ACOG delivers good news for moms and babies.

 

We all could use a little good news, right?  After decades of skyrocketing c-section rates and increasing interventions upon interventions, this trend in US obstetrics is miraculously reversing.  The American College of Obstetrics and Gynocologists (ACOG) and other professional groups have put out some excellent recommendations over the past couple of years. Not coincidentally, they are recommending practices that we midwives have never left and have always done because, well, it's common sense and they work.

WIN #1: Hands off the low-risk mom

1) In January 2017, ACOG published a committee opinion piece recommending a "hands off" approach to managing low risk births. This is a victory for women and their partners who have been saying for decades they just want to be left in peace to give birth to their babies.

What does "hands off" mean to ACOG?

  • Artificial rupture of membranes a.k.a. "breaking of waters" is not necessary in normal progressing births
  • Active labor starts at 6cm instead of 4cm.  They cited studies showing lower rates of epidurals and need for pitocin. 
  • If your water breaks, it's best to wait for labor instead of automatically being checked in to the hospital and induced.
  • IVs should not be required or routine.
  • An end to forced pushing or "purple/Valsalva" pushing.
  • Using intermittent instead of continuous fetal monitoring. 
  • Allowing a "laboring down" or resting phase for 1-2 hours before pushing.
  • Allowing  position changes during labor and pushing as long as it doesn't interfere with monitoring.

 

WIN #2 : Encourage one-on-one & emotional support in labor

There was a time when US hospitals banned any labor support at all. Not even the father of the baby could be present. Women were held hostage and often treated very poorly with no support, witnesses or recourse. Only after nurses and mothers in the 1958 wrote an anonymous article in Ladies Home Journal about the "Cruelty in Maternity Wards" did people take notice.  

First, the Lamaze and Bradley revolution of the 70s-80s got the fathers in the labor room doing support. The 90's brought in the professional doula movement. A cascade of studies and data have proven the efficacy of continuous labor support. Doctors, nurses and hospitals are not always friendly to doulas despite their importance to women and their efficacy and insurance coverage for doulas is extremely rare. This landmark recommendation may change that.  

If a doula were a drug, it would be unethical not to use it.
— John Kennell, MD

Facts cited in the report:

  • doula care saves money for consumers and government
  • c-section rate is 40% lower in births with doula care
  • linked to shortened labor 
  • decrease need for pain medication 
  • families report higher satisfaction with their labor

WIN #3: Delay the cord clamping

In December 2016, ACOG took a good look at delayed cord clamping.  Thankfully, ACOG is now recommending ending the practice in healthy, vigorous infants. And yes, it can be done even in c-section deliveries.

While "delayed cord clamping" may be framed as a "new" practice that has health benefits, we might also consider prematurely clamping of cords is harmful. Immediate cord clamping is a harmful practice with no physiologic or medical benefit. Babies that have their cords clamped immediately lose a significant amount of stem cells, iron rich blood cells, immune factors and reduced overall blood volume with effects similar to suffering a hemorrhage. Three cheers for ending this antiquated, bad habit!

WIN #4:  It's okay to eat in labor. 

In 2015, the American Society of Anesthesiologists said it's okay to "let" women eat in labor. Since the beginning of hospital birthing, women have been banned from eating during labor citing the risk of aspiration in case a woman needed to be "put under" general anesthesia.  The result has been millions of women doing the hardest physical endurance task of their lives fueled only on ice chips. It took decades to amass the data showing that the harms of starving women overshadow the remote possibility that she may need general anesthesia. Finally, they have come around to say most women would benefit from a light meal during labor.  They have even found that in some cases, aspirating stomach juices is harmful if you haven't been eating because they are more acidic and caustic on your lung tissues. Ew. 

YAY!!! No more sneaking food in the hospital!!!  Now you can eat your bananas and yogurt in peace, ladies!

YAY!!! No more sneaking food in the hospital!!!  Now you can eat your bananas and yogurt in peace, ladies!

In the real world, what does this mean? Am I going to automatically get a "hands off" birth?

Does this mean that my doctor won't touch the cord, will let me eat and I won't have to get induced if my water breaks?  Yes and no. Of all the various fields in the US medical system, obstetrics is known for being the slowest to change. 80% of US obstetric practices are not based on high level evidence. It takes an average of 11 years for practices to change after new evidence comes out. Sad, but true. 

