To Test or not to Test

During a rare quiet moment the other day I stumbled upon this article in the Toronto Star: ‘Over-testing can have a serious downside’. Written by Dr Sacha Bhatia, it’s a quick sum up of a phenomenon we are more than familiar with in the maternity care industry: that more tests and procedures do not equate to better outcomes. His article led me to the website for Choosing Wisely Canada, a new campaign by the CMA and the University of Toronto.  They are encouraging Canadian patients to think for themselves and ask their doctor 4 simple questions:

  1. Do I really need this test, treatment or procedure?

  2. What are the downsides?

  3. Are there simpler, safer options?

  4. What happens if I do nothing?

This is exactly what I encourage my clients to do – use their brain and ask intelligent questions. Think of a simple procedure like the Nuchal Translucency ultrasound most women have around 12 weeks and ask the 4 simple questions.

  1. Do you really need this procedure? This is a test that screens for Down Syndrome and other chromosomal abnormalities. For most women this is the first chance to have a look at their baby and they jump at the chance to do so. But do you really need this procedure? Will you abort a baby with Down Syndrome? If the answer is no then this is not a necessary procedure for you.

 

  1. What are the downsides? If the test indicates abnormalities, you will undoubtedly feel anxious and worried about your baby. The test generally used to confirm any issues is the amniocentesis which is a much more invasive and painful procedure with higher potential risks. So if you agree to the non-invasive NT test, you may find yourself in a position where you are forced to choose to undergo an amniocentesis to alleviate the stress brought on by the first test.

 

  1. Are there simpler, safer options? This test is already pretty safe and simple.

 

  1. What happens if you do nothing? If your baby is fine, then he will continue to be fine. If your baby has chromosomal abnormalities, he will continue to have chromosomal abnormalities.  So this test only affects your peace of mind. It’s up to you to decide if knowledge is power or if you would prefer to stay ignorant.

 

 

So you can see the Choosing Wisely Questions are pretty easy to apply to most maternity tests and procedures.  Take Continuous External Fetal Monitoring in labour:

  1. Do I really need this procedure? This monitors your baby’s heart rate continuously during labour. The research shows that continuous fetal monitoring holds no benefits over intermittent fetal monitoring, and in fact often creates problems. So no, you don’t really need this procedure.

 

  1. What are the downsides? The downside for you is that EFM limits your mobility and forces you to stay in bed or at least in your hospital room. If your hospital has portable wireless units you will have a little more mobility but you will still be expected to stay in range. Being tied down during labour is not ideal. It also steals your thunder, meaning that your caregivers will concentrate on what the monitor is telling them and ignore you.  Sometimes the information on the monitor will indicate fetal distress when there is none. Obstetricians err on the side of extreme caution, so any momentary irregularity in the tracing will cause them alarm.  The research shows that CFM does not actually catch things that IFM does not –but it does appear to cause distress in healthy obstetricians.

 

 

  1. Are there simpler, safer options? Yes, the simpler, safer option is intermittent monitoring with the EFM or even a Doppler.

 

  1. What happens if you do nothing? If your baby is in distress then no one will know. In this case occasional monitoring is the better choice over continuous monitoring or no monitoring.

 

So it’s wonderful that the CMA are on board with this initiative to stop overuse of unnecessary testing in medical care, but what is not wonderful is that

The Women’s Health section does not have a single word about maternity care.

Not a one.

So what’s up with that?

Now, Choosing Wisely had their inaugural meeting at the end of March, 2016, so I guess I should be a little kinder and give them a bit more time, but in the mean time if you feel like I do that there should be a large section on Obstetrics on their website, please visit their site and give them feedback! And please let me know what you said in the comments section below.

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Practice Defensive Birthing

Defensive birthing

Nowadays hospitals are practicing defensive medicine – which basically means they feel they have to use all their tools and interventions to prove that they’ve done everything they can to produce the best outcome.  But their idea of the best outcome starts and ends with a healthy baby. Sometimes the Mother gets lost along the way.  Mother friendly hospitals acknowledge that the mother’s experience is also important –a traumatic birth experience can result in poor bonding between Mother and Baby which can effect breast feeding success and cause postpartum depression. There are ways to optimize your birth experience even in the most intervention – happy hospitals.

Here are a few tips to help you negotiate these common road blocks on the way to your best birth:

 

speed bump

Childbirth is not an area where ignorance is bliss. You wouldn’t leave on a road trip without checking a map, don’t go blindly into labour. Go to prenatal classes, read books, decide what kind of birth you want and write a birth plan. For tips on how to do that, check here.

 

 

slow

 

Transfer to hospital can slow down or even stop your labour. If you show up too early the hospital may feel the need to ‘do something’ to speed you up. Stay at home as long as possible.

