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Door County Doula

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Systematic Review Provides Definitive Evidence of the Benefit of Delayed Cord Clamping

Summary: In this systematic review, researchers compared the effects of immediate and delayed cord clamping in babies born full-term. Following the usual methodology of systematic reviews, reviewers searched the literature, identified all published controlled trials that were relevant to the topic, and applied predetermined criteria to decide which studies to include. They then assessed the methodological quality of the included studies, using a standard grading scheme to rate each as either high or low quality. When more than one trial reported on a particular outcome, researchers used a statistical technique to pool their data (meta-analysis), which increases the power to detect differences between groups. Whenever feasible, the researchers reanalyzed data using only the high quality studies to determine if the weaknesses of the lower quality studies might have affected review results.

Fifteen trials involving 1912 newborns were included. In all but one of the trials, early cord clamping was defined as occurring immediately after birth or within 10 seconds, with the remaining trial allowing up to 60 seconds in the early clamping group. Delayed clamping was typically defined as occurring at three minutes or after the cord stopped pulsing, with one study defining delayed clamping as occurring two minutes after birth.

Delayed cord clamping was associated with an 80% reduction in newborn's likelihood of being anemic at 24-48 hours and half the risk of being anemic at 2-3 months. Statistically significant differences disappeared by 6 months. Delayed cord clamping also improved hematologic status (hematocrit level, mean hemoglobin level, and blood volume) in the hours after birth, as well as increasing mean serum ferritin levels (an indicator of iron deficiency) in both the short and long term. Immediate cord clamping has been justified on the theoretical grounds that late cord clamping would increase the incidence of symptomatic polycythemia (elevated red blood cell count), respiratory difficulties, and neonatal jaundice. However, babies in the delayed clamping group were no more likely to have clinical jaundice or to require phototherapy for elevated bilirubin levels than babies in the early clamping group. Similarly, there were no differences between the two groups in the likelihood of respiratory difficulties or admission to neonatal intensive care. While polycythemia was more common, this increase was not clinically important as no baby experienced clinical symptoms. One possible explanation for this is that laboratory norms have been set artificially low because they were determined in populations where immediate clamping was routine.

Significance for Normal Birth: Immediate cord clamping has been performed routinely for decades without evidence of benefit. Placental transfer of oxygenated blood, nutrients and stem cells continues for several minutes after birth. Physiologic principles suggest that the optimal transition to life outside the womb depends on this transfer. By emptying the engorged placenta, blood volume transfer to the newborn may also facilitate normal placental detachment. And, of course, delayed cord clamping keeps babies in their mother's arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding. This may be an important first step in promoting non-separation of mother and baby after birth. This systematic review provides the "gold standard" of evidence that immediate cord clamping is harmful for babies. It also reminds us that any routine interference in the normal physiology of birth, no matter how benign it seems, may have far-reaching ill effects. Childbirth educators and other birth professionals play a crucial role in informing women about the importance of delaying cord clamping for at least several minutes after birth.

 

Digital Rotation:
 When the Baby is OP Decreases Need for Cesarean Section and Instrumental Vaginal Delivery

Summary: In this prospective, controlled trial, researchers studied the effect of digital or manual rotation of the fetal head from occipito-posterior (OP) to occipito-anterior (OA) on mode of birth, position of the baby at birth, length of hospital stay, perineal integrity, Apgar score, and other obstetric and neonatal outcomes. Digital rotation is a technique where the physician or midwife applies pressure with the fingertips against the baby's head to help it turn to a more favorable position. Manual rotation is a variant using the practitioner's whole hand.

Nulliparous women were eligible for the study if they were in labor at term, the baby was engaged in the OP position, and at least one hour of second stage had elapsed (90 minutes if the woman had an epidural). Multiparous women had to meet the same criteria except that they were eligible after 30 minutes of second stage labor (1 hour if using an epidural). Women carrying a suspected macrosomic baby or who had previously had cesarean surgery were excluded. During the first six months of the study, 30 women were enrolled in the study as controls: they met study eligibility requirements but did not undergo digital rotation. In the second six month period, 31 women (the rotation group) met eligibility requirements and underwent digital or manual rotation of the fetal head by a physician or midwife experienced in the technique. Researchers confirmed OP position by ultrasound in the rotation group but relied on digital examination alone for the control group. While digital examination is not as reliable as ultrasound in the diagnosis of OP position, 85% of the babies in the control group eventually gave birth to a baby who was OP, suggesting that the diagnosis was accurate at least 85% of the time. To avoid possible bias, the clinicians who performed rotations did not participate in the woman's care thereafter.

Among women who underwent digital or manual rotation, 77% had spontaneous vaginal births compared with only 26% of those in the control group. They were also much more likely to give birth (regardless of mode of birth) to babies in the OA position (93% vs. 15%). None of the women who underwent rotation had a cesarean delivery compared with 23% of those who did not undergo rotation and vacuum-assisted delivery was also significantly less likely, with 23% in the rotation group versus 50% in the control group. All of these differences were highly statistically significant (very unlikely to be the result of chance). Duration of second stage was an average of 39 minutes shorter and the women were discharged almost a day earlier in the rotation group. Episiotomy was significantly more likely in the control group (65% versus 30%) Other outcomes, such as low Apgar scores and likelihood of postpartum hemorrhage or infection, were similar across the two groups, although the study was too small to detect differences in uncommon adverse outcomes.

