New Medical Guidelines Released to Prevent Cesareans

Earlier this week, the American Congress of Obstetricians and Gynecologists (ACOG) along with the Society for Maternal-Fetal Medicine (SMFM) released a joint Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery, in response to rapidly rising first-time cesarean birth rates that have shown no improvement in the death rates for moms or babies. (Complete details on the consensus can be found on ACOG’s website.) In the statement, the two groups put forth several new recommendations that propose to help prevent the first cesarean for women. If you are pregnant, you can use these new guidelines as a conversation starter during a prenatal appointment — find out how these new suggestions measure against your care provider’s routine practices. A sample summary of the recommendations is below.

A long first stage of labor — more than 20 hours in first-time moms — should not be cause for a cesarean. Many women are put on a time clock to dilate to 10cm, when in reality, a long labor alone should not be cause for a cesarean. If you hear statements like, “Your labor has stalled,” “You are not progressing,” or “Failure to progress,” followed by a recommendation for cesarean, ask: “Is my baby OK? Am I OK? What’s the risk in waiting or doing nothing right now? (or, what’s the alternative?)”

First-time moms should be permitted to push for at least 3 hours (2 hours for second-time moms) before recommending a cesarean. Unlike what Hollywood and The Baby Story show us, pushing can take a while. It’s important for moms to be given enough time to push out their baby, as long as mom and baby are both doing well.

Because induction raises the risk of cesarean, it should not be performed before 41 weeks unless medically indicated. Yes, 41 weeks! Allowing  baby enough time to continue developing and for your body to gear up for labor will give you the best chance of having a healthy mom and baby.

Ultrasounds performed late in pregnancy to determine your baby’s weight should be used only if there is clear indication, as these ultrasounds are linked to increased rate of cesarean for a “big baby,” which is rarely a good reason for cesarean. Ultrasounds have been shown, time and again, to be off by up to (or more than) a pound in either direction. If cesarean is suggested because your baby is estimated to be too big — get a second opinion from a care provider in another practice.

Continuous labor support — like that provided from a doula — is “one of the most effective tools” in improving birth outcomes. Good labor support is not just a “nice to have,” but a key component to improving your care during birth. Lamaze has known this for quite some time — check out our Healthy Care Practice number 3, “Bring a loved one, friend or doula for continuous support.

Being pregnant with twins does not automatically mean a cesarean, if twin A is in a head-down position for birth — even if the second twin is not head down. Vaginal birth for twin mamas — it IS possible!

Baby’s position in labor should be determined — especially if there are problems with baby moving down the birth canal — and if possible, an attempt should be made to manually re-position baby before suggesting a cesarean. A posterior baby (where baby faces toward your front instead of your back)  can cause problems in labor. Often, a baby will correct its position before birth, but not always, and this can cause issues. If you suspect an issue with your baby’s position during labor, mention it to your care provider. You can ask for ultrasound in labor to verify. Ask for help with trying to get baby in a better position for birth.

5 Ways to Be Your Own Best Advocate for During Birth

When seeking to maximize your comfort and minimize interventions during your hospital birth, there are simple things you can do to advocate for yourself. Be sure to also share these tips with your partner and birth support team, as they will be able to help advocate on your behalf while you are busy laboring. 

1. Request your nurse. While this isn’t always a possibility, you can ask upon check in for a nurse who is comfortable supporting a mom who is laboring without pain medication (if that is your preference). Similarly, if you end up with a nurse who is not the best fit, you can ask (politely) to have a different nurse.

2. Get out of the bed. Laboring in a bed, on your back, is a very uncomfortable position to experience contractions. But upon entering the hospital, you are asked to get into bed to be monitored, insert an IV port, and other general hospital procedures. You do not, however, have to do this lying down in bed! You can let your nurse know that you would like to sit up in bed, stand, sit on a birth ball, or kneel — positions that are all compatible with most hospital admittance procedures.

