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When a woman is first administered an epidural…she needs her doula.

indexWhen a woman is first administered an epidural…she needs her doula. In fact, she and her partner need, and want, their doula* very, very, much!

 
In most cases when a doula is present, this woman has just given up her dream to have a natural birth. This is difficult for her. And that is not even mentioning the pain she is dealing with at the time. She hurts; she is upset; she is scared. She may even feel that imaagesshe has just been forced down a path she did not want. She knows that this is a turning point in her labor and takes her closer to the possibility to major surgery. And all of this has a huge impact on her partner.

 
It is obvious…they both need the woman they have come to know and trust over the past several months. They jwant the woman they have handpicked to be with them throughout this journey of childbirth. They want that one consistent and ever present woman. They want their doula.

 
And why shouldn’t their doula remain with them? Around these parts, the anesthesiologist do not mind. There is plenty of space in the room. And the doula knows to stay out of the way. She is beneficial because imageksshe knows how to calm the woman so that she is not moving about during this precise procedure. She knows how to keep a watchful eye on the partner. She offers a sense of peace and calm for this couple with whom she has spent so many hours, as no one else in the room can offer.

 
imagesThen there are those first delicate moments immediately following the administration of the drugs. The woman’s blood pressure may drop; the baby may not react well; etc. Again…this is the time to have the soothing presence of the doula. This is the very important time for both mother and partner to be assured by this woman they trust so much.

 


The doula knows that the medical team must do what they need to do at such an intense time and is prepared to remind this couple of what is occurring, as she has already reviewed the possibilities weeks ago. She is also prepared to remind the mother of her options, her choices, with all the pros and cons. She is able to explain to the couple what might be occurring, even while the mother and baby are being cared for by the medical team.

 
kWhen an epidural is administered, which is a turning point in a woman’s labor, the woman and her partner need and want their doula.

 
It is very simple…the doula gives them what no one else can.

 

*For the purpose of this article, when I refer to a doula I am referring to a certified doula, or one in the process of certification, who abides by a set Code of Ethics and Standard of Practice.

Tools for Birth

When you are ready to give birth, you will have an arsenal full of tools you wish to use during this most important and exciting experience.  <<   

You will have all of your recent education, your birth wishes, your doula, your midwife. You will <have your birth ball, your birth pool, your willingness to do what you need to do.

Your desired ambiance will be created through lighting, music and aromatherapy. <And most important…you will have your open mind.

If things might not go as you originally hoped they would…you will have another set of tools that some call interventions. And you will know in your heart that there is a time and place for every intervention that man has created. <And so your tools will have grown to include pitocin, pain medication, epidural, and if need be, a cesarean.

And in the end, you will have your new baby in your arms. <Your dream of many days and weeks will be complete.< Perhaps not exactly as you had hoped and planned. And for that you may need to grieve. And that grieving will be good.

But you will forever know that you had prepared, and used,  your tools. And you had prepared, and used, your open mind. <And then, and for always, you will have your baby; your family.

 

What Impact Can IV Fluids Have on Mother, Baby and Breastfeeding?

 A Quick Look.

