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.

Childbirth: Can the U.S. improve? - Los Angeles Times

Childbirth: Can the U.S. improve? - Los Angeles Times

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Great website

I went to the Midwives Association of Washington State (MAWS) conference last Friday in Seattle. It was great- I learned a ton, and was very inspired. A friend introduced me to this website you all must check out: mothersnaturally.org
It has a fabulous due date calculator, among many other helpful tools, articles and info. I will add it to my link list on the right side of the blog here.

Well put, Jan Tritten

Please jump on over to Midwifery Today's community forum, where midwife Jan Tritten very beautifully articulates how I feel about birth.
Click here to read "Fear not; it is a miracle"

Widespread Use Of Labour Induction Potentially Harmful To Woman And Baby

11 May 2009

Induction of labor is on the rise in the U.S., standing at 41% according to a large national survey of women who gave birth in 2005. But, a new study published in the April issue of BJOG, the peer-reviewed journal of the Royal College of Obstetricians and Gynaecologists, finds that the best available evidence does not support many reasons medical providers give for using drugs or other measures to cause labor to begin.

The investigators found support only for inducing labor at or beyond 41 completed weeks of gestation and under some conditions when a woman's membranes break before labor. However, there is not good evidence for inducing labor in many other situations, including when the fetus is believed to be large or to have restricted growth, or when a woman is pregnant with twins, has insulin-dependent diabetes, or has low levels of amniotic fluid.

The study's lead author, Dr. Ellen Mozurkewich, a maternal-fetal medicine specialist at the University of Michigan, said, "The best available evidence does not support routine inductions in many situations for which induction is currently being recommended to patients. More research is necessary to clarify the risks and benefits of induction in these situations."

Many pregnant women may be receiving inappropriate care. For example, 17% of women who participated in Childbirth Connection's national Listening to Mothers II survey in 2005 said they had been induced because their caregiver was concerned that their baby was too big. However, best evidence suggests that labor induction is not beneficial in this case.

"We now know that every week of gestation counts in terms of brain and lung development. When there is no good reason to end pregnancy, mothers and babies benefit from waiting for labor to begin on its own," said Carol Sakala, Director of Programs, Childbirth Connection. "Starting labor early can lead to negative outcomes for the woman and/or baby."

To foster high quality maternity care, Childbirth Connection, a research and advocacy organization, commissioned this study through a grant from the Transforming Birth Fund of the New Hampshire Charitable Foundation.

Concerns about inducing labor without an established medical rationale include increased risk of cesarean section for some mothers (e.g., first-time mothers and women with a cervix that is firm and closed), and babies who are born before full lung and brain maturation. Estimates of how long a fetus has been developing can be off by up to two weeks, and labor induction can unwittingly end with a preterm birth.

Source
Childbirth Connection

Repeat C-sections Rise By Over That 40 Percent In One Decade, USA

- Nearly one-third of the 4.3 million childbirths in 2006 were delivered via C-section, compared with one-fifth in 1997.
- C-sections are more costly than vaginal deliveries, $4,500 versus $2,600 in deliveries without complications, and $6,100 versus $3,500 in deliveries with complications.
- Therefore, although C-sections account for 31 percent of all deliveries, they account for 45 percent of all costs associated with delivery.
- C-sections account for 34 percent of all deliveries by women who are privately insured but only 25 percent of deliveries by women who are uninsured.

For complete article, read here.

Terri's comments: Come on people, wake up. This section rate is absolute lunacy!
And VBACs are safe and possible- but, you have to be prepared. Get a good midwife, childbirth educator, doula, and read, read, read!

Home births "as safe as hospital"

The largest study of its kind has found that for low-risk women, giving birth at home is as safe as doing so in hospital with a midwife.

(Click here for audio interview)

Research from the Netherlands - which has a high rate of home births - found no difference in death rates of either mothers or babies in 530,000 births.

