Breastfeeding Problems Linked to Mom's Post-Birth Meds?

"Evidence-based care acknowledges that, sometimes, having no intervention is safest, and, sometimes, having interventions is safest.... Advocating for evidence-based practices and interventions is not an ideology that interventions are bad. It's taking an objective look at scientific research and actually applying it to individuals, rather than basing care on outdated traditions, fear, and the ridiculous idea that women shouldn't be involved in their own health care." - ImprovingBirth.Org

A new study is out that takes a look at the effect of intramuscular injections mothers receive immediately after birth and their effect on breastfeeding. These are injections that occur during the third stage of labor (before or after delivery of the placenta) that are intended to help the uterus begin to contract down to normal size. This helps prevent postpartum hemorrhage.

The International Breastfeeding Journal notes:

Existing RCTs found no links between uterotonics administered in third stage of labour and breastfeeding. These trials were published ten and twenty years ago, and, to our knowledge, more recent trials have not examined the impact of uterotonics on breastfeeding. In the absence of trial data, observation studies and biological mechanisms assume greater importance.

This Brown and Jordan article notes the background information on the literature:

Analysis of a large birth cohort (n=48,366) indicated that intramuscular injection of oxytocin, with or without ergometrine, in the third stage of labor reduced breastfeeding rates at 48 hours by 6-8% (adjusted odds ratio [OR]= 0.75, 95% confidence interval [CI] = 0.61-0.9 1; adjusted OR=0.77, 95% CI=0.65- 0.9 1), consistent with other observational studies. A randomized controlled trial (n = 132) of active management of the third stage with intravenous ergometrine indicated an increase in supplementation and cessation of breastfeeding by 1 and 4 weeks postpartum, mainly because lactation was inadequate for the infants' needs.

The medications this 2014 Brown and Jordan study looked at included oxytocin and ergometrine. The study gave mothers who had a vaginal birth within the past 6 months a questionnaire that asked about whether they received uterotonic injections, breastfeeding at birth, breastfeeding duration, and, where applicable, reasons for breastfeeding cessation, whether physical, social, or psychological. 82% of the mothers had received active management of the third stage, and 17% received physiological management.

Here are the study results:

No significant association was found between infant feeding mode at birth (breast/formula) and injection of uterotonics. However, mothers who had received uterotonics were significantly less likely to be breastfeeding at all at 2 and 6 weeks. Among mothers who had stopped breastfeeding, those who had received parenteral prophylactic uterotonics were significantly more likely to report stopping breastfeeding for physical reasons such as pain or difficulty.

What this means is that their study might imply that uterotonic injections during the third stage of labor do not affect breastfeeding initiation, but may affect breastfeeding duration.

As with all research, we can say that this study showed an association between the injections and the cessation of breastfeeding due to physical reasons, but we cannot necessarily say it is causation. It is an important point to keep in mind when reading about research.

There is a great deal of evidence for the benefits of uterotonics for prevention of postpartum hemorrhage. Randomized control trials and metasyntheses of research by organizations such as the World Health Organization and the Cochrane Library have found that administration of oxytocin or other uterotonic are highly effective at reducing postpartum bleeding and prolonged third stage, with no apparent side effects for the baby. Ergometrine is associated with nausea for the mother.

The data for this study was collected by self-report on a questionnaire filled out by the mothers. Of course there are data collection errors, like selection bias and recall bias, involved in this type of study. It is not secondary data analysis (e.g. they did not look at medical charts to determine if an injection was received and then link it to data for the mother showing whether she stopped breastfeeding at a certain point in time). It is not a prospective randomized control trial (the gold standard of research, though not always possible).

Interestingly, they removed mothers who had intravenous oxytocin from their statistical analyses, as they were likely to have been receiving it during labor for induction, and also more likely to have an epidural. However, when they did analyze this small sample, they found that the finding was still significant: women who had the intramuscular injection compared to those receiving it intravenously were less likely to be breastfeeding at 2 and 6 weeks. So what is it about the injection, then?

Also, their psychological questions on reasons for stopping found that mothers who had an active third stage were significantly more likely to say they stopped breastfeeding for reasons of pain and/or embarrassment. Why would receiving uterotonics after labor contribute to difficulty latching or embarrassment? Perhaps they are correlated but not causational.  Or perhaps the medication affects the baby's ability to latch. The authors suppose the two are related: mothers who have trouble latching will be more embarrassed to nurse in front of others. This is all conjecture.

Brown and Jordan note in their discussion section that active management may not reduce postpartum hemorrhage for women at low risk of hemorrhage. This is a good argument for more risk assessment antenatally and upon birth admission. Many obstetric hemorrhage initiatives in the U.S. include this as a recommendation for hospitals. There is always the argument, however, that even low risk women sometimes hemorrhage after birth (there are instances of low risk home birth mothers transferring due to excessive bleeding). In rural or resource-poor settings, it may be beneficial to standardize receipt of prophylactic uterotonics when transfer could be life-threatening.

Furthermore, when care is not standardized, more health care mistakes are made. This is what the field of quality improvement in healthcare has found, and the reason standards of care are emphasized. It also means that everyone is doing the same thing, which reduces the receipt of poor care one place and better care at another. Standardization of care has been shown to reduce life-threatening errors in healthcare. There are times when we have to weigh the pros and cons (e.g. prophylatic uterotonics can reduce morbidity and mortality associated with hemorrhage, but may decrease breastfeeding success and duration). I work with a lot of doctors and nurses in my job in healthcare quality improvement, and I've learned a lot about the capabilities of the providers in our healthcare system. I've seen how changes are made in a system.

As a doula and a social researcher, I am also a strong proponent of patient-centered care. I think that care should also focus on what is right for each individual. Sometimes that means asking the patient what they want, though they may defer to the care provider to make the decision. The care provider may then decide that the pros outweigh the cons.

Another point is that women are more and more high risk for OB hemorrhage in industrialized countries. With the increase in medical conditions, inductions, cesarean sections, pitocin augmentation, use of pain medication and analgesia, advanced maternal age, etc., more women are going to be high risk and therefore more will receive active management of the third stage. So a great intervention would be to recognize that more women need assistance with breastfeeding in the first 2 - 6 weeks so that they can overcome latch issues, embarrassment, perceived low milk supply, and so on.

Moreover, how do we know that the women who have physiologic third stages are somehow different than the women who do not? Since active management is, at the moment, is the norm, and is in the population in this study, the women who "choose" to have no uterotonic injections may already be better informed on breastfeeding, better linked-into breastfeeding help networks, etc.

I did find their explanation of the interaction and possible mechanism behind uterotonics and breastfeeding. The authors speculate:

It is possible that disruption of neuroendocrine/paracrine pathways may lead to suboptimal latching, nipple trauma, pain, and feeding difficulty.

They explain a bit more in the discussion how ergometrine and oxytocin may disrupt hormone balance.

More research is needed on active management of the third stage and its effect on breastfeeding!

I definitely think this article contributes to what a lot of lactation professionals have been noticing, however: Interventions during labor have an effect on breastfeeding success, and we know that epidurals and pitocin augmentation during labor are associated with breastfeeding issues. But does the post-delivery dose have a large enough effect to change practice?

I don't think this particular research article should lead to full-scale changes in recommendations or standards of care at this time. I was inspired to write this article for just that reason - those who may think this is definitive evidence that we should stop promoting prophylactic uterotonics. We do a lot of things prophylactically in our lives. A prophylactic is something that is designed to prevent something from occurring. I think that a lot of birth and breastfeeding advocates are quick to judge all medical interventions as bad, and also to believe research that reinforces their beliefs, and not believe research that does not (well, most people do that). I have taught to be critical of research and to examine it from all sides.