images (4)Written by guest author, Jacqueline Levine

Having IV fluids is a medical procedure. It’s meant to restore normal body fluid balance when there’s blood loss or dehydration, but the Listening to Mother’s Survey1 reports that 83% of women have IV in labor. Having a routine IV , as so many do, isn’t risk-free.2 An excess of IV fluid can dilute red blood cells and other components of the blood like clotting factors, so that less oxygen gets to the uterus and less to the fetus, increasing the possibility of post partum anemia or hemorrhage3,4.
Too much fluid can overcome normal pressure in blood vessels, and fluid goes where it shouldn’t. The mother’s and/or baby’s lungs can become “wet”5. Large amounts of fluid given quickly (a bolus) can interfere with the activity of the uterus.6 The type of IV fluids given can have unhappy effects as well, such as hyponatremia which can cause seizures, and symptomatic hypoglycemia in the baby7,8,9. Plastic IV lines may “off-gas” phthalates and other chemicals that are harmful. This list is brief. There are lots of studies that show harms from routine use of IV. Even the safety of “normal saline” has come under scrutiny.10 And the effect of IV administration lasts well into the days after the mother is disconnected from her hanging bag of fluids.
Fluid has weight, of course; haven’t you heard that helpful little reminder, “a pint’s a pound the world around”? If a laboring mother gets bag after bag of IV fluids, odds are that her baby will be born with an inflated birth weight. Breastfeeding success is often measured by how quickly the baby regains its birth weight after the normal weight loss in the first week or so. What exactly might that baby’s normal birth weight have been? What does it mean to the motherbaby pair when of them both are full of extra fluids? Water moves everywhere in the mother’s body and aside from ankles and wrists and fingers and toes that can be swollen like sausages, breasts and nipples hold water as well. A swollen breast with taut skin makes latching difficult. This scenario is often the beginning of early nursing troubles10: the transition from colostrum to mature milk may be delayed in a water-swollen breast, and a newborn may not able to achieve a deep latch so he can’t get sufficient food and cannot stimulate the breast well. Supplementation comes next. We know it and the studies show it. There are remedies to those situations…good support for mother and baby… but best-evidence, optimal maternity care is the answer.
Supplementation frequently comes next. We know it and the studies show it. There surely are remedies to the problem of swollen breasts, like Reverse Pressure Softening, and methods to build up milk supply, and ways to support better positioning for a baby who is having latch difficulties..
But the overarching answer is for mothers to be aware of best-evidence, optimal maternity care, and to understand their rights as patients to refuse routine interventions. By avoiding IV fluids except for compelling medical reasons, mothers will be able to avoid the negative consequences of fluid overload to their babies and themselves, and give themselves a chance at better breastfeeding beginnings.

Jacqueline (Jackie) Levine, LCCE, FACCE, CD(DONA), CLC is committed to providing a continuum of care for underserved women at PlannedJackie-Levine Parenthood, on Long Island, NY, where she has provided free Lamaze education, birth and breastfeeding support to all the women in her classes for the last 9 years. She is a guest lecturer on Childbirth in the US at CW Post, has worked for CIMS, contributed to the Lamaze e-newsletter Building Confidence Week-by-Week , all after her 30-year career as a designer in the garment center. Jackie is a recipient of the Lamaze Community Outreach Award, mother of three and Grandmother of five.” Science & Sensibility

 
References:
1-DeClerq E, Sakala C, Corry MP, et al. Listening to Mothers ll: Report of the Second National US Survey of Women’s Childbearing Experiences. New York: Childbirth Connection
2-Wasserfstrum N. Issues in fluid management during labor; general considerations. Clin Obstet Gynecol 1992;35(3):505-13
3-Carvalho JC, Mathias RS, Intravenous Hydration in obstetrics. Intl Anesthesiol Clin 1994:32(2):103-15
4- Carvalho JC, Mathias RS,Senra WG et al. Hemoglobin concentration variation and blood volume expansion during epidural anesthesia for cesarean section. Reg Anesth1991;16(1S):73
5-Gonik B., Cotton DB.,Peripartum colloid osmotic changes; influence of intravenous hydration. American Journal Obstet Gynecol1984;150(1):99-100
6-Cheek, T.G., Samuels, P.,Miller, F., Tobin, M., Gutshe, B.B. Iv load decreases uterine activity in active labor. Journal of Anaesthesia 1996;77:632-635
7-Stratton JF, Stronge J, Boylan PC. Hyponatremia and non-electrolyte solutions in laboring primigravida. Eur J Obstet Gynecol Reprod Biol 1995;59(2):149-151
8-west CR, Harding JE. Maternal water intoxication as a cause of neonatal seizures. J Pediatr Child Health 2004;40(12):709-10
9-Nordstrom L, Arulkumaran S, et al. Continuous maternal glucose infusion during labor; effects on maternal and fetal glucose and lactate levels. Am J Perina. Am J Perinatol;1995;12(5);357-62
10-http://www.modernmedicine.com/modernmedicine/Modern+Medicine+Now/Normal-saline-is-not-normal-may-be-harmful/ArticleNewsFeed/Article/detail/776186?ref=25
11-Chantry CJ, Nommsen-Rivers LA, Peerson JM et al. Excess Weight Loss in First-Born Breastfed Newborns Relates to Maternal Intrapartum Fluid Balance. Pediatrics 2010

Obstetricians Study Themselves

It is my privilege to share another thought provoking article by Jacqueline Levine, LCCE, FACCE, CD(DONA), CLC

Your obstetrician is afraid of being sued.

imsssagesShould that fear guide the way you’re treated during your pregnancy, labor, and the birth of your baby? Should fears of litigation have a direct effect on the rate of cesarean section in our country, and should your risk of having a c-section depend on your OB’s personality?