3. Get monitored and then get off. Most hospitals require a standard 15 minutes per hour monitoring on an electronic fetal monitor. If you’re not familiar with this device, it is made up of two elastic bands that are wrapped around your belly — one to monitor your contractions and one to monitor your baby’s heartbeat. Take note of the time you began monitoring so you can politely remind the nurse (who may have gotten tied up with other patients) when it’s time to come off. Also note that you can be monitored in other positions than lying back in bed. Most nurses are willing to work with you to find a position that is most comfortable, as long as you speak up.

4. Protect your hospital room environment. Turn down the lights, keep the door closed, adjust the thermostat, close the curtains (or keep them open!), ask for more pillows (they’re usually in a cabinet), ask for an ice pack or heating pad (some hospitals carry disposables), turn down the volume on the monitor. There are many things you can do to make your hospital room more comfortable, private, and peaceful.

5. Ask questions about procedures and ask for time to think it over when presented with a decision. Sometimes, nurses, midwives, and doctors get so caught up in the routine of their job, they forget to take the time to explain what they are doing. If you have a question about anything related to you or your baby’s care, ask! And if you are faced with making a decision (unless it’s an emergency), it’s ok to ask for more information and for more time to think it over.
photo credit: santheo via photopin cc

Evaluating the Research on Home Birth Safety – A Link Round Up

In the last two weeks, two studies were released on the topic of home birth safety. And that’s where the similarities end. The studies’ reports completely oppose each other — the Midwives Alliance of North America (MANA) study states that “among low-risk women, planned home births result in low rates of interventions without an increase in adverse outcomes for mothers and babies,” and the study from the New York-Presbyterian/Weill Cornell Medical Center showed that “patients [who] delivered babies at home by midwives had a roughly four times higher risk of neonatal deaths than babies delivered in the hospital by midwives.”

How can it be that two studies evaluating the same thing reported results that are so vastly different? Well, the answer is lies in how the studies were created and reported. As a family working to evaluate your options and preferences for place of birth, it’s important that you read both studies, as well as what both the critics and proponents have to say, and then decide for yourself the best option for you and your family. Below are links to the original studies and subsequent reviews:

Midwives Alliance of North America (MANA) study

New York-Presbyterian/Weill Cornell Medical Center Study

Review from Science & Sensibility

Review from The Daily Beast

Review from Citizens for Midwifery

Review from Live Science

Review from Huffington Post

 

 

 

60 Tips for Healthy Birth: Part 5 – Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

In this six-part series, we are sharing 10 tips for each of the Lamaze six Healthy Birth Practices that help guide women toward a safe and healthy birth. The Lamaze Healthy Birth Practices are supported by research studies that examine the benefits and risks of maternity care practices. Learn more about each practice, including short, informative videos at Lamaze.com. To read the rest of the 60 tips, check out the other posts in this series.

10 Ways to Avoid Giving Birth on Your Back and Follow Your Body’s Urges to Push

1. Learn why avoiding giving birth on your back and following your body’s urges to push is healthy for you and your baby.

2. Discuss early on with your care provider that you would like to do what comes naturally when it comes to positions and pushing during birth. If your care provider reacts negatively, this could be a red flag that she does not support evidence-based practices.

3. Take a good childbirth class to learn the many ways in which you can push out a baby, and in particular, the many positions you can push in/on/around a hospital bed that does not involve lying flat on your back.

4. Avoid interventions that restrict your mobility so you can easily move in any way you feel comfortable, including positions for pushing, like on all fours, standing, squatting, and side lying.

5. If interventions become necessary, involve your labor support team to help you remain as mobile as possible and get into upright positions for birthing.

6. Learn the difference between directed pushing and pushing with your body’s natural urges.

7. Include details in your birth plan about your preferences to push in a position that is most comfortable to you and to follow your body’s natural urges to push (ie, please don’t count or coach for pushing). Share your birth plan with your care provider during your pregnancy, and bring a copy of your birth plan to your place of birth to share with your nurses/attendants.

