February 7, 2007

Birth Trauma

Posted in Medical or Nursing Research at 4:55 pm by fingerpaintings

In the article Neonatal intracranial hemorrhage common after vaginal birth, Radiology 2007; 242: 535-41, more than a quarter of infants delivered vaginally have a small amount of asymptomatic intracranial bleeding compared with none delivered by cesarean section. Results are based on magnetic resonance imaging (MRI) in this study. Keeping in mind this is a very small study,  88 newborns (65 with vaginal delivery and 23 with cesarean delivery) were screened. Altogether, MRI showed that 17 infants suffered intracranial hemorrhages (ICHs), and seven infants had two or more types of hemorrhages.

Now this is the part that I don’t understand, ORGYN.com reported, “Women who gave birth vaginally were therefore significantly more likely to deliver babies with ICH, while those who had a prolonged duration of labor or a traumatic or assisted vaginal birth were not, compared with those who underwent cesarean section.” I immediately assumed it was the assisted vaginal births (induction/augmentation, forceps/vaccum) that would have significantly increased the cranial trauma in the vaginal birth category, but is this saying that is not the case? I will indeed dig further into this.

“Obviously, the vast majority of us who were born vaginally and may have had these types of bleeds are doing just fine,” concludes John Gilmore, from the University of North Caroline School of Medicine in Chapel Hill, “Humans have been born vaginally for a very long time, and our brains probably evolved to handle vaginal birth without major difficulty.”


January 25, 2006

Prenatal Nutrition

Posted in Medical or Nursing Research at 3:06 pm by fingerpaintings

To further my thoughts on prenatal nutrition here, ORGYN shows us that a well-balanced diet, including fish, is important:

Fish in pregnancy cultivates babies’ brains
Source: Generating Healthy Brains Meeting: Institute of Brain Chemistry and Human Nutrition, London, UK; 17 January 2006
Consumption of omega-3 fatty acids during pregnancy is linked to neurological benefits in the resulting child.

How much omega-3 fatty acids (FAs) a woman consumes during pregnancy may affect her child’s intelligence and social skills, research indicates.

Looking at data on 14,000 mother-child pairs collected over the past 15 years for the Avon Longitudinal Study of Parents and Children (ALSPAC), Dr Joseph Hibbeln (National Institutes of Health, Bethesda, Maryland, USA) and Dr Jean Golding (University of Bristol, UK) found that the children of women who ate the smallest amounts of omega-3 FAs during pregnancy had verbal IQs 6 points below average.

Additionally, children who had the best fine motor skills at 3.5 years of age were born to mothers who had the highest intake of omega-3s FAs in pregnancy.

The prevalence of social problems, such as the inability to make friends, was evident in 14 percent of 7-year-olds whose mothers had the lowest omega 3 FA intake, compared with 8 percent of those with mothers in the highest intake group.

The findings are of particular concern as, at least in the USA, pregnant women are advised to limit their intake of oily fish in order to avoid exposing their unborn babies to trace amounts of methyl mercury, which can damage the brain.

The researchers say the latest data suggest that the benefits of eating omega-3 FAs, however, outweigh any risks.

Posted: 23 January 2006

January 22, 2006

Another reason to homebirth

Posted in Mothers Speak at 6:07 pm by anne

Woman goes into the hospital to give birth, goes home a quadruple amputee

” Claudia Mejia gave birth eight and a half months ago at Orlando Regional South Seminole. She was transported to Orlando Regional Medical Center in Orlando where her arms and legs were amputated. She was told she had streptococcus, a flesh eating bacteria, and toxic shock syndrome, but no further explanation was given.


The hospital, in a letter, wrote that if she wanted to find out exactly what happened, she would have to sue them.”

 So, to add insult to injury, the gal in the next room could have flesh-eating bacteria gobbling away at her,  the nurse forget to wash her hands between patients, and the little boogers are eating your arms and legs for lunch.

 And the hospital doesn’t feel they owe you an explanation. 

January 19, 2006

Grasping at Implausible Straws

Posted in Medical or Nursing Research at 7:10 pm by fingerpaintings

In the obstetrical search for greener pastures when common sense and good nutrition is not the basis of care, ORGYN.com (subscription free) this week shows us not one, but two, reports that show their current methods of treating preterm birth are out to lunch.

Progressive gum disease predicts very preterm birth
Source: Obstetrics & Gynecology 2006; 107: 29-36
Estimating whether maternal periodontal disease is predictive of preterm or very preterm birth.

