Archive for July, 2009

When Your Water Breaks Before Labor Begins

Posted on July 22, 2009. Filed under: Birth, PROM | Tags: , , , |

*I think that the most interesting part of this post is the comment section. Be sure to read them all but especially the two stories that are told. One is from a couple whose water broke and they waited and the other is a woman who didn’t wait very long. I find it interesting how these stories developed and how they read side by side so be sure to read all the way down. And please continue to share, we all learn so much from each other.

When Your Water Breaks Before Labor Begins

It is NOT an emergency!!! It does not mean the baby is about to slide out onto the floor in the middle of Target or that you have to call an ambulance so you can get to the hospital ASAP. This is Hollywood and cultural fear of birth and you are actually putting yourself at higher risk for infection by running straight to the hospital.

When the water breaks before the onset of labor this is called premature rupture of membranes (PROM). PROM occurs in 8-10% of term (37 weeks+) pregnancies. Of those, 90% will begin labor within 48 hours.  Unless you or your baby is in some kind of danger or you are showing signs of infection, there is no reason to speed up this process.  Many mainstream pregnancy books and most OB’s  will tell you to go straight to the hospital and what we see in movies confirms that but you actually increase your risk of infection by doing that because the first thing that happens when you arrive is usually a vaginal exam. Interestingly enough, the recommendations are to avoid digital (finger) vaginal exams but anyone who has had a hospital birth knows that this is the first thing that happens  upon admission.

Vaginal exams push bacteria up past the cervix. Fluids in the vagina flow downstream and the only way they will back track is if they are pushed back. In a hospital setting it is not uncommon to have a vaginal check hourly or even more frequently and by several different people. Every time a vaginal exam is performed the infection risk is increased.  It simply is not a beneficial procedure contrary to popular belief in our society. Even with clean hands and sterile gloves, bacteria on the external of the vagina are introduced internally. This is especially an issue for GBS+ women.  When it really comes down to it, vaginal exams tell us nothing because dilation and effacement of the cervix really are not a good indicator of when a baby will be born. I had a client who has two centimeters and 50% effaced the morning of  40 weeks and 5 days. She was not in labor that morning.  She had her baby that night. Labor can progress quickly and examining the cervix is a rough estimate at best.

Another problem with going straight to the hospital when the water breaks is that hospital policy often puts time limits on the labor. Because of the increased risk of infection due to multiple vaginal exams, many hospitals will either being speeding up labor  immediately with pitocin. Some hospitals will give the mom 12 hours for labor to spontaneously begin and a few will give the mom 24 hours.  Some doctors even begin the c section scare tactics immediately. The problem with this is that creates performance pressure and if the mom is unable  to relax, often times labor will not begin or it will stall.  Once these interventions begin, the risk of infection increases and the risk of c section increases dramatically.

There is also the myth of ‘dry birth’ that is simply  not true because the body continues to make amniotic fluid which in turn will continue to leak but by no means leaves the amniotic sac and baby dry.  Because of this ‘dry birth’ myth, women are often times told that they must lay in bed and not move around so that fluid doesn’t continue to leak out. This is counterproductive as gravity is necessary to help the baby rotate and move into the pelvis and movement helps facilitate labor.

So, what do you do if your water breaks and you are not having contractions? First, check the color. If it is clear it is normal. If it is yellowish to dark brown or green, it could be meconium and you may want to call your care provider. Otherwise,  wait.  Like I said previously, 90% will begin labor in 48 hours.  Don’t put anything into the vagina, don’t check your own cervix, don’t have sex. Try to stimulate labor. There are many things you can do to help the process along. Take a walk. Cuddle with your partner as getting touchy feely releases oxytocin, the hormone responsible for causing contractions. This is also the reason that nipple stimulation works. Nipple stimulation triggers oxytocin.Also, the use of acupressure can trigger labor. There are two pressure points on the body that help stimulate contractions.

This provides pain relief as well as uterine stimulation

This provides uterine stimulation
When using pressure points, search for the area indicated in the pictures. They will feel like a bruise when pressed. Apply steady pressure to these areas for 30 second to a minute. Alternate between the pressure points. Pay attention as these pressure points can actually hyperstimulate the uterus.
Here is a video that helps clarify how to to use acupressure for labor induction but also comfort techniques for late stage pregnancy…
Lastly, while waiting, relax. Take a warm bath, it is ok to do even if the water has broken. Get a massage. The ability to relax can help labor to begin naturally. If you are worried about infection, monitor yourself. Take your temperature and watch for foul smelling discharge from the vagina.