 

 

do not

Well meaning nurses undermine your determination to have a natural birth by offering drugs every 2 seconds. Get the nurses on your side. Hit the drive through on the way to the hospital and pick up a dozen donuts. Print out a sign that says “We are trying  to have a natural birth! Please don’t talk about epidurals! I’ll ask for one if I want one.” Stick it on the donut box. Print another and stick it to the door.

traffic lightsUnfamiliar places make relaxing into labour difficult. Treat the hospital room like a hotel room. Don’t be afraid to open all the cupboards and check the place out. Use all the blankets and pillows, don’t be shy. You are paying for this room, make it yours. Find the light switches and turn them off!  Bring your bedside lamp from home or some battery powered candles and dim the lights.

 

picnic-areaYou need to eat and drink to keep your strength up – but do not expect the hospital to provide you with decent food. Bring a picnic and choose your snacks wisely. Nothing too smelly! Some old school nurses still believe you should restrict food and drink in labour, even though the research doesn’t support this and even the American Society of Anesthesiologists has stated that it’s okay.

 

pedestrian_crossing_vector_sign_9603The bed looks really inviting  but it’s best to stay upright as much as possible. If you must be monitored insist on sitting upright preferably on a birthing ball to keep your hips open and flexible.  Play music to calm and soothe you, or get you up and dancing. Moving your hips is a great way to get baby to move down and out. Dance and sway and walk around the floor.

 

car-wash-When you are beginning to think you can’t do this anymore -use the facilities! Seriously, if there’s a tub you want to get in it. And here’s a little secret – those pillows can totally go in the water. They’re designed to clean up after all kinds of bodily fluids, so if you need a bath pillow just grab one off the bed and use it. Hydro therapy can be very effective and if you are feeling like you might want an epidural, try the shower first.

 Bring a supportive pit crew. Your partner, a doula, a RMT, pit crewyour best friend. The more support the better.  How nice it can be when one person is rubbing your feet and another your back while a third is bringing you a drink of ice cold water. Your birthing suite should be like a 5 star resort with a spa, and you should be treated accordingly.  Unfortunately this isn’t usually the case, so you must bring your servants with you. If you find you prefer solitude when labouring, park your people at the door to keep it closed.

stop sign

Don’t let anyone tell you what to do. I’m not saying ignore doctor’s advice, but if you feel like you’re being bullied, you are. You can tell your doctor to change his attitude or get out. You can tell your nurse to shut the f up. You are in labour, dammit, and you can get away with anything! And have your pit crew back you up. A chorus of “she said no” is helpful to remind the staff that consent is actually required before they do anything.

 

wiggle road sign

 

Try to enjoy the journey. Your labour may seem endless while you are in it but soon it will be over and your baby will be in your arms. And then the real trip begins!

 

 

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So, what does a doula do, exactly?

Frequently asked questions, doula edition.
So you’ve heard the reports and seen the stats and you know that having a doula increases birth satisfaction, decreases interventions and is just the most awesome thing ever. But what does a doula do, exactly? Of course every labour is different and every woman has different needs and desires. Your doula will adapt to suit your specific requirements. She will provide emotional and physical support, guidance and unbiased information throughout the pregnancy and labour. She will make suggestions on books you might want to read, products you might find helpful and positions that will ease your pain. She will hold your hand, wipe your sweaty brow and tell you that you are awesome.

But won’t my husband/partner do that?
Maybe. Hopefully. But sometimes your husband/partner will be a bag of nerves. Sometimes they will freak out when you cry out. Sometimes they will shriek “Get the doctor in here now!” three hours too soon. Sometimes they will turn white and pass out. Your doula can reassure your partner that the noises you are making and the pains you are experiencing are normal, healthy and to be expected. She can help your partner get over their anxiety and suggest ways that they can comfort you physically. She can stay with you while your partner gets a snack or makes some phone calls. She can reassure you both that progress is being made and that there is no reason to be afraid. She can gently suggest that maybe sitting down now would be a good idea. She can hold your partner’s hand, wipe their sweaty brow and tell them that you are both awesome.

But what, exactly, does a doula do?
Your doula will arrive at the hospital or birthing place within 90 minutes of your phone call. She will immediately check out the space, draw curtains and close doors. She will make sure you are comfortable and not sitting in a puddle of your own amniotic fluid. She will find where the dry sheets and blankets are and make sure you have what you need. She will ask questions to find out how you are feeling and what has happened in her absence. And she will get you up on your feet and make you move around as much as possible. It’s good practice to shift positions every 30 to 45 minutes and your doula will keep her eye on the clock and make suggestions as to new positions to try. In the early stages of active labour your job is to find your rhythm and get your coping strategies in place, and your doula will help you do this. You may not even notice that’s what is going on, but your doula will notice what you naturally do during each contraction and will help you keep doing what is working for you. And if things start to change, your doula will try to help you get back on track, whether by trying a new position or motion or water therapy or whatever other tools she may have in her bag of tricks.

