{Ottawa Doula} Research to Action

I sat in on an  interesting presentation at work today about "knowledge translation" - a very basic term describing how research actually gets translated into practice.

She used a great story to kick-off the talk:

In 1497, a ship sailing with 160 sailors discovered that supplementing the men with lemon juice may have helped to ward off/cure scurvy. Guess how long it took for the British government to formally implement the citrus remedy onto every ship setting sail from the country?

368 years.


So for 368 years, more and more researchers discovered (and conducted trials) to assess the applicability of citrus juice in preventing or treating scurvy. But it took until 1865 for the "head honchos" to do anything with the life-saving information. Soon, all ships sailing from Britain used citrus fruits to ward of the impact of scurvy.


Luckily for us modern folks, the gap between research and practice has now shrunk to 17 years. Yikes - still doesn't seem that great, does it?

Let's take a birth-related example. Research for the past several years has shown that delayed cord clamping can have significant benefits for the newborn. However, most hospitals, unless you insist (and you have to be quick - they'll go "snip, snip" before you know it!) will cut the cord immediately after birth.

So why the gap? There are 2 main reasons:

• Researchers don't do enough to pass their findings on to health care practitioners - instead, they focus on publication, which they are bound to do by the institutions they work for ("publish or die" is pretty much the mantra in the research world)
• Doctors don't have time to read hundreds of studies published in medical journals

We're all working on solutions to the problem, mainly by attempting to be better at translating knowledge - by working directly with patients, health care professionals, and other interest groups.

But in the meantime, what's a poor pregnant mama to do? Maybe you've heard of something that could be beneficial to yourself or your baby, but it's not common practice at your institution. Here are some tips for putting your own research into action:

1) Stay really well informed. Avoid wasting time with websites like Baby Centre or books like What to Expect When You're Expecting. These are not sources of good quality evidence. Instead, check out these websites:

MotherRisk

Health Evidence

Cochrane Library

2) If you read something you want to know more about, print off a copy and bring it to your next prenatal appointment. Doctors are time-strapped, but they do appreciate (generally) patients who are well informed.

3) Compromise. Try to come to some agreement with your healthcare practitioner. It's never helpful to become angry, and most doctor's don't respond well to "unruly" patients. Remember that they're working within an institution, which comes along with many rules and regulations - sometimes they want to help, but their hands are tied.

4) Accept when something may not be possible. Despite all of your efforts to convince your doctor that a certain procedure is beneficial, they may be bound by hospital policy.

5) Know your rights. You do have rights as a patient!

6) If you can't change it, go somewhere else! If it's not too late, try to find a practitioner who is more willing to address your needs.

{Ottawa Doula} Swimming Upstream: Vaginal Birth after Two Cesareans

I have been immersed in a dilemma lately - not my own personal dilemma, but one of my client's.

This woman would like to attempt a vaginal birth after two cesareans. We hear A LOT of information out there about VBAC (pronounced v-back) after one cesarean, and most doctors and midwives would agree that it is a safer choice than scheduling a repeat cesarean (as long as you meet the "qualifications" - no ongoing medical problem where another c-section would make sense, and a low, transverse incision).

The American Congress of Obstetricians and Gynecologists (who issued the report I linked to above) also agree that a Trial of Labour (TOL) for a woman with two or more cesareans is a viable option. The risks of uterine rupture are higher, but variable. Studies differ in their methods and conclusions, and "risk" is communicated to patients in different ways.

For example, read this statement, as stated by my client's doctors (the numbers are not accurate here - this is just to illustrate how they have portrayed risk):

Your risk of uterine rupture triples after 2 cesarean sections. In all the cases of uterine rupture I've seen, the baby has ended up with cerebral palsy.

Now, read these statements, as a properly conducted study may present them:

Women who attempt TOL after 2 cesarean sections have a 1.9% risk of uterine rupture. Of these, only 0.06% experience a complete rupture (where the baby actually enters the abdominal cavity).  

1 in 6000 women who attempt TOL after multiple cesareans experience uterine rupture. 


The first one sounds a lot worse, doesn't it? If you're trying to scare a woman into scheduling a c-section, the first statement packs a lot more oomph.

OBs who have personally witnessed a uterine rupture are much more likely to inflate the risks, because their perception of risk has changed. It's no longer a magic number (eg. 0.5% of women who attempt a TOL after one cesarean section risk a uterine rupture), and instead the one case they've seen colours the way in which they treat all future patients.

To make matters worse, there are no doctors here in Ottawa (at least none I have come across) who support a woman desiring a TOL after multiple cesareans. My client has been continually hassled about her decision, and with each prenatal appointment she attends, a new resident provides more scary stories. No one seems to talk about the risks associated with another cesarean section, which I find interesting.

When you want to do something that goes against the grain, and no one in your community is willing to support you, what should you do?

1) Remember that as a patient, you have rights. You have the right to refuse interventions and treatments offered. You have the right to informed consent.

2) Become armed with research. Doctors are busy people, and often don't have time to stay abreast of new research. Do your own looking around, and begin compiling all the papers that support your decision (start with the new ACOG guidelines, which support your decision to try for a VBA2C). Bring them with you to every prenatal appt., as you'll often be seeing many different doctors and residents.

3) Yes, the health of you and your baby is important. But so is your experience, and oftentimes, doctors will play the "healthy mommy, healthy baby" card, in order to dissuade you from your desire for a positive birth experience. Seek the help of a professional (social work, counsellor, or doula) who can look at the benefits/risks objectively with you, and help you come to the right decision.

4) Did I say that health was important? You betcha! If you're desiring a VBAC (or VBA2C), you best be sure that you're eating really well (see a nutritionist or naturopath for help), exercising every day (gentle exercise such as walking, swimming or yoga) and reducing stress (do some yoga and you'll check two things off your list!). Many women also seek treatment from alternative health practitioners, such as acupuncturists, homeopaths and chiropractors.

5) Read the positive stories. There are women all over the world who have tried and successfully had a VBA2C (I've even read of a VBA4C!!)

Bottom line: if you're taking the plunge, first make sure you know how to swim. Oh...and a little faith goes a long way. Faith in yourself, your body, and your ability to do something that others think is impossible.

Share your story below of something you have accomplished when others tried to tell you it was impossible.