Doulas of North America published this somber but realistic commentary on the new guidelines: 

Change occurs slowly in maternal medicine even with new guidelines or recommendations from a body like ACOG. While there are some encouraging suggestions in this Opinion, doulas are unlikely to see significant change to care practices or hospital policies as a result. The Opinion, does, however serve as a resource to educate our clients on the most recent position of ACOG including the research cited within it. Childbirth educators can also reference this document to encourage expectant families to ask questions and advocate for their preferences in regards to early labor management, comfort measures, monitoring, positioning and pushing.

— Adrianne Gordon, MBA, CD(DONA), Blog Manager

The good news is that if your hospital and doctor are not up with these recommendations, you now have good support to ask for what you want in labor. This is how change is made. It's how we got the dads into the labor room, how we got rid of the routine shaving and enemas as well as drastically reduced episiotomies in this country. Be assertive, be persistent, and bring robust labor support.

Or......you could just hire a midwife. 

 

Midwives have always encouraged women eat in labor.

Midwives have always left the cord alone. 

Midwives have always given one-on-one emotional support.

Midwives have always been "hands off" the low risk mother.

 

Hands off  and common sense practices are staple in the Midwives Model of Care. Midwives have been doing these things correctly for generations. You won't have to fight for the care you want. It's good news that more of the things that make midwifery care great will be available for hospital/MD patients. But it's even better news that you can get this kind of care right now from your local midwife!

 

*CAVEAT EMPTOR: Not all midwives practice the Midwives Model of Care or evidence based care. Most midwives that are employed and supervised by physicians and work in hospital are limited by hospital regulation and obliged to work under medical model protocols, not midwifery based protocols. Keep this in mind when hiring a provider. You will have the most flexibility if you hire an independent midwife with hospital privileges, or in a free standing birth center or at home. Also, remember, all of the these recommendations are for low risk women only!

 

5 crazy things doctors used to tell pregnant women.

I admit I am a bit of a history junkie, especially when it comes to intersection of medicine, culture and childbearing. It's amazing the things they used to tell women. We have come a long way in the last century in caring for women. 

1. Women shouldn't gain weight in pregnancy, unless they are very thin. Then they can gain a little.

In the 40s Doctors commonly told women not to eat any additional calories during pregnancy. In the 1970s a weight gain of 15 pounds or less was preferred. If a woman wasn't thin, she was told not to gain any weight at all. My mother was 130 pounds and 5'3". She gained 10 pounds during pregnancy. Her doctor scolded her for gaining "too much".

Smaller babies used to be preferred by doctors before the evidence showing that low birth weight is linked to an array of long term health issues. (I like to believe that midwives have always loved chunky babies...)

2. Every pregnant woman should get an abdominal x-ray.

Starting in 1920's, x-rays were used on pregnant women to determine pelvic size, fetal size and fetal positioning. Today you can't get a dental x-ray without a 20 pound lead apron draped over your belly. What changed?

The work of Alice Stewart.

Alice Stewart was a Oxford University medical school professor that published an air tight epidemiological study linking x-rays to childhood leukemia in 1956. It was the height of the Atomic Era and because her results were not beneficial to the powerful nuclear industry, she was ridiculed and her work was discredited. But she continued to advocate tirelessly over the years. Her findings were eventually confirmed and additional studies were published showing an increased rate of serious abnormalities in neonates who were exposed to x-rays in the womb. Despite these warnings, x-rays continued to be used on pregnant women and babies continued to be irradiated until the mid-1970's, a full two decades after her original paper. 

3. Don't breastfeed. Formula is superior.

Formula was considered superior because it was more "scientific" and could be measured. It was an era when our culture believed science was superior to nature. The formula and condensed milk producers marketed heavily to pediatricians, which were at that time an emerging specialty. Pediatricians took the role of prescribing the "formula" ratio or constituents, and regulating intake. It was a system that appealed greatly to the science and chemistry based profession as opposed to the old fashioned wet nurse-animalistic-back woods-baby hanging off the breast.....way of feeding.  

Formula was "highly recommended" and touted as "perfect infant food".

Now we know human breast milk is much more than food. It contains prebiotics, probiotics, antibiotics, antivirals, stem cells and hormones. Now pediatricians strongly support human milk for human babies when possible, based on a large body of research showing artificial feeding contributes to diabetes, obesity, asthma, allergy and eczema, and other long term health risks.