I also think its unfair to blanket statement that all physicians and hospital medical professionals are the only ones to use interventions that may be harmful. Sometimes medical professionals close their eyes to the evidence of harm from routine interventions, but sometimes natural birth advocates (doulas, midwives) do to. 

"Midwives are often quick to criticize medical birth attendants for unwise interventions that disrupt normal birth and may cause harm. But how many of us are guilty of the same thing?" - Gail Hart

Even home birth midwives sometimes use supplements, herbs, etc that have not been tested or approved for effectiveness and safety. Doulas, too, make suggestions for some interventions for pregnant women and babies that we don't know are entirely safe or efficacious. We all have to pay close attention to good, solid evidence, and keep in mind that sometimes things are true even if they contradict what we believe. 

If you're interested in learning more on how to be a critical reviewer of research, I suggest you peruse Science and Sensibility's series of posts on "Understanding Research."


Brown, Amy and Sue Jordan (2014) Breastfeeding Medicine. Vol 9, No 10. DOl: 10.1 089/bfm.2014.0048

Active Management of Third Stage

Third Stage

The third stage of labor lasts from when the baby is born to when the placenta is birthed. Once the baby is expelled, the uterus generally continues contracting. Stimulation of the nipples by the baby helps the uterus contract down to pre-pregnancy size. The contractions and the hormones cause the placenta to detach from the uterine wall. The mother may feel another urge to push, but pushing out a squishy placenta is much easier than pushing out another baby!

The third stage generally lasts about an hour. It can last more than that, but generally the hospital won't even wait more than 30 minutes. If the placenta is taking a long time to detach and come out, there is a fear that it is a "retained placenta," and they may manually remove it. If the placenta is retained, or if pieces of it are retained, there is a risk for postpartum hemorrhage (excessive bleeding). This is why 1. the doctor or midwife will check to make sure the placenta is intact, and 2. the doctor or midwife may administer a shot or a bolus of pitocin to get the uterus to continue to contract.

Active Management 

Postpartum hemorrhage is the biggest childbirth complication and maternal killer worldwide. The World Health Organization recommends pitocin for all women to prevent postpartum hemorrhage and maternal mortality. They refer to this as "active management."

Many women want to avoid pitocin, even postpartum, because of it's potential side effects.  Normal expulsion of the placenta is possible without pitocin. We also have the luxury, in the United States, of having immediately available emergency care. If you begin to bleed excessively after birth, either your care provider would notice and take steps to stop it, or you would be able to call 911 and have an ambulance with you in a short time.

If you don't see a problem with receiving pitocin after birth, go for it. It is preventative, and recommended. And if you don't want it but end up needing it because of a suspected retained placenta, don't worry too much about it - it is a life saver in many instances!

The midwife at Midwife's Thinking Blog wants you to know something important:

Physiological placental birth is an option and possible if you manage to avoid induction, augmentation, an epidural or complications – but be aware of how difficult it may be, and don’t beat yourself up if it doesn’t happen.

Some medical interventions can mess with a physiological placental birth because they interrupt your body's natural production of oxytocin (your labor hormone!). Just something to keep in mind, and another bonus to a natural birth. Another thing that interrupts this - stress.

Keeping baby skin to skin and on the breast immediately after birth is a great way to help that placenta out!

In a world where the majority women are having inductions, pain medication, anesthesia, augmentation, and stressful birth environments in the hospital, active management of the third stage might be the best idea for most women. 

Cord Traction

I do have to add here that I don't think cord traction is a good idea. I'm not a doctor or a midwife, but cord traction seems like a terrible idea, yet one that is done ALL THE TIME. This is when the care provider pulls on the umbilical cord to help the placenta out (sometimes in conjunction with the pitocin). This can cause additional problems - a placenta that hasn't separated from the uterus yet can cause a partial detachment (adds to hemorrhage), you can snap the umbilical cord (not a huge deal), or worst case scenario, pull the uterus out!

Even though this is "faster," which doctors like, it doesn't seem to do much good. I really wouldn't want to risk making things worse by pulling on the cord, especially if the third stage hasn't been that long, yet! 



How long did it take for your placenta to come out? What are your thoughts on the active management of the third stage?

 

 

 

 

Baby is NOT at Term at 37 Weeks

I've already blogged about the inaccuracy of due dates, but I wanted to take the time to emphasize the fact that though many women and their doctors believe that 37 weeks is "at term" it is NOT.

A recent study conducted by a group of physicians associated with the March of Dimes organization points out that considering babies term at 37 weeks may not be such a good idea after all. There seems to be new evidence that suggests that the outcome for a baby born after less than 37 completed weeks of pregnancy is significantly different for one born after 38 completed weeks.
The study proposes that the phrase “late preterm” be used when describing neonates born between 37 0/7 weeks and 38 6/7 weeks because of the new research which states that babies born during this period suffer from increased mortality and neonatal morbidity when compared to children born later in the pregnancy. (via the unnecesarean)

Why is this a concern?
Many women find the end of pregnancy uncomfortable and exhausting. They and their family members have been waiting for months and they are anxious to finally meet their new baby. Women frequently request that their doctors deliver their baby once they've reached term, which many believe to be 37 weeks. Doctors are frequently happy to oblige to an induction or a cesarean section before the due date is reached. However, a baby that does not reach full gestation and initiate spontaneous labor may face severe complications.

Complications of non-medically indicated deliveries between 37 and 39 weeks:

• increased NICU admissions
• increased transient tachypnea of the newborn
• increased respiratory distress syndrome
• increased ventilator support
• increased suspected of proven sepsis
• increased newborn feeding problems and other transition issues
• Morbidity rates double for each gestational week earlier than 38 weeks

Via dou-la-la:

New research shows that those last weeks of pregnancy are more important than once thought for brain, lung and liver development. And there may be lasting consequences for babies born at 34 to 36 weeks, now called "late preterm."

A study in the American Journal of Obstetrics and Gynecology in October calculated that for each week a baby stayed in the womb between 32 and 39 weeks, there is a 23% decrease in problems such as respiratory distress, jaundice, seizures, temperature instability and brain hemorrhages.

A study of nearly 15,000 children in the Journal of Pediatrics in July found that those born between 32 and 36 weeks had lower reading and math scores in first grade than babies who went to full term. New research also suggests that late preterm infants are at higher risk for mild cognitive and behavioral problems and may have lower I.Q.s than those who go full term.

What's more, experts warn that a fetus's estimated age may be off by as much as two weeks either way, meaning that a baby thought to be 36 weeks along might be only 34.

Timing of Fetal Brain Development: cortex volume increases by 50% between 34 and 40 weeks gestation, brain volume increases at a rate of 15mL/week between 29 and 40 weeks gestation

Furthermore, the process of generating a due date relies on sometimes faulty memories of mothers about their cycle, and assumes all women’s cycles are the same length. Research shows that women’s cycles can vary widely, and these variances can profoundly impact when a baby will be mature enough to be born. (via lamaze)

Don't believe it when your doctor tells you he can tell by ultrasound that the baby is nice and big and so ready to come out -- ultrasound for measuring the baby's weight can be 1-1.5 lbs off!

And please please please do not ask your doctor to perform an induction or cesarean section once you've reached "term at 37 weeks." Baby is ready to come when he/she comes!

Where's the Evidence-Based Medicine?

