Wednesday, February 25, 2015

Reducing Primary Cesareans (Part 2)

Click here to read Part 1: The Primary Cesarean Reduction Movement

I just listened to an interesting webinar on Preventing Primary Cesareans! The presenter explored much of the research and data supporting the recommendations behind the SMFM and ACOG Statement Safe Prevention of the Primary Cesarean Delivery. I found a few of the points interesting enough to share them here.

Ideally the primary cesarean reduction issue would be addressed through a systems approach, where hospitals, payors, patients, and OB providers are all working to improve primary cesarean rates. This presentation mainly focused on the obstetrics areas that can be influenced to make change.

The presenter noted that the Healthy People 2020 target cesarean rate for low risk, full term, singleton, vertex pregnancies is 23.9%, BUT that the goal in 2010 was 15%. Clearly, the government had to lower its expectations.

Malpresentation contributes to 17% of pre-labor cesareans, and is a highly modifiable obstetric indication for preventing the first cesarean. For example, research shows that an external cephalic version at greater than 36 weeks has a success rate ranging from 35-86%. Care providers and hospitals should be offering and encouraging this procedure. Furthermore, more clinicians need to be trained in how to vaginally deliver breech babies. The presenter only recommended this when the second twin is breech. Vaginal breech delivery of the second twin does not increase morbidity when done by an experienced provider.

Failure to progress (or CPD) accounts for about 34 - 47% of intrapartum cesareans (the majority first stage arrest), and nonreassuring fetal status (heart rate tracing interpretation) accounts for about 10 - 27% of intrapartum cesareans. These are additional modifiable areas to prevent cesareans. 

A big one is Failure to Progress, aka labor arrest, aka cephalopelvic disproportion. This can be diagnosed during either first stage or second stage (pushing). We joke in the doula world that this is often "failure to wait." Many OB's are taught that labor progresses according to the Friedman's Curve. This curve is one of my biggest birth pet peeves. This curve basically says that during active labor, a primiparous woman should dilate about 1 centimeter per hour, and that (on average) the entire first stage should last about 13 hours. This is based on a 1955 study with a sample size of 500 primips. It looks like this:

A 2010 multicenter study of more than 200,000 deliveries looked at primips and multips. This study found that the 95th% was about 20 hours for the first stage, with a mean of 8.4. (Keep in mind that half of the women received pitocin and 80% of the women had an epidural). Here is the curve from this study. It shows that multiparous mothers generally have shorter labors and that active labor may not really get going for them until about 6 cm dilation. Then, the curve is quick. For first time moms, however, there is no definite "turning point," and the curve is more gradual. 

This is a reason for the big change to starting "Active Labor" at about 6 centimeters dilation and not diagnosing labor arrest unless the mother is not having cervical change for 4 or more hours after they are at least 6 cm dilated. Moreover, diagnosis of labor arrest in the second stage has also changed due to this study, which found longer pushing stages for first time mothers as well as for mothers who had an epidural. Much research has shown that no neonatal morbidities were (statistically) significantly increased as length of second stage increased. Some maternal morbidities were found to increase (statistically) significantly as pushing time increased (e.g. uterine atony).

Another important point is that we need to give women who are induced more time to labor! There are few adverse outcomes associated with increased patience for inductions. The recommendation is at least 24 hours of pitocin + no regular contractions + no cervical change = arrest. 

The presenter suggested that to addressing variation in diagnosis of nonreassuring fetal heart tones, we should really emphasize that moderate fetal heart rate variability is reassuring, as is FHR acceleration after fetal scalp stimulation.

I'm going to share her slide here so you can see what she lists as the non-medical factors in the hospital and among care providers that influence cesarean rates.

I liked that she addressed that the hospital has trouble with allowing women to labor longer on L&D, that OR staff often go home at about 8pm so many Cesareans are scheduled before then so no one has to come back to the hospital at night, and that nurses are very busy and have competing priorities. Physicians of course have their own personal reasons for "diagnosing" a cesarean, among them financial incentives to deliver the child themselves so they will get paid and not someone else! Research shows that hospitals that have salaried MDs (e.g. laborists; can also be midwives) have less variability in the time of day when diagnoses of fetal distress are made. 

She touches on myths among patients (labor is bad for the baby, long labor is bad, induced labor is the same as spontaneous labor, operative vaginal delivery is worse than cesareans, etc). This is something that childbirth educators and doulas try to impress on the public, but physicians need to be doing this education, too. 

