Alternative Strategy to Decrease Cesarean Section: Support by Doulas During Labor

Here is the link to a well-researched study on the benefit of doula support for families from the Journal of Perinatal Education.

Stand and Deliver? Upright Labor Positions Reduce Pain, Speed Birth

Newswise — Women who walk, sit, kneel or otherwise avoid lying in bed during early labor can shorten the first stage of labor by about an hour, according to a new Cochrane evidence review. Women who labored out of bed during the early stages were also 17 percent less likely to seek pain relief through epidural analgesia, the review found.

“This shortens labor by about an hour and, for a lot of women, an hour would be really important,” said Teri Stone-Godena, director of midwifery at the Yale School of Nursing, who had no affiliation with the review.

Fortunately, the review did not find any differences in birth outcomes for mothers or babies due to labor position. There were no differences in terms of interventions like birth by Caesarian section. “I think this means that women can be reassured that any position that they want to get into is OK,” Stone-Godena said.

Overall, the review included 21 studies, examining 3,706 births.

It appears in the latest issue of The Cochrane Library, which is a publication of The Cochrane Collaboration, an international organization that evaluates medical research. Systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic.

So why would staying out of bed shorten labor and reduce pain?

“Women who are upright and mobile are able to change their positions more easily,” said Annemarie Lawrence, lead review author and a research midwife at the Institute of Women’s and Children’s Health at Townsville Hospital in Queensland, Australia.

“The ability to change positions, to utilize a wider variety of positions, and try other options, such as hot showers, birthing balls and beanbag supports, may help reduce overall pain and give women a greater sense of control over the progress of their labor,” she said.

When women are upright, there is also more room for the baby to move downward because the diameter of the pelvis expands slightly. This puts less pressure on nerves in the spine, which could mean less pain.

“It may also be that women are more distractible when up and moving around,” Stone-Godena said. “When you are lying there looking at clock, it’s a lot different from being up and about.”

Being upright allows gravity to help the baby make her way into the world. Lawrence said, “The physiological advantages of upright positions and mobility include the effective use of gravity, which aids in the descent of the baby’s head. As the head is applied more directly and evenly against the cervix, the regularity, frequency, strength and therefore efficiency of uterine contractions are intensified.”

When the mom-to-be moves, this also helps the baby to get into the best position to hasten birth. “This improves its alignment for passage through the pelvis,” Lawrence said. “There is also a psychological advantage associated with the belief that being upright and mobile empowers women to actively participate in their birth experience and maintain a sense of control.”

Other research has found that feeling in control and able to make choices reduces pain and psychological distress in general.

In contrast, however, lying flat on one’s back during labor can put a great deal of pressure on the blood vessels in the abdomen. “There is widely accepted physiological evidence that the supine position may be harmful in late pregnancy and labor,” Lawrence said.

According to the reviewers, the supine position puts the entire weight of the pregnant uterus on the blood vessels that supply oxygen to both mother and child, which could potentially lead to problems with heart functioning in the mother and reduced oxygen to the baby. These outcomes could be serious in extreme cases. Lying on one’s side has no link with such problems, however.

Stone-Godena said that despite all the attention given to empowering women to have the type of birth experience they prefer, medical professionals still pressure women into lying in bed during labor, because it is more convenient this way for nurses and doctors — and makes fetal monitoring easier.

“I think this research is very vindicating of women being allowed to assume positions of comfort,” she said. “Listening to their bodies is what they need to do. Most of time when we limit people’s activity, it isn’t for reasons that are soundly based on evidence.”

She added, “This clearly shows that there are no advantages in staying in bed unless that’s where you want to be.”

The Cochrane Collaboration is an international nonprofit, independent organization that produces and disseminates systematic reviews of health care interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. Visit http://www.cochrane.org for more information.

Lawrence A, et al. Maternal positions and mobility during first stage of labor. Cochrane Database of Systematic Reviews. Issue 2, 2009.

Terri here- Very vindicating indeed. This research confirms what midwives and doulas have known all along.

Writing a Birth Plan

How to Write a Birth Plan
Advice and an example of how to write a birth plan for the woman that desires to have a natural, medication-free childbirth.
http://www.associatedcontent.comarticle/263836/how_to_write_a_birth_plan.html

Best Practices In Maternity Care Not Widely Used In The United States

(Terri here- informative article that shows why doulas really are necessary for hospital births. Sad, but true. And Lamaze really provides good, solid research on suggested practices. Check it out!)