There have been studies done on PROM and infection risk and Henci Goer, author of  The Thinking Woman’s Guide to a Better Birth, has written an article that discusses these studies and the flaws involved. I am including this study below:


When Research is Flawed:
Should Labor Be Induced Immediately
with Term Prelabor Rupture of Membranes?

by Henci Goer

Commentary on: Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TermPROM study group. N Engl J Med, 334(16), 1005-1010. [Abstract]

Study design and results: multicenter, multinational randomized controlled trial in developed countries of 5041 women with confirmed PROM at ≥ 37 completed weeks of gestation. Women were not in active labor, had a singleton fetus in cephalic presentation, and had no contraindication to trial participation.

Investigators randomly allocated trial participants to one of four groups: (1) immediate induction with oxytocin, (2) expectant management for 4 days before oxytocin induction or until an indication for induction developed, (3) immediate induction with prostaglandin E2 (PGE2) followed by oxytocin if necessary, or (4) expectant management for 4 days before PGE2 induction or until an indication for induction developed.

  • Selected background information [Note: These represent ranges in rates reported among the 4 study groups. No significant differences across groups were detected for any of the following:]
    • vaginal exam at trial admission: 35-39% digital, 64-67% speculum
    • number of digital vaginal exams: 49-63% had ≥ 4
    • Group B strep (GBS) status: 9-12% tested positive for GBS
    • median time to active labor in expectant groups: 16-17 h
  • Selected maternal outcomes:
    • cesarean rate: rates ranged among the 4 groups from 10-11% overall, 14-15% nulliparous women, 4-5% multiparous women
    • any sign of chorioamnionitis:
      • 4.0% induction/oxytocin vs. 8.6 % expectant/oxytocin, p < 0.001 [Absolute difference: 4.6%. Absolute difference for diagnosis based on criteria other than intrapartum fever (fever before labor, elevated white blood cell count, or foul-smelling amniotic fluid): 2.3%.]
      • 6.2% induction/prostaglandin vs. 7.8% expectant/prostaglandin. Difference did not achieve statistical significance, meaning it was likely to be due to chance.
  • Neonatal outcomes:
    • neonatal infection: rates ranged from 2-3% and were not significantly different across the 4 groups
    • stay in neonatal intensive care unit > 24 h:
      • 7% induction/oxytocin vs. 12% expectant/oxytocin, p < 0.001.
      • 9% induction/prostaglandin vs. 10% expectant/prostaglandin. Difference did not achieve statistical significance
    • antibiotics:
      • 8% induction/oxytocin vs. 14% expectant/oxytocin, p < 0.001.
      • 11% induction/prostaglandin vs. 12% expectant/prostaglandin, p = 0.003.
    • All other neonatal outcomes were similar, including, fetal distress, meconium-stained amniotic fluid, Apgar score < 7 at 1 or 5 min, cord blood pH < 7.1, need for oxygen resuscitation, jitteriness or irritability, seizures, hypotonia, abnormal level of consciousness, apnea, abnormal feeding at 48 h or more, and ventilation after resuscitation.

Problems include but are not limited to the following:

  • Failure to consider the effect of epidural analgesia on intrapartum fever confounds chorioamnionitis results. Most diagnoses of chorioamnionitis were made on the basis of intrapartum fever. At the time of the trial, the association between epidural analgesia and intrapartum fever was not widely known, and no adjustment was made for this factor. Had this been done, an excess probably would remain in the expectant group, but infection rates might have been lower in all groups.
  • Women who were colonized with GBS were not treated in labor. A secondary analysis looked at the effect of GBS status, based on vaginal swabs obtained at trial entry, on outcomes (Hannah, 1997). Calculations using that study’s data reveal that one-third of neonatal infections were in women testing positive for GBS. GBS also caused one of the four deaths in the expectant group in babies without lethal anomalies. Current standard practice—screening for GBS at the end of pregnancy and providing antibiotics in labor to those who are colonized—would have reduced, and might have eliminated neonatal infections in GBS + women, thus reducing infection rates overall, and it might have prevented the death. It is also possible that GBS status would not have been a factor or would have been less of a factor in neonatal infections were it not for women having vaginal exams at trial entry and multiple exams before delivery. (See next bullet points.)
  • Chorioamnionitis rates and possibly neonatal infection rates were confounded by multiple digital vaginal exams. Leaving aside epidural analgesia as a confounding factor in diagnosing chorioamnionitis, yet another secondary analysis reported that chorioamnionitis increased steadily with number of digital vaginal exams independent of other factors (Seaward, 1997). Compared with less than three, the odds ratio climbed from a 2-fold increase for 3 to 4 exams to a 5-fold increase with more than 8. Seaward (1998) reported in their evaluation of risk factors for neonatal infection that chorioamnionitis had the strongest independent association. The rate among infants of women with chorioamnionitis was 16%, a six-fold increase over those not experiencing chorioamnionitis.
  • Neonatal infection rates were confounded by vaginal exams at trial entry. A secondary analysis of trial data found that having a vaginal exam at trial entry increased the risk of neonatal infection by 250%, even after taking into account GBS status (Hannah, 1997). This difference is likely to be greater than appears because the analysis authors chose to combine digital and speculum exams, although only digital exams are believed to increase the risk of infection.
  • Neonatal infection rates were confounded by multiple digital vaginal exams during labor. According to another secondary analysis, the percentage of infections trended upward with the number of vaginal exams independent of other factors, including time from rupture of membranes to labor onset and length of active labor (Seaward, 1998). It rose from 2% in women with 3 to 4 exams to 5% in women with more than 8. The odds roughly doubled compared with women having fewer than 3 vaginal exams, although the difference only achieved statistical significance when 7 to 8 exams were compared with fewer than 3.

