip). Longer may be appropriate: for example, allowing one hour more if the mother has an epidural or if baby is malpositioned.***
    • Before instrumental deliveries are done, manual rotation of baby’s head should be considered. Before a cesarean is done, vacuum or forceps should be considered.
  • Previous edition said postpartum hemorrhage occurs in 20%. This was a typo. 😦 Should have said 2-5%. Updated this to say “about 5%” based on WHO and ACOG.

Chapter 14 – All About Cesarean

  • Updated “cesarean trends” section to address that rates have increased for all women across the board, and to address practice variations between birth places and how that influences cesarean rates at individual hospitals. Talk about the ACOG statement on need to reduce c-s.
  • Updated info on elective cesarean to reflect 2013 ACOG saying that if there are not medical reasons for cesarean, then vaginal delivery should be recommended. If elective is done, should be after 39 weeks.
  • Updated info on what counts as prolonged labor in need of cesarean (see chapter 13 notes)

Chapter 15 – What Life is Like for a New Mother Parent

  • Changed the order of topics for more logical flow
  • Replaced section on breast self-exams with new recommendations for long-term reproductive health care: Pap smear every 3 – 5 years. Under 40, clinical breast exam every 3 years. Over 40, may recommend annual breast exams and annual mammograms, or they may follow the USPFTF research-based recommendations for biennial mammograms starting at age 50

Chapter 16 – When Postpartum Becomes Complicated

  • Added brief info on PTSD after birth; noted that 5% of new dads experience PPMD; briefly address placental encapsulation (while noting research on its efficacy and safety is limited)

Chapter 17 – Caring for Your Baby

  • Tightened up some medical details to make room for some practical stuff like “how to hold a baby”, “dressing your baby”, “when and how to change a diaper” and typical wake-sleep patterns at 2 weeks, 4-6 months, and 2 years
  • Newborn procedures – removed silver nitrate and tetracycline from eye ointment options, leaving just erythromycin which is what is in current use. Changed hearing screening to note that it is now recommended for all babies. Added the pulse oximetry test. (learn more about this test: http://www.cdc.gov/ncbddd/heartdefects/cchd-facts.html)
  • ***Updated circumcision.*** New AAP guidelines say medical benefits outweigh risks, but not enough to recommend routine circ. http://pediatrics.aappublications.org/content/130/3/585.full; New CDC guidelines say circumcision reduces risk of HIV and 2 other STI’s, and given concerns over the spread of HIV we should do all we can to prevent, and it’s safer to circumcise a baby boy than an older boy or man http://www.cdc.gov/nchhstp/newsroom/docs/MC-factsheet-508.pdf. However, AAP says parents need to weigh benefits and risks, and CDC says delaying circ allows child to participate in decision-making. Note: there is a chair that can be used during the procedure rather than strapping baby to a board on his back – this leads to less distress for baby
  • Increased information about newborn cues, particularly disengagement cues, and overstimulation as a culprit in colicky behavior. Cited research that probiotics may help colic.
  • Updated vaccinations. Old edition didn’t really talk about the benefits, just all the reasons people might choose not to. Update covers benefits to child and community. Says the CDC believes that for the population as a whole, the benefits outweigh the risks, but some parents may have concerns about the risks. States that research does not show a connection between vaccines and autism. Suggests that if they want to opt out of vaccines or adjust timing they should do so only after research into benefits and risks and consultation with caregiver.