Birth Advocates are always saying that obstetricians shouldn't be doing such-and-such routine procedure anymore, because it is not the best for mother and baby. Doulas always talk with their clients (and anyone who will listen) about how unnecessary and unhelpful episiotomies, continuous electronic fetal monitoring and pushing on your back, just to name a few examples. But we are frustrated time and again by obstetricians (and sometimes midwives) who do them anyway! And we ask, "Why don''t they follow evidence-based medicine?!"

So have you ever wondered what exactly IS the evidence?Well, thanks to the Midwife Next Door, I didn't have to go find all the studies myself!

Complete with references, here are 10 Common Obstetric Procedures Not Supported By Science  (Please note:  many of these procedures are beneficial in specific situations.  It is their routine use without medical indication that is being addressed here) 

 

1.  Inductions/elective c-sections for suspected macrosomia (big baby): The Cochrane Database reports “no evidence of improved outcomes following induction of labour for non-diabetic women who are thought to be carrying large babies. Babies who are very large (macrosomic – over 4500 g) can sometimes have difficult and, occasionally, traumatic births. One suggestion to try to reduce this trauma and to reduce operative births has been to induce labour before the baby grows too big. However, the estimation of the baby’s weight in utero is difficult and not very accurate. Clinical estimations are based on feeling the uterus and measuring the height of the fundus of the uterus, and both are subject to considerable variation. Ultrasound scanning is also not accurate.”

• Cochrane Database of Systematic Reviews.  Induction of labor for suspected fetal macrosomia.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD000938/pdf_fs.html
• Gherman RB, Chauhan S, Ouzounian JG, Lerner H, Gonik B, Goodwin TM.  Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines.  Am J Obstet Gynecol.2006 Sep;195(3):657-72. Epub 2006 Apr 21.

2.  Pitocin to speed labor: I am referring here to the routine use of pitocin to speed up a normal labor.  Unfortunately, this happens more frequently than one might think.  Doctors and midwives have lives outside the hospital, and the temptation to speed labor in order to get home sooner is difficult to resist when you’re tired and anxious to get home.  Evidence shows:  “Early amniotomy and high doses of oxytocin may both increase the risk of fetal heart rate anomalies, but are both useful for avoiding prolonged labour.” 

• Verspyck E, Sentilhes L.  Abnormal fetal heart rate patterns associated with different labour managements and intrauterine resuscitation techniques.  J Gynecol Obstet Biol Reprod (Paris).2008 Feb;37 Suppl 1:S56-64. Epub 2008 Jan 9.
• Enkin M, Keirse M, Neilson J, Crowther C, Duley L, Hodnett E. A guide to effective care in pregnancy and childbirth. 2000et al. New York: Oxford University Press.
• Fraser W, Turcot L, Krauss I, Brisson-Carrol G. Amniotomy for shortening spontaneous labour. The Cochrane Database of Systematic Reviews. 1999;4:CD000015.F.
• Clark SL, Simpson KR, Knox GE, Garite TJ. Oxytocin: new perspectives on an old drug. Am J Obstet Gynecol. 2009; 200(1):35.e1–6.

3.  Amniotomy to speed labor: The Cochrane Library reports:  “Evidence does not support the routine breaking the waters for women in spontaneous labour.  The aim of breaking the waters (also known as artificial rupture of the membranes, ARM, or amniotomy), is to speed up and strengthen contractions, and thus shorten the length of labour. The membranes are punctured with a crochet-like long-handled hook during a vaginal examination, and the amniotic fluid floods out. Rupturing the membranes is thought to release chemicals and hormones that stimulate contractions. Amniotomy has been standard practice in recent years in many countries around the world. In some centres it is advocated and performed routinely in all women, and in many centres it is used for women whose labours have become prolonged. However, there is little evidence that a shorter labour has benefits for the mother or the baby. There are a number of potential important but rare risks associated with amniotomy, including problems with the umbilical cord or the baby’s heart rate.  The review of studies assessed the use of amniotomy routinely in all labours that started spontaneously. It also assessed the use of amniotomy in labours that started spontaneously but had become prolonged. There were 14 studies identified, involving 4893 women, none of which assessed whether amniotomy increased women’s pain in labour. The evidence showed no shortening of the length of first stage of labour and a possible increase in caesarean section. Routine amniotomy is not recommended for normally progressing labours or in labours which have become prolonged.”

• The Cochrane Library.  Amniotomy for shortening spontaneous labor.  http://onlinelibrary.wiley.com/o/cochrane/clsysrev/articles/CD006167/frame.html

4.  Continuous electronic fetal monitoring:  The American Congress of Obstetricians and Gynecologists (2005) recommends that healthy women with no complications may be monitored with intermittent auscultation or with EFM. Intermittent auscultation instead of EFM may safely reduce the cesarean rate.

• American College of Obstetricians and Gynecologists [ACOG]. (2005). ACOG practice bulletin #70: Intrapartum fetal heart rate monitoring. Obstetrics and Gynecology, 106(6), 1453–1460.
• Gourounti, K., & Sandall, J. (2007). Admission cardiotocographyversus intermittent auscultation of  fetal heart rate: Effects on neonatal Apgar score, on the rate of caesarean sections and on the rate of instrumentaldelivery—A systematic review. InternationalJournal of Nursing Studies, 44(6), 1029–1035.

5.  Requirement of “immediate” emergency services for women attempting a VBAC.  The recent NICHD consensus statement speaks:  “Given the low level of evidence for the requirement for “immediately available” surgical and anesthesia personnel in current guidelines, we recommend that the American College of Obstetricians and Gynecologists and the American Society of Anesthesiologists reassess this requirement with specific reference to other obstetric complications of comparable risk, risk stratification, and in light of limited physician and nursing resources.”

• Consensus Development Conference Panel Final Statement on VBAC.  http://consensus.nih.gov/2010/vbacstatement.htm

6.  Routine Episiotomy:  None of the following studies found a benefit to routine episiotomy.  Current recommendations are to use episiotomy when there are  indications of fetal distress and birth does not appear to be imminent.

•  Dannecker, C., Hillemanns, P., Strauss, A., Hasbargen, U., Hepp, H., & Anthuber, C. (2004). Episiotomy and perineal tears presumed to be imminent: Randomized controlled trial.Acta Obstetricia et Gynecologica Scandinavica, 83(4), 364–368.
• Hartmann, K., Viswanathan, M., Palmieri, R., Gartlehner, G., Thorp, J., & Lohr, K. N. (2005). Outcomes of routine episiotomy: A systematic review. Journal of the American Medical Association, 293(17), 2141–2148.
• Klein, M., Gauthier, R., Robbins, J., Kaczorowski, J., Jorgensen, S., Franco, E., et al. (1994). Relationship of episiotomy to perineal trauma and morbidity, sexual dysfunction, and pelvic floor relaxation. American Journal of Obstetrics and Gynecology, 171(3), 591–598.

7.  Routine ultrasound to estimate fetal size:“Fetal weight estimation is inaccurate, with poor sensitivity for prediction of fetal compromise.”  (Dudley 2005).  “Prediction of fetal macrosomia remains an inaccurate task even with modern ultrasound equipment” (Henrickson2oo8). ”Considerable error in fetal weight estimations. . .may limit the accuracy and clinical utility of these measurements” (Landon 2000).

• Dudley NJ.  A systematic review of the ultrasound estimation of fetal weight.  Ultrasound Obstet Gynecol. 2005 Jan;25(1):80-9.
• Henrickson T.  The macrosomic fetus: a challenge in current obstetrics.  Acta Obstet Gynecol Scand. 2008;87(2):134-45.
• Landon MB.  Prenatal diagnosis of macrosomia in pregnancy complicated by diabetes mellitus.  J Matern Fetal Med. 2000 Jan-Feb;9(1):52-4.