Comment: Based solely on the TermPROM trial, the American College of Obstetricians and Gynecologists (ACOG) recommends immediate induction, generally with oxytocin, for women with term PROM on the grounds that inducing labor will reduce chorioamnionitis, febrile morbidity, and neonatal antibiotic treatments without increasing cesarean rates (ACOG, 2007). The primary argument for immediate induction has always been reducing neonatal infections, which ACOG acknowledges it does not do, and, as can be seen in this deconstruction, with optimal care other benefits are likely to be smaller than currently appear.

By contrast, a Cochrane systematic review published in 2006 also evaluates term PROM management (Dare, 2006). Despite being heavily dependent on the TermPROM trial—three-quarters of the 6800 participants among the 12 trials in total come from the TermPROM trial—the reviewers reach a more tempered conclusion: “Since differences in outcomes between planned and expectant management may not be substantial, women need to be able to access the appropriate information to make an informed choice (p. 12).”

In summary, in the absence of signs of infection, expectant management remains a viable option. Nonetheless, the secondary analyses have given us a more nuanced picture. While the original trial report found no difference in neonatal infection rates between immediate induction and expectant management overall, the secondary analyses make clear that length of time between rupture and delivery matters. They also found that modifiable factors affected infection rates, which means we do not know what they would have been with optimal care.

For those choosing expectant management, the question arises of how long to wait before inducing labor if one prefers to set a limit. Consider the following: Seaward (1998) reported that time from membrane rupture to labor onset of 24-48 hours versus less than 12 hours was an independent predictor of neonatal infection. Infection rates with 24 hours or more to onset of labor were 4% versus the background 2% rate. Hannah (1996) reported that the median time to active labor, not labor onset, after membrane rupture was 16-17 hours. It therefore seems reasonable to wait about 18 hours before inducing labor. Half the group of women will have achieved active labor by this time, and, if induced, the remaining half are likely to have started labor by the 24-hour cut point.

Women with PROM at term who are GBS + constitute a special subset. The Centers for Disease Control (2002) guidelines for management of GBS + women say nothing about inducing women with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated. And given that it takes time to instill the recommended dose of antibiotics, common sense dictates that women who prefer not to wait for labor should delay induction until they have an adequate dose of antibiotics on board.

In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital vaginal exams until established in labor, and their use should be minimized during labor. Data also suggest that oxytocin is the induction agent of choice. It appears to reduce infection rates compared with PGE2 without any offsetting disadvantages.

References:

ACOG. (2007). Premature rupture of membranes. Practice Bulletin No. 80.
Centers for Disease Control and Prevention. (2002) Prevention of perinatal group B streptococcal disease. MMWR;51(No.RR-11).

Dare, M. R., Middleton, P., Crowther, C. A., Flenady, V. J., & Varatharaju, B. (2006). Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database Syst Rev(1), CD005302.

Hannah, M. E., Ohlsson, A., Farine, D., Hewson, S. A., Hodnett, E. D., Myhr, T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TermPROM study group. N Engl J Med, 334(16), 1005-1010.

Hannah, M. E., Ohlsson, A., Wang, E. E., Matlow, A., Foster, G. A., Willan, A. R., et al. (1997). Maternal colonization with group b streptococcus and prelabor rupture of membranes at term: The role of induction of labor. TermPROM study group. Am J Obstet Gynecol, 177(4), 780-785.

Seaward, P. G., Hannah, M. E., Myhr, T. L., Farine, D., Ohlsson, A., Wang, E. E., et al. (1997). International multicentre term prelabor rupture of membranes study: Evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. Am J Obstet Gynecol, 177(5), 1024-1029.

Seaward, P. G., Hannah, M. E., Myhr, T. L., Farine, D., Ohlsson, A., Wang, E. E., et al. (1998). International multicenter term prom study: Evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature rupture of the membranes. Am J Obstet Gynecol, 179(3 Pt 1), 635-639.