Chapter 18 – Feeding Your Baby

  • Split into two chapters. Feeding your baby and When Breastfeeding is Challenging. We did this because of feedback from students that it was overwhelming to see all the complications mixed in with the normal. Throughout the book, we separate typical from Complicated (chapter 7, 13, and 16) so that the complications info is there, but that it’s hopefully less anxiety inducing when it’s clearly labeled as the unusual circumstance.
  • In the past, lots of the information on general feeding practices no matter what they’re fed (when to feed, how much to feed, how to burp, spit-up, etc.) was in the midst of the breastfeeding content, so parents who were bottle-feeding might have skipped much of that important content, and only seen the info on bottles and formula at the end of the chapter. We re-organized the chapter a bit, to be: general feeding info, breastfeeding specific info, bottle-feeding (breast milk or formula) info, then a brief section on formula.
  • “Normal” breastfeeding challenges covered in Feeding Chapter: when your baby doesn’t get enough milk – ways to increase supply; breast fullness and tenderness, sore nipples and leaking
  • Issues covered in the “when breastfeeding is challenging” chapter: persistent sore nipples – causes and treatments; engorgement; plugged ducts; mastitis; persistent low milk supply; and situations that make breastfeeding challenging (cesarean, preemie / ill baby, multiples, nursing while pregnant / tandem nursing; working and nursing.)

Chapter 19 – When You’re Pregnant Again

  • Minor updates, including updated recommendations for books to read to older child.

Appendices

  • We will be moving the chart about pain medications to the website
  • We will add “The Road Map of Labor” graphic to the book, and have updated the “Summary of Normal Labor” chart to incorporate ideas from the road map

The new book will be available in March. We encourage you to check it out! We are also revising the Simple Guide to Having a Baby, which will be out in May 2016. It is similar content to PCN, but whereas PCN is written at a high school / college reading level, Simple Guide is 6th-8th grade reading level. It’s a good match for students with less formal education, for those for whom English is a second language, or those who are too busy to read the much longer PCN.

Seeding and Feeding a Baby’s Microbiome

What is the microbiome?

The collection of bacteria, viruses, fungi, and other organisms that live in and on the body. We have about 10 trillion human cells in our bodies, and about 100 trillion microbes. We have evolved in tandem with this microbiome for thousands of years. The balance of microbiomes varies throughout our body, and the bacteria found in our mouths is different than on our skin, which is different than in our intestines.

Why does the microbiome matter?

  • A balance of microbes leads to optimal health. An imbalance can lead to disease. For example, a vaginal yeast infection may occur when the healthy bacteria are reduced by antibiotics, allowing yeast to overgrow.
  • Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, and protect against infection.
  • An overgrowth of harmful bacteria can lead to infectious disease.
  • Disruption of the gut microbiota has been linked to inflammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers.
  • Many studies have shown that the presence of absence of specific microbes can cause life-long changes in immunity.

How does a baby’s microbiome develop?

  • During pregnancy
    • In the past, the womb was believed to be a sterile environment. However, microbes are found in the placenta, amniotic fluid, and in meconium. (The waste that accumulates in the fetal bowels.)
    • Maternal fecal microbes have been found in the uterine environment, leading to hypotheses that microbes from throughout the body are transferred through the bloodstream. And from there into the placenta, then the umbilical cord and the amniotic fluid.
    • Placental microbes are similar to the microbes in the mother’s mouth – especially types of bacteria that aid in the metabolism of food.
    • Healthy bacteria may benefit baby. For example, if the mother lived or worked on a farm, that might protect against allergies and asthma.
    • Others worry that unhealthy bacteria may affect baby. For example, obese women tend to have abnormal gut microbiota. This may be transferred to the baby.
    • Maternal diet affects the baby. E. coli bacteria (an unhealthy bacteria) was less common amongst babies whose mothers ate primarily organic foods.
  • At birth
    • During a vaginal birth, a baby is exposed to the microbes in mother’s vagina. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk.
    • When a baby is placed skin-to-skin on a parent, they are exposed to the parent’s skin microbiome. The baby’s skin, mouth, and digestive tract are “seeded” by whatever and whomever they first have contact with.
  • Through feeding
    • Breastmilk exposes the baby to more microbes. Several are gut microbes that influence digestion.
    • Breastmilk contains sugars (oligosaccharides) which are not digestible by babies, and whose role appears to be to nourish / feed a healthy microbiome in baby’s gut. These are also referred to as prebiotics. By helping healthy bacteria to grow, there is less room for unhealthy bacteria.
    • When solid food is introduced, the microbiome begins to evolve to a more adult-like combination of microbes.
  • Through the environment
    • As baby is held by various people, their microbiomes influence it.
    • As the baby starts to explore his world, crawling on the floor, playing outdoors, petting animals, and putting everything in his mouth, his microbiome shifts and evolves, becoming quite diverse by age 3. The “hygiene hypothesis” states that babies who are exposed to more symbiotic organisms have lower risks of asthma and allergies, and stronger immune systems.

