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Keeping Doulas at Births in Hospitals During Covid-19

Stages of Grief: Our community was thrown off-kilter mid-March 2020 with the official arrival and acknowledgement of COVID-19 as a global threat in the United States. It was upon us and as with any stressful event, many birthworkers, myself included, walked through the stages of grief in regards to the pandemic.

First Stage Denial: Surely this wasn’t really a thing, was it?

Second Stage Anger: I felt anger acutely as a doula. The restrictions on birth support hit me in the gut and I’m not ashamed to admit that initially I took it as a personal attack on doulas. Of course, I have since come to my senses and understand that at the heart of the decision by hospital administration was to keep everyone safe, including doulas, which brings me to the third stage.

Third Stage Bargaining: Birthworkers explored how to continue to offer birth support, even if virtual, and they pivoted to accommodate the needs of their clients through FaceTime, Zoom, text, and phone.

Fourth Stage Depression: Depression was in there too, and lingers today for many of us. As doulas, we yearn to be with our clients, sharing their birth space and offering physical support in their presence. It pains many of us when we are separated from our clients during birth. It’s truly a struggle that hits a doula right in the heart. And finally, we
encountered acceptance.

Fifth Stage Acceptance: COVID-19 will remain in our midst for awhile and have far-reaching implications on how births will look for the foreseeable future. It is our new, indefinite normal, restrictions, masks, hand sanitizer, and all.

Acceptance is unacceptable.

Doulas and birthing families have had six months of processing the restriction of doulas from physically attending births in the hospital setting. It’s time to push more aggressively to reintegrate doulas in-person at birth. If you are a birthing parent, I implore you to advocate for your doula, and for all doulas, to return to the hospital. Doulas should be
permitted to attend in person because it is the right of every laboring woman to have support, but also because the research is extensive proving that the continuous labor support doulas provide improves birth outcomes. Doulas help everyone, including the staff and care providers! In fact, reputable birthing organizations such as The Association of
Women’s Health, Obstetric, and Neonatal Nurses (AWHONN) have made statements early on defending doulas as essential members of the birth team, and encouraging them to be permitted to continue to serve in person DURING the pandemic. (https://awhonn.org/covid-19-archived-updates/)

Advocacy: So what are we to do to affect change in hospital policies? There needs to be a push from the birthing parents to hospital leadership. Contact the manager of the labor and delivery unit, and the administrator of the hospital. Make a phone call. It’s harder to ignore a voice on the line. Follow up your phone call with an email and a letter. Paper trails are also hard to dismiss. If there are other hospitals who have allowed doulas to return, be sure
to mention them as well. In Hampton Roads at the time of this writing the only hospitals permitting doulas to attend births alongside the primary birth partner are: Sentara Leigh, Sentara Obici, and Sentara Williamsburg. And don’t forget to express your wishes with your provider. Not just one, but to each doctor and/or midwife at every appointment.

This needs to come from the birthing families, not the doulas. The amount of research in favor of the presence of a doula is dizzying. And the number of statements by various obstetric, nursing, and birth organizations is compelling. The evidence is there and the need is higher than ever. What’s lacking is the advocacy for the presence of doulas during the pandemic. I have compiled some links in an effort to cut down on your need to research data. You will find them at the end of this post. Feel free to use any or all that you see fit. And write those letters, send those emails, and make those phone calls. The change must begin with the birthing women. Not the doulas. We believe in you and we support you. Be an advocate not just for yourself, but for all birthing families.

Below are some links to incorporate into your letters/emails/calls campaigning for the reintegration of doulas to attend births in-person. They are particularly timely and relevant since the statements were made in March 2020, right as the pandemic was taking hold in the US.

Cochrane Database Evidence that continuous labor support may improve outcomes for mom and baby:  https://www.cochrane.org/CD003766/PREG_continuous-support-women-during-childbirth

AWHONN Position Statement for Continuous Labor Support for Every Woman: https://www.jognn.org/article/S0884-2175(17)30482-3/pdf

ACOG (American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine’s joint document on the Safe Prevention of the Primary Cesarean Delivery: https://www.acog.org/en/Clinical/Clinical%20Guidance/Obstetric%20Care%20Con sensus/Articles/2014/03/Safe%20Prevention%20of%20the%20Primary%20Cesarean%20Delivery

ACOG Approaches to Limit Intervention During Labor and Birth: https://www.acog.org/clinical/clinical-guidance/committee-opinion/articles/2019/02/approaches-to-limit-intervention-during-labor-and-birth

