Abby Block, CD(DONA), CBC

Certified Birth Doula & Breastfeeding Counselor Serving Brooklyn & NYC

POSTBIRTH - An Acronym that Can Reduce Maternal Mortality and Morbidity in the Postpartum Period

Abby BlockComment

POSTBIRTH - An Acronym that Can Reduce Maternal Mortality and Morbidity in the Postpartum Period

by Sharon Muza, BS, LCCE, FACCE, CD(DONA), BDT(DONA), CLE

Full text of the article can be found here.

Maternal mortality and morbidity in the United States are as high as they have ever been.  More people are dying from complications of pregnancy or childbirth than ever before.  61 percent of deaths related to childbirth occur in the postpartum period and most of those occur in the first 42 days after birth. The current estimated maternal mortality rate in the U.S. is 23.7/100,000 live births (MacDorman, Declercq, Cabral, & Morton, 2016).  

There is agreement that we must improve the way we care for people in the postpartum period if we want to be able to reduce the complications and deaths that occur after giving birth.  Part of this improvement lies in how warning signs information is provided to families after birth.  As it is not possible to identify who will have a postbirth complication, it is imperative that everyone receive information about concerns in the postpartum period that will need to be evaluated by a health care provider.  The postpartum nurse or mother-baby nurse is in a unique position to educate families on what to watch for postpartum.

Unfortunately, current research indicates that the information that postpartum nurses teach to new parents about warning signs is inconsistent and often inaccurate.  There is also evidence that many postpartum nurses are not aware of the major risks that face people after they give birth that can cause death or serious complications.  Families report being flooded with physical and emotional situations in the first days postpartum that make it difficult to take in important information accurately and clearly.   For these reasons, the postpartum discharge education RNs provide must be clear, concise, and accurate. When appropriately informed and educated, postpartum nurses are in an ideal position to improve postbirth outcomes, if they are given adequate time to share information with the new family.

A new study, Nursesʼ Knowledge and Teaching of Possible Postpartum Complications, published in MCN: The American Journal of Maternal/Child Nursing, examines postpartum nurses’ knowledge of maternal morbidity and mortality, and information they shared with women before discharge about identifying potential warning signs of postpartum complications. 

Almost half the postpartum nurses in the study were not aware that maternal mortality rates have increased.  Almost all (93%) of nurses knew that hemorrhage was one of the top three causes of death, but only 68% knew that hypertension was another, and barely 39% could identify infection as the third leading cause of death.

Evidence On Doulas

Abby BlockComment
DoulaHeader1.png

The following text and photo is excerpted from "Evidence on: Doulas" a recent article August 14, 2017 by Rebecca Dekker, on her incredibly informative website, Evidence Based Birth. You can read the full text of her article here: https://evidencebasedbirth.com/the-evidence-for-doulas/


Why are doulas so effective? 

There are several reasons why we think doulas are so effective. The first reason is the “harsh environment” theory. In most developed countries, ever since birth moved out of the home and into the hospital, laboring people are frequently submitted to institutional routines, high intervention rates, staff who are strangers, lack of privacy, bright lighting, and needles.

Most of us would have a hard time dealing with these conditions when we’re feeling our best. But people in labor have to deal with these harsh conditions when they are in a very vulnerable state. These harsh conditions may slow down a person’s labor and their self-confidence. It is thought that a doula “buffers” this harsh environment by providing continuous support and companionship which promotes the mother’s self-esteem (Hofmeyr, Nikodem et al. 1991).

A second reason that doulas are effective is because doulas are a form of pain relief in themselves (Hofmeyr, 1991). With continuous support, laboring people are less likely to request epidurals or pain medication. It is thought that there is fewer use of medications because birthing people feel less pain when a doula is present. An additional benefit to the avoidance of epidural anesthesia is that women may avoid many medical interventions that often go along with an epidural, including Pitocin augmentation and continuous electronic fetal monitoring (Caton, Corry et al. 2002).