8.  Immediate cord clamping:  “Delaying clamping of the umbilical cord in full-term neonates for a minimum of 2 minutes following birth is beneficial to the newborn, extending into infancy” (Hutton & Hassan 2007).

• Hutton, E. K., & Hassan, E. S. (2007). Late vs early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA, 297(11), 1241-1252.

9. Directed (purple) pushing:  The following studies concluded that allowing the mother to push spontaneously (when, how long, and how hard to push are left up to the mother rather than directing her how to push), is superior to directed pushing.  Directed pushing is not recommended as there is greater risk of perineal trauma, fetal distress, and it does not significantly shorten the pushing phase of labor.

• A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194(1), 10–13
• Mayberry, L. J., Wood, S. H., Strange, L. B., Lee, L., Heisler, D. R., & Nielsen-Smith, K. (2000). Second-stage management: Promotion of evidence-based practice and a collaborative approach to patient care. Washington, DC: Association of Women’s Health, Obstetric and Neonatal Nurses (AWHONN).
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.
• Schaffer, J., Bloom, S., Casey, B., McIntire, D., Nihira, M., & Leveno, K. (2006). A randomized trial of the effects of coached vs. uncoached maternal pushing during the second stage of labor on postpartum pelvic floor structure and function. American Journal of Obstetrics and Gynecology, 192(5), 1692–1696.

10. Supine Pushing:  This, along with routine amniotomy and continuous fetal monitoring, is used in the vast majority of hospital births.  The following studies concluded that supine pushing is not beneficial and can even be harmful to the mother, by working against gravity, decreasing blood pressure which can lead to fetal intolerance of labor, increased episiotomy, increased use of vacuum/forceps, and increased pain for the mother.

• Gupta, J. K., Hofmeyr, G. J., & Smyth, R. (2004). Position in the second stage of labour for women without epidural anaesthesia. Cochrane Database of Systematic Reviews, Issue 4. Art. No.: CD002006.
• Johnson, N., Johnson, V., & Gupta, J. (1991). Maternal positions during labor. Obstetrical and Gynecological Survey, 46(7), 428–434.
• Roberts, J., & Hanson, L. (2007). Best practices in second stage labor care: Maternal bearing down and positioning. Journal of Midwifery & Women’s Health, 53(3), 238–245.

Weekend Movie: "Infant Mortality: Causes and Prevention"

Reducing Infant Mortality and Improving the Health of Babies

Listen to Obstetricians, Doulas, Neonatologists, Midwives, Psychologists, Pediatricians, and other Physicians explain how our health care system is failing babies and mothers and what we can do about it. 

http://www.reducinginfantmortality.com/

Reducing Infant Mortality from Debby Takikawa on Vimeo.

"Of the most common procedures in the hospital the top 6 come out of maternity care" 

"We're making it more technologically advanced in our country and we're not doing any better, and we're actually getting worse."

"The rate of prematuriy in the US has increased by 36% since the 1980's"

"Where we get into problems is when we decide that other women then those that are clearly indicated to need them, need to have interventions."

"Most maternity practices that are commonly used in the hospital were never designed to be used at the frequency we're seeing them used now..."

"We have become a little bit cavalier..." 

"It is estimated that for every week that a baby is born before term that they double their risk of having problems..." 

"We know that the use of narcotics at any point interferes with breastfeeding"

"Studies now that show that when women have interventions there are deficits in maternal infant attachment and in breastfeeding as well..."

"Among African American women, breastfeeding numbers are the lowest" 

"Midwives and family doctors primarily are the providers that we've seen in the research have the best outcomes." 

"You do not need someone with the skills of a board certified OB/GYN to do a normal vaginal birth"

"The US is the only industrialized country in the world that uses surgeons to attend normal childbirth."

 "And then we look at those other countries and we see that their healthcare costs are lower..."

"If the system is set up properly where you have a there's a safety net where you work in collaboration and have a nice team effort I think it can be a safe process"

 "A collaborative process...will give patients a better opportunity to have better outcomes."

"There are entire states where midwives are unable to find an OB/GYN who is willing to be available should a woman need to go to the hospital and access those services."

7 Reasons You Can't Have an Epidural

Planning on having epidural anesthesia?  Just because you want one doesn't mean you'll get it! 
Here are seven reasons why you may not be able to have one...

7 Reasons You Can't Have an Epidural

by Robin Elise Weiss

Epidural anesthesia is the most popular form of medicinal pain medication for labor and birth. Many women decide on using an epidural prior to labor and don't even look at other forms of pain relief for labor and birth. This is not necessarily a wise choice for labor and birth because there are many reasons why an epidural may not be in your future. Here are a few of the reasons you might not be able to have an epidural:

1. You are taking certain medications.
   Medications that you take can effect how likely you are to be able to get an epidural. The biggest culprit are blood thinners.
2. Your blood work isn't just right.
   If you have a low platelet count or sometimes other problems with your blood work may make the placement of an epidural more risky.
3. The doctor can't find the right space.
   Sometimes due to the normal growth of your back, your weight or back problems, including scoliosis, it may be impossible for the anesthesiologist to find the epidural space. Therefore you can't have the epidural placed in labor.
4. You are bleeding heavily.
   If you are bleeding heavily or are suffering from shock, you will not be given an epidural for safety reasons. Since many women tend to have lower blood pressure with an epidural, this may be made even more dangerous with the lowered blood pressure of some of these problems.
5. You have an infection of the back.
   It is not in your best interest to have your anesthesiologist place an epidural through an area that is infected. This can cause the infection to spread to the spine and other areas of your body and can potentially cause a great deal of damage.
6. No anesthesiologist is available.
   Your hospital may only have an anesthetist available during certain hours of the day or days of the week. You may also have an anesthesia department that covers an entire hospital and not just the labor and delivery unit.
7. Labor restrictions.
   Some hospitals will place restrictions on when you can have an epidural. It may be that you must be at a certain point in labor, like four (4) centimeters before an epidural can be given. Other hospitals may decide that epidural should not be given after a certain point of labor, for example when you've reached full dilation (10 centimeters).

What to Do if the Doctor Says No

You might be able to find out beforehand that an epidural is not in your laboring future. If this happens you are able to prepare by looking at other methods of pain relief for labor. A good childbirth class that focuses on many different types of pain relief from medications to natural forms of relief of pain may be the best option for filling your birth bag with many tools to cope with labor, particularly for the surprise revelation that you can't have an epidural.

Enlist support for getting through labor. Labor is hard work, with or without pain medications. Consider hiring a doula, even if you prefer an epidural. A professional labor assistant can help you and your partner through different pain relief options including natural pain relief like relaxation, positioning, massage, etc. She will also be trained in letting you know what your other options are for pain relief like Transcutaneous Electrical Nerve Stimulation (TENS), IV medications, etc.

If you are concerned about these issues be sure to talk to your doctor or midwife about your fears. It's also possible and highly recommended in some cases to actually visit the hospital and have a consultation with the anesthesiology department. They may do a physical exam of your spine, take a medical history, etc. This can help answer questions you may have about epidurals and labor. Being informed ahead of time is your best solution.