March of Dimes Position Statement on Doulas and Birth Outcomes, January 30, 2019: https://www.marchofdimes.org/materials/Doulas%20and%20birth%20outcomes%20 position%20statement%20final%20January%2030%20PM.pdf

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Risks and Benefits of Fetal Monitoring During Births by Horatio Daub MD, MPH

In a recent article in the August 1, 2020 edition of American Family Physician which is a peer reviewed and editorially independent journal of the American Academy of Family Physicians, there is an interesting study discussing “Intrapartum Fetal Monitoring.” It explains that continuous electronic fetal monitoring (CEFM) was developed to screen for evidence of fetal distress including hypoxic ischemic encephalopathy or fetal acidosis (compromised brain function due to inadequate circulation and oxygen delivery to the brain), cerebral palsy (which
is most likely caused by factors prior to birth), and impending fetal death during labor. Because of the low frequency of occurrence of these events during labor, CEFM has a false positive rate of 99%. In other words, lkg99% of the time when the monitoring shows a pathologic pattern, it is not indicative of an immediate danger for the fetus.

CEFM leads to increased rates of cesarean delivery

The widespread use of CEFM has led to increased rates of cesarean and other operative deliveries without any significant improvements in outcomes for the newborns. CEFM is a very blunt tool for detecting fetal distress. CEFM is falsely positive for fetal acidosis 67% of the time and when actually present, has a low sensitivity of 57% of correctly detecting fetal acidosis. When fetal acidosis is not present, there is a low specificity of CEFM with only 69% of the time showing a negative or normal result. Further complicating this is difficulty interpreting the CEFM tracing with agreement between experts on interpretations of the CEFM tracings only half of the time.

Structured Intermittent Auscultation (SIA)

Structured intermittent auscultation is preferred for women without risk factors as detailed below. ‘The main antepartum factors indicating high risk labor and the need for CEFM include any condition in which placental insufficiency is suspected such as intrauterine fetal growth restriction, known fetal anomalies, maternal preeclampsia/gestational hypertension or maternal type 1 diabetes mellitus. Intrapartum factors indicating high-risk labor and requiring CEFM include presence of meconium, presence of tachysystole (overactive uterine
contractions), signs or symptoms of intrauterine infection, unexplained vaginal bleeding, or use
of oxytocin or other uterine stimulants for labor induction or augmentation.

If one of the following is detected during SIA for a low-risk patient switching to CEFM is recommended to assess the National Institute of Health and Human Development category and to determine necessary clinical management: irregular fetal heart rate, fetal tachycardia (<160bpm for >10 minutes), fetal bradycardia (<110bpm for >100 minutes) or recurrent decelerations following contractions (<50% of contractions) or prolonged decelerations (>2 minutes but <10 minutes).

Risks of CEFM

The main risks of CEFM are increases in cesarean and operative vaginal delivery rates without improvements in fetal outcomes. Along with the increases on operative deliveries also come costs of longer hospital stays and higher risks of complications such as infections, bleeding, and bladder injury, etc. Another important consideration is that the ability of the laboring woman to move around and walk or assume a position that facilitates her delivery and labor is very restricted, making a normal natural labor and delivery almost impossible to achieve.

Barriers to Implementing SIA

Not all birthing facilities offer the option of SIA because of barriers in nursing staffing and education and physician oversight. Most organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM) recommend instituting SIA with the onset of the active phase of labor. However, there are differing ways of defining active labor. The two most commonly used are 4 cm of cervical
dilatation and 6 cm of cervical dilatation but regular uterine contractions which are strong and frequent (<5 contractions in a 10 minute period averaged over 30 minutes) without uterine stimulants is also important for active natural labor. Be sure to ask your birthing facility if the option of SIA is available.

Choosing Wisely Campaign: Advice for birthing women

A recommendation from the Choosing Wisely Campaign is to not automatically initiate CEFM during labor for women without risk factors, and consider SIA first. Another very important recommendation from the Choosing Wisely Campaign is: Don’t separate mothers and their newborns at birth unless medically absolutely necessary. Instead, help the mother to place her newborn in skin-to-skin contact immediately after birth and encourage ongoing skin-to-skin contact and always keeping the newborn in her room during the hospitalization after the birth.

Breastfeeding within a half an hour after birth is optimal both for the mother and infant’s health along with exclusive breast feeding for the first 6 months of life after which appropriate complementary foods should be introduced, and the infant should continue to breastfeed for one to 2 years or longer as desired. Worldwide, the lives of an estimated 1.5 million children less than the age of five would be saved annually if all children were fed according to this standard.