This finding—that people with doulas are less likely to have an epidural—is not due to the fact that clients with doulas in these studies were more likely to want these things up front and were more motivated to achieve them. In fact, randomized trials account for these differences—this is why they are called randomized, controlled trials. The people assigned to have a doula, and those assigned to not have a doula, are randomly assigned, meaning that the same percentage in each group would have a desire for an unmedicated birth.

A third reason why doulas are effective has to do with the attachment between the birthing person and doula which can lead to an increase in oxytocin, the hormone that promotes labor contractions. This theory was proposed by Dr. Amy Gilliland in her 2010a study about effective labor support. In personal correspondence with Dr. Gilliland, she wrote, “I believe the Doula Effect is related to attachment. When the mother feels vulnerable in labor, she directs attachment behaviors to suitable figures around her, who may or may not be her attachment figures (parent, mate). When the mother directs attachment seeking behaviors to the doula, the experienced doula (25 births or more) responds in a unique manner. She is able to respond as a secure base, thereby soothing the mother’s attachment system. The accompanying diminishment in stress hormones allows for a surge in oxytocin in both the mother and the doula… theoretically, oxytocin is the hormone of attachment, and it is released during soothing touch and extended eye contact, which are habitual behaviors of birth doulas.” (Personal communication, Dr. Amy Gilliland, July 2015).

Swedish oxytocin researcher Kristin Uvnas Moberg writes that the doula enhances oxytocin release which decreases stress reactions, fear, and anxiety, and increases contraction strength and effectiveness. In addition, the calming effect of the doula’s presence increases the mother’s own natural pain coping hormones (beta-endorphins), making labor feel less painful (Uvnas Moberg, 2014).

Based on the evidence, I have come up with a conceptual model of how doula support influences outcomes.

A conceptual model  is what researchers use to try and understand how a phenomenon works. Here is my conceptual model on the phenomenon of doula support.

 

ConceptualModelDoulasrevised2017.png

Black Breastfeeding Week

Abby BlockComment

In honor of World Breastfeeding Awareness Month, let's look at breastfeeding! Today, August 25th,  marks the beginning of Black Breastfeeding week. Why do we need a separate week devoted to highlighting this issue? Read on for more, with this article from http://blackbreastfeedingweek.org:

 

Black Breastfeeding Week was created because for over 40 years there has been a gaping racial disparity in breastfeeding rates. The most recent CDC data show that 75% of white women have ever breastfed versus 58.9% of black women. The fact that racial disparity in initiation and even bigger one for duration has lingered for so long is reason enough to take 7 days to focus on the issue, but here are a few more:

1. The high black infant mortality rate: Black babies are dying at twice the rate (in some place, nearly triple) the rate of white babies. This is a fact. The high infant mortality rate among black infants is mostly to their being disproportionately born too small, too sick or too soon. These babies need the immunities and nutritional benefit of breast milk the most. According to the CDC, increased breastfeeding among black women could decrease infant mortality rates by as much as 50%. So when I say breastfeeding is a life or death matter, this is what I mean. And it is not up for debate or commenting. This is the only reason I have ever needed to do this work, but I will continue with the list anyway.

2. High rates of diet-related disease: When you look at all the health conditions that breast milk—as the most complete “first food,” has been proven to reduce the risks of—African American children have them the most. From upper respiratory infections and Type II diabetes to asthma, Sudden Infant Death Syndrome and childhood obesity—these issues are rampant in our communities. And breast milk is the best preventative medicine nature provides.

3. Lack of diversity in lactation field: Not only are there blatant racial disparities in breastfeeding rates, there is a blatant disparity in breastfeeding leadership as well. It is not debatable that breastfeeding advocacy is white female-led. This is a problem. For one, it unfortunately perpetuates the common misconception that black women don’t breastfeed. It also means that many of the lactation professionals, though well-intentioned, are not culturally competent, sensitive or relevant enough to properly deal with African American moms. This is a week to discuss the lack of diversity among lactation consultants and to change our narrative. A time to highlight, celebrate and showcase the breastfeeding champions in our community who are often invisible. And to make sure that breastfeeding leadership also reflects the same parity we seek among women who breastfeed.