Significance for Normal Birth: When a baby is engaged in a posterior (OP) position during the second stage of labor, a large body of research suggests that the likelihood of vaginal birth is highly dependent on whether the baby rotates to an anterior (OA) position. Maternal hands-and-knees positioning has been associated with successful rotation to OA in at least one trial (Stremler, Hodnett, Petryshen, Stevens, Weston, & Willan, 2005) but may be difficult for women using an epidural, which sharply increases the chance of persistent OP (Lieberman, Davidson, Lee-Parritz, & Shearer, 2005). Forceps rotation is also effective but is risky for both the mother and the baby. Some practitioners perform vacuum-assisted rotations but this method has not been studied for safety and there is anecdotal evidence of harm (Society of Obstetricians and Gynaecologists of Canada, 2005). This trial provides evidence that manual and digital rotation are effective alternatives to instrumental rotation, and while larger studies are needed to have complete confidence about safety, this uncertainty must be balanced against the known harms of cesarean surgery, instrumental vaginal deliveries, and episiotomies.

While digital rotation is a relatively straightforward procedure, it is still considered among the obstetric "arts" in that it is a skill honed through experience that not every practitioner possesses. However, this study suggests that many if not most cesarean sections and instrumental vaginal births for persistent posterior position in second stage can be safely prevented with digital rotation. If a laboring woman is presented with the need for an operative delivery for prolonged second stage in the presence of fetal malposition, she should be informed that digital rotation is a low-risk alternative and arrangements should be made to provide access to a practitioner who can perform it if hers is unable. Pregnant women should also be advised that epidural analgesia can increase the likelihood of persistent malposition and of the potential consequences of this complication.

 

Epidural Use in Labor Appears to Disturb Newborns' Physiologic Response to Skin-to-skin Contact

Summary: In this prospective observational study, researchers examined the normal physiologic skin temperature patterns in breastfeeding newborns held skin-to-skin two days after birth and compared findings in babies whose mothers had received epidural analgesia and oxytocin in labor or oxytocin alone with those whose mothers were not exposed to either intervention. First-time mothers giving birth on a weekday to healthy, full-term, singleton infants with a 1-minute Apgar score of at least 8 were recruited and remained eligible if they were not separated from their babies after the birth and the babies were exclusively breastfed. The study took place in Sweden, where usual care includes immediate and prolonged skin-to-skin contact after the birth and rooming-in. At the maternity hospital where the study was conducted, sufentanil (an opioid that crosses the placenta) was included in the epidural preparation. In total, 47 mother-infant pairs participated in the study, 9 of whom underwent oxytocin augmentation (oxytocin group), 20 of whom had received both epidural analgesia and oxytocin in labor (epidural group), and 18 of whom had neither intervention (control group). Clinical characteristics across the three groups were similar except with respect to the use of nitrous oxide, which was more common in the epidural group.

On the second postpartum day, after exhibiting signs of hunger (e.g., rooting), each infant was undressed, weighed, placed skin-to-skin on the mother, and covered with a light blanket. The researchers documented interscapular (between the shoulder blades) temperatures immediately after the mother and infant established skin-to-skin contact, and at 5, 10, 20, and 30 minutes after the first reading. They also documented the time of onset and duration of breastfeeding as well as the environmental temperature in the maternity rooms. The temperature at the moment breastfeeding began was not documented, so the interval reading preceding onset of suckling was used as a proxy.

At the moment skin-to-skin contact commenced, babies in the epidural group had significantly higher temperatures than those in the control group. Epidural-exposed babies also exhibited a significant negative correlation between their age (in hours) and their temperature, such that the younger the baby, the higher the temperature at the first reading. This finding correlates with the well-documented finding that epidural analgesia raises maternal and newborn temperatures. In both the control group and the oxytocin group, temperatures rose significantly over the first 10 minutes of skin-to-skin contact and then remained stable, with the plateau level among control group babies slightly lower than that exhibited by oxytocin-exposed babies (35 vs 36 degrees Celsius). In contrast, temperatures in the epidural-exposed babies decreased significantly during the first 10 minutes, and then remained relatively stable around 34.5 degrees Celsius. In the control group, the temperature rise occurred after the onset of suckling and continued beyond five minutes. In contrast, temperatures rose in the oxytocin group immediately upon skin-to-skin contact and did not continue to rise after several minutes of suckling. In the epidural group, no temperature rise was noted after the onset of suckling.

Significance for Normal Birth: This small study does not provide strong evidence of any particular harm from epidurals or oxytocin augmentation. Rather, it serves as a cautionary tale of the wide-ranging and unpredictable disturbances caused by intervening in the normal process. For the first time, researchers have demonstrated the normal temperature patterns in babies on the second day of life who have not been separated from their mothers and who are held skin-to-skin. They have further demonstrated that interventions that took place in labor are associated with disturbances in this normal physiologic response many hours later. The complex hormonal changes that occur during skin-to-skin contact in the postpartum period are just beginning to be understood. However, evidence suggests that these hormonal shifts modulate newborns' feeding and bonding behavior, temperature stability, and how much they cry as well as the mother's mood. It is possible that some babies will not be able to reap the full benefits of skin-to-skin contact if they are not able to respond to this stimulus as nature intended. More research is needed to determine the clinical significance of the temperature pattern disturbances observed in this study. Given the evidence that epidurals containing fentanyl (a drug closely related to sufentanil) increase the risk of early breastfeeding cessation (Beilin, Bodian, Weiser, Hossain, Arnold, Feierman, et al., 2005), it is possible that such disturbances represent a pathway by which that labor interventions may impact newborn feeding behavior.

