Category Archives: Evidence based reserach

#DublinDoulas Perinatal Infant and Mental Health

Perinatal and Infant Mental Health in Ireland – Guest Blog

Perinatal and Infant  Mental Health in Ireland

Guest blog by Barbara Western

Perinatal and Infant  Mental Health in Ireland attracts a growing body of research. It is wonderful to see the attention moving towards infants and young children, a cohort who until the last 20 years, or so, have been seen as having little to no agency or as ‘tabula rasa’ – blank slates upon whom adults can impart knowledge and the proper way to conduct oneself. Sometimes, however, the focus can get skewed and researchers can often neglect that the individuals who are conceiving, carrying and birthing these babies are living, breathing humans as well. These are people who have contributed immensely to their communities. Individuals who have changed their lives and who have made sacrifices in relation to what they eat, what they drink, how they work and how they feel in order to ensure a healthy start for their offspring. There is an abundance of research on attachment theory (different from attachment parenting) that strongly supports the nurturing of a secure and healthy emotional bond between infants and their caregivers. The evidence for this theory is particularly poignant and hopeful for families where there has been a disruption in infant-caregiver bonding, for example if a mother or parent has experienced illness, complications or trauma during pregnancy, labour or birth.

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Meeting the family

Birth Trauma and perinatal infant and mental health

Thus, when an article purporting to be scientific research on birth trauma healing opens with a line like: “Research has proven that babies born without trauma enjoy an intact capacity to love and trust”, there is some serious cause for critical analysis. Anyone reading an alleged scientific article on any subject should hear alarm bells when the phrase ‘research has proven’ is used to make a claim. Scientific rigour and the most robust research can not ensure the proof of anything. All the scientific research method can do is analyse well constructed hypotheses and carefully collated data to show support that the variables being studied are evidence of a claim, or not. Any science that declares ‘this is proof’ is not good science. Any method that is applied with the claim of being the only one that is right or the only one that works is most likely marketing, and not science.

The onus on articles, like the one above on birth trauma, is to highlight the science that supports a theory or method and to omit emotive opinions and pseudoscientific claims. Women who have recently given birth can often be vulnerable and sleep deprived and may find it more difficult to discern the scientific authenticity of an article or method from the pseudoscientific claims the author(s) are making. Claims such as ‘babies are conscious from conception’ or that any separation of a baby from its mother after birth is perceived by the baby as ‘abandonment’ are categorically false and run the risk of causing increased distress to those who are already traumatised by birth. What is equally distressing is that the article above cites no references for these claims. The only links at the bottom of the article are to sources directly related to the author(s) and to a book by Dr Arthur Janov, the creator of ‘primal scream therapy’, a method that has virtually no rigorous scientific research to support its effectiveness.

Upon further reading, the article continues with questionable statements about ‘optimal birth’, such as “The mother works with the baby to help him be born successfully…Such a child will have a life script of ‘I can succeed’”. Another claim about ‘life scripts’ declares that “babies born by elective caesarean section (sometimes necessary) may have some of the following life scripts: ‘Life is something that happens to me’ or ‘I don’t like things happening suddenly when I am not ready’. These babies have also missed out on the important stimulation of the birth contractions.” While these life scripts may be tenuously linked with cognitive psychology and schema therapy, there is no scientific basis given for any of the above assumptions. While some people may connect with these claims on an intuitive level, it can be extremely dangerous for others to read them and to internalise self-blame or guilt for experiences that were outside of their control. Particularly when these claims are egregious and false.

The rest of the article goes on to promote the work of two doctors. It appears their areas of specialty are psychotherapy and developmental psychology. This is where things can get confusing. When a person refers to themselves as a ‘doctor’ or uses any professional title, we expect them to be an expert in the field in which they are qualified. We expect certain competencies, knowledge and skills in their qualified discipline. In the last decade, there has been an agreement between various psychotherapeutic and psychological associations & societies on the international standardisation of the accreditation and registration of psychotherapists and psychologists. This is important work that addresses the vulnerability of the clients involved as well as the power dynamic and the role of mental health professionals in the assessment, treatment and diagnosis of the individuals with whom they work. For too many years, psychology and psychotherapy have suffered from the prevalence of unqualified practitioners who are often more interested in marketing a toolkit they have developed or a book they have written than in providing an ethical and professional service.