Bag of tricks? Tell me more about this bag of tricks.
Your doula will bring a bag to the hospital that is a bit different from what you bring. She will probably have a heating pad or magic bag which can be quite soothing – if you like heat on your stomach or back when you suffer from menstrual cramps you might also like it when you are in labour. Ice packs are also an option. Some doulas bring their own birth ball and some hospitals provide them. (Others refuse to allow them. Boo.) Some doulas use TENS machines. All doulas have training in comfort measures that include massage, counter pressure and light touch. Your doula will probably advice you in advance to provide your own music, pillows and light snacks. Think about the food and drinks you like when you are recovering from the flu. Some hospitals still refuse solid food to women in labour but will provide soup and jello and fruit juice. 20150822_171946
What if I just want an epidural, right now?
In your prenatal visits you will have made a birth plan with your doula, and if your birth plan says “I want an epidural, right now” then your doula will support your choice to have that epidural, right now. If your birth plan says “I really don’t want to have an epidural” then your doula will gently remind you of your original plan, suggest a different position or hydro therapy or whatever but if you say “No, I don’t care, I want an epidural right now!” then your doula will support your choice to have that epidural, right now. Your doula is there to support you and your choices.

What happens in the prenatal visits?
You are likely to meet with your doula three times before you give birth. The first time is a free consultation session at which you will get to know her a little bit and decide if she’s the right doula for you. The second session will include birth planning and a little prenatal education. The third will most likely include breast feeding education, baby care and postnatal planning. By the end of these two sessions you should feel more confident and knowledgeable about the physiological process of childbirth and how you want to approach it, and you will have faith that your doula will support you in whatever choices you have to make along the way.

How long will my doula stay with me?
Your doula will stay 90 minutes to 2 hours after you give birth. She will make sure you have something to eat and drink. She can fetch any family members you have waiting down the hall, or shoo them away if you don’t want to see anyone yet. She will wait with you until your baby shows interest in breast feeding and help you get off to a good start. And when you are ready, she will leave and let you get on with the business of bonding with your baby.

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Why hire a doula?

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What is a doula?

DOULA : from the ancient greek “A woman who serves”.
DOULA : a woman experienced in childbirth who provides advice, information, emotional support, and physical comfort to a mother before, during, and just after childbirth.
Today we use the word doula to refer to a person educated and experienced in supporting women in childbirth and parenting. Many doulas offer prenatal classes and breast feeding support. Some doulas specialize in postpartum care, and others work with infertile couples. The primary purpose of a doula is to inform and reassure the expectant family, providing them with unbiased information to help them make informed choices along their journey to parenthood.

Why hire a doula?
Numerous clinical studies have shown that women supported by a doula have shorter labours with less interventions. They are half as likely to have a C-section and less likely to use an epidural. They have more success with breast feeding and more positive memories of their birth experience.

What about my partner?

Birth 3
Your doula can help support your partner while you are concentrating on birthing your baby. It is difficult to see your loved one in pain but your doula can reassure your partner that labour is progressing normally and that you are coping well. Your doula can show your partner massage techniques that will soothe you and can stay with you during meal and bathroom breaks.

A Baby Ready doula can be your support during this most important time. Let your doula help you write a birth plan and stick to it (as much as baby allows!) Your doula will help you and your partner remember what you learned during childbirth class, and provide you with information and coping techniques to help you labour in confidence. Your doula will encourage you to ask questions of your medical team so that you move through your labour and birthing informed and empowered. Think of your doula as your cheat sheet for the biggest exam of your life!

5 steps to an awesome induction.

251814_10151795813205514_1168844160_nI know what you’re thinking: “aren’t inductions always awful?” “Don’t you hire a doula to avoid an induction?” “aren’t doulas all anti-intervention at all costs?” The answers to these questions are no, yes and not at all. Sometimes inductions are necessary. Doulas are not magicians. Interventions have their place. Last month I was privileged to attend the birth of a sweet-faced little girl. Her Mother had developed complications and the decision was made to induce at 38 weeks. Here is what my client taught me about how to have an awesome induction.

Step 1. Keep a positive attitude. So your birth plan was to have a water birth at home with midwives, and you find yourself checking in to the hospital for an early induction. Oh well. It’s still your birth and your baby, let’s make the best of it.

Step 2. Take one step at a time. The OB is most likely to offer you gel, AROM, Pitocin, and an epidural as a welcome package. Try to space out these interventions. See if the gel will work by itself. Try to relax, sleep, and let your cervix do its thing. Put off the next intervention for as long as possible.

Step 3. Walk walk walk. Try and move around as much as possible. The longer you can stay mobile, the better position your baby will slip into for an easier birth. Remember, gravity is your friend. There are many upright positions for labouring even if you want to rest in bed. A portable fetal monitor even allows you to shower or get in the bath. You can still move around with ruptured membranes and a Pitocin drip if you are determined to do so.

Step 4. Don’t be a martyr. You don’t have to suffer. Pitocin induced contractions are much harder and stronger than the natural kind. Very few women can manage them without pain relief. Getting an epidural does not mean you’re a failure, it means you can enjoy some pain-free time to rest up for step 5.

Step 5. Wait till you feel pressure on your rectum and push that baby out like a boss. That’s what the epidural does best – gets you through transition without batting an eyelid. If you stop pressing the top up button when you begin to feel pressure in your bum you should have enough sensation to push effectively when the time comes. Slow steady pushing is the way to go.

That’s it, my 5 steps for an awesome induction. Remember, it’s still your birth and your baby and you are the one in charge.