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Getting Upright in Labor: InJoy and Lamaze Push Vertical Pushing

Posted on July 17, 2009. Filed under: Birth | Tags: , , , , , |

I am doing a series on the Lamaze Six Care Practices that Support Normal Birth. Here are Part 1, Part 2 and Part 3. In Part 4 I will be discussing the 5th Care Practice, which is Spontaneous Pushing in Upright or Gravity-Neutral Positions. In the mean time, below is a link to a very informative article and video on vertical pushing.

Great article and video on vertical pushing HERE.

Most women in hospitals do end up pushing on their backs. The Army hospital in Seoul, always wants the mom on her back and does not encourage any other position, in my experience. I have seen nurses lean the back of the bed back so that  mom is closer to flat on her back saying ‘let’s help baby out.’ The hospital here does have a squat bar but last time my client wanted it the nurse said she had to go find it and never did. After the birth she told my client that ‘oops, it was in the bathroom the whole time.’ You may have to insist on not pushing on your back. You may have to demand that the nurse find the bar but it should be your voice that the staff hears. A doula can help you by asking and reminding but ultimately the mom needs to be heard when she is in an ‘on your back’ environment.

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Brewer’s Pregnancy Diet for Overweight Mothers

Posted on July 15, 2009. Filed under: Pre eclampsia, Pregnancy, Pregnancy Brewer Diet | Tags: , , , , , |

Overweight mothers often times are told to restrict their calories and to only gain a small amount of weight or even none at all. I have read so many stories of care providers giving over weight moms a really hard time. The Well Rounded Mama talks about this here and shares stories from other women.  The scare tactics used against overweight moms range from ‘you will have a large baby and have a stroke while trying to push it out’ to ‘you will develop blood clots’ to ‘you will not be able to sustain a pregnancy.’ It’s really a shame and instead of berating these mothers for being overweight, it would be so nice if mainstream medical care would help them to be healthier and have the healthiest pregnancies possible by focusing on exercise and proper nutrition throughout pregnancy rather than numbers on a scale. Like I have said before, contrary to popular belief, you can not grow a baby with the extra fat on your hips!

In thinking about this topic, I decided to ask Joy Jones what her thoughts were. Joy is an RN and has been working with pregnant women and the Brewer’s Diet for more than thirty years.  She has  so much knowledge and insight on this that I asked her if I could repost our emails to each other here on my blog. THIS is the information women need. This is what they need to see when they are googling “pregnancy and obesity” and “weight gain recommendation for overweight moms” and ” diet for overweight pregnancy.” So here goes…

Hi Joy, 

I wanted to ask what your experience is with Brewer's and the overweight mother.
I would like to be able to advise an overweight client as I am not sure how she will
be treated by the doctors and what kind of dietary guidance and weight restrictions they will give her.
She walks daily and hired a personal trainer a few months ago and she said that as long she walks
regularly, her borderline high bp stays in the normal range. 

What are your thoughts?

Thanks,

Amy
Dear Amy,

Dr. Brewer's most basic response to this kind of question was......

1)  The kind of food eaten during pregnancy is more important than the number of pounds 
gained—both weekly and overall.

http://home.mindspring.com/~djsnjones/id11.html

2)  Each pregnancy grows a new placenta which needs an expanded blood volume in order to 
function  properly.All pregnancies have this need, regardless of the mother's beginning 
weight.

3)  In order to service the placenta adequately, the mother's blood volume needs to increase
 by 60% by the end of the second trimester, and then it needs to be maintained at that level
for the rest of the pregnancy.

4)  In order for that blood volume to expand by that much by the 24th week, and stay expanded
throughout the third trimester, the mother needs to eat according to a plan that includes a 
certain level of calories PLUS salt PLUS protein (it's not just about protein, and without 
all three components,this plan is not likely to work as it's designed to do).

5)  The mother's body can expand the blood volume only from the food that she eats.  It 
CANNOT create what she needs for expanding the blood volume, or for creating baby cells, or for creating 
new uterine  cells, by breaking down her extra body fat.

6)  There are many different reasons for a woman to become overweight.  But if part of the 
reason for a specific individual woman to be overweight includes too many carbohydrates or 
fats and too little exercise, then she may actually lose weight on the Brewer Diet, simply 
because she is changing her lifestyle to a more healthy way of eating.  But weight loss should
not be her goal, only a consequence of eating in a better way.