How about best-evidence optimal maternity care? Do you believe that the maternity protocols in use by OBs reflect the best science, using “Level A” evidence-based protocols and practices? And if there’s a proven, effective training program that takes just two days and lowers c-section and morbidity rates, shouldn’t that training be in use in every hospital and everywhere women have their babies? Common sense and our general understanding of ethical behavior make us want to answer those questions with confidence, just as you think they should be answered.

The dismal truth, however, is that those questions must be answered in just the unequivocal opposite of what your good sense tells you.
The cesarean rate in the US seems to have stopped rising and has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”; the report cites the current rate as 31.3%. That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization (WHO) and other orgs that promote and support optimal maternity care have been making that case for a good while.
Now, famously, ACOG has come out with a position paper, a report entitled “Safe Prevention of the Primary Cesarean Delivery”, with guidelines meant to prevent a first-time c-section; the study calls for “revisiting” the list of the “common indications” for cesarean. Those various rationales for section have held sway in maternity care for years. We understand that the new guidelines are a hard admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the general health of women and babies. ACOG wants to “prevent overuse” of c-section. (See Obstetric Care Consensus Number 1, March 2014, entitled “Safe Prevention of the Primary Care Delivery”, from the American College of Obstetricians and Gynecologist, along with the Society for Maternal-Fetal Medicine.)
We should understand that the forces driving maternity care are not totally about optimizing the health of mothers and babies, but rather respond to other imperatives. Examples follow.
At the 57th Annual Clinical Meeting of the American Congress of Obstetricians and Gynecologists (as reported in Medscape Today; Medscape Medical News, May 12, 2009), there was discussion of an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates”. I’ll just quote it directly so that you can have the very words of the study as reported (bold emphasis is mine):
PhysiciansBenefitCopingSupport“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out. Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery. Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean (s)delivery. Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem,” “We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,” “So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.”
This article is really a confession. It’s a way to say “You see, it’s not our fault that we have to do all these c-sections. We’re just human and fear is making us do unnecessary surgeries, just in case we get sued” and puts the OB in the role of victim. It’s “defensive” medicine…and where might this kind of medicine be taught in the medical curriculum? It’s an admission that what is being done in the way of care may be for the welfare of the OB, and not for the welfare of the women in his care. Do docs acknowledge the possible effect of malpractice insurance on birth options?
We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. We are right to feel that any doctor who picks up a scalpel and performs surgery for these “defensive” reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship. It’s easy for the OB to use cesarean delivery as an answer to all potential problems, to say that something might be wrong, do the surgery, and when of course everything turns out fine, mother and family are just relieved.
But should you have to give up your right to be treated according to your genuine health status, and have to risk the many documented hazards of c-section for both you and your baby, and perhaps compromise your future reproductive health to protect the personal welfare of your doc? So yes: your OB may treating you to promote his or her own personal, financial interest, since that study shows a willingness to admit that one of the reasons for the high cesarean rate is fear of litigation.
Another example: does your risk of c-section depend on your OB’s personality? Again, the answer is yes. A disturbing article, called “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality”, discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Here is the citation: Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation
The results of the study are very concise, and as before, quoting directly makes things abundantly clear: The obstetricians with the least anxiety had the lowest emergency cesarean rates. imagesThe obstetricians with the most anxiety had the highest rates.”
Statistical analysis revealed that the doctor’s trait anxiety levels were highly correlated with cesarean rates. It’s unlikely that the human condition and the pantheon of measureable personality traits has changed much since ’08. It’s likely that there are still discernible anxiety levels among OBs, that might cause them to react to those anxious feelings and perform sections for that anxiety.