 

Study Sheds Light on the Prevalence and Nature of  "Maternal Request" Cesarean Sections

Summary: This study combined qualitative and quantitative methods to evaluate the perceptions of both women and obstetricians of so-called "maternal request" cesarean sections. Four substudies comprised the study. In the first, 64 pregnant women (23 multiparous, 41 nulliparous) completed questionnaires about their wishes for their birth as well as information about past pregnancies and births. They then kept diaries throughout their pregnancies, recording information about events that occurred that affected their desires related to mode of birth. In the second substudy, researchers interviewed women who considered or were asked to consider cesarean sections during their pregnancies. In both of the first two substudies, women who had previously given birth by cesarean section were apparently included. In the third substudy, researchers interviewed 24 obstetricians, five of whom were specifically recruited to the study because of their strong views on one side or the other of the "maternal request" cesarean debate. Finally, 785 obstetricians completed postal questionnaires about their experience with maternal request cesarean section and their perceptions of its contribution to the overall rise in the cesarean section rate. The study took place from 2000-2001 in the United Kingdom.

Among women, concern for the safety of the baby tended to take priority over preferences about the mode of birth. Cesarean section was widely perceived as safer than vaginal birth for babies and many participants expressed an assumption that risks to the mother were minor. Only one nulliparous woman (2.6% of nulliparas) desired a cesarean section when asked early in her pregnancy what she would like for the birth of her baby. Among multiparas, 26% wanted a cesarean section early in their pregnancies, but some if not all of these women may have given birth by cesarean previously (the researchers did not specify). In women interviewed postnatally, 8 women asked for and had elective cesareans, but all 8 believed they had clinical justification for the operation, such as history of a previous loss or preexisting problems with their pelvic floor muscles. Among all respondents, fear of pain, a traumatic vaginal birth, or an unplanned cesarean after a difficult labor were common and arose from women's own experiences as well as from comments from health professionals, families, and friends. The obstetricians who were interviewed echoed the role of fear in prompting women's requests for cesarean sections, and some felt that women asking for elective cesarean sections were actually asking for a guarantee of the baby's safety more than a specific mode of birth. While the doctors stressed the importance of taking time to talk to women and explore safe and acceptable alternatives, some felt that they lacked the time necessary to do this properly.

Among the physicians responding to the survey, 55% reported having six or fewer requests for elective cesareans in the previous 12 months, including 4% who had had none. Despite this, 77% of obstetricians cited "maternal request" as one of the three main reasons for the rising cesarean rate in the UK. This was the most popular response given, with "litigation and defensive practice" cited by 67% of doctors. Qualitative data from the interviews suggested that that some doctors may have been known for performing elective cesareans and were therefore sought out by women wanting this option. Quantitative data from survey respondents seemed to support this: 28% of the doctors reported receiving two-thirds of the total requests.

Significance for Normal Birth: There is a widespread and growing public perception - reinforced by media reports - that women are to blame for the rising cesarean rate because they increasingly want medically unnecessary cesarean surgeries. Yet this study and the other available evidence suggest that cesareans done purely for maternal request are rare. This study sheds light on the nature of the contradiction and provides evidence about what motivates the women who do consider elective cesarean surgery. Indifference about mode of birth and preference for cesarean section appear to be fueled by the erroneous belief that cesareans are less risky for babies than vaginal birth. Further, women worry about having traumatic or painful labor and birth experiences and some explore the option of scheduled cesarean surgery as a means to manage these fears. Childbirth educators and other birth professionals must begin to address these fears more effectively with women, especially when the care provider is unable or unwilling to adequately explore women's feelings, beliefs, and concerns. We also must correct misinformation that leads women to think that vaginal birth is risky for babies or that cesarean section is a panacea that averts poor outcomes. Finally, we must recognize that framing the issue as one of "maternal request" is disingenuous at best and deceitful at worst, considering the evidence that women infrequently ask for elective cesarean sections and that those who do may be led to believe that their requests are medically justified. As advocates for better maternity care, we must work to refocus the debate on the obstetric practices and policies, such as routine electronic fetal monitoring or liberal use of induction, for which there is strong evidence that they put women and babies at risk for preventable cesareans.

 

Pilot Study Suggests Midwifery Care Is Optimal for Moderate-Risk Women

Summary: This study compared the pregnancy, birth and postpartum care practices and outcomes experienced by 196 moderate-risk women receiving nurse midwifery care with those of 179 similar women receiving physician care in the same hospital-based faculty practice. Each woman was assigned an "Optimality Index - US" score, calculated from 40 variables measuring optimal health status, care practices and outcomes. A companion "Perinatal Background Index" (PBI) score that captured demographic and health history was also assigned. Together, the two scores provide a valid measure of the process and outcomes of care within the context of the clinical situation of the individual woman.

Women in the midwife group had significantly higher optimality scores than women in the physician group (79% versus 70%). While some of this difference was attributable to differences in baseline medical risks (as measured by significant differences in PBI score), statistical analysis revealed that the provider type (i.e. midwife or physician) was twice as predictive of optimality scores. The cesarean section rate was 13% among women in the midwife group versus 34% in the physician group, a difference that also was not explained by health status alone. (The rates were 5.6% and 15.6% respectively after excluding women with preexisting chronic medical conditions.) In various statistical analyses, only type of provider accurately predicted cesarean rates in the two groups.