7)  If a mother adds extra exercise to her lifestyle, she needs to be careful to add enough 
calories to the Basic Plan of the Brewer Diet to compensate for that extra exercise.  
Otherwise, she may be at risk of burning up some of her precious protein intake for energy, 
thus risking having her blood volume drop and triggering the pre-eclampsia process.

http://home.mindspring.com/~djsnjones/id95.html

8)  A healthy eating style for a healthy pregnancy needs to also include a good level of 
healthy kinds of fats and a good level of healthy kinds of carbohydrates.  The Basic Plan 
of the Brewer Diet includes both of those food groups, and you can see how many servings 
of each (and examples of good  sources) at this page...

http://home.mindspring.com/~djsnjones/id96.html

If you haven't done it already, I also suggest that you check out the "Obesity" page on my 
website....

http://home.mindspring.com/~djsnjones/id69.html

PART II

Dear Amy,

I was answering in a hurry earlier because I was thinking that the laptop was going to walk 
off again  with my husband,but he is using something else today, so I can add a few things 
to my previous response.

"I wanted to ask what your experience is with Brewer's and the overweight mother."

I don't remember any specific overweight mothers from my experience, although I am sure that 
there  were some, since I've been working with pregnant mothers for almost 32 yrs, and probably 
about 500-700 mothers.  Whenever I worked with natural-oriented midwives, we tried to focus 
more on what the mother was eating between prenatal visits, more than on the number of pounds 
she was gaining during those times.  The mothers who stand out in my mind are the one who was 
apparently eating so  poorly that when I showed up to help with the birth, her bones were 
sticking out of her body, like those on an anorexic woman (I was not included in the teaching 
or monitoring of her diet during  the prenatal care)....or the mother who ate little more 
than cocoa puffs, no matter how hard we tried,  and ended up with PUPP syndrome and nursing 
problems.....or the 2-3 mothers who had 10 lb babies with no problems pushing them out 
(and the one who had to work harder at it)....or the mothers who got advised to cut back on 
salt or calories or to exercise a little extra and ended up with elevated BPs and 
pre-eclampsia symptoms and hospitalization and premature births as a result.....or 
the mothers  who were able to hold back their creeping BPs with hourly doses of protein and 
calories and sodium....and the mother who weaned her baby at 4 weeks so that she could go 
on a cruise with her extended family (leaving the baby at home)....and the ESL mother who
insisted on bottle-feeding her baby for the first 3 days because colostrom is obviously not
breast milk or adequate for feeding a baby. I also remember a few pregnant women who had lost 
a lot of weight before the pregnancy, who had to stand with their backs to the number display
on the scales, at every prenatal visit, so that they could eat well and not be anxious about 
the number of pounds that they were gaining. For those women  we also had to put many notes 
on the outside and inside of their charts to caution all the people caring for them to NOT 
tell them what their weight gain was.

I don't consider age or being slightly overweight or having recently lost a lot of weight 
as being risk factors on their own.  I think that the groups of women with those factors 
in their lives may have higher rates of pre-eclampsia (and the other complications associated
with low blood volume),simply because when those women go to mainstream care-givers they are 
labeled "high risk" and put on inadequate diets, which then creates the very complications 
which they are trying to prevent.

In addition,  on the subject of age, depending on lifestyle, you might have a 40 yr old woman 
who  is healthier than a 25 yr old--aside from the issue of increased difficulty in conceiving.

"I want to advise her as I am not sure how she will be treated by the doctors and what kind 
of dietary  guidance they will give her."

I can almost guarantee you that most doctors will treat her as "high risk" and try to control 
her  pregnancy and birth to pieces.  I think that the only way that she will have a chance 
at a normal  pregnancy and birth is to go to a very good midwife.  Homebirth would be her 
best bet.  But if she  is not comfortable with that option, she should not even 
attempt it, because if she does not believe  in her gut that homebirth is her safest option, 
she will most likely just get transported to a hospital  mid-labor, for lack of progress.  
Her cervix simply will not open if she is not laboring and giving birth in a place that feels 
safe to her, and with care-givers who feel safe to her.  Her next best  option would be a 
birth with a midwife in a free-standing birth center.  Her next best option would
be a hospital birth with a midwife--preferably a non-mainstream type of midwife (many midwives
are just  as medically-minded as OBs are, or almost as much).

For that last category, she should look for midwives who do not share an office with their 
back-up  doctors, but work in a practice which is independent from that of their back-up 
doctors.  She can  also interview midwives and see which ones insist on all the tests 
possible, and which ones make at least some of the various prenatal tests optional 
(the latter being the more natural-birth oriented  ones, in my opinion).She can also check 
various homebirth websites for suggested lists of questions  to ask midwives to see if they
are the kind of midwife that is more natural-birth oriented. She can also use the questions 
that I have listed on my first "Registry" page....

http://home.mindspring.com/~djsnjones/id97.html

I also suggest that she go to her local public library and check out "The Pregnancy After 30
Workbook",  by Gail Brewer (or she can get it through inter-library loan, through her local 
public library, if they don't have it).  The following is Dr. Brewer's chapter in that book....

