Thursday, January 30, 2014

The Evidence Says: Induction of labor, without medical reason that compromises mother/baby, is without merit…or evidence.

Childbirth~ that incredible human occurrence that causes joy and fear, avoidance and intrigue.  A woman’s body is uniquely designed to conceive, nourish and bring forth another human life.  But does Mother Nature need help?  That MUCH help that an estimated 20% of US women are induced yearly?1  This rate is important.  Since 1982, the American College of Obstetricians and Gynecologists (ACOG) have had specific guidelines in place that recommend against elective inductions in early term or before 39 weeks 5.  Similarly, the Association of Womens Health, Obstetrics and Neonatal Nursing (AWHONN) plus the March of Dimes have campaigns to make the public aware that babies should be growing inside the Mother’s uterus for as long as possible.

So how long is a pregnancy?    
    
If you count nine months and each month has 4 weeks, you count 36 weeks through simple math.  However, estimating gestational age is not that easy.  Called Naegele’s Rule, the expected date of delivery (EDD) is calculated by adding one year, subtracting three months, and adding seven days to the first day of a woman's last menstrual period (LMP). The result is approximately 280 days (40 weeks) from the LMP.  And the EDD or Due Date is an ESTIMATE.  Each woman with each pregnancy gestates their babies differently with approximate variation of up to five weeks.2

How does labor begin?

With the elegance of a symphony, the human body has a biochemical conversation between mother and baby throughout pregnancy.3  As the baby grows inside and matures, a hormonal orchestration occurs.  Hormones play a huge role in pregnancy and in the birth process. Here is an overview of hormonal interactions.

hCG: The early chorionic villi of the implanted ovum secrete human chorionic gonadotropin (hCG), which prolongs the life of the corpus luteum. The result is the continued production of estrogen and progesterone, which are necessary to maintain the endometrium. During pregnancy, hCG appears in maternal blood and is excreted in the mother's urine, allowing diagnosis of pregnancy by tests.

hPL: The chorionic cells of the placenta produce another hormone, human chorionic somatomammotropin which is also known as human placental lactogen (hPL). This hormone influences somatic cell growth of the fetus and facilitates preparation of the breasts for lactation.
The increase in hCG and hPL in the mother is thought to be responsible for many important changes during pregnancy such as growth of the uterus and the development of the breast duct system. Estrogen is also helpful in breast duct system development and progesterone is valuable in the development of the lobule-alveolar system.

The pituitary gland enlarges during pregnancy and is the source of production of oxytocin. The posterior lobe is the primary source of oxytocin, which has a stimulating effect on the uterine muscle and lactation.

The adrenal cortex increases in activity during pregnancy. The secretion of cortisol by the adrenals does not change yet the metabolism of cortisol is changed as a result of estrogen. There is an increase in aldosterone production by the adrenal glands and this hormone results in the decreased ability of the kidneys to handle salt during pregnancy. This leads to some fluid retention or edema.

Relaxin is produced by the ovaries and is primarily responsible for softening ligaments and cartilage. The softening of cartilage, especially in late pregnancy, is the cause of suprapubic discomfort, waddling, and the ability of the pelvis to spread during the birth process.
What happens when induction happens too soon?

For Babies: Organs such as brain, lungs and liver need ample time to develop ~ up to 39/40 weeks!  Babies born at 39+ weeks are less likely to have vision or hearing problems, have an easier time staying warm and can suck/swallow and eat better.6

For Mothers: induction of labor causes contractions that are characteristically harder, stronger and closer together than the normal progression of labor, making labor more difficult with which to cope.  There are higher risks of infection and uterine tears/rupture.  Inductions may not work if there are not sufficient oxytocin receptor sites on the uterus.  Oxytocin receptor sites are developed through the pregnancy and are necessary to receive the oxytocin that the body produces.  If there are insufficient oxytocin receptor sites, neither mother’s naturally-produced oxytocin nor the artificial oxytocin or Pitocin, will take effect.  Thus, with a “failed induction” a cesarean section occurs.3,6

AWHONN has a list of reasons – 40 of them – as to why a pregnancy should go the full 40 weeks.  You can access and print the pdf article for distribution by clicking here.


