Bring a loved one, friend, or Doula for continuous support

All images Courtesy: Google Images

This is the second time Aruban Breastfeeding Mamas is participating in Lamaze International's Healthy Birth Blog Carnival. These "Blog Carnivals" are based on Lamaze International's - The six Lamaze healthy birth practices. The third healthy birth practice is

Bring a loved one, friend, or Doula for continuous support





Having emotional, physical,comforting and informational support during labor can be empowering and can prove to be a blessing to the laboring woman. We will answer the following questions throughout the course of this blog, ; What are the benefits of having someone there to support me during labor? Why should I consider childbirth education classes and encourage my labor partner to attend with me? What is a Doula, and why should I consider hiring one? When meeting with a prospective labor Doula, what questions should I ask?

Benefits of having your partner/loved one/best friend there with you
 When a woman has an informed, caring and experienced labor support team/person there during childbirth it helps the mother to feel safer, more comfortable and relaxed during labor. Research supports that when a woman is calm, positive and assured about her labor, it increases the body's production of  hormones that ease the pain of contractions and help a mother to cope better.Women who are fully supported physically as well as emotionally, report feeling better and more satisfied about their birthing experience.









Why should I consider childbirth education classes and encourage my labor partner to attend with me?
Childbirth Education classes is a wonderful resource that can provide you and your labor partner with knowledge of pregnancy and childbirth, and can be a place to go to find support during pregnancy and get to know other pregnant couples/women. Childbirth Education classes offer a variety of benefits to you as well as your partner, even in subsequent pregnancies. If you have any questions and you need trust-worthy and current information, you can turn to your Childbirth Educator to provide the answers for you or will guide you to websites or books that contain the answer. In CBE (childbirth education) classes you will be taught the normal physiology and progression of pregnancy and childbirth and breastfeeding basics. Also included are coping strategies for pain and/or anxiety during labor. It's important that you as well as the person supporting you during labor (be it your partner, mother, sister or best friend) attend these classes together. Many a women report 'forgetting' what they learned in their class once labor begun. In such instances, a well educated and well informed labor partner can help the laboring mother to recall and implement all that she has learned.





What is a Doula, and why should I consider hiring one?

The word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.


A Birth Doula

• Recognizes birth as a key experience the mother will remember all her life
• Understands the physiology of birth and the emotional needs of a woman in labor
• Assists the woman in preparing for and carrying out her plans for birth
• Stays with the woman throughout the labor
• Provides emotional support, physical comfort measures and an objective viewpoint, as well as helping the woman get the information she needs to make informed decision
• Facilitates communication between the laboring woman, her partner and her clinical care providers
• Perceives her role as nurturing and protecting the woman's memory of the birth experience
• Allows the woman's partner to participate at his/her comfort level

Study findings indicate that, compared to women who do not receive continuous labor support, women who receive continuous, one-to-one support are less likely to:

• have cesarean surgery;
• give birth with vacuum extraction or forceps;
• have regional analgesia (e.g., an epidural);
• have the need for any analgesia (pain medication); and
• report dissatisfaction with or negative feelings about their childbirth experience (Hodnett et al., 2007).

Two previous reviews of the research on continuous labor support had similar findings (Leslie & Storton, 2007; Simkin & O’Hara, 2002). The authors of all three reviews found that, compared to care from hospital staff nurses or midwives, continuous labor support is more effective when the person providing labor support is not a member of the hospital staff (Hodnett et al., 2007; Leslie & Storton, 2007; Simkin & O’Hara, 2002). In one review, increased benefits were found when continuous support started early in labor (Hodnett et al., 2007).
Research findings suggest that the benefit of labor support has no economic or cultural boundaries. In one study, continuous support reduced pain for low-income women who would have labored alone if they had not had a doula present (Simkin & O’Hara, 2002). Another study found that fewer cesarean surgeries and less need for epidural analgesia occurred when middle-class, laboring women and their male partner had the support of a doula (McGrath & Kennell, 2008). The same study also found that women and their partners were more satisfied with their birth experience when a doula provided support. Higher rates of early initiation of breastfeeding were found in an urban, multicultural setting when a doula was present (Mottl-Santiago et al., 2008).