References:
1. “Intrapartum Fetal Monitoring,” American Family Physician American Family Physician,
2020;102(3):158-167
2. For more information on the Choosing Wisely Campaign, see
http://www.choosingwisely.org. For Primary care see
https://www.aafp.org/afp/recommendations/search.htm

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What is Birthpedia and How is it Changing the World of Birth?

A qualified resource where the worlds of hospital, birth center, and homebirth co-exist? A place
where parents’ choices are respected, where information isn’t condemning, but enlightening? A
resource like that simply didn’t exist… until now.

In this post, you will learn how Birthpedia is changing the way information about birth is being
presented and why future parents and birth professionals should know about it.
What a wonderful world it would be if every mother felt empowered during her pregnancy and
believed in her ability to give birth. But information for pregnancy and birth are now found in a
world of excessive data, obsession with social media, and self-diagnosis thanks to Google. The
upcoming generations of parents are found here, and they are lost. Between horror stories of their
mothers and the latest forum board on BabyCenter, parents are feeling anything but educated,
empowered, and prepared for the journey of parenthood. Confusion, debate, opinion, and fear
dominate their circles of influence. There has to be a better way. A midwife/OB can only stretch
themselves so thin. A doula can only have so many clients. And childbirth educators can only
reach those who take their classes.

Birthpedia is a subscription-based app and website that provides quick, current, and
qualified information to expectant families, delivered in short videos by birth professionals.
Birthpedia’s mission is to provide this information in a judgment-free space, helping expectant
families and parents of newborns make educated and informed decisions.
We believe that providing information in a collaborative way helps families feel supported and
equips them with essential knowledge—which empowers them to make informed decisions
within their experiences.
The app and website are organized into three main sections: ASK, SHARE, and DO.

The ASK Area:
Consists of five color-coded categories: Conception, Pregnancy, Labor &amp; Delivery, Postpartum,
and Newborn Care. A search bar allows for search on any topic or question, or by category. Each
question will be answered in a 1–3 minute video by a birth professional. The database of
questions will hold over 1000 videos from over 100 birth professionals called “contributors.”
Contributors include midwives, obstetricians, doulas, childbirth educators, massage therapists,
chiropractors, fertility specialists, anesthesiologists, aroma therapists, herbalists, and more.
Answers to questions are based on the most current information in each category and speak to
the pregnant family—regardless of where they choose to give birth.

The SHARE Area:

Users will find a variety of shared stories. These stories are inspirational: stories of birth,
fertility, and adoption. The videos share positive and redemptive real-life experiences. Sharing
these stories will inspire new parents to believe in themselves and their natural, instinctual, and
God-given abilities. They will encourage couples struggling with infertility, going through a
grueling adoption process, or preparing for a VBAC.

The DO Area:
Users will find a wide variety of instructional videos, such as prenatal and postpartum exercises,
prenatal yoga, labor positions, breastfeeding, babywearing, changing a diaper, nutritional food
prep, and more! These videos will encourage users to be more active and provide up-to-date
visuals to help guide them.

WHO is Birthpedia for?
First and foremost, future and expecting parents. Birthpedia offers three different subscriptions;
24 hours, monthly, or six months.
Birthpedia also serves to be an excellent reference resource for current birth professionals. Birth
Professionals can sign up for a Lifetime Membership and grow with this incredible resource for
the lifetime of their career!
Birthpedia aims to be a socially responsible company that strives to invest in improving the
global birth landscape for better birth outcomes.
At Birthpedia, we believe…
● every newborn baby deserves the right to their best birth.
● informed parents create better birth experiences for all involved.
● birth is a primal human function and should not be treated like a disease
● every woman giving birth has a right to respectful maternal care
● every woman has the freedom to choose how she wants to give birth without
condemnation.

You are invited to join the journey toward better birth with Birthpedia! Birthpedia can be found
online at www.birthpedia.net, Instagram @Birthpedia, and Facebook/Birthpedia. For a limited
time up until January 2020, all of the content is FREE as the Birthpedia database continues to
grow!

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Adina’s Testimonial

Attending the BirthWorks childbirth education workshop in Mt Dora, Florida this May was way more than I bargained for! The place was absolutely stunning. A Victorian style historical hotel with sprawling grounds against a backdrop of the magnificent lake and quaint town. But even more than that was the content of this 3 day workshop given by Cathy Daub. The workshop was so comprehensive and included topics such as grieving, mother daughter relationships, optimal pelvic positioning as well as many others that are not usually included in typical childbirth preparation classes. They were all taught through hands on experimental learning and not through didactic teaching. It was the BirthWorks experience I came out with!