08 Jan 2009

Despite best evidence, health care providers continue to perform routine procedures during labor and birth that often are unnecessary and can have harmful results for mothers and babies. The Centers for Disease Control's (CDC) most recent release of birth statistics reveals that the rate of cesarean surgery, for example, is on the rise to 31.1% of all births-50% greater than data from 1996. This information comes on the heels of The Milbank Report's Evidence-Based Maternity Care, which confirms that beneficial, evidence-based maternity care practices are underused in the U.S. health care system.

Research indicates that routinely used procedures, such as continuous electronic fetal monitoring, labor induction for low-risk women and cesarean surgery, have not improved health outcomes for women and, in fact, can cause harm. In contrast, care practices that support a healthy labor and birth are unavailable to or underused with the majority of women in the United States.

Beneficial care practices outlined by Evidence-Based Maternity Care, a report produced by a collaboration of Childbirth Connection, the Reforming States Group and the Milbank Memorial Fund, could have a positive impact on the quality of maternity care if widely implemented throughout the United States. Suggested practices include to:

- Let labor begin on its own.
- Walk, move around, and change positions throughout labor.
- Bring a loved one, friend, or doula to support you
- Avoid interventions that are not medically necessary
- Choose the most comfortable position to give birth and follow your body's urges to push
- Keep your baby with you - it's best for you, your baby and breastfeeding.

"Lamaze is alarmed by the current rate of cesarean surgery, and furthermore, by the overall poor adherence to the beneficial practices outlined above in much of the maternity care systems in the United States," says Lamaze International President Pam Spry, PhD, CNM, FACNM, LCCE. "We are continuing to work to provide women and care providers with evidence-based information to improve the quality of care."

Lamaze International has developed six care practice papers that are supported by research studies and represent "gold-standard" maternity care. When adopted, these care practices have a profound effect-instilling confidence in the mother, and facilitating a natural process that results in an active, healthy baby. Each one of the Lamaze care practices is cited in the Evidence-Based Maternity Care report as being underused in the U.S. maternity care system.

Debra Bingham, MS, RN, DrPH(c), Chair of the Lamaze International Institute for Normal Birth says, "As with any drug, we need to be sure that women and their babies receive the right dose of medical interventions. In the United States we are giving too high a dose of cesarean sections and other medical interventions which are causing harm to women and their babies. Yet there are many countries where life saving medical interventions are under dosed which can also cause harm. Every woman and her baby needs and deserves the right dose of medical interventions during childbirth."

The research is clear, when medically necessary, interventions, such as cesarean surgery, can be lifesaving procedures for both mother and baby, and worth the risks involved. However, in recent years, the rate of cesarean surgeries cause more risks than benefits for mothers and babies. Cesarean surgery is a major abdominal surgery, and carries both short-term risks, such as blood loss, clotting, infection and severe pain, and poses future risks, such as infertility and complications during future pregnancies such as percreta and accreta, which can lead to excessive bleeding, bladder injury, a hysterectomy, and maternal death. Cesarean surgery also increases harm to babies including women giving birth prior to full brain development, breathing problems, surgical injury and difficulties with breastfeeding.

For more information on the Six Care Practices that Support Normal Birth, finding a health care provider and how to give birth with confidence, visit http://www.lamaze.org.

About Lamaze International

Since its founding in 1960, Lamaze International has worked to promote, support and protect normal birth through education and advocacy through the dedicated efforts of professional childbirth educators, providers and parents. An international organization with regional, state and area networks, its members and volunteer leaders include childbirth educators, nurses, midwives, doulas, lactation consultants, physicians, students and consumers. For more information about Lamaze International and the Lamaze Institute for Normal Birth, visit http://www.lamaze.org.

"TODAY SHOW FEATURES DOULAS"

Help For Expectant and New Mothers Is National Trend

On Thursday, November 20th, the TODAY Show explored a growing national trend among pregnant women and new mothers: the hiring of a "doula." Debbie Aglietti, a New York doula and member of DONA International was interviewed about her work as a doula in the New York area.

"As more and more women see the advantages of using doulas, I suspect the term 'doula' will become more of a household word," said Debbie Young, DONA International President. DONA International is the oldest and largest doula organization. "In fact, last week Oprah Winfrey's guest, Nicole Kidman, made mention of the assistance she received from a doula in the birth of her daughter, Sunday Rose."