What can interfere with the establishment of a healthy microbiome?

  • During pregnancy and labor
    • Antibiotics given to mom can affect the mix of microbes in the placenta, amniotic fluid and vagina. This disrupted microbiome is inherited by the baby.
  • At birth
    • Babies born by cesarean, and thus not exposed to vaginal bacteria, are at increased risk of asthma, allergies, obesity, diabetes, and celiac disease. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown differences in their gut bacteria as much as seven years after delivery. (Salminen)
    • After cesarean birth, instead of skin-to-skin contact with the parents, the baby’s first exposures are to hospital bacteria and the bacteria of hospital staff. (Babies in NICU were found to be colonized by bacteria from the health care staff, from medical equipment, and from the counter-tops in the NICU. – Brooks)
  • Newborn care
    • After any birth, if baby is wrapped in a blanket, and placed on a clothed parent, rather than skin-to-skin, the transfer of skin microbes is not complete.
    • Early baths remove / reduce protective vernix, vaginal microbiome, and baby’s own newly seeded skin microbiome. Those are replaced by hospital microbes.
    • If baby is given antibiotics, it reduces microbial diversity, and the number of both harmful and helpful bacteria. The impact lasts over 8 weeks. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of antibiotics, or prolonged use, can have long-term side effects, increasing risk of obesity or inflammatory bowel disease in later life.
  • Feeding
    • Formula-fed babies (even those who just had short-term formula feeding in the first few days) had increased harmful bacteria and decreased helpful bacteria.

What can parents and health care providers do to foster a healthy microbiome?

  • During pregnancy:
    • A mother can increase exposure to diverse healthy bacteria. Taking probiotic supplements may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. (Research cited in Collado) You can eat probiotic foods which introduce healthy bacteria, such as fermented foods and foods with live cultures. And you can eat prebiotics – foods with oligosaccharides which feed healthy bacteria – see the list at the end of this article. (Reed)
    • Minimize exposure to unhealthy bacteria, such as food-borne illnesses.
  • During pregnancy and labor: Minimize exposure to antibiotics. If they are needed, consider consuming probiotics or prebiotics after the course of antibiotics is complete.
  • If baby will be delivered by cesarean, a baby’s initial seeding is from hospital bacteria and skin microbes rather than vaginal microbes. You can expose the baby to vaginal bacteria by swabbing. Although swabbing does not colonize the baby as well as vaginal birth, it helps. (Swabbed babies had twice as much maternal bacteria as babies who were born by cesarean but not swabbed. Babies who were born vaginally had six times as much maternal bacteria.) Here’s the process:
    • Sample mom’s vagina: make sure the mother is HIV-negative, strep-B negative, and has an acid, lactobacillus-dominated vagina.
    • Place sterile gauze in the mother’s vagina. Incubate gauze for one hour. Remove prior to surgery.
    • After birth, wipe baby’s mouth, face and hands with the gauze.
    • Note: If the caregiver will not do this procedure, the mother and partner can do it themselves.
  • After birth, baby should go straight onto the mother’s body, skin-to-skin. (Consider bringing a blanket from home to cover baby, rather than using a hospital blanket.)
  • In the first hours, encourage people other than the parents to look but not touch.
  • Wait 24 hours after birth to bathe the baby.
  • Feed baby only breastmilk for as long as possible.
  • If a breastfeeding mother develops mastitis or a yeast infection, ask a lactation consultant about treatment with lactobacillus probiotics.
  • Giving probiotics to a baby can treat antibiotic-induced diarrhea, prevent eczema, reduce colic symptoms, and possibly reduce obesity in later life. (Studies cited in Arrieta and Collado.)
  • Let your child explore their world, with plenty of time outdoors, digging in gardens, and exposure to animals, both pets and animals at petting zoos.
  • Offer your child diverse foods, including: fermented foods and foods with live cultures (Yogurt, buttermilk, sour cream, kefir, sauerkraut and other fermented vegetables, tempeh, miso, soy sauce, kimchi, dosas and sourdough breads, kombucha, etc.) and prebiotic foods that are high in oligosaccharides (onions, garlic, legumes,  asparagus, starchy vegetables like sweet potatoes, squash, turnips, parsnips, beets, and plantains)

Note: While many of those recommendations are supported by scientific research, not all have been adequately researched.