Diligence must be exercised when monitoring labor and fetal well-being. Hofbauer, the first to use oxytocin to induce labor, said in 1927 that oxytocin, "with its power of producing regular, rhythmical and forcible uterine contractions, should be regarded as a most beneficent and valuable agent, which, however, should always be employed with care and a realisation of its limitations and dangers." His words remain valid today.4

References:
3.    Smith, L. (2012) Impact of Birthing Practices on Breastfeeding (2nd Edition).
4.    Diligence Shyken, J.M. et al. (1995) Oxytocin to induce labor.  Clinical Obstetrics and Gynecology. June, 38(2):232-45.
5.    ACOG https://www.acog.org/About_ACOG/ACOG_Departments/Deliveries_Before_39_Weeks
6.    http://www.marchofdimes.com/pregnancy/why-at-least-39-weeks-is-best-for-your-baby.aspx

Monday, January 27, 2014

CDC/National Vital Statistics Report: Cesareans Trending Downward

The US primary cesarean delivery rate from 2006-2012. from the states that implemented the revised birth certificates showed an increase 2006-2009 and then a decrease from 2009-2012.

Significantly, state-specific primary cesarean rates by gestational age also declined.  The US cesarean rate reached an all-time high of 32.9% in 2009, then declined to 32.8% in 2010 and was reported as stable at 32.8% in 2011 and 2012.

Initiatives by ACOG (the American College of Obstetricians/Gynecologists), AWHONN (Association of Womens Health, Obstetrics and Neonatal Nursing) and March of Dimes in addition to countless childbirth education and doula organizations (including ICEA and Lamaze) educate women and families about the risks and benefits, surgical complications and higher costs of cesarean delivery.  Consumers are key in influencing the maternity care landscape.

To read the full report from the Center for Disease Control/National Vital Statistics, click here.

Friday, January 24, 2014

The Evidence Says: Routine Episiotomies ~ Not Evidence based Practice

One item many women try to include in their birth plan is an episiotomy.

Episiotomy has been at the center of controversy for a number of years. The following appears on the website of the American College of Obstetricians and Gynecologists:

“The use of episiotomy during labor should be restricted, with physicians encouraged to use clinical judgment to decide when the procedure is necessary, according to a new Practice Bulletin published by The American College of Obstetricians and Gynecologists (ACOG) in the April issue of Obstetrics & Gynecology. According to ACOG, "The best available data do not support the liberal or routine use of episiotomy. Nonetheless, there is a place for episiotomy for maternal or fetal indications such as avoiding severe maternal lacerations or facilitating or expediting difficult deliveries." (ACOG Practice Bulletin #71, 2006)

And according to the ICEA Position Paper on Episiotomy:

“Data suggest that women who have an episiotomy do not have significantly improved labor, delivery, and recovery compared with those who do not have one. Without sufficient data to develop evidence-based criteria for performing episiotomies, clinical judgment remains the best guide to determine when its use is warranted, according to ACOG.(ICEA PositionPaper: Episiotomy, 2013; ACOG Practice Bulletin #71, 2006)

While the ACOG bulletin has not been updated in eight years, the data is still the same. Yet why do physicians continue to use episiotomies routinely?  In their landmark book (should be a text and required reading of every and all birth professionals), Romano and Goer (Romano and Goer, 2012) state that prophylactic episiotomy champion Joseph DeLee (in the 1920 inaugural issue of the American Journal of Obstetrics and Gynecology) “admitted that while he lacked evidence for the benefits of his recommendations, adding he believed he probably would be able to produce some eventually, but at the same time he disparaged statistics as a basis for forming judgements.”