She did not cover medical legal issues due to time constraint (understandable - it is a major topic)! I would have liked to hear, though, ways that nurses can be involved in preventing the first cesarean. I work with a hospital that shared that they are getting their nurses educated and involved in educating and working with patients on how position changes can help the baby descend, pelvis open, and reduce first and second stage labor time (and nonreassuring fetal heart rates). I think this is a great initiative!

The presenter did mention doulas when prompted, praising their involvement, and the involvement of midwives, but did not touch on how they can make a difference in reducing primary cesareans. 

If you'd like to see the entire slide set or check the references, you can download the slide set from the National Perinatal Information Center website when they become available.

Monday, February 2, 2015

Social Media Tips for Birth Pros

My first tip for Birth Professionals is to Use Social Media!

Social media is used by a growing number of men and women of reproductive age, so it very helpful for birth professionals! Social media can only increase your exposure. It helps you provide frequent, updated business information to an audience without having to constantly figure out how to refresh your website. It drives people to your website and contact information. 

My second tip is to use social media wisely. Many professional organizations recommend that you avoid mentioning your clients on social media. You especially want to avoid reflecting on a negative experience, or share a photo of someone without their permission. Get permission from your clients if you'd like to use their images on the internet.

My third tip is to follow other birth professional social media accounts. How are you going to know what is going on in the world of birth/breastfeeding/babies if you don't follow along? This is the best way to find articles and information to share with your own audience. Don't just plan on making an account and only looking at your own page; make sure you are engaging with other birth pros so you can stay up-to-date for your clients!

Here are some site-specific tips:


Everyone tries to figure out how to work with the unknown algorithm that Facebook uses to decide whose posts show up on News Feeds and why. It is a fact that not all of your posts will be "served" to all of the people who "Like" you. Here are some of my tips to optimize use of Facebook.
  1. Fill our your Page completely. Make sure you have your logo as your profile photo, and use your cover photo to provide more information through an image, text, or upcoming event. Fill in your contact information and your business information, and make sure you include your website link. 
  2. Do not post more than two posts to a business page per day.  More than two posts per day (or 10 total per week) will result in A) An annoyed/jaded FB fan audience, and/or B) Facebook's algorithm will stop showing your posts to your whole page audience. And when you do post your two posts, make sure they are spread out (to catch morning and afternoon crowds, or lunch and evening crowds). If you discover more than one interesting post at once, you can "schedule" posts for future times to ensure your posts are spread out, and continue to engage an audience even if you decide to disconnect for a day. (note: Scheduling doesn't work through clicking the "share" button on a photo or post from another FB page).
  3. Interact with other Pages as Your Page. Did you know that you can "use Facebook as" your page? I highly recommend that you switch over sometimes and use this feature to Like other local businesses, like other page's posts, and comment on other page's posts. You can't do everything that you can with your individual Facebook page (for instance, join groups or like an individual's posts). 
  4. Engage people in conversation. Ask a question, share your own personal story, take a poll. The more people who are engaged in your posts, the better your Facebook page will do!


If you are hoping to increase your business, I recommend that you add a blog to your business website. 
  1. Update your blog regularly. Write about content that you are hoping will draw-in business. This can be specific to your business, or can be interesting information related to your business area. For instance, you can blog about the safety of water birth, and anyone interested in that topic may stumble on your blog. Or, you can write specifically about the services you offer. You can even video blog (Vlog) and post those on YouTube!
  2. Use at least one image on every blog post. Photos drive attention and traffic when posts are shared on Facebook and Pinterest, and for some reason make it more likely that your post will be read! Making your own informative text-based image to describe what the post is about is often sufficient.
  3. Post your blog posts on other social media sites. Now that you've written a post, make sure you share it far and wide (and add social media buttons so others can share, too)! Post to your Facebook page, Twitter account, pin it to Pinterest, post an image from it on Instagram.
Any website that refreshes content often will lead to increased exposure in search engines (part of Search Engine Optimization, or SEO, techniques). This is why a blog will drive people to your website, and why a web search will often find a Facebook, Twitter, or Pinterest post. 


My Facebook Page posts auto-tweet, which makes sharing across platforms really easy. I haven't figured out how to best use Twitter for business, yet, though Twitter offers information on how to make this useful for you. I mainly use twitter for this blog account - to share interesting articles. It makes a great depository for articles that I want to be able to find again later, or just to try to spread information and get conversations moving on certain topics. 
  1. Use hashtags. The best advice I have for using Twitter is to use hashtags. This is the most convenient way to join a conversation with others who are interested in the same things you are. If you write a post or share an article about doulas, use the hashtag #doulas. Then, anyone who is interested in doula stuff, too, can search #doulas and your article will pop up. It helps drive followers to you and gets the info out to a larger audience. 
  2. Make it Re-tweetable. Make sure you write posts in a way that is easy for people to simply click "retweet" and share with their followers. My advice here is just to say to make it relatable, and don't include anything that someone might have to take out if they want to share. 
Sharing on Twitter in addition to Facebook increases your audience - someone might see your post on Twitter but miss it on Facebook (or vice versa). 