Here is a 2 page handout of this information to share with clients.

Sources:

To learn more about practically any topic related to the perinatal period, check out Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Teaching Physical Skills

A common mistake I’ve seen in childbirth classes (and other types of classes) is that when an instructor teaches a physical skill, they spend several minutes talking about it, then run out of time for the students to actually DO the skill. I encourage you to flip it around. Talk as little as possible to give your students a sense of what you’ll be asking them to do and why, and then get them practicing as soon as possible. In my workshops, I teach that if you’ve got ten minutes, you spend one minute giving a very brief description of the activity. One minute demonstrating the activity. Then you have eight minutes for them to practice. As they’re practicing, you can walk / look around the room and give feedback, ask questions, and answer questions. But during 80% of the time you’ve got your students engaged and doing something with their bodies, rather than just sitting and listening to you. Here’s more details on each of the steps:

Step 1: Description

First, give a very brief overview of what you are going to do, describe when they would use this technique, and why – what the benefits of the technique would be. For example:

“I’m going to show you slow deep breathing. You can stay sitting and we’ll practice it together. Slow breathing is often the first comfort technique you’ll use in early labor. It helps you to relax, brings lots of oxygen to your baby and your muscles, and gives you something to focus on rather than just the pain.”

“I’m going to show you how to swaddle a baby – wrap it up tightly in a blanket. This is a great first step when you’re trying to calm a crying baby or when you’re trying to settle a drowsy baby to sleep.”

Keep this very brief. Provide just enough info so they know what to expect, and why it’s relevant to them, then quickly move on to them actually performing and practicing the skill.

Step 2: Demonstration

Next, demonstrate how the skill is done, with your body and/or AV’s, narrating each step as you do it. (It may also help to draw a diagram on the board, or point to a poster to illustrate a point.) Teach only the most basic version of the skill at this time. You’ll cover variations and adaptations during practice and feedback. Break the skill up into concrete, teachable steps, and illustrate each step clearly. Examples:

“Stand next to the chair, and place one foot up on it like this. You want your feet to be at a 90 degree angle from each other to open up your pelvis as much as possible to let that baby descend and.rotate. Then you’ll rock back and forth like this – see how much that changes the shape and position of my pelvis? OK, let’s all try.”

“You’ll hold the baby in your arms like this. See how my elbow is supporting his head and my hand is supporting the weight of his bottom? I hold him at the same height as the breast, with his tummy tucked tight against mine. OK, let’s all try.”

If there are several techniques you want to teach, teach them one at a time, with practice sessions between. So, don’t teach 6 positions, then have them practice all 6. Teach them one at a time.

Step 3: Practice

Next, have your students try the technique you have taught. This is where you should spend most of your time!

With hands-on experience of a technique, students will learn it better (and you’ll discover if you weren’t clear enough when you taught it!), remember it better, and adapt it to their use. This deeper learning means they are more likely to use this skill outside your class.

Practicing physical techniques in front of strangers can feel awkward to some people. Some things you can do to help with that: Turn on music during practice sessions so they can’t overhear each others’ conversations. Dimming the lights can also help, but don’t dim them too much, or it can feel strangely intimate. Acknowledge that it may seem silly, but tell them why you see value in teaching the skill. (“No, putting a diaper on a doll is really nothing like diapering your real squirmy baby. But it’s better to have practice some of the basic skills on a doll than it is to never have practiced.”) Be matter-of-fact about it when you demonstrate – if you’re embarrassed or awkward when you’re demo-ing, they’ll be embarrassed to practice it. Start with “easy” things that are generally socially acceptable, then move to things that might be more awkward. For example, teach ways to relieve leg cramps (calf stretches) first, then teach pelvic tilts standing up, then pelvic tilts on hands and knees, then squatting. Or teach hand massage, then upper back massage, then the lower back techniques like counter-pressure and double hip squeeze, which touch on more personal parts of the body.