With countless journal articles and studies demonstrating the lack of evidence to routine episiotomy, the question still remains. Is it due to the drive-thru style of labor and birth seen globally?  Does episiotomy fit into that style and further facilitate convenience? Only physicians can truly answer that question.

But here is what we DO know (Romano and Goer, 2012):


  1. Median episiotomy predisposes to anal sphincter laceration, but studies conflict on whether mediolateral episiotomy increases risk or has no effect.
  2. Performing episiotomy for “imminent tear” does not decrease anal sphincter injury rates.
  3. Episiotomy has no effect on neonatal outcomes.
  4. Episiotomy causes more pain in the postpartum period than spontaneous tears.
  5. Episiotomy causes more healing complications than spontaneous tears.
  6. Episiotomy does not preserve pelvic floor functioning as measured by pelvic floor muscle strength, urinary incontinence, and anal incontinence.
  7. Studies consistently find episiotomy adversely affects sexual functioning.
  8. Episiotomy neither prevents nor relieves shoulder dystocia.
  9. Anal lacerations rarely recur at subsequent births provided no median episiotomy is done.

Additionally, studies (deSilva, 2012) have shown that the use of oxytocin and semi-upright positions at the time of birth was associated with second-degree lacerations and episiotomies.  Recommendations for full upright positioning and avoiding oxytocin could reduce the need for episiotomy and risk of lacerations/perineal trauma.


Research references:

Cassado, J. et al. (2013) Does episiotomy protect against injury of the levator ani muscle in normal vaginal delivery. Neurourlogy and Urodynamics.

deSilva, F.M. et. al. (2012) Risk factors for birth-related perineal trauma: a cross-sectional study in a birth centre.  Journal of Clinical Nursing. Aug 21(15-16):2209-18.

Romano, A. and Goer, H. (2012), Optimal Care in Childbirth: The Case for a Physiologic Approach.  Classic Day Publishing.

Tuesday, January 21, 2014

The Evidence Says: Nitrous Oxide for Labor & Birth

Each year, Childbirth Today Blog brings a series called “The Evidence Says”.  This series covers major topics discussed in maternity care.  The 2014 Series begins with the topic: Nitrous Oxide.

Nitrous Oxide, or N2O, has been a common pain reliever for labor and childbirth in Europe, Canada and Australia for several centuries.  First produced by an English chemist in 1772, it was the first anesthetic to be commonly used but was replaced by either and chloroform due to the potency.  Nitrous oxide depresses normal brain function, although exactly how has not been discovered.  It is thought to increase the release of endorphin, dopamine and other natural pain relievers in the brain.  Nitrous also has an anti-anxiety effect, which may help women with tocophobia.

When nitrous oxide is inhaled, it quickly mixes with the air in the lungs.  It then passes into the bloodstream and into general circulation.  The gas then changes to a solution and reaches the brain in approximately 20 seconds.  The amount of gas that reaches the brain depends on the concentration inhaled and how long it is inhaled.  Like other substances, nitrous oxide crosses the
placental barrier and enters the baby’s blood stream.  However, unlike other medications, nitrous oxide does not have to be broken down by the liver and is thus metabolized and excreted rapidly.  Because of this rapid metabolization, the medication does not become concentrated in either the maternal or fetal body. Nitrous oxide is considered safe for mothers, baby’s and care providers when the nitrous is delivered as a 50% blend with oxygen.

The odorless nitrous oxide is delivered via a machine (with mask) that mixes the gas with oxygen in certain percentages.  The gas is only delivered when the machine detects that someone is inhaling into the mask.  The mask reduces wastage and tries to prevent others in the room from experiencing the effects of the gas.  There are various types of machines on the market, however availability is limited in the U.S.   The University of California San Francisco birth center has had their own machines for years, even after some the nitrous oxide machine manufacturers in the U.S. ceased production of the machines, after the surge in popularity of the epidural and other medications used for labor/birth.  It is reported that other U.S. facilities use nitrous oxide including University of Washington Hospital in Seattle, St. Joseph Regional Medical Center in Idaho, Okanogan Douglas Hospital in Washington, and Vanderbilt in Tennessee.  This patient information page appears on the Dartmouth-Hitchcock Children’s Hospital at Dartmouth in New Hampshire – Click Here. The American College of Nurse-Midwives have a detailed position paper on the use of nitrous oxide.