My husband is worried that our Doula will take over his role
The doula is also responsive to the needs of the father and respects his level of involvement. First-time fathers are usually inexperienced in understanding and reacting to the normal behavior of a woman during labor and they appreciate the reassurance the doula offers. An experienced father may also appreciate a doula. While he cares for the mother, the doula performs peripheral tasks such as getting ice, juice, or blankets for the mother. She also fills in for the father if he needs a break, gives him an occasional back rub, and supplies supportive information. Since each labor presents its own unique challenges, even experienced birthing couples benefit from the services of a doula. A doula may also provide these kinds of support for others who support a mother in labor, such as friends or other family members.
The doula's calm presence and commitment to the mother's well-being helps counteract the effects of stress hormones (adrenaline and noradrenaline) which are released when a woman in labor becomes anxious, fearful, or insecure. Elevated stress hormones cause labor to slow down or stop while heightening the perception of pain. A trusting, relaxed mother continues to produce oxytocin (the hormone that causes the uterus to contract). She has more effective contractions, but with less tension in her body, she feels less pain. With quiet reassurance, the doula helps the laboring mother and her partner to draw on their own unique talents and strengths.

A good doula takes her cues from the labor partner. If your partner is sitting close to you, holding your hand, and providing eye-to-eye contact and supportive words, the doula will not interfere. Instead, she will support and encourage both of you.





When meeting with a prospective Birth Doula, what questions should I ask?

• What training have you had? (If a doula is certified, you might consider checking with the organization.)
• Do you have one or more backup doulas for times when you are not available? May we meet her/them?
• What is your fee, what does it include and what are your refund policies?

When interviewing a birth doula

• Tell me about your experience as a birth doula.
• What is your philosophy about birth and supporting women and their partners through labor?
• May we meet to discuss our birth plans and the role you will play in supporting me through birth?
• May we call you with questions or concerns before and after the birth?
• When do you try to join women in labor? Do you come to our home or meet us at the place of birth?
• Do you meet with us after the birth to review the labor and answer questions?

It is a good idea for both you and your partner to meet doula candidates to decide if they are compatible with your family. Are they kind, warm and enthusiastic? Are they knowledgeable? Do they communicate well? Are they good listeners? Are they comfortable with your choices or do they seem to have their own agenda? Do you feel at ease with them?
The way that you feel with a doula is more important than the number of births that they have attended or how many new families they have nurtured. You may want to interview more than one doula and make comparisons before choosing your doula.




How do we do it here in Aruba?
The concept of a Doula is fairly new in Aruba. The lady who was my childbirth educator offers Doula services, and as far as I'm concerned, I think she's the only one. She focuses more on CBE classes though and keeps her work as a doula at a minimum. There are two women who are interested and are in the course of persuing doula training to be able to offer these services exclusively.  


Not using a Doula? Depending on your husband/partner, mother/sister or best friend for labor support? No worries! Here is Lamaze International's Birth partner cheat sheet., showing some guide lines and principles of how your labor partner can best support you and your choices. Remember, it's not always possible to be ready for any twist or turn that may pop up in labor, but by having the fundamental principles, your labor partner can assist you, come what may!


Healthy Birth Practice #3. Lamaze International and Injoy bring you the Lamaze Healthy Birth Practices on video. For more information, visit: www.lamaze.org

 


References:

Hodnett, E. D., Gates, S., Hofmeyr, G. J., & Sakala, C. (2007). Continuous support for women during childbirth. Cochrane Database of Systematic Reviews, Issue 3. Art. No.: CD003766. DOI: 10.1002/14651858.CD003766.pub2 (This review is available at no charge on the Childbirth Connection Web site at http://www.childbirthconnection.org/pdfs/continuous_support.pdf)
Leslie, M. S., & Storton, S. (2007). The Coalition for Improving Maternity Services: Evidence basis for the ten steps of mother-friendly care. Step 1: Offers all birthing mothers unrestricted access to birth companions, labor support, professional midwifery care. The Journal of Perinatal Education,16(Suppl. 1), 10S–19S.


Simkin, P., & O’Hara, M. (2002). Nonpharmacologic relief of pain during labor: Systematic reviews of five methods. American Journal of Obstetrics and Gynecology, 186(Suppl. 5), S131–S159.

McGrath, S. K., & Kennell, J. H. (2008). A randomized controlled trial of continuous labor support for middle-class couples: Effect on cesarean delivery rates. Birth, 35(2), 92–97.

Mottl-Santiago, J., Walker, C., Ewan, J., Vragovic, O., Winder, S., & Stubblefield, P. (2008). A hospital-based doula program and childbirth outcomes in an urban, multicultural setting. Maternal and Child Health Journal, 12(3), 372–377.

Walk, Move and Change positions

 This blog will join the many others in Lamaze International's Carnival Birth Blog, promoting Lamaze's 6 healthy birth practices. This one is #2.
This is a re-vamp and re-post from "Birthing positions and their effect on labor" posted earlier this month.