Home births have long been debated amid concerns about their safety.

UK obstetricians welcomed the study - published in the journal BJOG - but said it may not apply universally.

The number of mothers giving birth at home in the UK has been rising since it dipped to a low in 1988. Of all births in England and Wales in 2006, 2.7% took place at home, the most recent figures from the Office for National Statistics showed.

The research was carried out in the Netherlands after figures showed the country had one of the highest rates in Europe of babies dying during or just after birth.

It was suggested that home births could be a factor, as Dutch women are able and encouraged to choose this option. One third do so.

But a comparison of "low-risk" women who planned to give birth at home with those who planned to give birth in hospital with a midwife found no difference in death or serious illness among either baby or mother.

"We found that for low-risk mothers at the start of their labour it is just as safe to deliver at home with a midwife as it is in hospital with a midwife," said Professor Simone Buitendijk of the TNO Institute for Applied Scientific Research.

"These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth."

Hospital transfer

Low-risk women in the study were those who had no known complications - such as a baby in breech or one with a congenital abnormality, or a previous caesarean section.

Nearly a third of women who planned and started their labours at home ended up being transferred as complications arose - including for instance an abnormal fetal heart rate, or if the mother required more effective pain relief in the form of an epidural.

“ The NHS is simply not set up to meet the potential demand for home births ”
Louise Silverton Royal College of Midwives

But even when she needed to be transferred to the care of a doctor in a hospital, the risk to her or her baby was no higher than if she had started out her labour under the care of a midwife in hospital.

The researchers noted the importance of both highly-trained midwives who knew when to refer a home birth to hospital as well as rapid transportation.

While stressing the study was the most comprehensive yet into the safety of home births, they also acknowledged some caveats.

The group who chose to give birth in hospital rather than at home were more likely to be first-time mothers or of an ethnic minority background - the risk of complications is higher in both these groups.

The study did not compare the relative safety of home births against low-risk women who opted for doctor rather than midwife-led care. This is to be the subject of a future investigation.

Home option

But Professor Buitendijk said the study did have relevance for other countries like the UK with a highly developed health infrastructure and well-trained midwives.

“ Women need to be counselled on the unexpected emergencies which can arise during labour and can only be managed in a maternity hospital ”
RCOG

In the UK, the government has pledged to give all women the option of a home birth by the end of this year. At present just 2.7% of births in England and Wales take place at home, but there are considerable regional variations.

Louise Silverton, deputy general secretary of the Royal College of Midwives, said, the study was "a major step forward in showing that home is as safe as hospital, for low risk women giving birth when support services are in place.

"However, to begin providing more home births there has to be a seismic shift in the way maternity services are organised. The NHS is simply not set up to meet the potential demand for home births, because we are still in a culture where the vast majority of births are in hospital.

"There also has to be a major increase in the number of midwives because they are the people who will be in the homes delivering the babies."

The Royal College of Obstetricians and Gynaecologists (RCOG) said it supported home births "in cases of low-risk pregnancies provided the appropriate infrastructures and resources are present to support such a system.

But it added: "Women need to be counselled on the unexpected emergencies - such as cord prolapse, fetal heart rate abnormalities, undiagnosed breech, prolonged labour and postpartum haemorrhage - which can arise during labour and can only be managed in a maternity hospital.

"Such emergencies would always require the transfer of women by ambulance to the hospital as extra medical support is only present in hospital settings and would not be available to them when they deliver at home."

The Department of Health said that giving more mothers-to-be the opportunity to choose to give birth at home was one of its priority targets for 2009/10.

A spokesman said: "All Strategic Health Authorities (SHAs) have set out plans for implementing Maternity Matters to provide high-quality, safe maternity care for women and their babies."

Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7998417.stm

Published: 2009/04/15 08:08:24 GMT

© BBC MMIX

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.