http://home.mindspring.com/~djsnjones/id72.html

At the very least, I suggest that she hire a very, very good, very experienced, very well 
certified doula (and preferably one who has extensive experience in both home and birth center 
and hospital births), from the FIRST DAY that she knows that she is pregnant.  This doula 
can help her work her  way through finding out what are the best options for prenatal care 
in her area, help her to choose a more natural-birth oriented care-giver who also fits her 
unique comfort level and needs, and help  her through every step of the way as her 
care-giver offers (or insists on) various tests, procedures,  or life-style changes, helping 
her to see how much broader her choice of options is than her care-giver  might be giving her. 
A doula might charge a little more for this all-pregnancy kind of care than she  would for 
third-trimester/labor kind of care, but I suspect that she will be able to find a doula
willing to do this, especially if she explains why she needs this kind of help, and that she 
might be  willing to pay a little more for this kind of care.

She might also be interested in the article about how a woman with pre-existing hypertension 
was able to go off of her anti-hypertension drugs when she got pregnant, just by adding more 
salt to her diet....

http://home.mindspring.com/~djsnjones/id70.html

She might also be interested in the recent study which cautions women against doing too much 
exercise  when they are pregnant because it can increase their risk of developing pre-eclampsia – 
which I think underlines the Brewer caution to be very sure to add enough calories and salt to
the diet  when a pregnant woman has extra exercise in their lives (exercise of daily living 
as well as recreational exercise).  You can scroll down to the bottom of the page to where 
the paragraph in red lettering is.  I don't remember precisely, but I think that this study 
suggests that more than 15-20 min of moderate recreational exercise a day is too much for a
pregnant woman.

http://home.mindspring.com/~djsnjones/id95.html

Again, I hope that this helps.

Best wishes,
Joy
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The Six Care Practices that Support Normal Birth (Part Three)

Posted on July 12, 2009. Filed under: Birth, Cesarean, Epidural, Lamaze 6 care practices, pitocin | Tags: , , , , |

In Part One and Part Two of this segment, I discussed why I believe in the six care practices and the first three of the care practices which include: labor begins on its own , freedom of movement throughout labor and continuous labor support. The six care practices that support normal birth are based on research and evidence based maternity care. This is the healthiest and safest way to have a baby in most cases. In a normal healthy pregnancy most women can and should deliver their babies vaginally and with few interventions. All this medicalization of labor and delivery is not only not necessary, it’s also causes problems.

The fourth care practice is no routine interventions.

No Routine Intervention

Routine interventions are anything that is done or not allowed at hospital that isn’t medically necessary. Evidence based maternity care through research has shown that these interventions are not only not necessary but can cause more harm than good when used routinely. Here is a list of the most common routine interventions.

Restriction on eating and drinking: Back in the day when women were knocked out with general anesthesia food and drink were not allowed in case the woman vomited and inhaled it. Rarely is general ever used any more but it’s still the policy at most hospitals. Women need food and drink to keep their bodies fueled and hydrated for the hard work of labor.

Use of IV fluids: Because of the restriction on drink, the IV fluids are given to keep the mom from getting dehydrated.  IV fluids are just not properly balanced in a way that gives the mom the energy she needs to labor. The intervention spiral tends to begin with the IV and it’s easy access to the vein and it also keeps you tethered and restricts movement.  The IV line does provide quick access to the vein in case of an emergency. One compromise is a heparin lock. It’s the little catheter that put in the vein and shut off without the IV line actually being connected.

Continuous electronic fetal monitoring:  In a normal low risk labor continuous EFM isn’t recommended. Intermittent monitoring, or 20 minutes out of every hour is just as beneficial. With intermittent monitoring the mom is allowed the freedom of movement. Continuous EFM increases the number of inventions without improving outcomes.

Speeding up labor: Artificial rupture of membranes and augmentation of labor:  Speeding up labor sounds pretty tempting but when the water is artifically ruptured (AROM) it increases the pain of the labor and removes the baby’s cusion to move around and get into a better position. Infection risks are increased and most hospitals have a time limit on how long the water can be broken before intervening.  Augmenting labor with pitocin can make labor go faster but it also interupts the normal flow of hormones and makes labor much more painful while increasing the risk of fetal distress.

Epidurals: Epidurals do take the pain away (most times) but can also cause a cascade of other interventions and problems. They increase the risk of an OP baby (sunny side up) because the pelvis is over relaxed and baby finds it harder to rotate and turn without the gravity because mom is stuck in bed. The risk of c section increases and the drugs do reach the baby potentially causing breastfeeding problems. Please see my post To Epidural or Not to Epidural for more details on the risks of epidurals.  There are many other ways to cope with labor. Preparing physically and mentally for labor, continuous labor support and avoiding routine interventions all help make labor an easier process.