Walk, move, and change positions


This blog will discuss walking,moving around and changing positions throughout labor and why this is so beneficial.
Birthing positions will also be discussed. I am aiming to educate Aruban women especially, that they do have a say in choosing the position that eases the pain and facilitates the baby's birth.

In Aruba, especially when a women is under the care of an obstetrician, she is automatically put in the Lithotomy position. A Certain ob/gyn absolutely refuses to let you go in another position, such as on hands and knees because he doesn't want to have a rear-side view. With midwives however, there are infinite possibilities, and most if not all, aim to comply with your wishes, and even suggest alternative positions that help the labor along. Here are Birthing positions 101. Included are the advantages and disadvantages for the mother, fetus and birth attendant.

Moving around during labor is important and beneficial because

• When you walk around or move around in labor, your uterus works more efficiently
• Changing positions moves the bones of the pelvis to help the baby find the best fit through your birth canal
• Upright, side-lying, and forward-leaning positions allow plenty of blood flow to your baby, so he may be less likely to show signs of distress
• Actively responding to labor may help you feel more confident and less afraid. By feeling in control of your birthing process, you may be empowered and experience less pain due to less anxiety because of not being a "by-stander", so to speak, during childbirth.
• Research shows that moving freely in labor improves a woman's sense of control,may decrease her need for pain medication, and reduced the length of labor
  

Lithotomy Position
  










Advantages

Mother:

• Some women say they like the security of stirrups for their legs, particularly if they have used them    previously

Fetus :

• Easy to listen to Fetal heart rate

Birth Attendant :

• More control of birth situation

• Obstetric intervention easiest should it be necessary : forceps episiotomy, repair of lacerations, anesthesia     

•  More comfortable, less back strain

• Asepsis                

Disadvantages

  

Mother

•  Adverse affects on blood flow : The weight of the uterus compresses large blood vessels so as to decrease blood flow to the uterus and ultimately decrease oxygen to the baby.

• Less active participation with baby and birth attendant

• Stirrups can promote blood clots if legs are in them for a long time

• Decreased ability to push

• Sense of vulnerability

• Possible inhalation of vomit

Fetus :

• Changes in mother's blood flow can cause fetal distress or a depressed baby at birth
• Difficult for mother to see or hold baby after birth

Birth Attendant :

• Cannot easily interact with woman and is less able to elicit her cooperation

 
 Standing position






Adavantages


Mother :

• Reported improved uterine contractibility for First Stage of labor 
• Avoidance of negative hemodynamic changes  
• Can watch Birth
• May increase help of gravity

Fetus :

• 
  Uknown

Birth Attendant:

• Ease in interacting with women

Disadvantages

Mother :

• Fatigue
• Needs two supporters
• Hypothesized increased blood loss, uterine prolapse, edema of cervix and vulva

Fetus:

• May fall to the ground unless "caught"

Birth Attendant:

• Difficult to control baby's head and watch perineum 
• Difficult to assist with delivery

Sitting Position

      




Advantages 

Mother: 

• Shorter second "pushing" stage
• Most efficient for expulsive efforts
• Maintains some advantages from squatting ; increases pelvic diameter
• Easy to interact with baby and others
• Grunting may aid delivery

Fetus:

• Probably less negative hemodynamic effects than lithotomy thus less fetal distress
• Easy to listen to fetal heart rate

Birth Attendant:

• Good access to perineum for control of delivery
• Able to use interventions should it become necessary, such as episiotomy, forceps or pudenal anesthesia easily should it become necessary
  

Disadvantages

 Mother:

• Needs back support
• Might induce edema of vulva or cervix 

Fetus:

•  None

Birth Attendant:

• Some attendants may not want the mother's active participation in the birth

Hands and knees







Advantages

Mother:

• No weight on Inferior Vena Cava; thus probably less fetal distress
• Advocated for aiding delivery of shoulder 
• Useful for relieving pressure on umbilical cord if trapped or prolapsed 

Fetus:

• May be useful in rotating occiput posterior positions or in delivery of shoulders when they are "tight"

Birth Attendant:

• Good visualization of perineum and control of expulsion of presenting part
• Optimal control for breech delivery, according to some practitioners.