4. Unique cultural barriers among black women: While many of the “booby traps”™ to breastfeeding are universal, Black women also have unique cultural barriers and a complex history connected to breastfeeding. From our role as wet nurses in slavery being forced to breastfeed and nurture our slave owners children often to the detriment of our children, to the lack of mainstream role models and multi-generational support , to our own stereotyping within our community—we have a different dialogue around breastfeeding and it needs special attention.

5. Desert-Like Conditions in Our Communities: Many African American communities are “first food deserts”—it’s a term I coined to describe the desert like conditions in many urban areas I visited where women cannot access support for the best first food-breast milk. It is not fair to ask women, any woman, to breastfeed when she lives in a community that is devoid of support. It is a set up for failure. Please watch this video and educate yourself on the conditions in many vulnerable communities about what you can do (beyond leaving comments on blogs) to help transform these areas from “first food deserts” into First Food Friendly neighborhoods.

World Breastfeeding Awareness Month

Abby BlockComment

It's world breastfeeding awareness month! In honor of this, my next several posts will be focusing on breastfeeding information, resources, research, best practices, stories, and photos. I of course understand and respect that not all families I work with are breastfeeding, whether by choice or not, and there is of course some that fall in between. As a birth doula, I am always happy to support my doula clients any way they choose, however I find that most often, my clients are worried about and are asking me about breastfeeding -- usually right after birth and the postpartum visit. I had the great pleasure this year of becoming a Certified Breastfeeding Counselor, and am loving that I am able to provide a greater depth of support to my clients around breastfeeding.

To kick off the week, I want to share an awesome blog post from Lamaze's Science and Sensibility blog, which has excellent resources for breastfeeding or soon-to-be breastfeeding families.

Read the blog post here.

Beautiful Birth Photos

Abby BlockComment

These photos are beautiful! Whether it's a home birth, hospital birth, natural birth, cesarean birth, midwife birth, water birth, OB birth, breastfeeding or formula feeding, or it's a first or second or third child... there's no one right way to do it. Take a look here.

Folic Acid/Folate in Pregnancy: New Research on Potential Risks

Abby BlockComment

Folic Acid (otherwise known as Folate, in it's non-synthetic form) : we know it's important for a developing fetus, but should everyone be taking folate?? This article contains groundbreaking information on folic acid and an uncommon, but not rare, genetic condition.

"There’s no solid consensus, but some reports state that anywhere from 10 to 15 percent of Caucasians and more than 25 percent of Hispanics are unable to metabolize folic acid. Called methylenetetrahydrofolate reductase, or MTHFR for short, this defect refers to the MTHFR gene, which produces the enzyme responsible for converting synthetic folic acid (what’s found in prenatal vitamins and fortified grains) to methylated folate (the metabolized nutrient that protects against NTDs)."

Read the full article here.

The Cesarean Rate Epidemic

Abby BlockComment

This article looks at the current rates, state, and climate of Cesarean Births in the U.S. It provides statistics and rates, reasons for Cesareans, as well as the associated risks. 

Cesarean delivery may be a safe alternative to vaginal delivery but its use in 1 of 3 women giving birth in the US seems to high.
— contemporaryobgyn.modernmedicine.com

An excerpt discussing the rising rates and unusual number of Cesarean rates below:

"One possible reason for the rise in the cesarean delivery rate may be that there has simply been a rise in the need for cesarean. The most common indication for a primary cesarean is cephalo-pelvic disproportion, or arrest of progress in labor. It is unlikely that maternal pelvis size has changed over the past 3 decades, but it is possible that birth weight has increased. In fact, evidence suggests that rates of macrosomia have increased over the past 2 decades.8 Other issues that contribute to increasing rates of cesarean delivery, possibly through the mechanism of birth weight, are maternal obesity and gestational weight gain.9,10 Without question, the proportion of obese women has increased over the past decade and higher weight classes are associated with even higher rates of cesarean.11,12 In addition, increased gestational weight gain has been associated with cesarean delivery and is commonly above standard guidelines.13