Episiotomy: Routine episiotomy can be more harmful than tearing. Tears typically aren’t as bad as the cut would be and they heal faster. Episiotomy frequently causes more tearing and more pain. Avoiding epidurals and upright pushing positions reduce the risk of or need for episiotomy.

Medical need for interventions are occasionally necessary. Routine intervention should be avoided. Learning about the routine interventions and when they may become necessary and writing a birth plan can help reduce the chance of having routine interventions forced on a laboring woman. I think it is also very important for the partner to understand these procedures so that they can assist the mother as much as possible. Research is on the side of the mother when it comes to these routine interventions and discussing the written birth plan before the birth will help the labor go more smoothly.  Hiring a doula can also help keep routine interventions from being carried out as she can remind the mom of what the risks and benefits of the interventions are and of what her wants are.

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Going “Natural” and Being a “Hero”

Posted on July 8, 2009. Filed under: Epidural | Tags: , |

It makes me so mad when I hear women say “I am not one of those women who think I have to prove something and not get drugs.” Are they just trying to justify themselves with that? Do they think they have to defend their decision to use drugs in their birth? I have never had a client come to me and that she wants to go natural and the reasons for it are bragging rights. Quite frankly, I would rather hear the woman that says she thinks she is too wimpy to do it without an epidural. Then I can tell her how wrong she is and that she is completely capable of birthing her baby without an epidural because I have never met a woman that I thought couldn’t do it, that every woman has the strength and ability to do and that yes she may need help but she can totally and completely do it! I would tell her about a client of mine that is a girly girl and self admitted wimp that naturally birthed an OP baby after a HARD 36 hour labor and how she was happier with that birth experience than with her first epiduralized birth that included 25 hours of pitocin, 50 stitches from an episiotomy, a vaccum assisted birth, and a baby with meconium aspiration that spent 10 days in the NICU.

And while we are on it, going natural does not mean not having a c section. It means not using drugs or interventions although if you tell a couple of my med free moms that because they got an IV line they don’t count as having had a natural birth they might smack you for it. But really, if you are having a completely natural birth, you are not medicating, having an IV line, having an episiotomy or having any other routine intervention. You are just having your baby. If you are not having a c section then you are having a vaginal birth. It’s ok to say vagina or vaginal or vaginally. Really, it is.

But back to the whole hero thing…it just drives me nuts when I hear the whole “I don’t have to be a hero in the delivery room” bit. It has absolutely nothing to do with being a hero or with what anyone else thinks. Moms that come to me that want my help in having a natural birth do it because it is safer and healthier for both the mom and the baby. They want the natural experience of birthing their child with their body. They want to give their baby a gentle start without drugs in their systems. They want to minimize the risks of forceps and vacuum and cesareans. They want to minimize the risks of tearing because they have the ability to feel what is happening as it happens. They want to move during their labor and not be forced to push on their back. They want to reduce the risks of breastfeeding issues because having an epidural can cause latch problems for the baby. They do not want to run the risk of having pitocin because the epidural over relaxed their uteri. They understand that by having drugs they increase the risk of fetal distress and c section. They could care less about being a hero in the delivery room. I doubt any of them ever even had that thought.

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“Pit To Distress”

Posted on July 7, 2009. Filed under: Birth, Cesarean, pitocin | Tags: , , , , |

Yes this is a real term that is really used in hospitals. Now I have heard it all. “Pit to distress” is referring to administration of the maximum dosage of pitocin until the fetus is distressed and the mother needs a c section. I am not making this up. Go read about this for yourself here. If you think this would never happen to you, you may want to do some research. If you think this DID happen to you, please share your story.

Edit:

Here is an L&D nurse weighing in on this topic. She confirms that it is in fact practiced and referred to as “pit to distress”.

Here is another spin on it from an L&D Nurse, just to get a different perspective.

Here is a link from VBAC Facts weighing in on “Pit to Distress”

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Breech Pregnancy and Birth Survey

Posted on July 7, 2009. Filed under: Birth, breech, Cesarean, Pregnancy, vbac | Tags: , , |

All North American women who have had breech pregnancies or births are invited participate in an essay-response survey, which takes approximately 15-30 minutes to complete. We are interested in participants who had breech pregnancies (breech babies who turned head-down before birth). We would also like to hear from women who have given birth to breech babies, whether vaginally or by cesarean section; with midwives, physicians, or unassisted; at home, in a birth center or in a hospital. We welcome input from both singleton and multiple (twin, triplet, etc) breech pregnancies and births.

How to Participate:
To take the survey, please visit the Breech Pregnancy and Birth Survey

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EXCELLENT video on how to prevent cesareans!!!

