Dr. Rebecca Dekker –
Hi, everyone. On today’s podcast, we’re going to do a mini Q&A on peanut balls for labor, induction of labor for IVF pregnancies, and treatment for D-MER. Welcome to the Evidence Based Birth® Podcast. My name is Rebecca Dekker, and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence-based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details. Hi everyone, and welcome to today’s episode of the Evidence Based Birth® Podcast. My name is Dr. Rebecca Dekker, pronouns she/her, and I will be your teacher for today’s episode. Today, I’m so excited to answer some questions that we’ve been answering this past year inside the Ask the Research Team Forum for Evidence Based Birth® Pro Members. If you’ve ever wanted to personally ask me or one of the other researchers at EBB a question, you can always do so inside the EBB Pro membership, and you can learn more about that opportunity at ebbirth.com/membership. We have monthly, quarterly, and annual membership options available, as well as scholarships, and all of the proceeds go to support the free work that we publish here at Evidence Based Birth®. If you join as an EBB Pro Member, not only do you get our full library of PDF handouts and continuing education courses and certificates, but you also get access to live monthly trainings, a doula mentorship program, a midwifery brunch and learn, and of course, direct access to ask myself and the other researchers questions about the evidence. Today, I’ve chosen three questions from our EBB Pro Members to answer here on the podcast. So those three questions have to do with, number one, the evidence on peanut balls during the first stage of labor. Number two, whether induction at 39 weeks is medically necessary or evidence-based for parents who get pregnant through in vitro fertilization or IVF. And number three, risk factors and treatment for Dysphoric Milk Ejection Reflex, also known as D-MER.
Our first question comes from an EBB Pro Member who asked us, quote, I just recently had a provider I work with make a comment on the fact that research does not support using a peanut ball in early labor. I have tried looking myself. But most research articles talk about the first stage of labor and most agree it is helpful, but they don’t break down the first stage of labor into early labor and active labor. Do you know what the evidence says on using the peanut ball in labor? So this is a fantastic question. And our research fellow, Sara Ailshire, put together the answer for you all. So this person was asking about the research on labor in general and also early labor specifically. A lot of the research on the use of peanut balls focuses on their use when you’re laboring with an epidural and on birth outcomes in general.
So, the peanut ball is a peanut-shaped physio ball that helps facilitate different positions and can be especially helpful if you’re staying in bed and have more limited mobility due to an epidural in labor. Now, because this is the starting point for a lot of research on this topic, the impact of the peanut ball may have on birth outcomes when used in early labor, maybe before, say, someone has an epidural is not well documented. The one study that we were able to find that came closest to addressing this question about early labor and peanut balls was published by Hickey and Savage in 2019. They found that while using a peanut ball did not shorten the length of labor, they did find that when participants who used a peanut ball during the early or latent phase of labor, which they defined as being at or less than four centimeters dilation, were more likely to have a vaginal birth. And just a refresher for those of you who don’t know, early labor, sometimes called latent labor, is part of the first stage of labor, typically before you get to six centimeters dilation, although some researchers used to define it as before three to four centimeters dilation.
The one study we were able to find that came closest to answering your question was published by Hickey and Savage in 2019. These researchers found that while using a peanut ball did not shorten the overall length of labor, they did find that when participants who used a peanut ball during the early phase of labor, which they defined as being at or less than 4 centimeters dilation, were more likely to have a vaginal birth instead of a Cesarean. There are five other randomized controlled trials on the subject of peanut balls that were published in the last decade about the benefits of peanut balls in general, not just with early labor or the first stage of labor, so I wanted to go briefly over those as well. The first one was published by Tussey et al in 2015. This randomized controlled study looked at the use of the peanut ball among participants who had an epidural. Those who were assigned to have a peanut ball during labor did so after their epidural was administered. The main health outcomes that the study was looking at were the length of labor and the type of birth, whether it was a spontaneous vaginal birth or a Cesarean birth. The researchers defined the length of the first stage of labor from when the peanut ball would have been initially used, all the way to full effacement and dilation. And they defined the second stage of labor as from complete cervical dilation to birth. The researchers found that women who used the peanut ball had a first stage of labor that was on average 29 minutes shorter than the control group. And they had the second stage of the pushing phase of labor that was 11 minutes shorter than the control group.