#DublinDoulas Perinatal Infant and Mental Health
Growing with a family

Scientifically proved versus “opinion” in pregnancy and postpartum marketing

It is hard for someone marketing a theory or product to admit that it may not work, that it requires updating or that it may not be suitable for everyone. Years may have been invested in writing, training and selling their product(s). This is where marketing veers sharply away from the scientific method. A person who is selling a self-designed birth tool or service has to believe strongly that they are offering something that no one else can offer. They have to develop a marketing language that makes their product or service appear to be more effective than the competition. The problem with this is that the language to sell a product can appear to use scientific language and terms when the theories or concepts being discussed are pseudoscience. In the above article the words: cellular, hormones, brain and nervous system appear by the second paragraph with absolutely no references to explain how these biological terms or processes relate to birth or birth trauma. This is a powerful, and sometimes disingenuous, use of language to convince people that they need something that may be entirely unnecessary or even ineffective. Current research supports the theory that using terms like ‘brain’ and ‘neuro’ in marketing or health & social sciences literature appeals to the reader so that the reader will believe what the literature says, even if it is irrelevant pseudoscience. This verges on the unethical when individuals are expected to part with money for a service or product that appears to have scientific support but when critically analysed offers no more evidence than opinions and anecdotes, which are notoriously unreliable and biased.

Treating birth trauma

Going back to the content of the above article, the ideas relating to ‘re-patterning’ (defined as “creating the birth that should have happened”) and encouraging a baby to relive their birth trauma with the alleged effect of healing are highly questionable, at best, and unethical, at worst, due to the lack of evidence to support this practice. Robust and scientifically sound therapeutic approaches to healing birth trauma will draw from the most reliable and valid psychological research and not from unsupported claims in relation to an esoteric practice such as rebirthing. In fact, the most recent research on treatment of trauma is a 3 phase approach that takes the individual being treated into account. Some will gain benefits from re-living and reprocessing a traumatic event while others will not find it helpful or may even find it harmful. If the trauma is more complex or ongoing, then different approaches will be more appropriate (http://psychcentral.com/lib/ treatment-of-ptsd/). The key here being that anyone undergoing therapeutic intervention should be assessed individually by a trained  and qualified mental health professional and a treatment plan should be designed accordingly, ideally in collaboration between the individual and the professional. There is an additional ethical consideration in that the babies undergoing the interventions described in the article are not able to give their consent. This means their parents – who may be sleep deprived or suffering from PTSD – are being expected to give consent for an intervention that is based on little to no empirical evidence.

#DublinDoulas Perinatal Infant and Mental Health
With cuddles from Grandma

Partners in healing rather than treatment from an “expert”

In Perinatal and Infant  Mental Health in Ireland, there are a plethora of therapeutic tools and treatments where the person imparting the therapy or intervention implies that they are ‘the expert’ and the one being treated is the passive recipient of the intervention. This is not authentic therapy, where the quality of the therapeutic alliance is one of the biggest determinants of efficacy and the individual in therapy is facilitated to adopt healthier coping styles and to feel empowered and more confident in their ability to face life’s stressors. In the above article, one has to question: where is the facilitated care for the mother? The baby appears to have been given an intervention that the creators of the therapy claim will heal trauma for the infant. But what about the trauma affecting the mother and wider family? It is implied that once the baby is relieved of trauma then the parents can go back to parenting and a normal life, without the interference of the baby’s cries. This is far too simplistic and ignores the numerous other factors at play when it comes to birth trauma. Significant factors like: maternal morbidity, family history, prior birth trauma, socio-economic status, mental health history, expectations of childbirth, adjustment to the role of parent, and many more aspects can influence the way in which a woman and her family integrate and heal from a traumatic birth.