Maternal gum disease in early pregnancy is an independent predictor of preterm delivery, researchers have found.

And progression of gum disease during pregnancy is associated with an increased risk of delivering very preterm, the study, by Steven Offenbacher (University of North Carolina at Chapel Hill, USA) and colleagues, also showed.

While an association between maternal oral infections and abnormal pregnancy outcomes has been previously reported, some studies have failed to confirm the link.

To investigate further, Offenbacher et al prospectively studied the obstetric outcomes of 1020 pregnant women, who underwent periodontal examinations antepartum—at less than 26 weeks’ gestation—and after delivery.

After adjusting for potential confounders, the researchers found that the relative risk of preterm birth was 60 percent higher for women with moderate-severe periodontal disease than for women with healthy gums, while that for spontaneous preterm birth was increased two fold. The unadjusted rate of very preterm delivery was significantly higher for women who experienced progression of periodontal disease during pregnancy than for women without disease progression.

Offenbacher and team say the findings “indicate that maternal periodontal disease progression during pregnancy may, in part, contribute to deliveries at less than 32 weeks of gestation.”

Posted: 17 January 2006

How interesting that Dr. Price, in his comprehensive research into nutrition and it’s affect on oral health shows conclusively that nutrition is the backbone to a cavity-free, healthy smile.

For example, when Price visited his first people, isolated Swiss mountain villagers, he noticed right away that the children’s teeth were covered with a thin film of green slime, yet they had no tooth decay.

Dr. Price also noticed that, in addition to their healthy teeth and gums, all the people he discovered were hardy and strong, despite the sometimes difficult living conditions they had to endure. Eskimo women, for example, gave birth to one healthy baby after another with little difficulty.

Next up, treatments used to prevent (prophilactic) preterm labour not only caused it, it caused severe preterm birth in pregnancies prior to 30 weeks gestation.

Preterm birth drug may increase early delivery risk
Source: An International Journal of Obstetrics and Gynaecology 2006; Not yet available online
Investigating whether metronidazole reduces preterm birth rates in high-risk women.

A drug often used for the prevention of preterm birth may actually increase the risk of early delivery, a UK study has found.

The effect was so strong that the randomized study was stopped early, and the researchers, led by Andrew Shennan from St. Thomas’ Hospital in London, concluded that they “do not recommend continued use of metronidazole in the clinical setting for the prevention of preterm delivery.”

For the study, 900 pregnant women were tested for vaginal fetal fibronectin (fFN), which is a known indicator for high-risk preterm delivery at 24 and 27 weeks’ gestation. Of the 116 (13%) women who tested positive for the marker, 99 were randomly assigned to receive a 1-week course of oral metronidazole or placebo.

Preterm delivery, before 37 weeks’ gestation, was 60 percent more common among the women given metronidazole than among those assigned to receive placebo. Moreover, there was an almost doubling in the risk of delivery before 30 weeks’ gestation with active treatment.

On the basis of their study and others, the researchers say “there is evidence to suggest that the commonly used antimicrobial agent metronidazole when used alone has no benefit in the prevention of preterm delivery in high-risk women.

“Indeed, this and other clinical trials suggest positive harm,” the team concludes.

Posted: 16 January 2006

When will physicians stop using mothers and babies as their guinea pigs and demand nutrition be taught in medical schools? Is that too much to ask?

January 11, 2006

Seeing Zebras

Posted in Provider's paradigm at 7:28 pm by anne

Medscape has a medical student blog.    I like it a lot, actually, what little of it there is.   I especially liked this post from a medical student who was diagnosed with “Medicalstudentitis,”  or seeing the worst when the symptoms warranted only the obvious.   “When you hear hoofbeats, think horses, not zebras,” the student reminds his colleagues.

Breastfeeding and Obesity

Posted in Breastfeeding, Medical or Nursing Research at 4:45 pm by anne

Breastfed babies may become leaner kids
Tue Jan 10, 2006 4:22 PM GMT
By Amy Norton

NEW YORK (Reuters Health) – A new study suggests that the longer
infants are breastfed, the lower the likelihood they’ll be overweight
as adolescents, a relationship that does not appear to be influenced
by sociocultural factors.

The findings, published in the journal Epidemiology, add to the not
always consistent body of research on breastfeeding and childhood
weight gain. While a number of studies have suggested that breastfed
babies are less likely to become overweight than bottle-fed infants,
others have found no such benefit or that the weight difference does
not last far into childhood.