Disadvantages

Mother:

• Very tiring : Bean bags and pillows useful for maintaining position or for rest between contractions                      
  
• Difficult to interact with baby and birth attendant, but can turn immediately after delivery and hold baby
• Cramps in arms and legs

Fetus:

• Difficult to monitor baby unless one uses fetal scalp electrode ( which will leave a beautiful bald spot for ever on your baby's scalp)

Birth Attendant:

• Must reorient landmarks and adapt hand maneuvers for delivery
• Usually turn woman to recumbent position for delivery of placenta, repair of lacerations and rest

Dorsal Recumbent 

 Advantages

Mother:

• Less tension on perineum
• Less pressure on legs
• No stirrups, thus less likely to develop thrombosis

Fetus:

• Easy to listen to fetal heart rate

Birth Attendant:

• Easy access to perineum
• Able to do pudendal anesthesia or episiotomy easily should these become necessary
  

Disadvantages

Mother:

• Same blood flow changes as lithotomy
• Difficult to participate in birth
• decreased ability to push

Fetus:

• Fetal distress can occur because of restricted blood flow 

Birth Attendant:

• Cannot easily interact with woman
• Forceps delivery more difficult to do since there is less counter pressure on fetus

Lateral Recumbent





Advantages 

Mother:

• Corrects or avoids adverse hemodynamic effects of lithotomy position
• May prevents some perineal tearing because of less tension on perineum
• May help to rotate occiput posterior presentations
• May be helpful in relieving a Shoulder dystocia 
• Comfortable for many mothers and conducive to resting in between contractions

Fetus:

• Promotes maximum uterine blood flow and thus fetal oxygenation

Birth Attendant:

• Conducive for controlled delivery
• Preferred by some British practitioners

Disadvantages

Mother:

• Least efficient for expulsive efforts, this may be desirable to avoid a precipitous delivery (delivering in an unusually quick amount of time) for a repeat mother
• Needs someone to hold leg up for the delivery

Fetal:

• More difficult to listen to fetal heart tones

Birth Attendant:

• Some practitioners consider this position akward
• Unable to see and interact with mother as easily, cannot see her face directly
• Difficult to repair episiotomy or use forceps in the event that these would become necessary
  

  Squatting Position

Advantages

Mother:

• Good expulsive effort: shorter second "pushing" stage
• Pressure of the thighs against the abdomen may aid in expulsion by increasing intra-abdominal pressure and promoting longtitudinal alignment of the fetus with the birth canal
• Improves pelvic bone diameter. Anteroposterior diameter of outlet increased by 0.5-2 cm :Transverse diameter is also increased ( opening of vagina made wider with less perineal trauma and tears as a result)
• Avoids adverse hemodynamic effect of lithotomy
• Facilitates interaction with birth attendant and baby and others present

Fetus:

• Promotes fetal descent and rotation

Birth Attendant:

• Some visibility of perineum
• Maternal effort is maximized in accomplishing the birth

Disadvantages

Mother:

• Legs can become fatigued, especially if woman is not supported
• Uterine prolapse may be more likely due to strenuous bearing down effort
• May promote increased perineal and cervical edema (swelling)
• Rapid descent and expulsion of fetus may be accompanied by vaginal and perineal lacerations
• Increased blood loss possible

Fetus:

• Rapid expulsion may result in sudden reduction in intracervical pressure and cause cerebral bleeding in the brain of a premature infant whose skull bones are not yet firm.

Birth Attendant:

• Cannot intervene easily in this position to help control the expulsion of the baby or to administer an episiotomy or pudenal nerve block should these become necessary
  

Partner Tip

During active labor, some women have a hard time deciding how they want to move. The media has ingrained in most women a sense of "capture" and "helplessness" during the birthing process and so they think they are expected to stay in bed. Labor partners do well to educate themselves along with the pregnant woman about different labor and birthing positions to help "guide" the laboring woman. The labor partner would do well to offer suggestions and tips especially when the mother seems discouraged, frightened or uncomfortable. 

Leaving you now with a video of healthy birth practice #2 out of 6 from Lamaze International

For more information on Lamaze's other 5 healthy birth practices visit Amy Romano's blog : Science & Sensibility

All images courtesy of: Google Images

Closed Glottis pushing/Valsalva's Maneuver a.k.a. Purple Pushing

A common and long standing practice at our hospital here in Aruba which I would like to address  is closed glottis pushing or "purple pushing". This is when a woman, who in the second stage of labor or the "pushing stage" has coached pushing. The nurse/OB, stands in front or next to you and instructs you to hold your breath and push for 10 counts/seconds. This is the part where you feel : 1) you're either going to poop out contents that have not even reached your bowels or 2) your head is going to explode and will be a huge mess to clean up afterwards ...whichever comes first.


This practice is a common mistake that takes place at all  our hospital births. Why? It starts with the woman's lack of childbirth education about pushing, and the nurses' lack of concern or ignorance about such practices. 
Why is holding your breath for ten seconds not good during pushing? I mean.. soooo many women have done it inconsequently. Yeah, that's what we're all lead to believe. Modern research is indicating otherwise. 