The researchers also reported that the peanut ball was well received by participants who stated that they were satisfied with this non-invasive intervention. Then in 2016, Roth et al., published a randomized controlled trial, and they wanted to see if using a peanut ball during labor in women who were having an elective induction with an epidural decreased the length of the entire first stage of labor and if it decreased the pushing time. The people in the peanut ball group received the peanut ball 30 minutes after their epidural was placed, and their positions with the peanut ball were regularly rotated by nurses. The researchers found that only those who were giving birth for the first time saw any decrease in the length of the first stage of labor with the peanut ball. The use of the peanut ball did not decrease the length of the first stage of labor for those who had given birth before, and it did not decrease the length of pushing time in this study.
Then in 2018, Mercier and Kwan published a randomized controlled trial looking specifically at the use of the peanut ball in birthing people who were in the first stage of labor, specifically in the active phase of labor, which they defined as starting at 6 centimeters dilation. The peanut ball, for those who received it, the use was discontinued once they reached 10 centimeters when the participant was ready to start pushing. Now this study had some problems. They had people dropping out of the study. Some people whose labors progressed too quickly, so they couldn’t have the intervention that they were assigned to. And so this impacted the results in that they were not able to find… significant improvements in decreasing the time of labor, or decreasing rates of Cesarean birth. So this is not the highest quality study for us to turn to. And then we have two randomized trials published in 2024. One was published by Dieckmann, Goniak, and Etas. And in this randomized controlled trial, they wanted to evaluate the impact of using a peanut ball in labor on pain, fatigue, and the overall experience of labor. Like most of the studies, this was a small study. There were 45 women in the peanut ball group and 45 in the control group. They found that participants who used a peanut ball were less likely to report fatigue. And they reported less pain, and that the peanut ball was a positive influence on their experience of labor.
The researchers saw what might be a trend towards a shorter length of labor compared to the control group. But these results were not statistically significant, meaning that this finding could be due to chance. Or it could be due to the fact that the study was too small. And then in 2024, Duarte de Sena Fraga et al. Randomly assigned 100 women in active labor, so they were not in the early phase, they were past that early phase of labor. To have either a peanut ball or not. This is the first study I’ve seen where none of the participants had an epidural, so everybody was in spontaneous labor, nobody was being induced, and nobody had an epidural. The peanut ball was introduced to the intervention group during labor, and its use continued through the second stage of labor or the pushing phase. The researchers found higher satisfaction levels in the peanut ball group, as well as a shorter first stage of labor and shorter pushing phase. The total length of labor was shortened by an average of 89 minutes in the peanut ball group. They did not find any differences between groups in pain scores, fatigue, or any other health outcomes or birth outcomes. However, if this study had been larger, they might have seen some of the trends that they were seeing turn into significant outcomes. So the bottom line on peanut balls in labor, overall, the studies on this topic tend to be smaller, and we haven’t had a systematic review to combine data from randomized trials since 2019. What we do know from the evidence, though, is that peanut balls are easy to use, they’re non-invasive, and there’s some consistent evidence that they shorten the length of labor. Most importantly, people who have used a peanut ball in labor as well as care providers tend to view this intervention and their experiences with it favorably. I hope this helped answer some of your questions on the topic of peanut balls. It was fun to dive into the recent literature on this one. You also might want to check out our classic EBB podcast episode number 45, which is all about how to use peanut balls in labor.