In the new study, however, Harvard researchers found that even within
a single family, children who were breastfed for a longer time were
slightly less likely to become overweight than their siblings who were
breastfed for a shorter period.

The difference within families was similar to that found in the study
population as a whole, where each 4-month increase in breastfeeding
was linked to a 6 percent dip in the risk of becoming overweight by

Since siblings are raised under much the same circumstances, the
findings “lend credence” to the idea that breastfeeding itself confers
a weight benefit, Dr. Matthew W. Gillman, the study’s lead author,
told Reuters Health.

One of the obstacles in studying the effects of breastfeeding on
childhood weight is that both are “socially patterned,” explained
Gillman, an associate professor of nutrition at the Harvard School of
Public Health in Boston.

For example, mothers with more education or higher incomes are more
likely to breastfeed, and their children are also less likely to be
overweight. So studies need to control for such influences.

Following families in which siblings had different breastfeeding
patterns accomplishes that to a large degree.

For their study, Gillman and his colleagues surveyed 5,614 siblings
between the ages of 9 and 14 who were part of a larger study that had
previously linked longer breastfeeding duration to a lower risk of
obesity later in life.

The fact that the findings within families were close to those in the
overall group suggests that breastfeeding itself affects weight later
in life, according to the researchers.

The reason is not entirely clear, but one general theory, Gillman
said, is that breast milk has lasting metabolic effects that aid in
weight control. Another, he added, is that breastfeeding has
behavioral effects; with breastfeeding, the length of any one feeding
depends mostly on the baby, whereas mothers who bottle-feed may keep
feeding their infants until the bottle is empty.

In this way, Gillman explained, breastfeeding may encourage more
“self-regulation” of calorie intake later in life.

Whatever the effects of breastfeeding on a child’s weight, he noted,
breast milk is considered the best nutrition for infants, so the
possibility of weight benefits could be seen as a potential bonus to a
healthy practice.

Experts recommend that babies be breastfeed exclusively for at least
the first six months of life.

SOURCE: Epidemiology, January 2006.

January 10, 2006

Posted in Provider's paradigm at 12:28 am by anne

Do you follow –even occasionally — the discussions on nursing bulletin boards?  I don’t, as a rule, but did today.   As a rule I’m impressed with the kindness, flexibility and knowledge that most posters show.   But today I came across some posts that sound like they could have been posted by 90% of the L&D nurses I know in Birmingham, Alabama, the backwater of evidence based maternity care,  I thought I would share this amalgamation of posts with you.
They are right, though– they do not understand why women go to the HOSPITAL for birth and refuse medical care, like EFM, anesthesia, etc.    Those mothers who want to try normal birth but for whatever reason don’t finish with one are ‘failed,’ which in my estimation is a poor attitude toward those, her clients, she is to advocate for.
I suppose that “natural” appendectomies would be performed as they were in the old days: with six strong Bohemians holding the patient down while a barber cut without anesthetic. I guess the old trepining procedure (cutting a glabelar triangular hole in the skull with a rock to let out evil spirits) is natural, too.
For those who want that “natural” experience, more power to them. But, please, stay at home and have the baby. Why come to the hospital? And if you do, expect the full-court press to protect you and yours. Why? BECAUSE YOU’LL SUE EVERYONE if we don’t.
That’s just it. There’s nothing “natural” about being in a hospital. But, if you go to one, you should expect — and receive — medical care. I am NOT saying that every laboring mom should have an epidural/intrathecal. I AM saying that she should expect (1) fetal heart monitors and vital sign monitoring, (2) remaining NPO in case of an emergent c/s, (3) a c/s if her baby is showing lates or other NRFHT, (4) a spinal anesthetic for a c/s if she doesn’t already have an epidural, (5) a general anesthetic for a true crash and therefore no memory at all of the birth of her baby.  

Don’t give me this garbage about me being biased toward epidurals. Of course I recommend them. But, I can say with absolute certainty that I have NEVER snuck up on a patient and popped in an epidural. I DO tell women in initial interview (for medical hx, know who is on the floor, etc.) that they should NOT tell me ‘absolutely no to any epidural’ because I cannot in good conscience or legal right come back later when she’s in excruitiating pain saying, ‘give me that epidural.’ It’s now under duress.