Women in the midwife group were more likely to drink or eat (95% versus 80%), maintain mobility in labor (68% versus 28%), and use non-pharmacologic methods of pain relief (88% versus 51%). Epidural use was lower in the midwife group (31% versus 51%), as was use of any pharmacologic pain relief methods (64% versus 82%).

Significance for Normal Birth: Traditional measures of maternity care outcomes have focused on morbidity and mortality indicators. This approach has several drawbacks. In the United States morbidity and mortality are fortunately rare, so studies assessing these outcomes must be large in order to demonstrate significant differences. Furthermore, these "negative" indicators are poor measures of the effectiveness of care that is intended to promote "positive" outcomes like health and wellness in population experiencing a physiologically normal process. The Optimality Index - US has emerged as an important new tool for measuring maternity care to capture both the process and outcomes of different styles of practice.

In this and other studies, midwifery care has been associated with high optimality, demonstrating appropriate use of interventions and good outcomes given the individual women's clinical situations. Midwives are often assumed to care for only low-risk women but many midwives also care for women at moderate or high risk. This study finds that midwifery may be optimal for moderate risk population by promoting good outcomes with less reliance on technological and surgical intervention and a greater attention to the care practices that support normal birth.

 

Anal Sphincter Tears Highly Associated with Obstetric Management Practices in Vaginal Birth

After adjusting for maternal age, race and gestational age, all six modifiable factors were significantly associated with anal sphincter tears. Combining modifiable factors yielded very high increases in risk for anal sphincter damage. For instance, having a forceps assisted birth resulted in 13.6 times the likelihood of anal sphincter tear and an episiotomy was associated with 5.3 times the risk, but women who experienced both an episiotomy and a forceps-assisted birth had 25.3 times the risk of anal sphincter tear compared with women without risk factors. The highest risk for anal sphincter tear was found among women who had an epidural, forceps and an episiotomy. The only combination that did not appreciably increase risk was an OP baby with vacuum extraction.

Significance for Normal Birth: Third and fourth degree perineal tears are highly associated with pain and incontinence in the postpartum period and contribute to long-term pelvic floor dysfunction. Unfortunately, this argument has fueled the debate about the rights of women to choose medically unnecessary cesarean surgeries rather than prompting examination of the obstetric management practices that have been contributing to excess risk of anal sphincter damage in vaginal births. This study provides evidence of a strong link between modifiable obstetric practices such as episiotomy, epidural use, and instrumental vaginal birth, and anal sphincter tears. This study also reinforces that when instrumental vaginal delivery becomes necessary, episiotomy should be avoided and that vacuum extraction is less likely to injure the anal sphincter than forceps delivery.

While there will always be some instances when these interventions are necessary for fetal or maternal wellbeing, their overuse is contributing to excess maternal morbidity with long-term consequences. Care practices such as avoiding routine interventions, promoting comfort in labor through mobility and nonpharmacologic techniques, and encouraging physiologic, spontaneous pushing in non-supine positions (none of which were assessed in this study) minimize the risk of severe lacerations both directly, in the case of spontaneous non-supine pushing, and indirectly, by reducing the need for epidural, promoting optimal positioning of the fetus, and reducing forceps and vacuum use.

 

Acupuncture after PROM at Term Shortens Labor and Reduces Use of Oxytocin

Summary:The aim of this Norwegian clinical trial was to determine if acupuncture treatment affected the course of labor or need for artificial induction or augmentation in women with prelabor rupture of membranes at term (PROM). Women who had confirmed PROM and were carrying singleton babies in the head-down position were randomized to receive acupuncture (n=48) or no acupuncture (n=52). Midwives provided a 20-minute acupuncture treatment that stimulated nine different points. Pharmacologic induction was initiated in both groups if labor had not started by 24 hours after membrane rupture.

The active phase of labor was significantly shorter in the acupuncture group (4.4 hours versus 6.1 hours), a relationship that became even stronger after controlling for parity, epidural use, and infant birth weight. When the analysis was limited to those women who underwent induction, active phase of labor was twice as long in women who did not receive acupuncture compared with those who did. Acupuncture was also associated with less use of oxytocin for augmentation of labor. There were nonsignificant differences in instrumental vaginal birth, rate of induction, and time from rupture of membranes to birth, all favoring acupuncture. There were no adverse fetal, neonatal or maternal effects of acupuncture treatment.

Significance for Normal Birth: While the large majority of women will go into labor on their own after membranes rupture at term, many providers encourage pharmacologic induction out of concern about infection. There is minimal evidence that a policy of routine induction for PROM prevents infection and several studies report increases in cesarean rates with induction for PROM versus expectant management. Furthermore, pharmacologic induction always brings with it other interventions such as intravenous lines, electronic fetal monitoring and restrictions on mobility in labor, transforming a normal birth into a medicalized one and introducing potentially unnecessary risks. Low-risk techniques to encourage labor to start may be beneficial in preventing complications of both prolonged membrane rupture and aggressive induction protocols.

This small but well-designed study suggests that acupuncture treatment influences labor initiation and progress in women with PROM. A larger trial may be able to confirm an effect on mode of birth, rates of induction and/or likelihood of infection. But in the meantime, the fact that acupuncture has not been shown to be harmful to birthing women or their newborns suggests that it is an optimal first-line approach when encouraging labor to start is desirable.