Our next question comes from another EBB Pro Member and doula, who asks, is there any recent research on inducing at 39 weeks for IVF pregnancies? I’ve had several IVF moms in the last few months, and they’ve all been pressured to induce at 39 weeks based on the thought that if you needed help getting pregnant, you will need help getting labor started. So I was the one who wrote this answer to our Pro Member, and I wrote back that unfortunately, there hasn’t been much research done specifically on 39-week induction for pregnancies resulting from IVF. But just to verify, I did another literature search to check and see if anything new had come out since the last time I checked, and I found a few items of interest. First, the Society for Maternal-Fetal Medicine in the United States, called SMFM, came out with a new practice guideline for managing pregnancies that result from in vitro fertilization. Among their recommendations, they include this new one. Quote, in the absence of studies focused specifically on timing of delivery for pregnancies achieved with IVF, We recommend shared decision-making between patients and healthcare providers when considering induction of labor at 39 weeks of gestation, grade 1c evidence, end quote. Now, the grade 1C indicates to me that there’s probably not strong evidence on this subject. In fact, I’ve not been able to find any. So it’s not a requirement that you be induced, and it’s not even a strong recommendation from the SMFM. But you’ll probably see a lot of providers recommending 39-week induction.
A literature review was also published in 2021 on this subject. This is an opinion-based paper, and they did not include any statistics to report on outcomes from studies on this topic. Now, since maternal-fetal medicine specialists are the physicians who are commonly involved in caring for people with IVF pregnancies, and they tend to have more of a risk-avoidant perspective, I would not be surprised if you tend to see induction encouraged at 39 weeks in this population. But as I’ve said before, I’ve yet to see a randomized controlled trial on this subject. I also checked UpToDate, which is a membership platform where you can look at reviews of the evidence on different health topics, and I did not see anything in there. The articles that they have on management of pregnancy after IVF are mainly focused on reducing the risk of preterm birth rather than the risk of going past your due date or going post-term. So I’m sorry that this is really not all that helpful. Since we don’t have evidence on inducing labor for IVF pregnancies specifically, your next best evidence is probably the evidence on advanced maternal age. So there are a couple of resources at EBB that you can check out and learn more to help your clients or if you’re the one who’s pregnant, help yourself learn how to ask the right questions and advocate for what is important to you.
So first of all, you should know that we have an EBB signature article on advanced maternal age. You can access that for free at ebbirth.com/ama. And in this article, though we’re focused on pregnancies in which someone is 35 or older, we do talk about some of the evidence on in vitro fertilization, as AMA and IVF often walk hand in hand with each other. Also, don’t forget, if you’re an EBB Pro Member, you can send the printer-friendly version of the signature article to your clients from your PDF library inside the Academy. You can also refer people to our podcast and signature article on the ARRIVE trial and the evidence on elective induction at 39 weeks. We also have a free one-page handout on this subject at ebbirth.com/arrive. So that article dives more into elective inductions at 39 weeks and why you’re hearing so much lately about 39-week induction, even though the ARRIVE trial did not specifically study IVF pregnancies. A few more resources. For our Pro Members, we have a continuing education course on due dates and advanced maternal age, and that discusses the evidence on induction versus waiting for labor to start on its own, as well as the evidence on prenatal tests towards the end of a high-risk pregnancy, such as the non-stress test and the biophysical profile. Another EBB resource that anyone can purchase, not just Pro Members, is the EBB Pocket Guide to induction. It includes the evidence on all the different medical and non-medical induction strategies and a cheat sheet of questions to ask your doctor about any proposed induction that they’re recommending, as well as tips for an induction itself if you decide to go that route. So start with those resources and you’ll gain more information to help your client ask more questions about their actual risks and make the right decisions for their own circumstances. This is a very highly personalized subject and there’s not a lot of evidence to guide decision making. We know the struggle with this topic is real, people being pressured or told they should have inductions just because they got pregnant through IVF. Our team members at EBB who are doulas and have their own client load, they are helping their clients advocate for themselves with regard to this topic every single day. You’re not alone and your clients are lucky to have such a wonderful educator and supporter in you.