These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean, and how many of those factors have to do with a mother’s or baby’s actual health status? Of course there’s literature that proposes other reasons for the high c-section rate, but the studies discussed here expose a side of obstetric practice that is particularly damning. Each doctor makes a choice either to treat ethically, or alternately, with regard for his/her own interests and inclinations.
Here’s some mixed news from the industry. It’s the publication of the study entitled: “Scientific Evidence Underlying the American College of Obstetricians and Gynecologists Practice Bulletins (Wright, Jason D. MD; Pawar, Neha MD; Gonzalez, Julie S. R. MD., et al), published in Obstetrics and Gynecology in 2011”. This study examines the protocols and guidelines used in obstetric care as to their basis in good science. We can only applaud OB’s decision to examine their own guidelines and protocols, no? This quote comes from the Abstract of the study: “We examined the quality of evidence that underlies the recommendations made by the American College of Obstetricians and Gynecologists (the College)”. So far, so good
But the words that cause that frisson of anxiety are in the conclusion of the study: “One third of the recommendations put forth by the College in its practice bulletins are based on good and consistent scientific evidence.” That evidence is called “Level A”. That can only mean that the remaining two-thirds are not. That’s 70% of the care protocols used on birthing women are not based on the best science! Doctor #1What does this mean to each birthing woman? Must she be on the lookout for practices based on anecdotes, opinions, traditions and other poorly supported evidence? How will she know? And why should she ever even have to worry?
Making that point even more painfully is this study from the Society for Maternal-Fetal Medicine’s 34th Annual Meeting, presented February 6, 2014, with this title Training Reduces Cesarean Delivery and Neonatal Morbidity, and published online in Medscape Medical News © 2014 Feb 07, 2014. This important study needs to be quoted:
“A multifaceted intervention program for health professionals aimed at reducing the rate of cesarean delivery succeeded in doing just that, according to a new multihospital study…. “Our hypothesis was that intervention at the right time would provide the chance to improve the quality of obstetrical care and reduce morbidity. “… ” The program involved a 2-day on-site training workshop for health professionals that focused on the best clinical practices for intrapartum care…. and that did significantly reduce neonatal major morbidity (OR, 0.81; P = .028) and effect minor morbidity (OR, 0.88; P < .001). …
“This study of more than 100,000 women shows that an interventional program can not only reduce the chance of cesarean delivery, but can also reduce neonatal morbidity, noted William Grobman, MD, professor of obstetrics and gynecology-maternal fetal medicine at the Northwestern University Feinberg School of Medicine in Chicago.
“The important thing is that this did not involve new therapies or methods. This was totally about the delivery of health services,” Dr. Grobman told Medscape Medical News. “We often focus on new treatments, but sometimes it’s the relatively simple things — education, quality improvements, quality control, and feedback — that can substantially affect maternal and child health.”
Shall we assume that nurses and docs just don’t know “best clinical practices’ without this extra training, or forgot them, or find it inconvenient to use them? If it takes only two days of training to correct bad practices, what can we think?
Is the problem not clear? Bad practices based on less-than scientific evidence and unethical behavior and personal character traits and fear of litigation and ignorance…the “ignoring” of best clinical practices, can guide maternity care. If only a third of maternity protocols…for both mother and newborn…are based on best-evidence science, what about the rest of the care woman and their babies receive? And if that unscientific behavior can be remedied by a mere two-day course that reminds docs and nurses how to observe optimal care practices and can fix the huge problem of high c-section rates and other insults to the health of mother and baby, how can a mother make her way through this system without coming to some kind of harm? We have the words of the maternity caregivers themselves to read and ponder.
OBs are ducking questions about the morality of performing cesareans for defensive reasons, and ducking patient’s questions about best-evidence care, but somehow we have to make them face this reality: “Approximately one-third to one-half of maternal deaths can be attributed to the cesarean procedure itself.” And: “There are no well-documented prospective trials demonstrating benefit to the fetus or to the mother that would justify the extent of the increase in the primary cesarean rate.” These quotes are from Obstetrics: Normal & Problem Pregnancies, 3rd Ed. Gabbe et al. p634).
There are many caring and dedicated practicioners who stay current and give only best-evidence care. We admire the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers, and not for their own welfare, but the high section rate illustrates the fact that they may just be a minority.