There is an anecdote in the above article that depicts a 15 to 20 minute intervention whereby one of the doctors cited in the article invites a woman to bring up her ‘niggling’ baby to the front of the room. It is established that the baby has been fed and wasn’t hungry but that he had endured a protracted second stage of labour. The alleged expert holds the baby’s head and then pushes on his feet until he ceases crying and this is seen as evidence that the baby has somehow re-experienced or re-patterned his birth. The idea that one single aspect of birth (long 2nd stage) is deemed the causal variable in the baby’s current discomfort and that one expert can change the trajectory of the infant-parent relationship simply by holding a baby for a few moments completely undermines the entire discipline of perinatal and infant mental health research. In addition, it reduces the role of the mother to passive participant in the care and nurturing of her child. While the power of touch has some robust evidence behind it as a way of deepening bonds and expressing and eliciting compassion, it would be far more effective to empower a mother and to encourage her to hold her own baby to facilitate and deepen the bond between them.

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Bonding with mummy

Promoting parental competence and confidence in parents who have experienced birth trauma

This therapeutic method neglects situations where a baby may have spent spent time in NICU or when a mother or her baby have experienced interventions or complications during pregnancy, labour and birth. Complications during birth can occur for myriad reasons and can affect the mother, the baby and the extended family to varying degrees. The methods of dealing with birth trauma in this article ignore the scientifically supported therapeutic tenets of early individualised family-based interventions – particularly those that promote parental competence and confidence – that reduce maternal stress and depression and increase maternal self-esteem, leading to more positive early parent-infant interactions. Assessment and treatment of an infant’s mental health involves much more than one therapist holding the baby for a few moments in the hopes of ‘re-patterning’ the baby’s birth experience. It involves the mother or caregiver, the infant and the support of an entire team.

#DublinDoulas Perinatal Mental and Infant Health
At six months old bonding with family and exploring

Infant Mental Health

As an emerging discipline, Perinatal and Infant  Mental Health in Ireland embraces the most current empirical research on infant-child development and its intrinsic relationship with parents and caregivers, in the early years of life. Contrary to the idea that the mother is totally separate from the infant, a recent Infant Mental Health Group Networks Evaluation (2015) document, states that a quality infant mental health model will draw on the skills and knowledge of a “network of professionals involved in providing services and support to caregivers, families and children age 0-3” (p. 5). This group will then work closely with the wider community to support primary caregivers, infants and families to achieve optimum mental health and wellbeing across the perinatal period. This requires that consideration not only be given to the physical needs but also to the psychological, social, cultural and geographical issues facing women, men, infants and families during this time.

#DublinDoulas Perinatal Infant and Mental Health
Loving mummy

Birth trauma does not lead to the  irrevocable disruption of bonding between parent and child

In reality, if there is a disruption to the infant-parent bond due to trauma of any kind then overwhelming evidence suggests that the bond will not be irrevocably disrupted. In fact, even in cases where there has been prolonged difficulties or separation, interdisciplinary professional mental health support will take time but it will have a much more significant long term beneficial effect for the infant-parent/caregiver relationship than biased and pseudoscientific therapies. A mother, parent or caregiver should be encouraged and supported to take an active part, if they are able, in nurturing and protecting the bond with their child. If there is trauma involved, families should find great comfort in the robust evidence that in time and with evidence based support, mothers and infants can, and do, heal and go on to thrive in their relationships.

Barbara Western is a Graduate Member of the Psychological Society of Ireland (PSI) and is the Communications & PR Officer for the PSI Perinatal and Infant Mental Health Special Interest Group. 
Facebook: PSI Perinatal and Infant Mental Health Special Interest Group
Twitter: @Perinatal_SIG
#DublinDoulas #DoublinDoula #TheDublinDoulas

LINKS

http://www.psihq.ie/page/art/337/0 Psychological Society of Ireland PIMHSIG webpage

http://www.psihq.ie/page/file_dwn/260/PIMHSIG%20Executive%20Summary%20Jan2016.pdf Summary of the PIMHSIG Position Paper on Perinatal and Infant Mental Health

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sifting

Focus on Spinning Babies: 10 things a doula should know

This weekend I got to attend a great Spinning Babies Workshop given by Spinning Baby trainer Jennifer Walker. It was a wonderful inspiring session and I would recommend it or similar to any doula.