Moral of the story... GET A DOULA! :) 

Racism and Birth Weight

Over the past two decades in the United States there have been concerted efforts to reduce the number of preterm deliveries and low birth weight babies. Such births are the second leading cause of infant mortality across the population at large, and among African Americans the first cause. Furthermore, African American women are two to  three times more likely than white women to deliver preterm. Although the overall number of preterm births has been reduced in the US the gap appears to have widened because preterm births have declined faster among white than African American women. A large number of epidemiological studies have attempted to account for this disparity in terms of maternal age, education, lifestyle, and or socio-economical position. However, the results make it clear that these variables account for only a small proportion of the difference. Moreover, college-educated black mothers are more likely to deliver very low birth weight infants than are college-educated white mothers. And, further, it has been shown that women recently immigrated to the US bear infants of higher birth weight than do women of the same race/ethnic category (as defined by the US census) born and raised in the United States, despite the frequency of lower socioeconomic status among the immigrants. Researchers involved with these studies argue that their findings "suggest that growing up as a woman of color in the US is somehow toxic to pregnancy, and imply a social etiology for racial/ethnic disparities in prematurity that is not solely explained by economics or education.

Regardless of their socioeconomic level, African Americans who reported the experience of racial discrimination in three or more situations proved to be at more than three times the risk for preterm delivery as compared to women who reported no experience of racism. Further, recent studies have supported this conceptual model. [Epidemiologist Nancy] Krieger's conclusion is that "biological expressions of race relations" appear to be at work in accounting for the findings about low birth weight and she goes on to caution that human biology should never be studied in the abstract. this example makes strikingly clear how individual women should not be held fully accountable for the outcomes of pregnancies. in the united states, and elsewhere too, no doubt, persistent experiences of racism in every day life continue to take their toll, despite dramatic political reforms throughout the latter part of the 20th century.

from Local Biologies and Human Differences By Margaret Lock, Nguyen Vinh-Kim

Emergency Unassisted Labor and Delivery Guide

A great deal of women give birth unassisted by a trained healthcare provider. This includes women in developing countries who give birth on the side of the field and then go right back to plowing, women in developing countries who don't have money or access to a care provider or health facility, women all over the world who plan to birth unassisted at home, and women who find themselves having an unplanned unassisted birth before their care provider can be with them.

This post is about the last group of women: the women who hadn't planned on birthing without help, at home or in the car or wherever, but hopefully have access to emergency supplies. Its also a great crash-course for the women, or dad/partner, about the basics of labor and delivery, and mom and baby postpartum.


Amy Romano on Science and Sensibility wrote a great post on Birth during Times of Disaster: Keeping Women and Babies Safe

In it she included a link to an emergency childbirth guide from the American College of Nurse-Midwives that includes a lot of really great information for women and partners who must deal with an emergency birth in a location where there are no skilled birth attendants present. I include some bits of the text below:


FROM THE AMERICAN COLLEGE OF NURSE-MIDWIVES
Giving Birth “In Place”: A Guide to Emergency Preparedness for Childbirth
Deanne Williams, CNM, MSN

This is not a “do-it-yourself”guide for a planned home birth, nor is it all the information you need for every emergency. It is not meant to replace the knowledge and skills of a doctor or midwife. The information is a basic guide for parents-to-be who want to be ready in case they have to give birth before they can get to a hospital or birth center.

CALL FOR HELP
If you think you are in labor, try to get to a hospital, birth
center, or clinic. If you are alone or travel seems unwise,
call the emergency number in your community and ask for
help. After you have called for help, keep your front door
unlocked so that rescue workers can get in if you are unable
to come to the door. Call a neighbor to come and help the
family. If the phones are working, keep talking to emergency
services or your health care provider who can “talk
you through” a labor and birth.
If your labor is going fast and birth seems near, stay at
home and have your baby in a safe place rather than in the
back seat of the car. Fast labors are usually very normal,
and the mothers and babies can both do well. Slow labors
will give you time to get to a hospital or birth center, or for
a health care provider to get to you. Get out your supply kit
and put the supplies where you can easily reach them.
As the helper, your job is to
Keep mom comfortable. It is good for her to walk, take a
shower, get a massage, and move even if she is in bed.
Be sure she drinks lots of fluids. Water, tea, and juice are
the best.
Be sure she goes to the bathroom every hour.
Say and do things that create a calm feeling, even if you
are very nervous.
Wear gloves if you are going to be touching blood.
Wash your hands or gloves often.
Do not let pets into the labor and birth room.
Talk to mom about the sounds of childbirth. Making
groaning or crying noise during labor is ok and can help
the mom-to-be. It can scare the helpers. So mom has to
try to not scream and lose control, and the helpers have
to let mom make the noise that helps her cope.
Decide how to help other members of the family. Will
they be present for the birth? What do they need to
feel safe?


PREPARE THE BED
To keep the mattress from getting wet, cover it and the
sheets with a shower curtain and then cover the shower
curtain with another clean sheet, plastic-backed under pads
and lots of pillows for comfort. The mother may want to
spend a lot of time in bed, or she may prefer to be on her
feet or in a chair. Whatever feels best is okay.

WHEN THE BABY’S HEAD IS COMING FIRST
If you know your baby has been head down during the last
weeks of pregnancy, chances are good that the baby will be
head first at birth. This is the most common position for a
baby. First labors can last for 12 hours or more, whereas the
next babies can come much faster.

The Urge to Push
The longest part of labor is the time it takes for the cervix
to open wide enough for the baby to pass into the birth
canal or vagina (first stage). You can tell the cervix has
feel with your fingers to find out if the cord is around the
baby’s neck. If you find a cord around the neck, this is not
an emergency! Gently lift the cord over the baby’s head, or
loosen it so there is room for the body to slip through the
loop of cord.
The baby’s head will turn to one side and with the next
contraction the mother should push to deliver the body. If
the body does not come out, push on the side of the baby’s
head to move the head toward the mother’s back. The
shoulder will be born. The rest of the body slips out easily
followed by a lot of blood-colored water.

If the Head Is Born but the Body Does Not Come Out After
Three Pushes
The mom must lie down on her back, put two pillows under
her bottom, bring her knees up to her chest, grab her knees,
and push hard with each contraction. After the baby is born,
place her or him on the mother’s chest and tummy, skin to
skin, and cover both with towels. If the baby is not crying,
rub her back firmly. If she still does not cry, lay her down
so that she is looking up at the ceiling, tilt her head back to
straighten her airway, and keep rubbing. Not every baby
has to cry, but this is the best way to be sure the baby is
getting the air she needs.

If the Baby Is Gagging on Fluids in Her Mouth and Turning
Blue
Use the baby blanket to wipe the fluids out of her mouth
and nose. If this does not help, use the bulb syringe to help
clear things out. Just squeeze the bulb, place the tip in the
nose or mouth, and release the squeeze. This will suck fluid
into the bulb. Move the bulb away from the baby and
squeeze again to empty the bulb. Repeat until the fluid is
removed.
If the baby is still not breathing, follow the CPR
directions.

THE UMBILICAL CORD
There is no rush to cut the cord. All you have to do is keep
the baby close to the mom so the cord is not pulled tight. If
you pick the cord up between your fingers, you can feel the
baby’s pulse. Within about 10 minutes the pulse will stop.
At that time you can tie and cut the cord. Remember the
cord is connected to the placenta (afterbirth) which is still
inside the mother.