ifffmagesWe have only that one day, that one chance for each baby we birth,

so when deciding on a caregiver, it’s our responsibility to get familiar with best-evidence, optimal maternity care and question our health care provider about his/her practices. We need to learn the facts about normal, healthy birth, and conservative reasons for c-section based on real health status as well. Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website www.thebirthsurvey.com Your prospective OB knows that best-evidence information is out there for you to see, so question him/her closely about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care upon mother and baby. If you sense a defensive posture about his stats, or an air of reluctance to tell you what you want to know, politely say your thank-you’s, and head for the door.

Jackie-Levine“Jacqueline (Jackie) Levine, LCCE, FACCE, CD(DONA), CLC is committed to providing a continuum of care for underserved women at Planned Parenthood, on Long Island, NY, where she has provided free Lamaze education, birth and breastfeeding support to all the women in her classes for the last 9 years. She is a guest lecturer on Childbirth in the US at CW Post, has worked for CIMS, contributed to the Lamaze e-newsletter Building Confidence Week-by-Week , all after her 30-year career as a designer in the garment center. Jackie is a recipient of the Lamaze Community Outreach Award, mother of three and Grandmother of five.” Science & Sensibility

Please feel free to send comments/questions to Jackie: birthlink@optonline.net

 

From the Mouth of a Doctor!

True story….yesterday a doctor, as in MD, said she loved delivering with doulas.


“It makes for such a more peaceful birth.”


She then says to the couple that a doula saves lots of money.

She said an anesthesiologist charges $1600 to perform an epidural…and that does not even include the medicine & equipment.


Thank you Ms Doctor!!!!

Epidurals and Cesareans

I found this interview with Dr. Aaron Caughey, by Kate Fillion, enlightening as well as fascinating.  If you are considering using an epidural, I strongly encourage you to read this!!!


Here are a couple of excerpts from this interview:

Dr. Caughey says, “The epidural slows labour down. Many times, in the first stage, after an epidural you’ll see a decrease in the rate of contractions. In the second stage it’s blockading your nerves, so you have less motor strength and can’t push as hard.”

Q: Is there an incentive for a physician to order a C-section even if it’s the woman’s first pregnancy?

A: The physician doesn’t make that much more for a Caesarean delivery, about 10 per cent more in the U.S. For the physician, the main incentive is related to time and convenience. If I’m on call all weekend, and I’ve got somebody in labour who’s been six centimetres dilated for a couple of hours and it’s 5 p.m. on a Friday—well, if I do a C-section now, I might get to leave the hospital to see my family. If I give her two more hours, and she dilates further, that still doesn’t mean she’s ready to deliver. It could be midnight before she’s completely dilated, and then she could push for three or four hours, and at the end, I’m paid about the same as if I’d just done the C-section 12 hours earlier.


Dr. Aaron Caughey on labour and how epidurals changed childbirth…a must read!!!

http://www2.macleans.ca/2011/09/26/on-labour-how-epidurals-changed-childbirth-and-why-women-don%e2%80%99t-have-to-push-so-much/#.ToMZqTC_YnA.facebook

Birth Doulas are for ANY kind of childbirth!!!

More and more people seem to understand the benefits a birth doula has to offer to a woman and her family, when that woman wishes to have a natural childbirth experience.

But how many people realize what benefits a doula offers when a woman chooses to use an epidural? Or how about the comfort a doula is able to give when there is a cesarean?

When a women tells me she wishes to have an epidural as soon as possible, I smile and assure her that I understand her wishes, which are absolutely her right.

I then explain how our local hospital does not typically admit a woman until she is in active labor. I suggest we work  on ways of coping until she is admitted, even how to stay active in triage. I then move on to the realities and mechanics of having an epidural. After this, I discuss her second stage of labor…actually giving birth. Then her wishes for her new born baby should be planned for, such as skin-to-skin, bonding, breastfeeding, having the nursery staff come to her and her baby.

Every time I am with a woman who suddenly finds she is going to have a cesarean, there is disbelief, deep regret, confusion…..an overall feeling of being a failure in some way. Her family is usually at a lost, feeling much the same way. And did I mention fear? I, as a doula, am there to help qualm these rampant and sudden emotions. I guess my job is to help restore peacefulness. I work fast and furious to try to accomplish this, assuring the woman that I will still be there for her. After all, there is still much work for me after the baby is delivered.

My point with these ramblings…a birth doula is there to provide physical, emotional, and informational support to the mother and her partner before, during, and just after birth…

NO MATTER WHAT TYPE OF CHILDBIRTH!!!

To Epidural or not…….

Are you planning on having an epidural? If so, that is certainly your choice…but have you considered all of the effects, and not just for yourself, but for your baby, too? I mean really considered???

If you tell me yes to these questions, then I say go for it.

But what are you going to do until you care provider allows for the epidural to be administered? How are you going to handle your labor until that point? An epidural is usually not given until you are well into active labor, about 5 centimeters.

And what if, as happens so often, you have “break through” pain? Do you know what you will do then?

And don’t forget about the 2nd stage…pushing.

My point…….an epidural does not take away the need for education, coping tools, and the need for a birth doula!

Please…..what are your thoughts????

Kenny…..Triad Birth Doula