Posted on July 6, 2009. Filed under: Birth, Cesarean, vbac | Tags: , |

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Do You Know What You are Signing? Elective Cesarean

Posted on July 5, 2009. Filed under: Birth, Cesarean, Elective Cesarean, vbac | Tags: , , , , , , , , |

Below is a copy and pasted version of a real elective cesarean consent form provided by an L&D nurse on her blog. Often times women sign these when they schedule their cesarean but they sign them without reading it or if they do read it they do not understand exactly what they are reading. Yes, they may see the words on the page but they do not realize that the risks outlined on that page are so very real. I have made some additional notes within the content of the form. My notes are in italics.

Consent for Elective Cesarean Section

A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.

I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.

(Print Patient Name)

Patient’s Initials

_____ I have informed the doctor of all my known allergies.

_____ The details of the procedure have been explained to me in terms I understand.

_____ Alternative methods and their benefits and disadvantages have been explained to me. How many times are the benefits of VBAC explained? Does the patient understand that with a successful VBAC the risk of uterine rupture (which is initially 0.05%) decreases and that the risk of rupture (before labor and during) increases with each cesarean?

_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:

* Pain or discomfort

* Wound infection; and/or infection of the bladder or uterus. Bladder infections are very common after cesareans because of the catheter. It is not uncommon to be re-catheterized after cesarean because of the inability to urinate independently. This increases the risk of bladder infection immensely. Obviously the uterus is at risk for infection as it has been cut open.

* Blood clots in my legs or lungs You are four times more likely to develop a clot after a cesarean than a vaginal birth. This may not seem like a big deal to most people but as a person with a hereditary blood clotting disorder and a mother with chronic DVT, and a sister who had a hysterectomy at 23 years old because of a blood clot in her ovary, I can tell you first hand that this is real and it is serious.

* Injury to the baby Babies born by c section 50% more likely to have lower APGAR scores than those born vaginally. About 2% of babies born via cesarean are cut by the scalpel. After my own cesarean my OB told me about a friend that she went to school with that cut a baby on her face so badly that she required plastic surgery. What a nice welcome to the world.

* Decreased bowel function (ileus)

* Injury to the urinary tract of GI tract I have ready many stories of the bladder being cut by the scalpel. If you are not aware, the bladder sits on the uterus and is connected by a layer of tissue that must be separated so that the bladder can be moved out of the way and the uterine incision made.

* Increased blood loss (2x that of a vaginal delivery)

* Risk of additional surgeries

* Post surgical adhesions causing pain/complications with future surgeries Adhesions make subsequent cesareans more difficult and longer to perform. They do not interfere with vaginal deliveries.

* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization We were in the hospital six days total as a result of this very thing.

_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.

_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to: These aspects of cesarean are so very important and so often omitted from the discussion. Risks are increased with every cesarean.

* Placenta previa, where the placenta covers the cervix.

* Placenta accreta, where the placenta grows into the muscle of the uterus.

* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.

* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.

_____ I have been informed of what to expect post-operatively, including but not limited to:

* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.

_____ The doctor has answered all of my questions regarding this procedure.

_____ I am aware and accept that no guarantees about the results of the procedure have been made.

I certify that I have read and understand the above and that all blanks were filled in prior to my signature.

________________________________ Patient Signature/Date

________________________________ Witness Signature/Date

I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.

________________________________

Physician Signature/Date

________copy given to patient ________copy placed in office chart

(Initial) (Initial)

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

What is not included on the consent form is the psychological effects on both mom and baby when a cesarean is done. The interference with the normal hormonal processes that both the mom and baby go through do have an affect on bonding and breastfeeding. I have talked to some people who say that they had no bonding issues at all and that breastfeeding was easily established after a c section and that is wonderful. However, MANY times this is not the case. Many mothers and babies do have problems. The rate of postpartum depression is higher as well.

Because the c section rate in the US is so high (31% for 2008) many people just assume that it’s routine and simple and safe. So many women are not taking time to fully understand the consequences of a c section. There are medical reasons for them but that is the small minority. Most c sections are unnecessary. Most primary c sections should have never happened to begin with. The data is there, these are not my opinions. I believe that if women were truly informed and educated on the risks and benefits involved in current obstetrical practices that they would take a more active role in their births. For this to happen, we have to start questioning procedures and asking the questions. We have to have a level of awareness and believe in our bodies abilities to birth.

ICAN’s (International Cesarean Awareness Network) Patient Choice Cesarean Position Statement says:

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.

All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”

Food for thought…

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Breastfeeding w/in 1 hr of birth reduced neonatal mortality 31%

Posted on July 4, 2009. Filed under: Breastfeeding | Tags: , , , , |

Amazing!

Breastfeeding w/in 1 hr of birth reduced neonatal mortality 31%

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