In conservative antenatal education we are all taught to focus on the cervix as a measure of progress and change in labour. As doulas we know that the cervix is simply a symptom of the work of the fundus and all the surrounding ligaments, soft tissues and muscles and we rarely consider dilation in supporting a woman ‘s prgression in labour. Instead we look at the depth the intensity and the woman’s state. Is she still building endorphins, or has she entered into that trance like state of deep labour?

What Spinning Babies offers is an additional perspective to progression and movement (or lack of) in labour based on the baby’s position within the mother’s pelvis,  rather than on cervical dilation. An understanding of optimal positioning and of the symptoms of sub optimal positioning and how these can arise over the pregnancy can offer opportunities for the doula or midwife (or both) to take action to improve the positioning and therefore improve progression towards birth.

Here are the Top Ten Things that I learnt

1. Where the baby is,  is more important than dilation

A woman can be quite dilated, but if her baby is not in an optimal position to progress through the pelvis then the dilation is of no consequence, alternatively the woman can be hardly dilated at all, but once her baby gets into an optimal position, the labour can progress very quickly indeed. The position of the baby is determined by the mother and her pelvic balance.

2. Knowing the difference between passive patience and active patience

Passive patience is very high up on the doula check list in general. There is that idyllic image of the doula sitting and knitting which Michel Odent paints, and most experienced doulas will only become more hands on when the mother or her birth partner need and request more hands on support. However, in the worskshop, the point was made that whilst time is not often given to a birthing mother in our highly medicalised birth culture, continuing to simply wait and wait and wait for labour to progress can sometimes not help if the baby is not in an optimal position. Instead, if the doula and midwife can recognise the symptoms of sub optimal positioning and know exactly where in the pelvis the baby is and identify what aspect of the soft tissues, ligaments, muscles or fascia are contributing to the sub optimal positioning then action can be taken to improve the position of the baby. However its important to note that this is not some natural form of “active management of labour”, but rather an active style of waiting and supporting.

3. Balancing the pelvis, womb and everything that supports them enables good maternal position and baby’s position

Most women’s pelvis’ are not balanced. We all have previous injuries that we may have encountered along our teenage years or repetitive strains that we do on account of our job, or as part of our less than optimal posture. Also we all favour one side over the other to do certain tasks; for example writing, pulling or picking up things. All of these things accumulate and eventually we become unbalanced. When pregnancy starts we can take action to balance our pelvis’. There are exercises we can do daily and others weekly to improve pelvic balance and these are referred to as The Three Sisters, or more recently the Fantastic Four! In addition the practice of yoga and optimal sleeping positions can also be of great benefit.

4. Pelvis’ are differently shaped and shape will determine ease of the baby’s passage through it.

All women will have a slightly differently shaped pelvis. However in addition to the individual variations women have, there are generic groups of pelvis’. Some pelvis’ are more narrow in the inlet but wider in the outlet and others are wider in the inlet and narrower at the outlet. Depending which type of pelvis a woman has will determine whether the space for her baby to engage, rotate and descend is tighter or narrower or wider. It will also determine in which part of her pelvis the baby will have the narrowest fit during the journey to birth.

pelvis shapes
The four main types of pelvic shapes

 

Pelvis’ have three parts to them, an inlet a mid pelvis and an outlet. In Ireland traditionally most women have a gynecoid pelvis, however with a greater number of women from different cultures birthing in Ireland, a wider range of pelvic shapes are now more common. It can help if the woman knows the shape of her own pelvis.

5. Often where the baby is, is dependent on the quality and balance of the soft tissues

For example the tone of the muscles, the amount of tension in the round ligaments, the alignment and symmetry of the broad ligament, the tightness of the lateral sacral ligament, the length or shortness of the muscles, notablly the psoas muscle, and the pelvic floor muscles can all affect balance and ultimately the position of the baby. Hence the importance of daily balance practices during pregnancy and body work such as yoga, and also at least one visit to the chiropractor or osteopath during late pregnancy, or if funds permit visits throughout pregnancy!