Step 4: Feedback

The practice and feedback steps are often interwoven. Proper guidance results in quicker, more effective skill acquisition. Learning without guidance is learning by trial and error. It is slower, and less effective than learning with feedback.

As they practice a technique, they discover questions about it that they wouldn’t have ever discovered if you had just demonstrated it and not given them time to practice. During feedback, ask often if they have questions. Their questions will allow you to provide more details about the technique: the when, why, and how to do it get fleshed out in more detail during this process. All the things you may have been tempted to cover in lecture format will still get covered. However, because they come in response to questions and a state of inquiry amongst your students, they will pay more attention to your answer, and remember it better than they would have remembered lecture information you spoon fed to them.

As they practice, they may discover things that aren’t working for them, and you can provide suggestions for adaptation. Then they can experiment some more.

While observing them, you may notice that they misunderstood the demonstration. If so, find another way to show them, but point out that you are doing so. “Ok, let’s try doing this a little differently to see if that will work better for you.” Don’t criticize or blame them. Always find something to praise, and then mold that into success. Encourage them to problem-solve together.

For example, if during counter-pressure practice it looks to me like the partner’s hand is too high, instead of just telling him he’s doing it wrong, I might ask her, “how does that feel?” then I might say to him “your hand is a little higher than I typically place mine… try moving it down a couple inches.” Then I ask mom again, “How does that feel?” Then I encourage them to practice and experiment more with hand placement and pressure to find the spot that’s perfect for her.

Learning from other people’s examples – both good and bad

One of the best ways to learn how to teach physical skills is to watch other people do it. Watch lots of other people! Each one will highlight slightly different information, each will have different analogies. By watching several, you collect a sampling of good ideas. (And sometimes you learn what not to do.

Today, with YouTube, it’s easy to observe a wide variety of teaching styles. If you look up something like “pelvic tilts for pregnancy” or “bathing a newborn”, you will find lots of videos. Some are professional and polished. Some are made with phones propped up on someone’s dining room table.(And sometimes those are the best teaching examples….)

Watch several videos, taking notes as you go along. What are the key points that they cover? Where did they give too much detail? Where were they not clear? How long did it take for them to get to the point of the exercise vs. did they spend a lot of time giving details you don’t really need to know? Did they make it look easy to do? (And I don’t just mean was it easy for them… I mean if I was a really uncoordinated feeling person and I watched them do it, would I think that I could do it?) How was their pacing? Could you practice along with them or were they too fast? Too slow?

Now you practice teaching it. Try out some of the things you saw in the videos. What works well for you? Are there things that you thought would work but you just can’t make it flow quite right?

When you’re teaching, try to pay attention to how much time you spend talking about something while your students sit still versus how much time they spend practicing. The more time they spend practicing and adapting something to their own abilities, the more likely they are to use it during labor or after birth.

Health Care Coverage for Pregnancy and Birth

Having a baby can be expensive, and different kinds of maternity care have different costs. In the United States, a licensed midwife may charge as little as $3000 for prenatal care and attendance at an uncomplicated home birth. Using a midwife for prenatal care and a birth center for the birth may cost $4,000 to $5,000. (Note: These estimates don’t include the costs of prenatal tests, such as ultrasound scans and blood tests.) Using an obstetrician for prenatal care, having prenatal tests and having an uncomplicated vaginal birth in a hospital yields average charges of $30,000. A complicated cesarean birth can increase that cost to more than $50,000.. (Source.) Most health insurance plans are required to cover the basic costs for maternity care, but the details of what each plan covers varies.