4. Babies don't feel pain.

I was recently in a delivery room and heard not one, but two physicians make this claim. Right before a very painful procedure on the baby, the doctor told the mother, "Babies don't feel pain. In fact, they can't fully feel pain until they are 3 years old and the nervous system is fully developed.". Jaw......drop. Really?  These parents could not make sense of this claim. They wanted to believe this doctor, a seemingly bright and compassionate graduate from a top medical school. But, as experienced parents, listening to their baby wail in pain, they could not. 

How could anyone believe that babies don't feel pain? Back in the old days when we used diaper pins on our cloth diapers, if a baby wouldn't stop crying, the first thing you would do was check and see if they were being poked by a diaper pin. Common sense, isn't it?  This elegant article by Oxford university explains it in detail. Not only do they do feel pain, but they feel pain just like adults.

Curious about this myth and where it came from, I did a little research and found that indeed, at one time doctors were taught in medical school that babies felt no pain. Babies were blank slates, with empty minds, tossed in the trash if they didn't breathe immediately after birth. (That is until our hero Dr. Apgar came along and changed that barbaric practice-more on her later!) But in the 1980's there was a surge of interest with 44 studies published on the topic. Finally science caught up with common sense and this assumption was reversed. Ironically, I received an update from the American Academy of Pediatrics into my inbox not long after that "painful' incident in the labor room.  It was an official AAP statement on how to avoid the negative effects of pain in newborns, and that the "prevention of pain in neonates should be the goal of all pediatricians and health care professionals who work with neonates". Now, as to why this young top medical school graduate was taught and now practicing according to such outdated information is beyond me!

5. Smoking cigarettes in pregnancy isn't harmful...ANd sometimes even helpful!

Cigarettes were heavily marketed to both doctors and women in the 1940s and 1950s. Pregnancy books of the time recommended moderation in smoking and discouraged a woman from quitting because it would be too stressful on the body. A common recommendation was to limit cigarettes to 4 a day. Some doctors encouraged women to smoke in pregnancy to control weight gain. It was also acceptable to recommend women to smoke to "calm their nerves". They believed that "hysteria" and "neurosis" were more harmful that cigarette smoke.  By 1964 with the Surgeon General's report on smoking, doctors and the public were finally made aware of the harms of cigarette smoking and began slowly reversing the recommendations. 

A cigarette ad targeting mothers and pregnant women.

A cigarette ad targeting mothers and pregnant women.

Even when new evidence isn't controversial, it still takes an average of 17 years from the time it is published until it reaches clinical practice in mainstream medicine. This is why I recommend you choose a doctor or midwife that is both up on the research and willing to practice according to well selected studies and common sense instead of following hospital policy or antiquated standards of care. Some examples of discredited practices still widely in use are denying women food in labor, inductions for a suspected big baby, banning VBAC, elective inductions and forcing women to give birth in a non-upright position. To get up to date on the latest evidence I recommend Rebecca Decker, a PhD prepared nurse and researcher that publishes her work at Evidence Based Birth. Her articles are very readable and non-biased. Fact check what your provider tells you see if it lines up with the current evidence. You shouldn't have to wait 17 years to get the good care you deserve!

Have you heard any stories from you mothers, grandmothers, great aunts and elder friends about what doctors used to tell them? It's amazing how sharply women will remember their births and the events leading up to them. Ask them! I'd love to hear about them.

Alaska shatters myths about modern midwives.

The Midwives Model of Care has been proven to provide high quality safe care, low cesarean rates, less unnecessary interventions, reduced costs, expanded access and higher patient satisfaction. In the US, the majority of midwives are either CNMs (nursing school trained with masters degrees) or CPM (direct-entry or apprenticeship model trained). 

The scope, legal status, reputation and availability of these two kinds of midwives varies greatly across the US. 24 US states license both kinds midwives for out-of-hospital birth. Other states restrict the practice of midwifery to only hospital-based nursing school trained midwives. In some states like Alabama, CPMs are illegal and they will prosecute or revoke the license of a CNM attending a home birth. Even stand-alone birth centers are illegal. Drive across the state line to Florida and both CPMs and CNMs birth center and home births are not only legal but the government pays them as providers in their state medicaid programs. Quite the contrast!