 

Gap Between Expectations and Experiences May Affect Women's Ability to Adapt to Early Labor

Summary: In this qualitative study of women's experiences in early labor, researchers interviewed 23 women who had recently given birth for the first time about their labor experiences and management strategies used prior to hospitalization. Qualitative data from the 60-90 minute semi-structured interviews were analyzed to identify central and supporting themes of the women's responses. Participants were primarily Caucasian and well-educated and all of them were partnered and had attended childbirth preparation classes.

"Confronting the relative incongruence between expectations and actual experiences" (p. 348) emerged as the central theme. The women tended to have very defined expectations of the performance aspects (i.e., what to do) in early labor but were more uncertain about what labor would feel like. This disconnect meant that women had to readjust and reappraise their expectations as early labor set in. They tended to overlook or downplay symptoms of labor onset, or to attribute them to other causes such as bladder infection, gastrointestinal upset or "overdoing it." Women used a combination of learned strategies, suggestions from others and intuition to manage the physical and emotional demands of labor, using techniques that were often at odds with their original plans for early labor. The strategies used were varied and tended to address many different needs, including promoting comfort, preparing for hospitalization, and garnering support and reassurance. Husbands, family members, friends and doulas played important roles in supporting the women as they made decisions about their labors and managed the sensations they were experiencing. However, when more than one person was providing early labor support, unanticipated conflicts among the support companions and the need to negotiate and collaborate were frequently reported. The women reported ambivalence and uncertainty about the need for and timing of hospitalization and several of the participants reported anxiety about the possibility of going in too soon and being sent home.

The authors conclude that "reappraisal and modifications of expectations and planned activities are additional tasks in the early labor experience for first-time mothers" and caution that "the notion that early labor is a light-hearted precursor to the 'real' work of active labor and delivery negates the complexities of the mind-body recognition of and adaptation to the birthing process. The fact that this crucial undertaking begins outside of the hospital setting should not minimize its significance within the continuum of childbirth." (p. 352).

Significance for Normal Birth: For women who choose hospital birth, there is mounting evidence that their likelihood of achieving vaginal birth is strongly influenced by how long they stay home. But simply advising women to stay home until active labor is well established may contribute to anxiety and confusion if we don't equip them with appropriate information, support, and anticipatory guidance. This small study suggests that women spend energy and time in early labor sorting out their expectations, devising new plans, managing mixed emotions, and second guessing decisions. Providing women with strategies to anticipate and deal with gaps between expectations and experiences may help them adapt better to early labor and have confidence in their management strategies. Reassessing how we teach women to self-diagnose labor - or introducing models that include home visitation or outpatient early labor assessment and support, as proposed by the study authors - may help women who choose hospital birth to optimize the timing of hospitalization to achieve normal births.

 

Cesarean Delivery Associated with Increased Risk of Neonatal Death

Summary: In this epidemiologic study, analysts compared neonatal mortality rates (death before 28 days after birth) according to delivery route in 5,800,000 babies born alive in the United States between 1998 and 2001 to women at "no indicated risk" for cesarean surgery or other poor outcome. "No indicated risk" was defined as singleton, term gestations (37-41 weeks), baby presenting head-down, no medical risk factors or complications of labor noted on the birth certificate, and no prior cesareans.

Significance for Normal Birth: Many doctors and women alike believe that delivery by cesarean is safer for babies than vaginal birth. The "premium baby" argument is particularly persuasive for women who have had difficulty conceiving or who anticipate having one or at most two children. It is difficult to disentangle neonatal deaths caused by complications that resulted in the need for cesarean surgery from risks attributable to the surgery itself. By isolating an ultra low-risk population of sufficient size to overcome that problem, this study establishes the falsehood of that belief. This is important information for women in a climate in which cesarean surgery is presented as benign if not superior to normal birth and in which cesareans are frequently undertaken casually and sometimes electively.

 

Systematic Review Shows Acupuncture, Self-Hypnosis Effective Non-Pharmacologic Pain Management Strategies

Summary: This Cochrane systematic review evaluated the effects of several complementary or alternative therapies on use of pharmacologic pain relief in labor, maternal satisfaction, and other obstetric outcomes. Using predetermined eligibility criteria, researchers identified fourteen trials involving 1537 women who were randomized to an alternative pain management modality, a placebo, no treatment, or pharmacologic forms of pain management.

Evidence from three trials involving 496 women suggested that women receiving acupuncture are less likely to require pharmacologic forms of analgesia (including epidural) and may have reduced need for oxytocin augmentation than women who received no treatment or "sham" acupuncture. Meta-analysis of five trials involving 749 women suggest that hypnosis reduces the need for pharmacologic forms of pain relief (including epidural) and improves maternal satisfaction and may result in higher rates of vaginal birth and less use of oxytocin augmentation compared with routine care. No evidence of significant benefit was found for acupressure, aromatherapy, massage, relaxation, or audio-analgesia; however, trials were few in number and extremely small in size for aromatherapy, massage, relaxation, and audio-analgesia, which means benefit cannot be ruled out. No evidence of harm was found for any of the interventions studied. Trials involving other forms of non-pharmacologic pain relief such as hydrotherapy and continuous labor support were not included in this review.