Another reason for increasing cesarean rates may be a rise in elective cesarean delivery, also known as cesarean delivery by maternal request (CDMR). Because there was no ICD-9 code for CDMR, it is unclear what proportion of cesareans are due to it. One recent study, however, estimated the proportion as high as 4% in the United States.14 Interestingly, CDMR is more common in other countries, such as Brazil, Taiwan, and Chile. A study in Chile comparing women receiving private care (cesarean rate >40%) to women receiving public care (cesarean rate <20%) found that 8% of those receiving private care and 11% of those receiving public care stated a preference for cesarean delivery, with the vast majority preferring to deliver vaginally.15 Thus, even in this setting, it is unclear that maternal preferences are driving the increase in cesarean delivery rate."

Full article can be read here: http://contemporaryobgyn.modernmedicine.com/contemporary-obgyn/news/cesarean-epidemic-are-we-too-quick-cut?cfcache=true

 

Why delay cord clamping?

Abby BlockComment

Science and Sensibility, the research blog from Lamaze, has an excellently evidence based article on the practice of delayed cord clamping. The article is structured by listing objections, which is a great way to go about learning the benefits, as well as to be prepared to answer to someone's concerns about this practice. Delayed cord clamping is becoming so much better understood and common place. Many Ob and midwife practices in Brooklyn and NYC do this as a matter of protocol. 

Read the full article here

 

 

VBACs are more likely successful if you call the midwife

Abby BlockComment

A new study shows that VBACs (Vaginal Birth After Cesarean) are more likely to be successful if a midwife provides the care instead of an obstetrician. 

You can read a portion of the abstract of the study here, and an excerpt is below:

Background

Research is yet to identify effective and safe interventions to increase the vaginal birth after cesarean (VBAC) rate. This research aimed to compare intended and actual VBAC rates before and after implementation of midwife-led antenatal care for women with one previous cesarean birth and no other risk factors in a large, tertiary maternity hospital in England.

 

Conclusions

Implementation of midwife-led antenatal care for women with one previous cesarean offers a safe and effective alternative to traditional obstetrician-led antenatal care, and is associated with increased rates of intended and actual VBAC.

Breastmilk Storage

Abby BlockComment

This is not about storage in terms of how to store your pumped milk. This is about how much milk your body can store. I love this infographic below from Nancy Mohrbacher. It explains, in part, why babies may have such varied feeding patterns, even babies from the same mother :)

Mothering The Mother: Postpartum Support for Women

Abby BlockComment

During prenatal sessions with my doula clients, I always make a point to discuss postpartum plans. In the way in which every woman usually has some sort of birth preferences (hospital birth, home birth, birthing center birth, midwife, doctor or OB, natural birth, epidural birth, and so forth...) it is important to develop some ideas around what the plan is for postpartum care. 

Some of the questions I encourage my pregnant couples to ask themselves are: what is our sleeping arrangement and what are our beliefs in infant sleep? Where is our healthy food coming from? Who's around if we need support? Would we like a postpartum doula? How much time can we take off? Who is in charge of feeding? Who is in charge of feeding? Who will do the laundry and the chores?

Mothering the Mother: New Mothers Need a Focused Period of Rest and Recovery

An excerpt:

The postpartum period is considered to be the roughly six-week period when a woman recovers from the magnitude of pregnancy and birth. It is also the wild, messy, tender, achy, exhilarating time when a woman begins the process of shedding one way of being for an entirely new identity. It is a fleeting, essential moment, a powerful pause before the full initiation of the next chapter of her life. But in a society that encourages a new mother to "bounce back," right after birth, a woman is pushed to do the opposite of resting and recovering; she is encouraged to get back to a version of her body and her life that is gone forever. She has been forever transformed by the profound act of making another human being and requires care and attention before hurtling forward.

