ACOG Issues New Guidelines on Managing Stillbirth

Yesterday, ACOG released new guidelines on managing stillbirth.

Overall, it's a generally solid, informative, although very clinically-driven, piece that gives a run-down of the known stats and evidence currently available.

What really struck me was the section on Management. Stillbirth is universally devastating for new mothers and families. They've spent at least 5 months (since stillbirth is deemed to occur after 20 weeks) pregnant feeling this child grow inside them and anticipating its birth, only to have their worst fears realized.

In token appreciation to this great loss, the ACOG guidelines state:

After a stillbirth, sensitivity to the family's emotional state is important. Parents should be given the opportunity to hold their baby and perform cultural or religious activities, such as baptism.

In response to this tragedy and its overwhelming impact on the mental and emotional health of their patients, clinicians are advised in a brief, single sentence to be sensitive to the family's emotional state.

The other 3.5 paragraphs are devoted on how to get a family to agree to an autopsy or get their consent for a number of additional tests if they can't be talked into a full autopsy, citing this reasoning:

"Parents want answers when they have a stillbirth, so clinicians should not be afraid to request an autopsy. Without a thorough evaluation it will be difficult to counsel women on their risk of having another stillbirth," said Dr. Fretts.

While I agree in principle, in practice, far too many families are so emotionally blindsided, they can't see the benefit of the autopsy or testing at the time. Perhaps its due to the lip service physicians are instructed to pay to the family's emotional state, wrapped up in a single sentence with a few token activities thrown in.

Perhaps the guidelines could read, "families should be allowed to hold their babies for as long as they like, call whatever family members they wish to come support them, dress the baby and take pictures, as needed. Families should be moved to a location off the maternity floor to avoid painful contact with other families experiencing the joy of their new babies if they so wish".

It would seem to me that by truly showing empathy to the emotional needs of the family, it would be easier to broach painful topics such as autopsy and post-mortem testing.

Expanded Midwifery Care in Ireland

Here's a positive article on the expanded use of midwives in Ireland.


It's a good read that highlights many of the benefits of midwifery care. Enjoy!

Good Article on VBAC

Here's a well-written article on the soon-to-be lost option of VBAC that does a great job of highlighting the erroneous reasons hospitals and doctors report on why they don't offer VBAC.

This is one of my favorite parts:

In 1999, after several high-profile cases in which women undergoing VBAC ruptured their uterus, the American College of Obstetricians and Gynecologists (ACOG) changed its guidelines from stipulating that surgeons and anesthesiologists should be "readily available" during a VBAC to "immediately available." "Our goal wasn't to narrow the scope of patients who would be eligible, but to make it safe," says Dr. Carolyn Zelop, co-author of ACOG's most recent VBAC guidelines.

I wonder how much longer it will take before ACOG realizes that in their efforts to "make it safe", they'd caused more harm than help.

Unfortunately, I don't think it will be any time soon.

Campaign to Change Hospital Policy Against Midwifery Care

I received this email from an expectant father seeking help in changing a local hospital's policy on midwives attending births. If you live in the area (and even if you don't), please consider making a phone call or sending a letter/email to the hospital administrator to heighten awareness of the issue and hopefully change hospital policy for the benefit of mothers and babies:

My wife and I are expecting our first in September. We are eager and excited to work with a specific midwife/nurse practitioner who works in a woman's health office near our home. This office is connected with Holy Cross Hospital in Silver Spring, Maryland. For this reason, we can not work with our midwife during birth because Holy Cross does not allow midwives to help women deliver in their hospital. They are the only hospital in our region that does this horrible practice. I was hoping you could help get the word out and help me to begin a campaign with the hospital leadership.


The president of the hospital is:

CEO and President: Kevin Sexton

Holy Cross Hospital

1500 Forest Glen Rd.

Silver Spring, MD 20910

301-754-7010
E-mail Address: sextok [at] holycrosshealth.org

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

If you've never phoned, written or emailed such a letter, here are some sample scripts with talking points to include:

"My name is ____________________. I live in _______ near ________ hospital. I wanted to share with you how the lack of access to midwifery care at ________ hospital has affected me and other women and families in the vicinity. (List 1 or 2 examples from the list below or add your own).

• I chose to travel ____ miles rather than give birth in this hospital due to the lack of midwifery care providers


• I had to choose a provider I'm not comfortable with because of the lack of midwifery care at this hospital


• Parents have the right to choose how, where, and with whom their children will be born.


• Women deserve to have access to all the nationally certified maternity care providers that women in other states, like Wisconsin and Minnesota, can choose from -- including CPMs


• Midwives are known to do an excellent job working with under-served populations, including undocumented worker populations, who are more accustomed to midwifery care in their home countries


• With obstetricians leaving that profession, midwives can help fill the gap for normal births in a cost effective fashion


• With their unique out-of-hospital training, Certified Professional Midwives can be a vital part of emergency services in times of epidemics, natural disasters or terrorist attacks (when hospitals might be overwhelmed with actual medical emergencies), allowing obstetricians to oversee the cases that required their surgical expertise


• I want the option of midwifery care available for my children,
  when they start to have children of their own

(You should pick the talking points that make the most sense in your situation and/or best represent your point of view or comfort level.)