6. Every woman benefits from daily practice during pregnancy to improve balance

The three sisters of balance (now the fantastic four) are useful daily practices in pregnancy and can also be used in labour as well if imbalance is suspected. They are

i. Rebozo sifting

sifting 2 sifting 3

ii. hanging the uterus

HANGING 3 HANGING 4 HANGING 6 HANGIING 8

iii. side lying release

SIDE LYING 6SIDE LYING 3 SIDE LYING 2

 iv. Standing sacral release

FASCIA

7. Tips to try in early labour or just before if the baby is high and at the pelvic inlet but doesnt engage

As doulas we are generally familiar with the symptoms that this scenario presents. Mothers will have a start stop labour that may go on for several days as the baby tries to engage,  the contractions may be double ones and painful but the true trance like state of labour doesn’t come on and the energy of the labour doesn’t move forwards. This can apply to early labour at home and to early labour in hospital/home.

Good tools to use here in addition to the Fantastic Four, are

  • Posterior pelvic tilts against a wall, as opposed to an anterior pelvic tilt (which women are often encouraged to do whilst sitting on a ball).
  • Abdominal lift and tuck if the mum is multparous,, this literally helps to lift the mum’s tummy into the pelvic area,
  • Crawling on hands and knees
  • Polarity techniques
  • Vigorous circling on the ball can be used (the analogy being an egg slipping into an egg cup if it is spun on the rim enough),
  • Walchers manoeuvre ie actually leaning back on the bed with the feet hanging off, or alternatively leaning backwards over the ball in a sort of half “camel” back bend for three contractions,

WACHERS

8. Tips to try when the baby is in the mid pelvis but not effectively rotating and so despite contractions the labour doesnt progress

The head has engaged in this case but is sitting at an angle within the pelvis in an asymmetrical way and has not completed the rotation it needs to within the pelvis in order for labour to continue. This is usually because the baby has not been able to adopt a good position, more often than not it can be due to the head not being tucked in, but being deflexed instead.

Symptoms here are where the labour has stayed at more or less the same point for a long period of time and the woman is tired. The woman reports continuous pain even between the contractions. She may be advanced in terms of dilation up to of between 5cm and 8cm. There may be a premature urge to push. Options to help here include

  • The Fantastic Four especially the side lying release for three contractions
  • Open knee chest position
  • Shaking the apple tree with the open knee chest. This enables the baby to move out of the pelvis a tiny bit and then when the baby returns he or she may have improved flexion with the chin tucked in,
  • Lunges, and lifting one leg up high in a lunge using a bed or a chair or going sideways up and down the stairs

APPLE TREE

9. Tips to try when the baby is in the outlet

At this point the mother may be fully dilated and it may even be possible to see the head through the labia, but the baby’s progress may be impeded due to a high arch within the pelvis or other positional issues associated with the outlet., More than likely though progress could be impeded by the  mother being asked to push in a way that makes her uncomfortable. Symptoms can include the lack of an urge to push and a cervical lip, or a lot of pressure from the care giver to do coached pushing. Options to help here in addition to the Fantastic Four include:

  • Squatting on a ball and leaning backwards can enable a wider opening at the pelvic arch
  • Putting pressure on the sacrotuberal ligaments so that they can release, even to the point of manually assisting the release if you are confident (that wouldnt be me!)
  • Sitting on the toilet with a straight back and bringing the knees together rather than extending them wide out
  • Ensuring that the mother is not curling around the baby, but is sitting or lying on her left side with her back straight, this is especially true if the baby is OP, as the baby will have a straight back and needs the mother’s straight back to get out! If she is lying on her side she will need a straight back and could use a peanut ball.

OUTLET OUTLET 2 OUTLET 3

10. The importance of a tucked head in the baby

When the baby’s head is well tucked in then all the aspects of passing through the pelvis and putting appropriate pressure on the cervix can be achieved. Flexion is probably the most important aspect of  baby’s position. A LOA position promotes a good head tuck whereas an ROA may do the opposite. Practising the Fantastic Four in Pregnancy and using good sleep practices and safe movement practices during pregnancy will enable a baby to be more tucked in. This includes  exercises such as yoga, which naturally ensures that ligaments and muscles are well toned and the psoas is released from accumulated tension.