More reasons to breastfeed: Antibodies

Abby BlockComment

As if we need another god reason to breastfeed newborns, but here you go anyway... excerpted from "Antibodies in Breastmilk Prime the Baby's Gut to Handle Mom's Invading Microbes."

“… the breast milk is also loaded with microbes, which means a brand-new baby’s gut is subject to a full-on invasion of tiny, foreign animals from the moment he or she starts feeding. The infant’s immune system, rather than attack these foreign organisms like an immune system is designed to do, instead sits back and lets them invade. And now we know a bit more about why: In a study published Thursday in the journal Cell, researchers from the University of California Berkeley found that in addition to all those microbes, mother’s milk is loaded up with antibodies to the very same microbes it contains. In other words, the milk contains both the beneficial microbes and what the body needs to be able to accept them.”

 

What to expect with your baby's weight after birth

Abby BlockComment

This is an excellent article, with very wise advice on baby's weight loss within a the first couple of weeks of life. If you have concerns or questions about your newborn's weight loss and milk intake, you are of course advised to seek support from a Lactation Consultant (IBCLC), a Certified Breastfeeding Counselor (CBC), or a Certified Lactation Counselor (CLC). Any of these lactation professionals should be able to support you or point you in the right direction.

An excerpt is below and the full article can be read here.

"This weight loss has nothing whatsoever to do with breastfeeding and milk intake.  In fact, the authors suggest that if clinicians want to use weight loss as a gauge of milk intake, they calculate baby’s weight loss not from birth weight, but from their weight at 24 hours.  According to their findings, this could neutralize the effect of the mother’s IV fluids on newborn weight loss.

This is one more reason weight loss alone should not be used to determine when newborns need formula supplements.   The Academy of Breastfeeding Medicine put this well in one of its protocols: “Weight loss in the range of 8-10% may be within normal limits….If all else is going well and the physical exam is normal, it is an indication for careful assessment and possible breastfeeding assistance.”

Let Babies Figure it Out On Their Own

Abby BlockComment

This is a great piece on infant physical development. When my first son was 3 months old, I had the wonderful opportunity to take an infant developmental movement class at a nearby yoga studio. My teacher taught me so many wonderful things that I would never have otherwise learned about supporting my son's physical development. Even as someone who is quite physically attuned, with my background as a dancer and my current yoga practice, I just had no idea how many of the things that I was doing were not helpful, and potentially detrimental, to my kid's budding physicality. This article explains some of what I learned in my class.

"When an infant is propped or placed in sitting and standing before they have developed adequate upper body strength to move their own body into sitting and standing, their spinal curves will be develop out of sequence. The result, which I have seen over the years in my work with infants, children, athletes and adults, can become organ, glandular and/or spinal challenges such as scoliosis and lordosis because the cervical and lumbar curves have become dominant.

When a newborn or an infant is “propped” in a sitting position or placed into equipment by a caregiver, they will either stiffen or flop over. When a young infant is consistently sat and stood up, they will usually extend their limbs and stiffen throughout their entire body (a fear response) in an effort to support the weight of their head. This stiffening is easily felt when holding them and will not only disrupt the integration of their arms and legs with their torso but also delay their ability to roll over."

 

What A Doula Does

Abby BlockComment

I adore this blog post written by my dear doula colleague, Yiska Obadia. You can read an excerpt below, and the full article here.

"Doulas are there to serve their clients. You want to birth naturally? I will support you. You want an epidural? I will support you. You want an epidural and to avoid a c-section? I will do my best to help you achieve that. Doulas serve our clients in helping them to achieve the birth THEY want as well as supporting them wholeheartedly with the birth they get."

A cervix in labor

Abby BlockComment

What does it look like? Check out this handy guide to understanding how your cervix will change in the late third trimester and in labor. Maybe you followed your pregnancy by reading about your baby's size being compared to fruit... and now you get to read about your cervix in relation to fruit :)