THE BABY
At the time of birth, most babies are blue or dusky. Some
cry right away and others do not. Do not spank the baby,
but rub up and down her back until you know she is taking
deep breaths. Once the baby starts to cry, her color will be
more like her mom, but her hands and feet will still be blue.
Now is the time to keep the baby warm. Remove the wet
towel that is over the baby and put another dry towel and
blanket over the mother and baby. Put a hat on the baby.
The mother can help keep the baby warm with her body
heat.
Put the baby to breast. Even if you did not plan to
breastfeed, one of the safest things you can do for mom and
baby is put the baby to breast. A breastfeeding baby helps
keep the mother from bleeding too much and gets the food
it needs right away. If the cord is too short to allow the baby
to reach the breast, it is ok to wait until you cut the cord.

CUTTING THE CORD
There are no nerve endings in the cord so it does not hurt
either the baby or the mother when it is cut. It is very
slippery so take your time because there is no rush. Wash
your hands, put on gloves and then get the container with
the scissors and shoelace. Tie one of the laces around the
cord very tightly with a double knot about 3 inches from the
baby’s tummy. The baby will cry when she is uncovered
because she is cold, not because it hurts. Tie the other
shoelace around the cord about 2 inches from the first knot.
Pick up the scissors by the handle without touching the
blades. Cut between the knots you have tied. It is rubbery
and tough to cut especially if you have dull scissors. After
it is cut, place the end of the cord that is still connected to
the mother’s placenta into the mixing bowl. Cover the baby
again to keep her warm.

THE PLACENTA OR AFTERBIRTH (THIRD STAGE)
The placenta looks like a big piece of raw meat with a shiny
film on one side. On the other side it has membranes that
are attached to the placenta (the membranes look like skin
that has been peeled off). When the placenta is ready to
come, you will see a gush of blood from the vagina and the
cord will get a little longer. Put the bowl close to the
mother’s vagina and put more waterproof pads under her
bottom. Ask the mother to sit up and push out the placenta
into the bowl.
There will be a lot of blood and water coming after the
placenta. Firmly rub the mother’s stomach below her belly
button until most of the bleeding stops. This will hurt but
needs to be done. The heaviest bleeding should stop in a
minute and then the bleeding will be more like a heavy
period. If the bleeding increases again, very firmly rub the
mother’s lower belly until the bleeding slows. When it is
firm, you will be able to feel the uterus (womb), which is
the size of a large grapefruit, in the lower belly. A firm
uterus is a good thing because it will stop the mom from
bleeding too much.
Mom’s bottom and her uterus may be sore. You may see
places where the mother’s skin has torn around her vagina.
Most of these tears will heal without any problems. Mom
will feel better when you put an ice pack on her bottom
where the baby came out and then put the sanitary pad on
top of the ice pack. She may want to take a couple of pain
pills at this time.

Put the placenta in a medium-sized trash bag and wipe
off any blood on the outside of the bag. Put this bag into a
second trash bag. Take the placenta with you to the hospital
or birth center. If you cannot leave the house for more than
4 hours, put the bagged placenta in a container with a lid
and put it in the freezer.

CLEAN UP
After the mother has delivered the placenta and the bleeding
has slowed down, give her a drink of juice, soup, or
milk and something to eat like crackers and cheese or a
peanut butter and jelly sandwich. Put on gloves to clean up
the bed. Roll up the sheet and pads inside the shower
curtain and put in a large plastic bag. Have clean under pads
ready to cover the sheets and a sanitary pad for the mother.
The dirty sheets and towels can be washed in cold water
with bleach or ammonia added. Wear gloves when touching
items that are bloody. Put a diaper on the baby or you will
be sorry!

BREASTFEEDING
It is important for the mother to breastfeed the baby in the
first hour after birth and at least every 2 hours until her milk
comes in.
● Breastfeeding will keep the uterus firm and decrease
bleeding.
● Colostrum, the liquid that is in the breasts right after birth
until the milk comes in, will give the baby all of the food
she needs and it will help prevent infection.
● Even if the emergency situation continues for days,
weeks, or months, there will always be a ready supply of
safe and perfect food for the baby.

Getting Started With Breastfeeding
A newborn will nurse best in the first hour after birth when
she is awake and alert. The mother may be more comfortable
if she lies on her side with pillows under her head. The
mother and baby should be face-to-face and belly-to-belly.

The baby will also nurse better if they are skin-to-skin (see
Figure 2).
The mother should place her nipple and breast against the
baby’s lips. The baby will lick and try to nurse. The mother
needs to help out by placing her nipple into the baby’s open
mouth. It may take a few tries before the baby can start
sucking. If the baby is sleepy, rub her belly and back firmly
to wake her up. If the baby is too sleepy, try uncovering her
for a short time and rubbing the mother’s nipple against the
baby’s lips. If the mother gets tired, take short breaks and
start again. Once the baby nurses for the first time it gets
easier.
If the baby sucks a few times and then lets go and the
mom has large breasts, mom may need to help the baby
breathe by using her finger to hold some breast tissue away
from the baby’s nose.

What to Avoid
● Don’t use a pacifier or a bottle to start the baby sucking.
It confuses some babies because they do not suck the
same on the mother’s breast and a bottle or pacifier.
● Do not separate the mother and baby for very long. The
more they stay together, including when they sleep, the
sooner breastfeeding will be well established.

CARE OF THE MOTHER
If you still cannot get to the hospital or birth center to be
checked, the mother should go to the bathroom within
an hour after the baby is born.
If the room is cold, you can use the hot water bottle to
help keep the baby warm. Just wrap the warm bottle
in a blanket and place it next to the baby’s back.

After birth in a hospital, women are usually offered
Tylenol or Advil for pain every 3 to 4 hours as
needed. This would be a good choice at home if the
mother does not have an allergy to this medication.
When a new mother gets out of bed for the first time, she
may feel dizzy. It is important to have her leave the
baby on the center of the bed and get up slowly:
● Sit up on the side of the bed to see how she feels.
● Have an adult take her to the bathroom and wait to be
sure that she is not feeling faint.
● If she says she is going to faint, believe her and have her
lie down on the floor. Do not attempt to walk her back to
bed. You have about 10 seconds to get her down on the
floor before she passes out and bangs her head on the way
down! Once she is down flat, she will wake up and feel
better. Just wait a few minutes and then carefully help her
back to bed.
In a couple of hours the mom may want to take a shower.
Be sure she has had something to eat and is not dizzy when
she gets up. It is good to have someone close by because
dizziness can return quickly.


To read more of this guide, including a list of emergency supplies to keep on hand, what to do if baby comes bottom first, and baby care in the first couple days, click here.

Thank goodness for the Labor Progress Handbook!

I'm still waiting on my home birth client to go into labor, and she may end up not being my first doula birth after all. One of my other clients has been dealing with high blood pressure for several weeks and may have to be induced. Needless to say I have been finding out as much as I can about hypertension, pre-eclampsia, induction and laboring with these conditions.

She is currently being tested for protein in her urine to see if she may have pre-eclampsia in addition to her hypertension. Pre-eclampsia is

a condition that typically starts after the 20th week of pregnancy and is related to increased blood pressure and protein in the mother's urine (as a result of kidney problems). Preeclampsia affects the placenta, and it can affect the mother's kidney, liver, and brain. When preeclampsia causes seizures, the condition is known as eclampsia--the second leading cause of maternal death in the U.S. Preeclampsia is also a leading cause of fetal complications, which include low birth weight, premature birth, and stillbirth. 

An increase in BP in late pregnancy is fairly common, and does not always become pre-eclampsia. There is no proven way to prevent pre-eclampsia, and the only way to treat it is to have good medical care. The only "cure" is to deliver the baby.