No risk from eating during labour

(Terri here- I am SO grateful to the BBC that we finally have a study to back this up! Midwives and mothers have always instinctively known this. It is SO sad as a doula to be with a client in labor who keeps crying about how hungry she is, after x hours of labor, and to NOT be able to offer her anything to eat for strength and nourishment.)

It is safe for most healthy women to eat during labour, research has found.

The study found eating a light diet during labour has no effect on the duration of labour, the need for assisted delivery, or Caesarean rates.

Since the 1940s it has been common practice to prevent eating during labour to cut the risk of complications if surgery is required.

But the King's College London study, featured online in the British Medical Journal, suggests this is too cautious.

“ Denial of food can be seen as authoritarian and intimidating, which may for some women increase feelings of fear and apprehension during labour ”
King's College London

Some doctors have previously advised women not to eat during labour to minimise the risk that they would breathe food into their lungs should they need an emergency caesarean under general anaesthetic - a condition known as pulmonary aspiration.

But pulmonary aspiration has declined dramatically in recent years, mainly due to the increased use of local anaesthesia for caesarean deliveries.

Many doctors and midwives also argue that preventing food intake during labour can be detrimental to the mother, her baby and the progress of the delivery.

However, previous research on the subject has proved inconclusive.

The King's team focused on 2,426 healthy women having their first baby. Each women was either allowed small, regular amounts of food during labour, such as bread, fruit and yoghurt, or water only.

No differences

The natural birth rate in both groups was the same, at 44%. Average duration of labour was also similar, 597 minutes for the eating group, and 612 minutes for the water only group.

The caesarean rate was also the same - 29% for the eating group, and 30% for the water group.

And in both groups around one in three women vomited during labour.

There were also no differences in the condition of the babies at birth or admission to special care units.

The researchers, led by Professor Andrew Shennan, said the study showed that there was no pressing reason to deny women food during labour.

They wrote: "Denial of food can be seen as authoritarian and intimidating, which may for some women increase feelings of fear and apprehension during labour.

"Eating and drinking may allow mothers to feel normal and healthy."

Current guidelines from the National Institute for Clinical Excellence (NICE) recommend that low risk women in normal labour may eat and drink.

Dr Virginia Beckett, a consultant obstetrician and spokesperson for the Royal College of Obstetricians and Gynaecologists, said it was fine for healthy women at low risk to eat during labour.

But she stressed that it was not a good idea for those who were at higher risk, such as women who were obese.

Women using pethidine to reduce pain during labour, should also avoid food, as the drug relaxed the gut muscles, making problems more likely.

Dr Beckett said: "Eating during labour is not going to make things better, but it is not going to make things worse, and it might make you feel more of a human being, and that is quite important.

"We would not want women to be sitting there eating a roast dinner, but it is reasonable to suggest it is safe for low-risk women to eat small amounts of preferably liquid food during labour."

Story from BBC NEWS:
http://news.bbc.co.uk/go/pr/fr/-/2/hi/health/7961689.stm

Published: 2009/03/25 00:02:12 GMT

© BBC MMIX

Jennifer Block: Extreme Birth, Indeed

Jennifer Block: Extreme Birth, Indeed

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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

National Cesarean Rate Continues to Rise

(Terri here: This report is so disheartening. Please check out Lamaze's website for great information, as noted in the last paragraph of this article. I LOVE Lamaze's Care Practice Papers- they are essential to any pregnant mama.)

Evidence Increases for Risks in Cesarean
Surgery as National Rate Continues to Rise

WASHINGTON (March 18, 2009)—As research continues to mount for the risks of cesarean surgery, the Centers for Disease Control released new, staggering statistics reporting that 31.8% of women endure birth by cesarean in the United States (2007). This announcement comes after the release of significant findings from the New England Journal of Medicine reinforcing that birth by cesarean surgery before 39 weeks of pregnancy causes increased complications in newborns.