Pinterest is great for birth businesses for two reasons: 1) The majority of users are young women, and 2) It is often an indication of things that people want in the future. Women pin merchandise they are interested in or ideas they want to come back to in the future. It is a great place not only for you to save ideas and links on a virtual cork board, but for your clients to save your business' ideas and links! 
  1. Create topic-specific boards. You may love all things birthy, but if you're using Pinterest for business, you want to make what you share easily accessible for your followers who may only be interested in certain topics. For instance, make a "breastfeeding" board, a "labor support" board, a "newborn" board, etc! Users can choose to follow some or all of your boards. 
  2. Auto-share on Twitter. If you have both a Twitter and a Pinterest account, you can set your Pins to automatically tweet (make sure the pin's description is included). This drives those who may be on Twitter to the content you find on Pinterest. 


Instagram is a great idea for a business that plans to have a lot of visual items to share. Where twitter is text, Instagram is photos. For a birth business I envision two uses: 

1) To keep your fans, community, clients, etc. interested in what is going on with your life (keeps things personal, which people like, but you have to be willing to be a public sharer). An example might be a picture of you getting coffee after being up all night with a laboring woman, you wearing your own baby, etc. and,
2) For sharing what is going on with your business, for instance, a picture of a newly decorated room in your birth center, childbirth education supplies you have ready for the next class you're going to teach, or (with permission) your clients' newborn photos!

Here are some tips:
  1. Make a business page, not a personal page. And use it like a business. Make all of your posts relate to your business, not your personal life. Your clients probably don't care what you ate for dinner every night last week. 
  2. Use hashtags is my advice, again, for the same reason as above. If your business Instagram account is public, people can find it by searching the hashtags. 

If you get really into using social media for your business, you can analyze your analytics! You can set up analytics on your blog to see where your traffic is coming from, including referral sites or search words. Twitter and Facebook also support analytics (on FB it is called "insights"). You can see what day of the week or what time of day you are getting the most engagement on your posts, and how many new page likes you have this week compared to last week. 

There are other great resources out there for more tips on using social media; I suggest starting with Your Doula Bag's Pinterest Board "Social Media for Doulas"! 

Saturday, January 17, 2015

Weekend Movie: From Womb to Womb

Biological Anthropologist Julienne Rutherford has a fascinating talk available online that is a short but nice overview of the effect of epigenetics from womb to womb. Essentially she discusses the effects on the intrauterine environment, and whether the womb that we develop in affects the womb that our female offspring produce when they reproduce. The purpose is to understand how we pass down, generation to generation, the effects of our socio-ecological environment. Put another way, how our grandmother's life affects our life, and the lives of ensuing generations.

Her talk covers how placentas play a role, how Life Course Theory is part of it, but isn't the whole picture, and how studying primates can help us get an idea of the impact of intrauterine environments on the health and lives of future offspring.
"We are more than our genes. Genes get switched on and off constantly. All the DNA in our bodies in all the cells is essentially identical, but some get turned on, some get turned off...
But even more subtley, gene expression can be affected by our environment in the now, in the lived experience. Molecules attach to the DNA, which sort of locks it down, so its inexpressible - can't get turned on. This phenomenon is called epigenetics. Epi = beyond, above. Something beyond just the molecule themselves. How are the molecules regulated.
We know from a variety of experiments and observations in humans and other animals that the lived experience of an organism can have enormous impacts on how the genes are regulated. We also know that some of these molecular locks can be inherited along with the DNA itself. So, for ex, some genes in the stress pathway of maternal ,fetal, and placental tissues are regulated differently in people who have experienced poor nutrition, poor rearing behavior... high levels of psychosocial stress, institutional racism and discrimination, and the experience of war..."

It's one more argument for improving social and economic environments in order to improve a population's health and future potential. People often think that a poor or unhealthy person can just "do better" to make themselves healthier or more wealthy, but so much depends on our socio-ecological environments, and that of our ancestors.
"The placenta contains the mysteries of the past and predictions for the future..."

You can view Dr. Rutherford's 23 minute presentation on the website for the Cusp Conference 2014.

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