This is why, if the doctor finds she may have pre-e, she will most likely be induced as soon as possible. I have made several suggestions over the past couple weeks for lowering her blood pressure, and she has told me that she has tried relaxing more. Unfortunately her BP is still high, though I don't know how high. I am worried about her being induced, because that is what she had to go through last time for being "late" and she definitely did not have an easy time of it. If she does not have pre-e her doctor still wants to try to get her going as soon as possible, and has said she will be stripping her membranes next week.

For those who do not know what stripping membranes is:

Stripping the membranes is where a health care provider will separate your bag of water from the cervix, it is not intended to break your water, however, it may. It may also cause infection, and may be painful for some. The reason that we tell people that we are stripping their membranes is to "get things going" in regards to labor. This little technique is usually done during a vaginal exam at the end of pregnancy, with or without the knowledge or consent of the woman. Stripping the membranes, we are told, is supposed to stimulate production of prostiglandins in the cervix and bring on contractions. I have heard doctors tell my clients after stripping their membranes they will have the baby in two days. While this may appear to work for some, at term it's all a guessing game. There is no scientific work to date that can back up the routine procedure of stripping membranes. (from Childbirth.org)

Needless to say I am now preparing for the possibility of her being induced very soon, and for the probability of her being told to labor in bed for her hypertension.

And this brings us to the title of my post: Thank goodness for The Labor Progress Handbook!
In my panic of "yikes my first birth might be a hospital birth medical induction stuck in bed omg how do I support a woman in this situation I'm freaking out!" I found exactly the information I needed in Penny Simkin's wonderful doula/care provider labor guide:

- Many caregivers restrict the woman with pregnancy-induced hypertension to bed in labor (and late pregnancy) because blood pressure is usually lowered while a woman lies on her left side. The book states that whether such treatment has resulted in improved outcomes or less progression of pre-eclampsia is not known.

- While caring for a woman who is restricted to the bed with PIH, explain why left-sided bedrest is being asked of her, help her focus on comfort measures that she can use in bed, such as relaxation, breathing patterns, vocalization, guided imagery and visualizations, other attention-focusing measures, massage of back and feet. If some walking is acceptable, have her walk to the bathroom and to the shower or tub. Water therapy frequently lower high blood pressure.

- Assess her emotional state. Raise spirits by having her wash her face, brush her hair, play upbeat music, have a new visitor come chat with her optimistically. She may benefit from a good cry. Acknowledge her frustration and giver her a pep talk.

- Women restricted to bed may still be able to use position changes to improve labor progress (and coping). If the mother does not have any indicators of malposition it is appropriate to try to "rollover." The bed-ridden woman spends 20-30 minutes in each of the following positions: semi-sitting, left-side-lying, left semi-prone, hands and knees lean, right semi-prone, right side-lying, and back around again.

Panic over  :]

Doula Musings

I've noticed that Prenatal meetings with first-time moms go very differently than with experienced moms. First-timers listen intently, like a student, absorbing everything I talk about and waiting for more. They ask questions but the meetings are very much led by me. Previous birth-ers talk a lot about what they know, what they've experienced, what they're hoping for next time. Its a lot less teaching, but I still want to be sure they have even better information/support than they had before!

I went to a Bradley class with one of my mamas! Bradley is one type of childbirth education workshop options. It is referred to as "husband-coached childbirth" and is a lot about getting the dad involved as the birth partner. I was perusing the workbook and apparently Bradley method is very big on drinking a lot of orange juice? For both mom and coach? I asked my client about it and she shrugged and said its something about getting fluids + vitamin C. Interesting.

I really enjoyed attending the childbirth class. I got to be referred to as "the doula" in front of a group of people, including by the workshop leader, which was extremely exciting for me. I learned what was being taught to my client, and compared it to what I knew. I learned some possible techniques for turning a mal-positioned baby in addition to some I already knew. Here is a list:

1. Positive thinking and visualization.
2. Walking around/squatting/swimming in a pool.
3. Breech tilt - lay on back and prop legs up to lift hips higher than head
4. Put music in your pocket so baby wants to turn towards the sound
5. Place cold on top of your tummy and warm beneath your bottom (heating pad or shallow bath water). Baby will want to turn towards the warmth.
6. Child's pose with your hips higher than your head can also lift baby out of pelvis.

7. Chiropractor - Webster's breech technique
8. Acupuncture/moxibustion
9. External Version

We also did a review of what the stages of labor would be like for mom and labor coach. Plus 30 minutes of labor rehearsal, with 1 min long contractions every two minutes walking, sitting, laying down. It was great for getting comfortable with one another.

The workshop leader was big on her phrase "Shake Your Booty" as a solution for everything - mal-positioned baby? Put on some music and shake your booty. Labor stalling? Shake your booty. Haha. It was pretty cute.

My first mom (home birth) texted me yesterday letting me know that she's been contracting a lot the past few days and she thought she was in labor a couple times now already and been wrong. So I'm still waiting with bated breath...

Shoulder Dystocia

Shoulder Dystocia is a type of difficult childbirth in which the baby's shoulders get stuck in the pelvis after the head is delivered and additional action must be taken to get the baby out. It occurs in less than 1% of all births.

A common strategy to deal with shoulder dystocia is the McRoberts Maneuver, in which the mother, already in a lithotomy position (on her back) legs are pushed tightly up against her stomach.  An obstetrician will also frequently cut an episiotomy to help the baby out, although it is not the perineum, but the pelvic bone, that is holding the baby back.

Here is a video of the McRoberts Maneuver:


Suprapubic pressure
Pushing on the top of the pubic bone in an attempt to widen it.

Zavanelli maneuver
Involves pushing back the delivered head into the birth canal and then performing a Cesarean section. A study on 9 cases using this maneuver in 1988 found:

In one of these cases, the fetal head “remained outside the vulva for twenty to twenty-five minutes before it was reinserted” and the baby was delivered by cesarean. There was one stillbirth among these nine cases, one mother suffered from sepsis and subsequent hysterectomy, one baby was born with an Apgar score of 1/4 but was reported normal at age seven, and one baby currently has some degree of mental retardation.

 Another study in 1993 found even more infant problems, and

Maternal complications included two ruptured uteruses, three lacerations of lower uterine segments, six transfusions, and eight morbid postoperative courses. (The All-Fours Maneuver for Reducing Shoulder Dystocia During Labor)

The Gaskin Maneuver, or the All-Fours Maneuver
The woman turns over onto her hands and knees, which flexes and widens the pelvis.

I introduced the all-fours maneuver in the United States in 1976, after learning about it from a Belizean midwife who had, in turn, learned it from Mayan midwives in the highlands of Guatemala.

 Out of 4452 births in the study and 82 babies with shoulder dystocia,

Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.

“The most significant observations of the study were the negative findings. No still births or neonatal deaths were reported. Not a single infant suffered Erb palsy, either transient or permanent, and no newborns experienced seizures, hemorrhage, hypoxic-ischemic encephalopathy, cerebral palsy, or fractured clavicle. No patients required any tocolytic medication during labor. No vaginal, cervical, or uterine lacerations occurred. No women required transfusions. And no cases of postpartum, ileus or pulmonary embolus were reported. Overall, the maternal complication associated with the use of the “Gaskin Maneuver” was 1.2 percent (one case of postpartum hemorrhage, transfusion not required), and the neonatal complication rate was 4.9 percent. . . None of these patients required any additional maneuvers. . . Not only was the Gaskin Maneuver instrumental in relieving shoulder impact in every instance, it is also a non-invasive procedure requiring only a change of maternal position.” The average time needed to assume the position and complete the delivery was 2-3 minutes, with the longest reported interval being 6 minutes. (The All-Fours Maneuver for Reducing Shoulder Dystocia During Labor)

The Gaskin Maneuver may not be useful, however, if the mother has been numbed by an epidural anesthesia.  And it is not easy to do if the mother is hooked up to several monitors and an IV.

