Abby Block, CD(DONA), CBC

Doula & Breastfeeding Support ~ Serving Brooklyn & NYC

nyc doula

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
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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.

 

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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.

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 :)

From Spinning Babies... The Sacrotuberous Ligament: Key to Unlocking a Long Labor

Abby BlockComment

This article is definitely worth a read if you are pregnant and preparing for labor. And especially if you are interested in anatomy! According to the article, it may be particularly applicable if any of the following are present:

  • A long and difficult labor in which normal remedies (Rebozo Sifting, Position Changes, Spinning Babies Maneuvers) are not fully effective

  • Persistently malpositioned baby

  • Highly athletic mother (especially those who are highly athletic into their pregnancy)

  • History of any trauma in which the ligaments of the pelvis could have been affected (accidents, falls, etc.)

  • A visible Pelvic Upslip: One (usually left) iliac crest superior to the other, one leg (usually left) functionally shorter than the other.

 

http://spinningbabies.blogspot.com/2016/04/the-sacrotuberous-ligament-key-to.html?m=1

NYC's Newest Birthing Center at LOMA

Abby BlockComment

Finally, earlier this year, New York City unveiled a new in-hospital birthing center. Until recently, our only in-hospital birthing center was the Birthing Center at Mt. Sinai West (formerly known as St. Luke's Roosevelt). As of this winter, women have another in-hospital birthing center option: The Birthing Center at New York Presbyterian/ Lower Manhattan Hospital. I had the pleasure of attending a birth there as a doula just a few weeks ago, and the facilities are beautiful! (Not to mention the birth, too, of course!!)

Hopefully this trend will continue in NYC. There are so many women looking for low intervention birth settings, with the option to labor in a tub amongst other great options available in the birthing center. NYC residents also have the option to give birth at the Brooklyn Birthing Center, an out-of-hospital freestanding birthing center, and New York City's only independent birthing center.

Read more about the opening of Lower Manhattan's Birthing Center here.

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A secret to a quick and easy childbirth?

Abby BlockComment

There is certainly not one quick and easy solution that's going to work for everyone. I also don't even believe that this is THE way to go, but I have seen scenarios in which women do completely ignore the fact that hey are in labor, whether intentionally or not, and give birth quite smoothly and swiftly. But this is not to discount the women who need to focus and actively think in one way or another. There is no one right way to birth. But I think this article raises some interesting points worth thinking about.

Read the article here:

http://www.dailymail.co.uk/health/article-3147111/The-secret-quick-painless-childbirth-Just-don-t-think-ban-partner-room-leading-doctor-claims.html

http://www.dailymail.co.uk/health/article-3147111/The-secret-quick-painless-childbirth-Just-don-t-think-ban-partner-room-leading-doctor-claims.html

Natural Hospital Birth

Abby BlockComment

As a birth doula serving clients who live primarily in Brooklyn and Manhattan, I work with many women who see both OBs (often low intervention practices) and midwives in the hospital setting. However, many of my clients are looking for a holistic birth experience, or a natural birth experience, within a setting that typically is not set up to accommodate un-medicated births. The odds are generally stacked against women hoping to have intervention-free births in a hospital. BUT, as a doula, I have witnessed many women successfully do this! Here are a few resources on how to work towards, or achieve some version of, a natural hospital birth:

Video

Book

 

New Evidence: Give Women More Time in Labor.

Abby BlockComment

This one is so simple, so straight forward. Give women a bit more time to labor and we can reduce the cesarean rate. This is of course assuming that everything points to the mother and the baby being in good health. As long as everyone is doing find, and the mother is game, let's create the space and be encouraging and supporting to women who want to labor just a bit longer and potentially avoid a c-section. This recent study showed that giving mothers just one more hour of time can cut the Cesarean rate in half. That's big. Here's the article you can read to learn more:

http://www.huffingtonpost.com/entry/new-evidence-that-we-just-need-to-give-women-more-time-to-labor_us_56ec4f66e4b084c672203418