8. Consider “laboring down” to shorten the amount of time spent actively pushing and to provide you with more energy to push in upright positions.

9. If you are birthing at a hospital, ask your nurses in advance of pushing about using the squat bar. Nearly all maternity beds come with a squat bar attachment, but staff may need some time to locate it and bring it to your room. The squat bar  is an excellent tool that can help support your squatting position in labor and birth. It can even be used for women who have an epidural.

10. You may find that pushing on your back and/or pushing with the encouragement or coaching of your labor support team is actually helpful — and that’s ok, too! Labor and birth is about what works best for you and your baby to have the most healthy and positive experience.

60 Tips for Healthy Birth: Part 4 – Avoid Interventions that Are Not Medically Necessary

In this six-part series, we are sharing 10 tips for each of the Lamaze six Healthy Birth Practices that help guide women toward a safe and healthy birth. The Lamaze Healthy Birth Practices are supported by research studies that examine the benefits and risks of maternity care practices. Learn more about each practice, including short, informative videos at Lamaze.com. To read the rest of the 60 tips, check out the other posts in this series.

10 Ways to Avoid Interventions that Are Not Medically Necessary

1. Learn why avoiding interventions that are not medically necessary is important for you and your baby.

2. Ask your care provider (the earlier, the better) about the kinds of interventions they use and when they use them. You can ask about their rates of interventions, but you’ll  most likely get more accurate and telling answers with more open-ended questions, like, “For what reasons would you recommend an induction?” and “Why would I need a cesarean?”

3. Take a quality childbirth education class to really get to know different interventions and how they interplay with one another. For example, you cannot be induced without having continuous external fetal monitoring and IV fluids.

4. Learn about the interventions used regularly at your chosen place of birth. Sometimes, those rates are available publicly and sometimes (more often), they are not. You can also ask during your hospital tour or at a prenatal visit with your care provider. But your best bet is to ask local doulas and childbirth educators, who will most certainly have insider knowledge.

5. Research and practice a variety of coping and comfort measures, as well as position changes, to use during your labor and birth.

6. Consider hiring a doula, who is trained on the use of interventions and can offer additional resources for you to make the best informed decision about your care. A doula will not advocate on your behalf, but can help you be a better advocate for yourself.

7. When you hit 40 weeks and there is no sign of labor, remind yourself that 40 weeks is not a deadline but a vague estimate and that a healthy pregnancy can go to 42 weeks and beyond. Also remind yourself that you will not, in fact, be pregnant forever. As uncomfortable as you may be at 40 weeks of pregnancy, the healthy choice in most cases is to let labor begin on its own.

8. If faced with the decision to induce your labor, first find out why, and second, find out your Bishop’s Score. And, learn why an induction might be necessary and when it is not.

9. Make sure your partner or birth support person (spouse, partner, friend, family member) knows about your birth preferences and understands how best to support you during birth. Your birth partner will be an invaluable asset to your birth experience.

10. Interventions can be medically necessary and life-saving. If interventions become necessary, find out how you can keep your labor as healthy as possible.

 

photo credit: Rick Bolin via photopin cc

When to Head to the Hospital in Labor

It’s the million dollar question for nearly every first-time mom nearing the end of her pregnancy. Knowing when to head to the hospital so that you don’t arrive too early and not so late that you have your baby on the side of the road is a hard to nail down. It’s not a perfect science, but there are some tips that can help guide you to know the right time for you. Most care providers give the standard “5-1-1″ guidelines for when to call them and/or head to the hospital: when your contractions are consistently 5 minutes apart, lasting for 1 minute each, and going on for at least an hour. But this could mean that you are at the hospital earlier than you had wanted, with several more hours of active labor ahead.

Review the following questions and begin to formulate a plan for when you will go to the hospital when you are in labor. Talk it over with your care provider and birth support team for input.