External Version

"If the midwife has determined in the course of the [prenatal] massage that the baby is in a breech (bottom-first) or transverse (side-lying) position, she will do an inversion, an external version of the baby in utero." - Yucutan, Mexico. Brigitte Jordan, Birth in Four Cultures

When I first read that, for some reason my mind went to an image of a traditional midwife making a model of the baby that she would use to "symbolically" turn the baby. Ha, shows how I used to think about the efficacy of a traditional Mexican midwife's practices. yeesh. 

An external version is actually of a turning of the baby inside the mom's tummy! How fantastic is that? 


These days, a breech or transverse baby is usually identified by prenatal ultrasound scans.

External cephalic version was widely performed in the U.S. until the 1950's, and is commonly employed by traditional midwives the world over, as well as by trained midwives and physicians in Europe.  In the US the standard management strategy for breech birth and other malpresentations is the Cesarean section.

"[The Midwife] locates the baby's head and hip and by applying strong, even pressure to these parts, shifts the baby's body into the more favorable head-down position. This procedure is sometimes painful but since the perceived alternative is a Cesarean section in the hospital, the women much prefer to tolerate a few minutes' discomfort at home. [She] will do a version as often as necessary from the eigth month on, up to the time of birth."  - Yucutan, Mexico. Brigitte Jordan, Birth in Four Cultures

Today, in the medical setting, breech external versions are done at the doctor's office. A nonstress test and ultrasound are used to assess the baby's well-being. The mother may be given an injection of terbutaline to relax her uterus. She may also be given an epidural to relax the abdominal muscles and prevent pain from the procedure, but this is time-consuming and expensive. With the guidance of an ultrasound the doctor presses on her abdomen to lift the baby out of the pelvis and turn the baby head-down. This is usually only done after 36 weeks. On the rare occasion that labor begins or the fetus or mother develops a serious problem during version, an emergency cesarean section (C-section) may be done to deliver the fetus.

Versions are successful 60-70% of the time. 


They are most likely to succeed when:

• The mother has already had at least one pregnancy and childbirth.
• The fetus, or a foot or leg, has not dropped down into the pelvis (has not engaged).
• The fetus is surrounded by a normal amount of amniotic fluid.

Potential Risks:
Potential risks of version, for which the fetus and mother are closely monitored, include:

• Twisting or squeezing of the umbilical cord, reducing blood flow and oxygen to the fetus.
• The beginning of labor, which can be caused by rupture of the amniotic sac around the fetus (premature rupture of the membranes, or PROM).
• Placenta abruptio, rupture of the uterus, or damage to the umbilical cord. The potential exists for such complications, but they are very rare.

I was just informed of an alternative form of Breech version that carries fewer risks and a higher success rate - The Webster Breech Version.


Chiropractic Care: The late Larry Webster, D.C., of the International Chiropractic Pediatric Association, developed a technique which enabled chiropractors to release stress on the pregnant woman's pelvis and cause relaxation to the uterus and surrounding ligaments. The relaxed uterus would make it easier for a breech baby to turn naturally. The technique is known as the Webster Breech Technique.

The Journal of Manipulative and Physiological Therapeutics reported in the July/August 2002 issue that 82% of doctors using the Webster Technique reported success. Further, the results from the study suggest that it may be beneficial to perform the Webster Technique in the 8th month of pregnancy.


To add, other than the manual manipulation of the baby there are other ways to promote the turning of a baby, such as visualization, body positions such as the pelvic tilt and knee-chest, using a rebozo, and so on!

Kangaroo Care

from www.kangaroomothercare.com

What is it? 

A universally available and biologically sound method of care for all newborns, but in particular for premature babies, with three components ...

1 Skin-to-skin Contact
2 Exclusive breastfeeding
3 Support to the mother infant dyad

"Invented" in 1979 - Dr Rey and Martinez started programme in Bogota, Colombia, in response to shortage of incubators and severe hospital infections.

Effects:

The baby has a stable heart rate (no bradycardia), more regular breathing (a 75 percent decrease in apneic episodes), improved oxygen saturation levels, no cold stress, longer periods of sleep, more rapid weight gain, more rapid brain development, reduction of "purposeless" activity, decreased crying, longer periods of alertness, more successful breastfeeding episodes, and earlier hospital discharge. Benefits to the parents include "closure" over having a baby in NICU; feeling close to their babies (earlier bonding); having confidence that they can care for their baby, even better than hospital staff; gaining confidence that their baby is well cared for; and feeling in control—not to mention significantly decreased cost! (Midwifery Today)

Biologically, we know that the newborn is born with the skills and behaviours it needs to grow and be well, all it needs is to be undisturbed in skin-to-skin contact with mother, and it will breastfeed.

From evolutionary arguments we understand that the baby is extremely immature, and that its well-being is dependent on continuing its gestation in skin-to-skin contact with mother, and that the mothers milk is uniquely adapted top the immature gut.

Anthropology provides ample evidence that the behaviour we infer or deduce from biology and evolutionary arguments is in fact the normal behaviour for the human race: newborns and babies should be in constant contact with mother and should exclusively breastfeed.

Neurology can explain the mechanisms that we observe when baby is in skin-to-skin contact and when it is separated.

Physiology and research provides overwhelming evidence that Kangaroo Mother Care is not only safe, but superior.

For infants born too soon, being premature on top of being immature: continuing the gestation on mothers skin-to-skin contact and with breast milk is even more important than for fullterm infants.

The above contrasts starkly with twentieth century high technology practice, in which separation of mother and child is accepted as necessary and normal.

Separation is common, but abnormal and harmful.

Placenta Previa and Placenta Accreta

Turns out my mother's birth experience with me involved her placenta not coming out after I did. In hospitals they only wait 30 minutes for the placenta, even though it has been known to take up to two hours after birth to come out safely. However, in the hospitals they worry about placenta accreta, or the placenta remaining attached to the uterine wall, which can cause severe bleeding. Thusly, they anesthetized my mom and went in and got it! So today's lesson, for myself and any readers, will be on placenta accreta.

The condition of the placenta attaching too deeply to the uterine wall is known as either placenta accreta, placenta increta, or placenta percreta, depending on the severity and deepness of the placenta attachment. Approximately 1 in 2,500 pregnancies experience placenta accreta, increta or percreta.

The cause is unknown, though it can be related to either previous cesarean deliveries or a condition known as placenta previa. This occurs when the uterus is covering the cervix and is diagnosed during pregnancy. Placenta accreta is present in 5% to 10% of women with placenta previa. Placenta accreta if difficult to diagnose and is usually not confirmed before labor.

 If it occurs in childbirth, the placenta will be manually removed before there is too much hemorrhaging. In severe cases a hysterectomy, or the removal of the uterus, may be required.


My mother doesn't really remember it, she says she was groggy, so she's not sure if she actually had placenta accreta or maybe just a retained placenta and they were worried about placenta accreta.


There are ways to help your placenta along if it is taking a while. Breastfeeding the baby or nipple stimulation helps the uterus to contract and expel the placenta. Occasionally, changing to an upright position lets gravity help the placenta out. You may also have a managed third stage, where you're given an injection of oxytocin to make your uterus contract.

By the way, I don't recommend a google image search of 'retained placenta.' Its mostly cows.