The Affordable Care Act requires all Americans to obtain basic health insurance or pay a tax. Expectant parents (or those planning a pregnancy) have five main options for obtaining health insurance:

  • Through their employer. They can get this coverage even if they are already pregnant, and they won’t pay more than 9.5% of their income towards coverage.
  • Through their spouse’s employer. They should check costs carefully. It might be cheaper  to choose another option.
  • Through their parents’ insurance, if they are under 26 year old. They should check to see if the plan covers pregnancy for a dependent, as about 70% do NOT.
  • Individual coverage from a state exchange. They can go to the Marketplace at healthcare.gov or call 1-800-318-2596 to check their eligibility and compare their options. Lower middle-income families may qualify for tax credits, lower deductibles, or subsidies to help pay the insurance premiums. They must enroll during the open enrollment period, which lasts from November 15 through February 15 of each year.If they got pregnant after this period, they will not be able to get health insurance for that calendar year through the exchange.
  • Medicaid or CHIP – the Children’s Health Insurance Program for low income families. Expectant parents can apply for these at any time, via healthcare.gov or through their state’s agency directly. Note: Medicaid recipients may not have as much choice about caregiver and hospital. Because Medicaid does not reimburse providers as fully as private insurance companies to, many providers accept only a limited number of Medicaid clients, or none at all.

If they’re shopping for insurance options, they can ask each company for a copy of their “Summary of Benefits and Coverage” and look on page 7 in the “Having a Baby” section to learn what common costs are paid by the insurance and what deductibles and co-pays they may be responsible for.

Whether they’re researching existing health insurance or choosing a new plan, they should also look at the detailed information about what care is covered. Visit our web site, http://www.PCNGuide.com, to download a work sheet of questions to research. If they don’t understand the extent of their coverage, contact an insurance company representative for clarification. That way, if they decide to have an uncovered or partially covered service, they’ll know how much they’ll pay out of pocket.

Some insurance plans cover—but don’t directly pay for—such services as midwifery care, childbirth preparation classes, birth or postpartum doulas, home birth, and breastfeeding assistance. Instead, parents pay for these services and the insurance company reimburses them.

Parents may also use a flexible spending account (FSA) or health savings account (HSA) to pay for uncovered or partially covered services. Both accounts allow someone to set aside money before paying taxes on it, to use for qualified medical expenses. FSAs are employer-established benefit plans. HSAs are available for employees or individuals with high-deductible insurance policies..

When the baby is born, a parent can choose to add the baby to their existing health insurance, or they can apply for new insurance through the health exchange, even if it’s outside the normal time frame for open enrollment.

Gestational Hypertension Update

ACOG issued a report on Hypertension in Pregnancy in November 2013. Key points:

Proteinuria is no longer required for a diagnosis of preeclampsia – It can be diagnosed if mom has high blood pressure (gestational or chronic hypertension) plus

  • lowered platelets
  • impaired liver function
  • renal insufficiency
  • pulmonary edema
  • new onset of severe headaches or vision disturbances

Women with a history of early onset preeclampsia and preterm delivery may benefit from daily low-dose aspirin. None of these are recommended to reduce hypertension: low salt intake or vitamin C or E.

Mild gestational hypertension (BP 140/90) and mild preeclampsia is treated with: daily kick counts, twice-weekly blood pressure checks (at home or clinic), weekly blood tests and possibly fetal monitoring. (Note: not hypertensive medication.) Bed rest is not recommended, though some caregivers may recommend reduced activity and reduced stress. Ultrasounds may be done to assess fetal growth, and if IUGR is detected,more testing may be done.

Delivery at 37 weeks is recommended for all women with hypertension.

For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures.

If baby is past 34 weeks, they will deliver baby as soon as she is stabilized.

If baby is under 34 weeks, she will be transferred to a hospital with a NICU, given corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable.

Other indications for delivery, even before 34 weeks are: very low platelets, liver enzymes twice the normal value, increasing renal dysfunction, fetal growth restriction (under 5th percentile), very low amniotic fluid (AFI <5 cm).

For women with preeclampsia, cesarean need not be the presumed mode of delivery. Mode of delivery should be determined by gestational age, fetal presentation, cervical status, and maternal and fetal conditions.

Women who continue to have high blood pressure more than 24 hours after birth should avoid non-steroidal anti-inflammatories (e.g. ibuprofen) for pain relief.