What are your goals? Do you want to stay in the comfort of your own home as long as possible in labor? Or, do you feel more comfortable in the hospital setting? Are you seeking a low intervention birth? Or, are you planning on having an epidural for pain relief? Knowing your goals for labor will help you decide how long to labor at home.

Ask for professional feedback. If you’ve hired a doula or if your doctor or midwife know about your wishes to labor at home as long as possible, call them for feedback when you’re in a good labor pattern. Talk to them for a 10-15 minutes, while you’re having a few contractions, so they can help assess where you are in labor and whether or not you should go into the hospital.

Take note of what’s happening between contractions. As your labor progresses closer to transition (7/8 cm dilation), you will most likely begin to decrease your activity between your contractions. Prior to this point, you may feel like walking, talking, and moving around in between contractions. When you stop feeling the ability to be mobile in between contractions, you may want to consider going to the hospital.

Listen to your gut. In this time of information overload and “Are You in Labor” online quizzes, we often overlook the most important natural instinct we have: our intuition, or “gut feeling.” When in labor, take a few moments to sit quietly by yourself and find out what your gut is telling you. Many women who’ve had babies will tell you: “you’ll just know.” And usually, it’s true.

 

How did you know when it was time to go?

Keep Moving During Labor

When women give birth in the movies, they are generally portrayed one way: lying down, in bed. But research shows that moving freely in labor improves a woman’s sense of control, decreases her need for pain medication, and may reduce the length of her labor. Sometimes it is hard to move in labor due to routine procedures or lack of support and space. A recent US study found that 71 percent of laboring women did not walk at all during active labor. Instead, women often labor in bed propped up with pillows. Many women who have labored this way say next time they want to be more upright. This following list provides steps you can take to increase the chance that you will be able to maintain freedom of movement during labor.

  1. Choose a care provider and your birth place carefully to make sure you will be encouraged and supported to move and change positions. Find a care provider who will support you in choosing the positions that work best for you. When choosing a birth setting, look for birth balls, rocking chairs, squatting bars, and tubs.
  2. No matter where you give birth, stay home until you are in active labor, when contractions are five minutes apart and last about one minute. If your cervix is not dilated more than 4 centimeters when you arrive at your birth setting, consider going home or for a walk until your cervix dilates more. It’s often easier to move and respond to your labor at home. You can rock, slow
    dance, walk, or sit on your birth ball. Listen to your body and rest when needed.
  3. Once at the birth setting, request that your care provider not use any unnecessary intervention that may make it harder to move around. This will mean that continuous monitoring of the baby’s heart rate (“continuous EFM”) and intravenous lines (IVs), are only used when needed for medical reasons. If there is a medical reason for these, tell your care provider that you want to maintain as much freedom of movement as possible. There may be ways to minimize the effect of these interventions on your ability to move freely.
  4. Arrange to have continuous support in labor from a professional labor assistant (a doula) or a close friend or family member who makes you feel safe and confident. Ask them to remind you to try different positions or activities in labor.
  5. Consider the impact that pain medications will have on your ability to freely move during labor. All pain medications make it hard to stand or walk in labor. It is usually impossible when an epidural is used. You may hear about a “walking epidural” but this usually just allows you to move your legs in bed or walk short distances. Pain medications often lead to the need for other interventions, such as IVs and continuous electronic fetal monitoring, which restrict movement. Choose to birth at a place that provides easy access to a tub. Using water in labor decreases the need for pain medication. If you want an epidural in labor as a pain coping technique, wait until labor has progressed and you have already used lots of movement to help the baby rotate and move down in the pelvis. Encourage your support team to learn about ways to support a woman with an epidural and encourage movement compatible with epidural use.
  6. Attend a childbirth class that focuses on active labor, giving you and your partner plenty of movement and position options. Keep a list of the positions that you like best and bring it with you as a reminder in labor. Practice positions and movements before your labor begins, so you and your partner feel comfortable and confident using them.