Alaska has a unique and functional system that allows families to choose freely from a number of licensed professionals for their maternity care in and out of the hospital, including both kinds of midwives, CNMs and CPMs*.  Depending on which state you come from, you may have a very different opinion and impression of the different kinds of midwives and what they do. This system saves a lot of money and gives more families access to attentive maternity care. Here are some of the common misconceptions about CNMs and CPMs. 

Myth: Certified Nurse Midwives (CNMs) are the only legitimate kind of midwife in the US. All the others are "lay midwives"- untrained and uneducated.

Fact: Certified Professional Midwives (CPM) are professionals having completed educational and clinical training requirements. In Alaska, a CPMs training history is certified by the state and subject to additional rigorous licensing requirements.

A common accusation is that non-nurse midwives are untrained, unqualified to attend births. They say that the only legitimate path to midwifery is to first become a nurse (4 years of university), then work experience (1-2 years usually) followed by graduate school (2 years). That's 7+ years!

The International Conference of Midwives sets standards for midwifery education worldwide including the best systems like New Zealand and the United Kingdom. Their training lasts 3 years and is a totally separate educational path from nursing. So clearly, by the highest international standards you do not need to be a nurse or train for 7+ years to become a proficient midwife.

Alaskan CPMs are required to complete a State approved academic program or a MEAC accredited midwifery school on top of a clinical apprenticeship program that lasts 3-5 years. Upon completion of coursework and clinical requirements they must pass a rigorous national board exam. CDMs are trained to order and interpret labs, carry drugs, suture, and do everything to operate an accredited birth center independently.

CPMs, a CNM and an MD working together in a safe and successful practice in Alaska.   Integrated Women's Wellness and Center for Birth

CPMs, a CNM and an MD working together in a safe and successful practice in Alaska.

Integrated Women's Wellness and Center for Birth

Myth: Certified nurse midwives work under a doctor's supervision. Other midwives work on their own out of the "back alley".

Fact: In Alaska, both CNMs and CPMs can practice independently without physician oversight. They often work side by side.

7 out of 9 birth centers in Alaska employ both CPMs and CNMs. They work side by side in the birth center setting. During clinic visits, CNMs offer a wider scope of service, due to their expanded medical training such as prescribing birth control. Some birth center CNMs also attend home births with CPMs.

Here is one such example. These 5 talented midwives are part of a successful practice, and have trained via 3 different routes to earn their credentials: 1 nursing school trained, one foreign trained and two apprenticeship trained.

Myth: CNMs are safe, all other midwives are dangerous.

Fact: CPM birth statistics have been collected by the State of Alaska since 1993. Outcomes show high levels of patient safety.

In Alaska, with regulatory oversight, a long history of midwifery, and collaborative practices, we have excellent outcomes. CPMs have access to necessary training, life saving drugs and equipment to keep birth safe. CPMs have mandatory reporting for all birth outcomes have been and tracked by the State of Alaska since 1993.

Since midwives work independently in the State of Alaska, as opposed to under physician supervision, they are able to practice the Midwifery Model of Care, which has been proven to reduce the incidence of birth trauma, injury and cesarean section while increasing patient satisfaction. 

6% of the births in our state are attended out of hospital, the majority by Non-nurse midwives. CPMs are well trained, educated and licensed. It's a birth model that works-family centered, Low intervention, accessible care that saves money.

In states where only Certified Nurse Midwives are recognized and Certified Professional Midwives are not recognized, access to out of hospital birth is severely limited. Since most CNMs work in the hospital setting, it creates an environment where women either birth unassisted (without professional attendant) or hire anyone who calls themselves a "midwife". More and more families are demanding birth options. Out-of-hospital birth has increased 50% over the last decade. Alaska is a great example of providing access and options for safe, supportive care with both CNM and CPM midwifes.

*CPMs are awarded an additional credential in Alaska upon licensure, as a CDM, or Certified Direct-Entry Midwife. This title is a remnant from decades old licensure-before the CPM credential was created and standardized across North America. 

What kind of midwife did you have? How is access to midwifery where you live?

My sister had a baby....with me!!

My sister had a baby....with me!!

So my sister had a baby. With me. At my house on an island in the Gulf of Alaska. One of the most remote towns in the US.

Last spring called me, exhausted and exasperated. In a few months she would be giving birth. Her previous postpartum was miserable after a traumatic birth of a preemie with no adult to help her as she drove back and forth to the NICU, trying to pump milk and care for her family.