Significance for Normal Birth: Epidural analgesia, used by the majority of laboring women today, while effective, restricts women's freedom of movement and typically necessitates routine or frequent use of interventions such as intravenous lines, continuous electronic fetal monitoring, oxytocin augmentation, and bladder catheterization. In short, epidurals and other pain relief drugs often transform a normal labor into a medicalized event. Epidural use is also associated with an increased risk of instrumental vaginal delivery, intrapartum fever, fetal malposition, and anal sphincter laceration (Lieberman & O'Donoghue, 2002). Opioids do not provide sufficient pain relief for many women and increase the risk of neonatal respiratory problems. Nonpharmacologic modalities, if effective, have the potential to avoid these harms while maintaining or enhancing women's satisfaction with the birth experience. This systematic review provides the "gold standard" of evidence that acupuncture and hypnotherapy are effective alternative pain relief methods.

 

Amniotic-Fluid Embolism Associated with Induction of Labor

Summary: This epidemiological study analyzed factors associated with amniotic-fluid embolism (AFE) in 3 million women delivering singleton infants in Canadian hospitals between 1991 and 2002. Overall, 180 cases were diagnosed from hospital discharge records for a rate of 6.0 per 100,000 births. Of these, 24 (13%) were fatal for a maternal mortality rate of 0.8 per 100,000 births. After taking into account confounding factors, medical induction, i.e. induction with oxytocin or prostaglandins, remained an independent risk factor, nearly doubling the risk of AFE (adjusted odds ratio 1.8, 95% confidence interval 1.3 - 2.7). Medical induction of labor conferred an excess risk of AFE of 4-5 per 100,000 births compared with spontaneous labor onset and an excess risk of maternal death of 1-2 per 100,000 births.

In the U.S., where 4 million women give birth annually, and the induction rate is about 20%, the authors calculated that inducing labor results in 30-40 excess cases of AFE per year and 10-15 maternal deaths. (Reviewer's note: Listening to Mothers II, a national survey of women giving birth in 2005, reported that 34% of labors were induced, according to the women themselves (Declercq et al., 2006). This increases the number of excess AFE cases to 55-70 per year and maternal deaths to 15-25.) Surgical induction, i.e. induction by rupturing membranes, was not associated with AFE.

Other factors positively associated with AFE were maternal age = 35 years, cesarean section, vaginal instrumental delivery, placenta previa or abruption, eclampsia, polyhydramnios, cervical laceration or uterine rupture, and fetal distress. Study authors note that the association with cesarean section is likely to represent the consequences of AFE, not a cause, although cesarean as a causal factor cannot be ruled out.

Significance for Normal Birth: Amniotic fluid embolism is thought to arise when simultaneous tears in the fetal membranes and uterine blood vessels permit amniotic fluid to enter the maternal venous circulation. It is not known what substances in amniotic fluid cause the sudden breathing difficulties and cardiopulmonary collapse that constitute the syndrome, but one theory is that it is an anaphylactic reaction to exposure to fetal cells and other components of amniotic fluid in susceptible women. Uterine stimulation has long been suspected of being a contributing factor, but AFE's rarity has made determining this difficult. This study is the first one of a population large enough to have the statistical power to detect a difference between groups, and its findings confirm the association. The extremely small possibility of AFE should not deter induction for compelling medical reasons, but many inductions are undertaken electively or for less than compelling reasons. In these cases, because of its catastrophic nature, the excess potential for AFE should be given serious consideration.

 

Continuous Support by Lay Doulas Improves Obstetric Outcomes for Low-Income Women

Summary: In this randomized, controlled trial, researchers compared the obstetric outcomes of women laboring accompanied by family or friends without special training with those laboring with the added support of a family member or friend who had completed a brief "lay doula" training. Eligible low-risk nulliparas attending an ambulatory care center serving low-income, underinsured women were randomized during pregnancy to the doula (n=298) or control (n=300) group. Those randomized to the doula care group identified a female friend or relative to provide lay doula care and, together with her chosen companion, attended a 4-hour training course taught by a DONA-certified doula. The training course was provided in two, 2-hour sessions and was conducted in the location of the participants' choosing. Topics included an overview of childbirth, how to assess labor progress, coping strategies and comfort measures for labor, and supportive techniques such as praise, reassurance, and anticipatory guidance.

Women randomized to the lay doula group had significantly shorter labors and greater cervical dilation at the time of epidural analgesia and their newborns had higher Apgar scores at 1 and 5 minutes. No statistically significant differences were found in the rate of cesarean surgery, length of second stage of labor or overall epidural use. A secondary analysis of participants who actually received doula care versus those who did not (i.e., not intent-to-treat) showed the same significant findings and also revealed a non-significant trend toward a lower cesarean surgery rate in the doula group (10.6% versus 15.5% in the control group, p = .09).

Significance for Normal Birth: The results of this randomized, controlled trial are consistent with those of other well-designed trials and systematic reviews of doula care in labor. The authors of the study suggest that professional doula care may not be affordable or accessible to low-income women nor cost-efficient for hospitals to provide. A model in which a brief training is provided to a female companion of the pregnant woman's choosing may overcome these obstacles and appears to result in many of the same benefits as have been found with traditional doula care. However, more research is warranted to determine the feasibility of replicating the training model used in this study, where a single trainer provided individualized workshops in a variety of community-based settings.

The lack of significant effect on cesarean or epidural rates observed in this trial may result from the high baseline rates of epidurals, oxytocin augmentation and cesarean surgery in the hospital where the study took place. While continuous labor support is associated with numerous benefits for laboring women, the study authors assert that their results "[support] the hypothesis that the effects of the birth environment typified by high rates of medical intervention have the ability to overpower the benefits of continuous support in labor" (p. 461).