Quick checklist for place of birth

  • Safe place to walk
  • iPod, smart phone, other MP3 player for dancing music
  • A tub
  • Birth ball
  • Rocking chair
  • Squatting bar
  • Telemetry (portable device used for continuous fetal monitoring)
  • Policy for intermittent auscultation (heart rate monitoring)
  • Policy for respecting women’s choices for labor support

For more information on the importance of maintaining movement during labor, check out the Lamaze Health Birth Practice video all about walking, moving, and changing positions during labor.

Do I Need to Take a Hospital Tour?

This is a question many first time parents ask. There are different options depending on where you are giving birth — virtual, group or private tour. The hospital tour is an optimal time to find out how your desired birth fits into the hospitals policies and procedures.

Lamaze has created a webcast that offers insight on how taking a hospital tour can impact your labor and birth experience, the best questions to ask during a hospital tour, and tips for getting the most out of your hospital tour. Webcast presenter Allison Walsh is a Lamaze Certified Childbirth Educator and Manager of Parent Education and Lactation Services at Beth Israel Hospital in New York City.

During the webcast, you will discover:

  • The importance of taking a hospital tour before the big moment arrives
  • Tips on preventing the “mad scramble” to the hospital
  • Key issues to explore when on your tour
  • Tips to learn about hospital and provider policy on labor support, mobility, nutrition, comfort measures, breastfeeding and many more

 

For an additional hospital tour resource, check out the Lamaze tip sheet: Tips on Getting the Most from Your Hospital Tour.

 

About Allison Walsh, IBCLC, LCCE

Allison is a Lamaze Certified Childbirth Educator, Board Certified Lactation Consultant, mother of three and the Manager of Parent Education and Lactation Services at Beth Israel Hospital in New York City. As a childbirth educator, hospital administrator and delegate to the United States Breastfeeding Committee, she has been advocating for safe and healthy birth initiatives in hospitals and care centers for most of her career. Allison’s focus is implementing evidence-based maternity and surgical practices, and reaching international, national and state breastfeeding goals.

Next Week: Getting the Most Out of Your Hospital Tour

Knowing how to spot good maternity care is the key to getting it, which is why Lamaze International is presenting a complimentary webcast next Wednesday, called “Getting the Most Out of Your Hospital Tour.” The free presentation, held on Wednesday, April 24 from 12:00 p.m. to 1:00 p.m. EST, will prepare you to:

  • Feel confident that you know what to do and where to go when the big moment arrives
  • Make sure the hospital you’ve chosen can meet your personal preferences
  • Sleuth out whether hospital practices reflect evidence-based practices for a safe and healthy delivery
Your presenter, Allison Walsh, IBCLC, LCCE, is a Lamaze Certified Childbirth Educator, Board Certified Lactation Consultant, mother of three and the Manager of Parent Education and Lactation Services at Beth Israel Hospital in New York City.

Register today
 for “Getting the Most Out of Your Hospital Tour.” 

Getting the Most Out of Your Hospital Tour Webcast

Having taken two different hospital tours, I remember how exciting (and a bit nerve wracking) it feels to spend time in the place where you will soon meet your baby! But hospital tours also serve a greater purpose — to find out if your chosen place of birth meets your needs and supports the best maternity care. Knowing how to spot good maternity care is the key to getting it, which is why Lamaze International is presenting a complimentary webcast called “Getting the Most Out of Your Hospital Tour.” The free presentation, held on Wednesday, April 24 from 12:00 p.m. to 1:00 p.m. EST, will prepare you to:

  • Feel confident that you know what to do and where to go when the big moment arrives
  • Make sure the hospital you’ve chosen can meet your personal preferences
  • Sleuth out whether hospital practices reflect evidence-based practices for a safe and healthy delivery
Your presenter, Allison Walsh, IBCLC, LCCE, is a Lamaze Certified Childbirth Educator, Board Certified Lactation Consultant, mother of three and the Manager of Parent Education and Lactation Services at Beth Israel Hospital in New York City.

Register today
 for “Getting the Most Out of Your Hospital Tour.”