In an article from mar 15 2003, Lisa Miller CNM spoke about this topic and strongly advised against it. Why? Because of the following :

Purple pushing--or closed-glottis pushing--during which the patient holds her breath for 10 seconds while pushing, is safe in the approximately 80% of women with low-risk pregnancies. But that doesn't mean it works best. Furthermore, in physiologically high-risk cases, the baby can't tolerate that kind of pushing

 In one study of 10 healthy, near-term pregnancies, near-infrared spectroscopy used to evaluate fetal effects revealed that closed glottis and coached pushing efforts led to decreased mean cerebral 02 saturation and increased mean cerebral blood volume. All Apgar scores were below 7 at 1 minute and below 9 at 5 minutes.

 This maneuver causes a trapping of blood in veins, preventing it from entering the heart. When the breath is released, the intrathoracic pressure drops and the trapped blood is quickly propelled through the heart, producing an increase in the heart rate (tachycardia) and the blood pressure. Immediately, a reflex bradycardia ensues. All of this disrupts the blood flow to the uterus and ultimately to the baby. This disruption in blood flow indicates a disruption in oxygen flow, which ultimately shows up on the fetal heart monitor as fetal distress.

There is no clear evidence that closed glottis pushing (Valsalva's Maneuver) shortens second stage, decreases fatigue or minimizes pain. It has otherwise been suggested that bearing down for a prolonged period with a closed glottis alters the contractile pattern of uterine smooth muscle, leading to inefficient contractions and failure to progress. Studies suggest that encouraging women to believe in their ability to push the baby out may be as important as the type of breathing. A variety of studies published between 1992 and 1996 show that physiological effects of Valsalva's Maneuver can include: impeded venous return; decreased cardiac filling and output; increased intrathoracic pressure; affected flow velocity in middle cerebral artery; raised intraoccular pressure; changed heart action potential/repolarization; increased arterial pressure; increased peripheral venous pressure; altered body fluid pH, which contributes to inefficient uterine contractions; decreased fetal cerebral oxygenation. (Nursing Times 95:15, April 15, 1999)

Open-glottis pushing, on the other hand, allows the patient to exhale while bearing down and leads to minimal increases in maternal blood pressure and intrathoracic pressure, maintained blood flow, and decreased fetal hypoxia. Long Valsalva pushing can adversely affect maternal hemodynamics, which in turn adversely affects fetal oxygenation

Another consequence of purple pushing that often happens when a woman pushes "in her face" , is that the blood vessels around the eyes and around the pupil burst and thus the new mom sports the new look of blood-shut eyes. ( Yes, another thing they fail to mention to you). This poses no real harm to the mom, but it doesn't quite make you look so sexy or motherly in those post-delivery pictures. 
Many women do not know these risks. Many women, when in the pushing stage, forget these things and will depend on the nurse/ob for instructions trusting that they know what's best. But as we have learned, even the best and most educated doctors don't always do what is in the best interest of the mother and baby. 

However, there are alternatives to facilitate pushing and eases the baby downward and out. The supine position (laying down on your back) offers minimal comfort or ease and actually makes it harder for the baby to make its descent. While on the other hand, a squatting position makes use of gravity to help the baby through the birth canal with less head-exploding pushing. It also aids in : facilitation of alignment of the presenting part to the pelvic axis, encouragement of the mother's efforts toward giving birth, allowing for larger pelvic diameters, improving comfort, and promoting fetal well being. Granted, there are certain obstetricians here in Aruba who absolutely refuse to let a laboring woman go into the hands and knees position for example and require them to get on their back! This is where our midwives are so cherished and valued. Midwives will work with you and get the position that is most comfortable for you when it comes time to push. 


Another accessory unknown to most mothers is the birthing stool. This is wonderful chair that looks like it's missing a chunk in the middle. According to me, only one midwife here in Aruba has one, and I was set to use it for my daughter's birth! That is...until I was unfortunately handed over to an ob in my 41st week due to pre-eclampsia. So there went my no tearing/minimal perineal damage experience with the birthing stool. 

                                                                    Birthing stool 
                    
Pregnant Aruban moms, future pregnant Aruban mothers, Take this to heart. Educate yourselves. Find out what your options are. Stand up for the birthing experience you want and deserve. I mean, come on, AZV (social insurance that practically everybody has) will pay for your prenatal appointments wherever you choose to go. And if the ob/gyn or midwife does not share your point of view on childbirth or is not willing to comply with the birthing experience you want..then by all means... NEXT PLEASE