One of the really vital things was teaching and facilitating using open ended questions and letting the other party find their inner guide to direct them. That evening I had a chance to really practice this skill. Being a doula, I had a client in labor and sent a backup.  Right before pushing, my backup called me asking if I could speak to the client as she was panicking about pushing. Instead of going into my long speech about why she shouldn’t be scared to push and how she’s done this in the past, I asked her what her fear was. She said she’s afraid she can’t do it. I asked her what she felt she needed to be able to move forward and she said she thought she needed help from the doctor. I said what kind of help. She said she remembered from her last birth that the doctor did supra pubic pressure because the baby’s shoulders got stuck. I gently reminded her that the only reason the doctor did that was to help the shoulders but the head was out already. So she said, “oh ok, but I’m still scared.”  So I asked her, “What do u want?”  She said she wanted her baby to come out without pushing. I said great. Imagine it. She said she can’t because she  has no energy. So at that point I told her to visualize G-ds energy as she inhales coming into her uterus and as she exhales pushing out her baby. She said,”Ok you visualize it for me!”   I said sure and she hung up empowered and pushed her 9 and half pound baby out with one push!!!

It was such a great lesson for me and I can’t thank Cathy and BirthWorks enough!

Earlier that day this same client was laboring pretty slow so I instructed my backup to do the rocking technique we had just learned that morning and she progressed very quickly to 10 cm!

Recently I had a prenatal meeting for a client who had 2 previous c sections and I used the grieving process we learned, asking her if she wanted to share anything that was hurting her  and she ended up telling me about a few childhood moves her family made when she was in school and how she was afraid to get too close to anyone and then have to move again and she came up with the idea that she was scared to carry something through to the end, the finish line. Explaining to her how we birth the way we live, both her previous births she stalled at 3 cm and wasn’t able to progress further. That awareness was amazing for her and it’s all due to the skills I learned in the grieving session.

Thanks a lot!

Adina Hoffman

 

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The Baby Way

What better way to show cardinal movement, rotation of a baby through the
pelvis, than by demonstrating with The Baby Way, manufactured by BirthWorks
International. This is an “Ah Ha” moment for any pregnant woman, helping her to
understand the importance of movement in labor.
Our imagination is much more powerful than we may realize. Showing a baby doll
fitting snugly through a pelvic model, even if cloth, still gives the impression of a
tight fit. When women feel their own pelvises in BirthWorks classes, they can
experience and imagine more space that is there for their baby to move into.
Then when they see the diameters of the pelvis in The Baby Way, they understand
how the baby rotates to move through the pelvis in optimal pelvic positions. This is a powerful connection sure to have a
great impact on any woman giving birth.
The Baby Way is a must have tool for anyone birth professional including childbirth educators, doulas, nurses, doctors,
and pregnant woman. (See demonstration on BirthWorks website interview Nicholas Olow with Cathy Daub)

www.birthworks.org/product/the-baby-way-2/

The diagrams below show the pelvis in an upright
position which is optimal for birthing. Note that the
pelvic inlet is wider from side to side. Since the
widest part of the baby is the shoulders, the baby
must enter the inlet and then tuck his chin to turn 90
degrees so the shoulders can pass through. In
contrast, the outlet is wider from front to back.
Therefore, the baby must turn 90 degrees once again
to move his/her shoulders through the outlet.
Turn the head into a breech position with feet first and
demonstrate how a breech baby also turns and rotates to
pass through.

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BirthWorks with Birthpedia Conference – Highlights

Our conferences are being described by attendees as, “The BirthWorks Experience” and this is different from other conferences they have attended.   Our program is based on the practice of human values along with integration of the mind, body, and spirit.  This is experienced in all of our conferences and workshops as well as in our training programs. The setting of the Lakeside Inn overlooking the lake was infused with peace itself, thus enhancing the theme of our conference, “Peace in Birth.”

All keynote speakers and presenters focused their talks on the theme of how birthing families and health care professionals can have more peace in birth.  They addressed this in a multitude of ways ranging from birthing vocabulary, to mother/baby skin-to-skin contact, to empowering high risk moms, to the importance of comprehensive childbirth education, to avoiding birth-worker burnout, to healing through birth stories and finding peace after experiencing birth trauma to name a few. I will touch on some of the keynote lectures here.

Nancy Wainer explored the world of birthing vocabulary and its effects on pregnancy, labor, and birth.  She made distinctions such as “We don’t catch babies, we receive them.”  The Bag of waters becomes the “amniotic release.”  The mucous plug becomes “Baby Gel.”  Is there such a thing as a “Natural Cesarean?” or a “Gentle Cesarean?”