I’m sure you do have plenty of moms who go “natural” and have “a beautiful birth.” More power to them. It doesn’t always happen that way and you know it. The more common is the scared primip screaming her head off ready to die or kill someone. Get real.

So, keep the bias AGAINST anesthesia to yourself. If you want to root for the mom to go natural, you better make sure she (1) plans to get pregnant, not ‘just happened, (2) goes to every prenatel class or laMaz or whatever for ‘visualization of no pain’, (3) was born with a naturally high pain tolerance and a tough attitude. When you can guarantee all that, then y’all can start being all high-and-mighty about so-called natural childbirth.

And, yes, if a mom is clamping down from the pain and not progressing, there is a small segment who will benefit from the relaxation provided by an epidural. Also, at the low concentrations of local anesthetic now commonly used, there is less numbness than there used to be. We expect them to feel the contraction, not the pain so much. And, we expect them to feel more at the end, through the less-well-covered sacral nerves.

Like I said, for a “normal, low risk pregnancy” mom can come to the hospital and decline an epidural. There is NO forcing them on ANYONE.

So keep your to yourself and get real.

Oh and believe me, nothing irritates me more than some failed homebirther walking in the door allready hating on the L&D staff, acting as if we are the enemy! Puhleeze….the very 1st thing I do is explain that the minute they sign their “consent for tx” forms and are officially admitted that I have certain legal obligations to fulfill and if they refuse any that such will be documented and placed in their medical record. As well as,of course, re-iterating that we are there to ensure the well being of themselves and their baby.
Her paradigm appears to be  1. technology guarantees safety 2. Every patient is a potential litigant.  Proven efficacy or safety isn’t on the list. 
The changes propelled by consumers in the ’70s were largely cosmetic, when you think of it.   And we’ve gone backwards, actually, in the net effect.  (IOW we have wallpaper, awake moms and dads’ support but a 30% c-s rate)
While we’re at it, my 8-year old, who hasn’t even passed Epidemiology 101, can refute this (regarding the lamentable state of midwifery in Missouri)
“Given all of the advances in technology, our great physicians, great training and great hospitals, physicians should be delivering babies, and babies should be delivered in hospitals,” Harris said. “It is the safest and best practice.”

January 8, 2006

Coached Breathing Doesn’t Work During Pushing

Posted in Medical or Nursing Research at 3:36 am by fingerpaintings

Reuters reported Dec. 30 what many birth professionals have long known, “Pregnant women coached through their first delivery do not fare much better than those who just do what feels natural.” The study, published in the January 2006 Gray Journal (American Journal of Obstetrics and Gynecology) found “the difference has little impact on the overall birth, which experts say can take up to 14 hours on average” when “women who were told to push 10 minutes for every contraction gave birth 13 minutes faster than those who were not given specific instructions.

While I doubt that this study will suddenly stop all of the nurses from yelling pushing instructions at mothers who suddenly are found to be at the magical 10 cms dilation, it is important that this information is available for professionals and expectant parents. This procedure of coaching mothers to attempt to forcibly exhale with the nose and mouth closed to the count of 10, taking a deep breath and doing it again is called the Valsalva maneuver. Named after Dr. Antonio Valsalva (1666-1723), the Valsalva maneuver was an original method of inflating the middle ear which is still practiced today. It is also used as a diagnostic tool to evaluate the condition of the heart and is sometimes done as a treatment to correct abnormal heart rhythms or relieve chest pain. Its use in obstetrics started when heavily medicated mothers couldn’t feel the urge to push and it was believed the Valsalva maneuver would speed descent of the baby and hasten delivery.

The World Health Organization’s Care in Normal Birth, Chapter 4 explains the risks. The practice of encouraging sustained, directed (Valsalva) bearing down efforts during the second stage of labour is widely advocated in many delivery wards. The alternative is supporting the women’s spontaneous pattern of expulsive efforts (exhalatory bearing down efforts). These two practices have been compared in several trials (Barnett and Humenick 1982, Knauth and Haloburdo 1986, Parnell et al 1993, Thomson 1993). The spontaneous pushing resulted in three to five relatively brief (4-6 seconds) bearing-down efforts with each contraction, compared with the 10-30 second duration of sustained bearing-down efforts, accompanied by breath holding. The latter method results in somewhat shorter second stages of labour, but may cause respiratory-induced alterations in heart rate and stroke volume. If the woman is lying flat on her back, it may be associated with compression of the aorta and reduced blood flow to the uterus. In the published trials mean umbilical artery pH was lower in the groups with sustained bearing down, and Apgar scores tended to be depressed. The available evidence is limited, but the pattern emerges that sustained and early bearing-down efforts result in a modest decrease in the duration of the second stage, but this does not appear to confer any benefit; it seems to compromise maternal-fetal gas exchange. The shorter spontaneous pushing efforts seem to be superior (Sleep et al 1989). It goes on to state in Chapter 6, under Practices which are Clearly Harmful or Ineffective and Should be Eliminated, “Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour (4.4).