DISCLAIMER: These were things that I personally took from the workshop[. For guidelines and more information please either attend a Spinning Babies Workshop or consult the spinningbabies website

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coombe paula me and anne

Focus on caesarean section – International Day of the Midwife 2016

Top  10 things I learnt at the Essence of Midwifery Conference

It was great to be invited to several events over this week in support of all the wonderful midwives who work so hard to support women during their journey to pregnancy birth and beyond in Ireland. The big day was the Essence of Midwifery conference at The Coombe. As usual they put on a great show and there were some great speakers and posters with the focus being on caesarean section and choice within it.

Maternity Strategy 2016

coombe susan kent1. That the maternity strategy has been launched a 100 days and nothing has yet been implemented. With a government now voted in, when is the action going to start in ensuring that women have access to along side midwifery led units?  The overview of the Strategy was given by Deputy Chief Nurse and Midwife Susan Kent

Caesarean Section Rate

2. That the c section rate in the North of Ireland was 36% but investment in evidenced based research, support, care pathways, informing women of their choices and in trusting women was able to reduce it to 25%. (Dr Niamh McCabe and Margaret Rogan Consultant Midwife.) There are four main reasons for c section (1) compromised baby, (2) “failure to progress”, (3) breech presentation and (4) previous caesarean section. Niamh and Margaret highlighted this last issue and the lack of informed choice surrounding VBAC in Northern Ireland that was a major factor in maintaining the high caesarean rate.

Risks of Elective Repeat Caesareans

RISKS OF ERCS
Risks of Elective Repeat Caesarean section

3. .Women are rarely told the risks of Elective Repeat Caesarean Section (ERCS), instead the risks of VBAC are the primary focus of discussion. Niamh discussed some of the risks including placenta acretia and hysterectomy. Niamh pointed out that she hardly ever used to see placenta acretia when she started out in her practise and now she sees about one a month.

coombe signs of uterine rupture
Signs of uterine rupture in a VBAC

4. Women hoping for a VBAC are absolutely encouraged to use the water pool for labour and birth and also CTG as Niamh argued that it is almost impossible to have a uterine rupture without an abnormal CTG . However, if its a woman’s choice then she doesn’t have to have it and there are other signs that can be looked for. Niamh said that the rate of uterine rupture has increased over the years as more and more women are having c-births.

5. The increased risk of a fetal death with a VBAC is about the same risk as when you had the caesarean birth the first time round. The increased risk is perceived because in general  if you had a normal birth the first time round then the chances of your second baby dying is much less than your first.

MATERNAL DEATH RATE CS6. You are three times more likely to die with a ERCS than with a VBAC

7. The risk of a VBAC is about the same as of an IOL

Michel Odent

MICHEL ODENT8.Birth is a series of involuntary processes hindered by the interference of the neocortex

9. Melatonin and oxytocin work together to promote surges and birth. Light in the blue spectrum inhibits the production of melatonin. The most common spectrum used in delivery suite lights is blue spectrum. The light emanating from mobile phones is also in the blue end of the spectrum. Mobiles and apps are not good for connecting with your inner self and increasing oxytocin levels. Michel Odent.

Decision Making in Midwifery and Obstetrics

10. When we make decisions around pregnancy labour and birth we tend to believe that the more information we have the better decisions we will make, however what we need is sufficient information to reduce our uncertainty enough to make a decision.

Also decisions are often based on heuristic pattern recognition. Once we see a pattern it is difficult to erase it from our minds so even though what we are seeing is marginally different from the pattern we know, we will recognise it as the same. Situations that are similar to ones we recognise can fool us into making quick decisions based on faulty recognition. On the other hand we like using patterns to make decisions because it enables us to make decisions more quickly. Until we recognise a pattern we have to work things out from first principles, and that takes time which most HCPs dont have.   Prof Maskery.

Top 5 things I enjoyed

1. The company of being with midwives and womencoombe paula me and anne

2. The Japanese water blessing offered in honour of the daycoombe song

coombe studnet midwives13. The student midwife discourse “keep it going keep it going keep it going keep it going keep it going . . . keep it going keep it going” “Exactly how long is a breath?”

4.  The poster presentations. My favourite was the poster looking at caring for same sex couples

5. The food (lunch and the lovely dinner)

 

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