Doulas provide non-medical care for pregnant women and/or new mothers and families. The term "doula" actually comes from the Greek word for a woman who serves.

Doulas work as a team with physicians and midwives in hospitals and in home births. A birth doula is a professional labor support person who accompanies women in labor to provide emotional support, physical comfort and information to help clients feel fully informed. Birth doulas can provide reassurance and perspective and help with relaxation, comforting touch and positioning. Birth doulas also facilitate communication between the woman, her partner and her caregivers. A postpartum doula is trained to help new mothers in the early weeks with their new baby. From help with breastfeeding, education on newborn care, running errands, nighttime support and anything else a new family needs help with, parents find the additional assistance invaluable.

Despite Dr. Snyderman's Today Show statement that doulas are a luxury, doulas assist women and families from all socioeconomic levels. In some cases Medicaid covers their work. In other cases, community volunteers offer doula services for low-income families for free. Some families find their doulas because their hospital offers their services for free or at low-cost. In Illinois, the state government pays for doula services under their "Ounce of Prevention" program. Other programs, such as Chicago Doula Project and PALS in Philadelphia, offer doulas for low-income mothers. Currently, doula services are not covered by most health insurance providers, but DONA International is working to change that.

Numerous clinical studies have found that a doula's presence at birth:

· Tends to result in shorter labors with fewer complications
· Increases positive feelings about one's childbirth experience
· Reduces the need for Pitocin (a labor-inducing drug), forceps or vacuum extraction and cesareans
· Reduces the mother's request for pain medication and/or epidurals

Interview a potential doula about how postpartum and birth doulas assist new mothers, pregnant women and overwhelmed spouses. Ask her to discuss the types of tasks doulas do. Tasks could include:
· Putting on music and assisting the birthing mother into a more comfortable position
· Helping a new mother with techniques for easier breastfeeding
· Offering guidance to make the first bath at home go smoothly

Families should seek to find a doula that is right for them.

With any kind of service provider, whether it's a nanny, doula, midwife or OB/GYN, it is important to get references, ask questions and make sure you are comfortable with that practitioner and their experience.

Click here to view the video.

Doulas have been working in hospitals all over the US and, in fact, internationally for over 15 years with good success. They function as part of a team effort with the hospital staff and the woman's choice of caregivers to help the family have the best birth possible. There are always exceptions to the good people in any profession and unfortunately one hospital took that exception to ban doulas. But that is one hospital out of over 7,500 hospitals in the US.

In DONA International's Code of Ethics and Standards of Practice, doulas pledge to treat the health care professionals that work with their clients with respect. When a nurse comes into the room to check on my client, I step to the other side of the bed and if there is any non-medical thing I can do to assist her and serve my client, I will be glad to do that. The doula helps the mother ask appropriate questions so that the mother can make the best choices possible for herself and her baby. The doula should never speak in place of the family.

Doulas are available to women with various economic means. There are many private practice doulas who work with clients who can afford to pay for their services. Many of these same doulas also take clients who cannot afford to pay their full fee at a reduced rate or may pass them on to another doula in the area that is charging less. There are also many volunteer programs or state run agencies that offer doula services for very little or free. In the press release info below you see some of them mentioned. The vast majority of doulas are in this work because it is their "heart work" and they would likely do it for free if they did not have family obligations. But I want to make it clear that doulas are worth every penny they charge. It is up to each doula to decide if and what she charges.

DONA certified doulas have approximately 50 or more hours of education behind them before they get certified. That includes the workshop, breastfeeding class, childbirth education class, reading and working with families. Then they have to document their work and write papers about their experience. It is not a simple process but it is a worthwhile process!

Doulas on the Today Show-

Tune in to a feature on doulas scheduled for NBC's Today Show on Thursday, November 6, 2008 early in the 8:00 am EST hour.

Ami Schmitz, Today Show medical producer, recently gave birth with the assistance of a DONA certified birth doula and wants to sing the praises of doulas and DONA International! She, along with Dr. Nancy Snyderman, NBC News Chief Medical Editor, will present this segment.

An expanded companion article about doulas and DONA International will be available on the Today Show web site, which will include the interviews they did with Debbie Young, current DONA president. The article should be available on Thursday, but it might be necessary to type "doula" in the search engine if it is not the top news that day.

This segment will air barring breaking news that takes precedence.