Michel Odent MD discussed how the human placenta transfers antibodies to the mother so that the mother’s microbiota is friendly to the baby. Today most women give birth where there are unfriendly microbes, not colonized in the same way. Today we must ask, “How is our health to be organized?” He said, there are only two kinds of birth: birth at home, and birth elsewhere.  Today, we have dysregulation of the immune system comparing only with hospital birth.   We need to find new ways to adapt.   He went on to say that too often we associate stress as a negative way of thinking, but there are times when we need stress hormones. In a pre-labor cesarean section, babies are not being exposed to fetal stress hormones. For example, corticosteroids are needed for maturation of the baby’s lungs.  Also, understanding the birth process means understanding “Neocortical inhibition” which should become part of the birth vocabulary.  We need to wonder why birth is so difficult for some women and not for others.  It has to do with “Neocortical inhibition.”  The neocortex must stop working in labor.”  Women need to be protected against key inhibitory functions.

Michel made the trip across the Atlantic at the age of 88.  We gave him a tribute slide show of his work through the years, including pictures as a child, and also gave him a journal in which everyone at the conference wrote words of gratitude to him for his lifelong work in birth.  When asked the question, “What made you become interested in birth?”  he answered, “Oh, I’m not interested in birth – I’m interested in humans but of course birth is a part of human existence.”

Brad Bootstaylor MD:  Is one of three obstetricians in Georgia performing vaginal breeches in a hospital setting.  His Dads catch babies 90% of the time. He sees birth as a natural event that may or may not need managing. He emphasized the need to always have a conversation with birthing parents in shared decision making, hearing their needs and then discussing how they can work together. Even in an emergency cesarean, the process is important.  He said, “I help her to remember that her job is to bring her baby here to the earth.”  He shared seven pearls of care some of which were respecting a patient’s values, enhancing physical comfort, providing emotional support, involving the family and especially listening to the mother.

Dr. Bootstaylor said he enjoys his work and brings a positive attitude to women giving birth and their families. He doesn’t think, “Oh my, she’s still here!” He has assisted many women in vaginal breech births thus helping to avoid the major surgery of a cesarean.  Above all, he feels a trusting relationship is essential to any birth.

Lewis Mehl Madrona:  Being a board certified family physician and psychiatrist of the native Lakota American Indian background, Lewis brings storytelling as a form of healing in his culture and he has applied that to birth over much of his life. He acknowledged that there are both good and bad stories but they are the glue that hold people together.  Every story we hear affects our physiology whether we like it or not.  If we use it, it grows up; if not used, it fades away.  How do we make sense of story trauma?  Know that even in the worst trauma, good comes out of bad.  This transforms the victim into a hero.   What makes people feel better is giving meaning to what happened.    You can’t erase a story once it is told.  We can also strengthen good stories by retelling them over and over again. Lewis said story-based medicine may treat pain.  Listening without interruption and judgment is the greatest gift we can give anyone.

Mary Renfrew:  is a leading health researcher and midwife.  She has conducted research in maternity care and in infant feeding for over 30 years and her work has informed and helped to shape policy and practice in those fields both nationally and internationally.  Her work has a core focus on improving health and care for women, babies, and families and reducing the impact of inequalities.   Due to ankle surgery, her fascinating lecture was presented through skype.  She spoke about global challenges and developments in midwifery and how to tackle those through evidence and through education thereby moving evidence into policy and practice.

Amber Price: As the only CEO in the country who is also a midwife, Amber had much to share with us about how she is making changes to help pregnant women and women in labor at the Tristar Centennial Women’s and Children’s Hospital in Nashville TN. She said as a society, we dictate behavior for mothers and babies, but instead, we need to teach and not mandate. Below are just a few of the points she made in her talk.  View her entire fascinating talk by purchasing it at birthpedia.net/learn

  • 52% of pregnant women in the US are obese with BMIs over 50. Hospitals need equipment to meet their needs. If women don’t get what they need, they won’t come back.
  • Women think they are going to be treated like a queen in the hospital, but are often disappointed.
  • Both women and health care providers feel alone and largely unsupported.
  • There is mutual distrust between women and healthcare providers, exacerbated by word of mouth and the media.
  • Procedure rather than patient centered care is prioritized by healthcare providers. Women’s reports of care indicate that interventions are routinely imposed on them without meaningful informed consent.
  • The difference between home and hospital birth is that birthing women take on guest status. People are in control in their own homes,  however, when walking into the hospital, the minute they ask “May I use the bathroom?” or “May I have something to eat,” someone has power over them.

See our next E-news for the Professional Forums held at our conference.