So this is a great and interesting topic. I’m so thankful that our members asked about it. And Morgan Richardson Cayama, our EBB Pro Research Fellow, helped compile some evidence to answer this question for you all. So D-MER stands for Dysphoric Milk Ejection Reflex. It’s sometimes called D-MER or D-M-E-R. D-MER is a condition that affects those who lactate, who are breastfeeding, chestfeeding, or pumping milk. It can cause a sudden and intense wave of negative emotions right before your milk is letting down. And that can happen the first time your milk lets down. And then it can also sometimes repeat throughout the feeding or throughout the pumping session. As your milk lets down again. Now, it’s quick and it just lasts 30 to 90 seconds. However, it can cause intense feelings of unhappiness. The medical term for that is dysphoria and other unpleasant emotions such as a pit in your stomach, a feeling of anxiety or doom, dread, anger, hopelessness, self-hate, a sinking feeling, agitation, irritability, or worthlessness. As the name suggests, this condition is a reflex. It’s not something that you can control. For some people, the symptoms may be mild, and for the others, the symptoms may be quite severe. It’s only recently that we’ve begun to have evidence to help educate people on this subject. Before that, people mainly shared anecdotes about what was happening to them.
So a study published in 2019 suggests that as many as 9% of people who lactate experience D-MER. Some sources that we came across in our search note that it is likely tied to hormones and potential drops in dopamine that occur when oxytocin is released to trigger milk ejection. However, not all researchers agree on this theory. We also don’t know why some people experience D-MER while others do not. A history of trauma has been speculated as a potential factor, but not all people who experience D-MER have this history. And it may be that some people are more sensitive to the hormonal shifts that are occurring while milk is letting down. At least one case study in the literature notes that symptoms of D-MER might decrease by three months postpartum, but for some birthing people, these symptoms may continue throughout their lactation journey. The website UpToDate, which I mentioned earlier, they compile and summarize research. They have a small section dedicated to D-MER, and the author of their page states that the condition can recur through subsequent pregnancies for some people. In terms of treatment, unfortunately, there are no recognized definitive treatments for D-MER. However, there have been some case studies published about individual clients or parents where few different strategies have shown promise.
Overall, eating and drinking while nursing has been found to be beneficial unless one of the D-MER symptoms that you’re experiencing is related to nausea or vomiting. Specifically, adding protein to your diet and maintaining your blood sugar levels might help. Mental health support has also been recommended along with mindfulness approaches and tracking the experience, perhaps journaling or tracking your symptoms and the length of time that the negative feelings are occurring during a feeding. You can also experiment with positioning and latching positions while feeding along with skin-to-skin contact between you and your baby to stimulate more oxytocin production. That might release some more endorphins to help counteract that sinking feeling or wave of negative emotions. Also, you can be aware that there are some factors that can worsen symptoms of D-MER, such as tiredness and lack of sleep, stress, and caffeine intake. A couple of resources that you might find helpful and that you can pass on to your clients. There is a website all about D-MER that is meant for the public and has a lot of helpful information and firsthand accounts. And that URL is d-mer.org. We also found an open access article published in 2018 by Dr. Kerstin Uvnas-Moberg and Dr. Kathleen Kendall-Tackett. And this article is really helpful. The title of the article is The Mystery of D-MER. What can hormonal research tell us about Dysphoric Milk Ejection Reflex? And I’ll link to that in the show notes. I’m so glad our Pro Member asked this question. It was really thought-provoking. For myself, this is Rebecca, my info, I personally experienced D-MER with all three of my children when I nursed them, and I remember vividly how horrible it felt. And in the beginning, it always made me wonder what was wrong with me and why was I having this sinking feeling of hopelessness that would kind of wave through my body and then dissipate. Just finding out later on that this is a true condition that it has a hormonal cause, and that I wasn’t alone, was really helpful for me because then I knew I wasn’t imagining it and that the feeling would go away each time. I hope this information about D-MER is helpful for anyone out there listening who has experienced this before too.
So that wraps up our mini Q&A all about peanut balls, induction for IVF, and D-MER. We’ll make sure to link to all of the scientific references on the blog page that goes along with this podcast. Thanks for listening. And remember, if you have a question about the research on childbirth, remember that our research team at EBB is available to answer questions inside the EBB Pro membership. Looking ahead to next week, we have a fantastic birth story for you coming up on the EBB podcast. And in the course of sharing that birth story, we’re going to talk about what to do if your OB says, I don’t know how to support upright birth. So thanks again for listening and I’ll see you next week.
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