 

Inducing Labor Increases Risk of Preterm Babies

WASHINGTON (July 31, 2006)- The pregnant woman who wakes in the middle of the night, realizes she's in labor and yells, "It's time!" is an uncommon scene. A recent survey revealed that 44 percent of women in the United States have induced labors. More than one-third of those mothers were induced for non-medical reasons. Scheduling an induction without medical indication increases the risk of giving birth to preterm baby.

Premature babies have a greater risk of medical complications. Babies born even a few days premature are more likely to endure health problems. Neither doctors nor mothers can determine a baby's due date with 100 percent accuracy. Therefore, a scheduled induction at 39 weeks could result in giving birth to a preterm baby who is only 36 weeks gestation.

According to the March of Dimes, late preterm (or near term) are babies born between 34 and 36 weeks gestation and are at increased risk for medical problems, including breathing, brain development, maintaining body temperature and weight and jaundice. Preterm babies also can encounter breastfeeding difficulties. "Near term infants are often sleepier and have less energy" says Jeanette Crenshaw, MSN, RN, IBCLC, LCCE, president elect of Lamaze International. "And preterm babies often have underdeveloped fat pads in their cheeks, which can make breastfeeding more difficult."

So why, despite the risks, does the rate of inductions continue to rise? Women and their doctors schedule induced labors for many reasons. For women with conditions, induction can be life-saving for mother and baby. However, the more recent trend is to schedule inductions for reasons of convenience. Stephanie Rosenberg, mother of one, said of her birth experience, "my doctor wanted to induce, saying - you have a healthy baby, there's no need to go to your due date." I was not comfortable with this;I wanted my body, as well as my baby, to be ready to deliver!

Despite a doctor's legal responsibility to inform women on the risks of all medical procedures, many do not. As a result, women are making choices without the facts. Christina, a mother who was induced at 37 and 38 weeks for her last two births, said "my doctors did not seem concerned about me having a preterm baby and did not discuss the risks of induction."

The overuse of labor-inducing drugs increases the liability for hospitals. Knowing the risks caused by preterm birth, some hospitals have implemented guidelines that prohibit inductions before 39 or 40 weeks without a medical indication. Additionally, hospitals are taking greater care to educate mothers on the risks of early induction. Classes, such as Lamaze childbirth education classes, help teach mothers about induction as well as how to effectively communicate with their health care provider.

More information on pregnancy, birth and the use of labor-inducing medications can be found in The Official Lamaze Guide: Giving Birth with Confidence. To order the book and find a Lamaze childbirth education class in your area, visit the Lamaze International Web site at www.lamaze.org.


Randomized Controlled Trial Supports Delayed Cord Clamping for Term Infants

Summary: In this prospective, multi-center trial researchers examined the effect of delayed cord clamping on iron-deficiency anemia and clinical outcomes in term newborns. Two hundred seventy-six healthy women with uncomplicated pregnancies were randomized to three groups: cord clamping immediately after birth, at 1 minute and at 3 minutes. Venous hematocrit (to measure anemia) and bilirubin (to measure pathologic jaundice) were drawn at 6 hours and 24-48 hours after birth. Newborn physical exams were performed by clinicians who did not know to which group the infant was assigned.

Anemia at 6 hours of age was significantly more common in newborns who were randomized to the immediate cord clamping group. There was also a significant difference at 24-48 hours of age (16.8% of newborns in the immediate clamping group versus 2.2% at 1 minute and 3.3% at 3 minutes). Significantly more infants in the 3-minute group had elevated hematocrit levels (polycythemia) at 6 hours of age. However, none of the polycythemic babies exhibited symptoms or required treatment, and this difference did not persist to 24-48 hours of age. There were no significant differences in bilirubin values, rates of neonatal adverse events, or the infants weight gain and rate of exclusive breastfeeding in the first month of life. There were no significant differences in maternal outcomes such as blood loss or maternal hematocrit levels.

Significance for Normal Birth: Immediate cord clamping is a practice that has been performed routinely for decades without evidence of benefit. Placental transfer of oxygenated blood, nutrients and stem cells continues for several minutes after birth. Physiologic principles suggest that the optimal transition to life outside the womb depends on this transfer. The study authors note that higher newborn iron levels at birth correlate with less likelihood of childhood anemia, a condition with long-term neurologic consequences. Some pediatricians recommend iron supplementation for breastfed infants, but it may be that by providing the full complement of iron, delayed cord clamping is the only iron supplement healthy babies need. As an added bonus, delayed cord clamping keeps babies in their mother's arms, the ideal place to regulate their temperature and initiate bonding and breastfeeding. This may be an important first step in promoting non-separation of mother and baby after birth.


Risk of Placental Abnormalities Rises with History of Multiple Cesareans

Getahun, D. Oyelese, Y., Salihu, H., Ananth, C. V. (2006). Previous cesarean delivery and risks of placenta previa and placental abruption. Obstetrics & Gynecology. 107(4), 771-8. [Abstract]

Summary: This large retrospective cohort study examined the association between history of one or more previous cesarean surgeries and the risk of placental abruption or placenta previa in a subsequent pregnancy. Data were obtained from a Missouri state-wide dataset in which siblings were linked to one another and to their biological mothers. Missouri's vital statistics recording system has been described as a :gold standard" for its reliability and validity in previous literature.