The advantages of self-administering nitrous oxide include increase perception of control, can be used anytime during labor, does not appear to have adverse effects on the baby’s condition at the moment of birth, can be quickly administered and the effects are nearly immediate, effects reverse when inhalation stops, does not require the presence of an anesthesiologist.  While there are few reported complications using nitrous oxide as an anesthetic during labor and birth, nitrous does appear to have more side effects such as nausea, vomiting, dizziness and drowsiness.  Nitrous oxide administration does limit position changes and movement due to the mask being connected to the administration machine and may cause additional complications if used in conjunction with other pain relievers.

More research about the use of Nitrous Oxide for use during labor and birth.  However, at first glance, it does appear to be preferable to narcotics and epidural anesthesia.


References and Resources:

American College of Nurse-Midwives  (2011) Position Statement: Nitrous Oxide for Labor Analgesia. Last access 1/21/14. 

Agency for Healthcare Research and Quality. (2012). Executive Summary: Nitrous Oxide for Management of Labor Pain.  Last access 1/21/14.
http://www.effectivehealthcare.ahrq.gov/ehc/products/260/1230/CER67_NitrousOxide_ExecutiveSummary_20120817.pdf

Baysinger, C.  and the American Society of Anesthesiologists Research Statement (no date)
http://www.asahq.org/For-Members/Clinical-Information/Nitrous-Oxide.aspx#adverse

College of Midwives of Ontario (2012) Position Statement: The Use of Nitrous Oxide at Home Births.  Last access 1/21/14.
http://www.cmo.on.ca/documents/GCMO_C020812_TheUseofNitrousOxideatHomeBirths_Council_FEB82012.pdf

Jones, L. et al. (2012) Pain management for women in labor: an overview of systematic reviews.  Cochrane Database of Systematic Reviews. Mar 14;3.

Klomp, T. et al. (2012) Inhaled analgesia for pain management in labor.  Cochrane Database Systematic Review, September 12;9.


Rooks, J.P. (2011)  Safety and risks of nitrous oxide labor analgesia: a review.  Journal of Midwifery and Womens Health.  Nov/Dec. 56(6):557-65.

Tuesday, January 07, 2014

CDC Releases Birth Report for 2012

On December 30, the Center for Disease Control issued its Birth Report for 2012.

Of the 3, 952, 937 births in the US, 98.6% of births were in the hospital setting and 85.8% of births were physician attended.  There were 50,000 births that took place outside of the hospital setting, with 66% as homebirths and most of the rest in birth centers.  The CDC stated that more births took place in the home than before 1989.

The cesarean rate for non-Hispanic white women 2012 was 32.8%, rising from 20.7% in 1996 (a 60% increase), yet declining from 2011.  The cesarean rate did, however, rise for non-Hispanic black women (35.8%) and Hispanic women (32.2%) - each hitting an all time high.





The preterm birth awareness movements in the maternity care community may be working.  The preterm birth rate fell for the sixth year to 11.54%, down 2% from 2011 and down 10% from 2006!




We must stay vigilant to the trends and continue to present evidence-based best practice as the only option in maternity care, not only in the US but world-wide.  To this end, the International Childbirth Education Association is increasing the number of evidence-based researched position papers and these are free on the website: www.icea.org.  The number of position papers is expected to grow from the current seven to nearly twenty by the end of 2014.

To read the entire CDC Birth Report for 2012, click here.

To access the current ICEA Position Papers, click here.

Wednesday, January 01, 2014

Happy New Year!

May 2014 be the best year yet for all of our readers & friends - and readers & friends to come!