Despite the latest advances in medical technology, health care providers cannot determine a baby’s due date with 100% accuracy. Therefore, cesarean surgeries scheduled before a woman’s estimated due date could result in a baby born as early as 36 weeks to a few days before the baby is actually due. During the last few weeks of pregnancy, a baby’s lungs mature and a protective layer of fat forms, both of which are vital developments for a healthy baby. In addition, babies need time for their lung cells to shift from being fluid producing to fluid absorbing cells. Without time during labor to prepare the baby to breathe, lungs cells may not be ready. Thus, babies born by cesarean surgery, even when they are full-term, need to go to an intensive care unit more frequently than babies who were born vaginally to get help breathing.

Research published in the New England Journal of Medicine (NEJM) supports earlier findings that cesarean surgery performed prior to 39 weeks of pregnancy increases poor outcomes in babies. Of the babies in the NEJM study born before 39 weeks, more than 26% had complications, including the need to be on a ventilator, respiratory distress syndrome, low blood sugar and severe infection (sepsis).

“Overuse of cesarean surgery complicates the otherwise natural process of birth,” says Lamaze Institute Chair Debra Bingham, LCCE, MS, RN, DrPH, “Allowing the natural process to occur not only reduces risks for mothers in this and future pregnancies, but also reduces health risks for her baby.”

Spontaneous labor is almost always the best indication for a baby’s physical readiness for life outside of the womb. As one of the key steps to a healthy birth, Lamaze International recommends that women let labor begin on its own. Allowing labor to begin naturally increases the likelihood that a baby is healthy and ready for birth. When a birth outcome is good, mother and baby can bond and start breastfeeding immediately after birth—both of which provide the best start for a baby’s growth and development.

Lamaze International President Pam Spry, PhD, CNM, FACNM, LCCE says, “Maternity care in the United States is at a crossroads. The most commonly used practices don’t align with the best evidence for a healthy birth.” The Milbank Report’s Evidence-Based Maternity Care: What It Is and What It Can Achieve reveals that several routine maternity care practices, including cesarean surgery, contradict best evidence and are overused in the United States.

Cesarean surgery—a major abdominal surgery—also carries risks for women, such as blood loss, clotting, infection and severe pain, and poses future risks, such as infertility and complications during future pregnancies such as stillbirth and placenta problems like percreta and accreta, which can lead to excessive bleeding, bladder injury, hysterectomy and maternal death. The research is clear, however, that when medically necessary, cesarean surgery can be a lifesaving procedure for both mother and baby, and worth the risks involved.

Two of the most important decisions a woman can make are where she gives birth and who she chooses as her care provider. Lamaze International has developed tools to help women with these decisions, including the questions to ask and other reference material. Visit http://magazine.lamaze.org/ to learn more about the Lamaze during pregnancy, birth and beyond.

###

About Lamaze International
Since its founding in 1960, Lamaze International has worked to promote, support and protect 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, visit www.lamaze.org.

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.

Aquarobics May Help Ease Labor-

Women who exercised during pregnancy needed less pain meds, study found

Terri here: I HIGHLY recommend this. I did prenatal water aerobics during my last two trimesters when I was pregnant with my daughter. There are SO many benefits to this: easy on your joints, low-impact exercise keeps you in shape for the upcoming marathon of labor, it feels fantastic to be weightless when you're so big, AND being in water actually helps keep or get the baby in a good position (meaning vertex and anterior: head down and facing the right way!). The classes do not need to be prenatal necessarily, and if you do nothing else- just go swimming on your own.

Patience During Stalled Labor Can Avoid Many C-sections, Study Shows

ScienceDaily (2008-11-03) -- Pregnant women whose labor stalls while in the active phase of childbirth can reduce health risks to themselves and their infants by waiting out the delivery process for an extra two hours, according to a new study.

Terri here: Well, ya think? It is nice when they do these studies to verify the obvious, but apparently it isn't so obvious, or the section rate would not be where it is now in this country.

Here is the link.