Getting back to today’s article, “Women in both groups experienced about the same number of forceps use, Caesarean deliveries and skin tears, among other complications. Less clear was whether extra pushing encouraged by a coach could lead to bladder trouble. In an earlier study, the researchers tested bladder function in 128 of the mothers three months later. While such problems usually resolve on their own over time, women who had been coached had a smaller bladder capacity and felt the urge to urinate more often, they previously found.” I also question if Valsalva pushing can also be implicated in causing or aggrivating hemorrhoids. We have all seen mothers with broken blood vessels in her eyes and face from pushing wrongly, universally a result of coached pushing.

The argument for Valsalva pushing is that a mother with a complete epidural and/or intrathecal block cannot feel the urge to push. Certainly her uterus will continue to contract and bring her baby down, but the effects are much more muted when not accompanied by the spontaneous bearing down women’s bodies were designed to bring baby into the world most efficiently with. This begs the question, will staff have the patience to allow fetal descent before Valsalva or at least allow a more physiological second stage with open glottis pushing in shorter stints? Rarely in my experience. Turning over patients is always a priority in modern day obstetrics and with high epidural rates, rarely is a woman allowed to “labour down” as we have come to call the time from full dilation until crowning after an epidural placement where the mother is left alone to let her uterus bring baby down. Instead mothers are made to push for hours, exhausted and shaking, while her baby’s heart rate dips ever lower because of the lack of oxygen caused by the unnatural pushing efforts of coached breathing. I hope we learn from this that normal physiological second stages work and do not need to be fixed by clocks and coached breathing.

January 7, 2006

Down Syndrome Screening

Posted in Medical or Nursing Research at 6:15 pm by fingerpaintings

It is all over the media, screening methods for Down Syndrome and other congenital abnormalities can now be done as early as 11 weeks, though the accuracy is less than 85%. What isn’t reported is the toll this information will have. What isn’t covered is that 85% of babies after prenatal screening only terminate their pregnancies when the screen shows positive for Down Syndrome. Nevermind that previous and current screening methods have a high false-positive rate.

This week the CDC released a report on live birth outcomes showing that Down Syndrome is more common that previously thought, 1:733 compared to previous estimates of 1:800-1000. Live birth outcomes. So what does that make the true statistics when we previously noted that 85% of babies suspected of having Down Syndrome are aborted?

I have a personal story about this. Two of my cousins were pregnant at the same time. Both were screened with both AFP and ultrasound (several timesfor different reasons) during their pregnancies. Cousin M was told she would have a son and that he had Down Syndrome and had subsequent ultrasounds to confirm this. Her and her husband were strongly urged to abort their son, they chose not to and prepared for their son’s birth. Cousin K was screened several times because of her having HELLP during her first pregnancy. She chose not to know the sex of her child and also eagerly anticipated her baby’s birth. Cousin K went into labour early and finding her baby breech, she underwent a caesarean for the delivery of her daughter… who had a major heart defect, slanted eyes and symian creases in her hands. While awaiting heart surgery, Cousin M had her son, a healthy normal boy. During Cousin K wait for her daughter’s surgery, genetic testing was done and indeed her daughter does have Down Syndrome.

What scares me most is the sheer number of babies who will be aborted with or without Down Syndrome and other genetic anomalies, and the number of babies who will be aborted for no reason other than a false postive test result with no followup. How does positive prenatal genetic testing results effect your practice?

Consumer Reports on Unnecessary Surgeries

Posted in The Spin Machine at 4:46 pm by anne

From our friends at Consumer Reports — 12 Surgeries You May Be Better Off Without. 

 It shouldn’t come as any surprise that episiotomy, cesarean section and hysterectomy are 3,4, and 5 on the list.   

 What does surprise me, though, are the women in my life who underwent these procedures for the most dubious of reasons  credit their care providers for ‘saving’ their life or health.   I fail to understand the snow job at work here.

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