Risk for previa in the second birth was increased 50% among women with a previous cesarean surgery. Among women with two previous cesareans, there was a two-fold increase in the risk of previa in the third pregnancy. Risk for abruption in the subsequent pregnancy was increased 30% in both the second and third births when the prior birth was by cesarean. A pregnancy occurring within the first year after giving birth by cesarean was associated with further elevations of the risk for both previa and abruption. The researchers controlled for the effects of potential confounding factors such as maternal age, race and smoking status.

Significance for Normal Birth: This study adds to the growing body of research showing strong evidence of a dose-response relationship between cesarean surgeries and placental complications in subsequent pregnancies: the more cesareans, the more complications. The doubling of risk for placenta previa in women with two previous cesareans is particularly troubling because previa in the presence of a cesarean scar is associated with placenta accreta, a complication that results in very high maternal morbidity and mortality. The long-term reproductive risks of cesarean surgery are only beginning to be understood. As the evidence of harm accumulates, it becomes ever clearer that preventing unnecessary primary cesareans is a crucial measure for protecting the health of both mothers and babies.

Policy of Induction of Labor at 41 Weeks Associated with Excessive Use of Medical Interventions

Fok, W. Y., Chan, L. Y., Yuet Tsui, M. H., Leung, T. N., Lau, T. K., Hung Chung, T. K. (2006). When to induce labor for post-term? a study of induction at 41 weeks versus 42 weeks. European Journal of Obstetrics & Gynecology, 125, 206-210. [Abstract]

Summary:This retrospective study compared outcomes of "post-term" pregnancies occurring when a hospital protocol required induction at 42 weeks with those occurring after the protocol was changed to require routine induction at 41 weeks. Prior to the protocol change, a routine cardiotocogram (non-stress test) was performed at 41 weeks and if normal, induction was scheduled at 42 weeks. The hospital was a university-affiliated obstetric unit in Hong Kong performing over 5000 births per year.

Routine induction of labor at 41 weeks only reduced the mean gestational age at delivery by 3 days while more than doubling the rate of labor induction in women at or beyond 41 weeks of gestation. The average length of labor was significantly longer, and use of epidural analgesia was significantly more common among "post-term" women after the protocol changed. There were no differences in maternal characteristics, mode of birth, or newborn outcomes across the two groups. Outcomes were unchanged when the researchers repeated their analyses controlling for parity.

Significance for Normal Birth: Complex hormonal signals between baby and mother allow labor to begin on its own. While this may happen for many women up to two weeks (or more) after the estimated due date, many care providers believe that routine induction at 41 weeks is associated with improved perinatal outcomes. This assertion is based on previous research that may be critically flawed.

This retrospective study is not big enough to detect differences in rare adverse maternal and infant outcomes, but it provides compelling data that suggest that inducing labor at 41 weeks is associated with very high rates of obstetric interventions. Use of pharmacologic induction agents and epidural analgesia became much more common on this obstetric unit once the clinical protocol began requiring induction of labor at 41 weeks. Labor was also considerably longer when induction was required at 41 weeks, compared with labors occurring at the same hospital prior to the protocol change. The trade-off of such excessive intervention was a mere 3-day difference in the average gestational age at birth. Women facing induction at 41 weeks need to know that waiting just a few more days will likely allow labor to start on its own and help avoid potentially harmful interventions.

New Pediatric Growth Charts Reflect Breastfeeding as the Norm

WHO Multicentre Growth Reference Study Group (2006). "WHO Child Growth Standards." Acta P├Ždiatrica, Supplement 450. [Full Text ]

Summary: The first of a series of new pediatric growth charts have been released by the World Health Organization (WHO). The new growth standards were developed to replace existing pediatric growth charts based on growth patterns in predominantly formula-fed populations. Beginning almost a decade ago, the WHO undertook a detailed and elaborate statistical study, sampling thousands of infants from eight ethnically diverse, economically stable nations where at least 20% of women had access to breastfeeding support and followed WHO infant feeding guidelines. The healthy, term infants who participated were followed by trained researchers biweekly for 2 months, monthly up to 12 months, and bimonthly up to 24 months. An additional sample of children was followed up to 71 months. Breastfeeding support was provided as needed. Data were collected on infant growth patterns and achievement of motor skills.

The resulting infant growth standards offer pediatric providers and parents the first evidence-based information on how children should grow under optimal conditions. The researchers found that there was very little ethnic variability in average growth or achievement of motor skills, suggesting that poverty and sub-optimal nutrition are responsible for previously observed regional variability in infant growth.

Significance for Normal Birth: The WHO infant growth charts are an important step in positioning breastfeeding as the norm and reversing decades of erroneous advice to parents of breastfed infants who were told that their infants were failing to thrive because they gained weight more slowly than formula fed infants. Now, more formula fed babies will be seen to "fall off the curve" by gaining weight too rapidly, an important predictor of childhood obesity.

The results of the WHO Multicentre Growth Reference Study provide solid evidence that breastfeeding contributes to the optimal growth and motor development of infants. Interventions in normal birth, including cesarean surgery and unnecessary separation of mothers and babies impede women's ability to initiate successful breastfeeding with their newborns thereby contributing to less than optimal infant growth and development.

 
 
 
 
 
Disclaimer:
The information contained on this website is designed for educational purposes only. The information is not meant to replace the recommendations or advice of your midwife or doctor. Please consult your midwife or doctor regarding your health care.

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