"I hope that in light of these factors, you will reconsider your policy and allow midwives to have privileges within this hospital to attend to birthing women and their families. Thank you for your consideration in this matter."


Please spread the word to help this and other families in the area gain full access to the care providers of their choice.

Time to Take a Page from the NHS Book...

The National Health Service (NHS) Institute for Innovation and Improvement recently released a new initiative and toolkit to "to assist maternity units in achieving low caesarean section rates while maintaining safe outcomes for mothers and babies."


According to this article, after only 18 months, c-section rates dropped from 24% in 2007 to a mere 16% in November 2008.


The idea of a 16% c-section rate is the US seems like a dream. That is half our current c-section rate and very close to the World Health Organization's (WHO) target rate of 10-15% or less.


The truly intriguing aspect of the toolkit is that it is one of introspection. The NHS created a tool to help providers and maternity care units self-evaluate their practices against evidence-based standards, to see how their actions impacted the number of cesarean births and how altering those practices could help or hinder birth outcomes.


The American College of Obstetricians & Gynecologist's (ACOG) has stated that they are "committed" to reducing the number of c-sections. However, their approach, in sharp contrast to the NHS, has been to simply blame the mother - we're too fat, too lazy, too old, too small, or even "that's what they wanted" and so on and so forth...ad nauseam...


If ACOG is truly committed to lowering c-section rates nationwide, it's time for them to take a page from the NHS's book: start implementing the necessary steps to create the change you want to see.


Namely, start practicing evidence-based medicine and the rest will follow...

Common Chemicals May Delay Pregnancy

Another recently-published study has found a link between exposure to common chemicals and the time it takes a woman to conceive as well as birth defects and growth restriction in fetuses. It's yet another example of how the expansion of technological options can have unintended side effects on our species.

The most disturbing fact is that the chemicals were known toxins in the process of being phased out. While it's encouraging that they are being removed from products, the reality is that the damage has been done; while they will no longer be present in newly-manufactured items, there presence will linger in landfills, water supplies, and our bodies for decades to come.


We must remember that our actions today force the outcomes of tomorrow. More due diligence is needed on the safety of such technologies before they are used to prevent this seemingly never-ending cycle of self-destruction through industrialization.

Understanding the Dangers of Cesarean Birth: Making Informed Decisions

Understanding the Dangers of Cesarean Birth: Making Informed Decisions, a new book by Nicette Jukelevics, MA, ICCE of the wonderful resource on vaginal birth after cesarean section, VBAC.com has just been published.


You can learn more about the book and view the table of contents at: http://www.dangersofcesareanbirth.com


I haven't had a chance to read it yet, but I'm certain it will move onto my list of recommended resources.


Buy your copy from Amazon using GoodSearch and the vendor will donate to the Coalition for Improving Maternity Services (CIMS). Go to www.goodsearch.com/goodshop.aspx, choose CIMS as your charity, then choose Amazon and enter Dangers of Cesarean Birth in the Amazon search bar.


This is a timely book I'm sure will help empower and inform mothers to help stem the tide of ever-increasing c-sections without improved outcomes for mothers and babies.


Please pass this along to all the mothers in your life.

New Research on Predicting Pre-eclampsia

Researchers at the University of Bristol have conducted a new study which may help predict which mothers are at risk of later developing pre-eclampsia.

Flaxseed Oil and Risk of Pre-term Birth

New study finds link between flaxseed oil consumption in pregnancy and pre-term birth



An interesting read....

How Different They Are...

Yesterday, I ran across this article, which details the story of a UK mother with a history of precipitous labor (labor lasting less than 3 hours), who chose a homebirth (which nearly became an unassisted birth) with her last child to avoid giving birth en route to the hospital.


She and I share commonality in that both my labors were also precipitous. My first was born in 3 hours and my second in a mere 45 minutes.


As I read further, I was struck by a seemingly small detail, but one that truly crystallizes the differences between the US and UK maternity systems:

"After Charlotte was born doctors had recommended that Hazel have a home birth if she ever fell pregnant again..."

Ummm, did I read that correctly?


In the US, homebirth would never be suggested as the solution to precipitous labor. I can personally attest to the one-and-only US answer: "medically necessary" induction.


In my case, this would mean inducing between 36-37 weeks, as both my children were also born before 38 weeks.


So, despite the fact that precipitous labor at term is typically moving so quickly because it is completely uncomplicated, because everything is going right, I would be forced, not only to undergo a decidedly unnecessary induction with all the added risks it entails, but also at the additional risk of delivering a pre-term infant, and all in the name of "preventing complications".


This is a perfect example of how overmedicalized the US system is: instead of letting labor progress normally on its own, the desire for a false sense of control makes modern obstetricians believe they must save me from myself, that only by their aggressive intervention could I be saved from the risk of birthing in my own time, in my own home.


In all probability, my next birth will be unassisted, not as an active choice, but due to the lack of one.



My choices are:


1. Plan a hospital birth

This means accepting an induction and all its ancillary interventions between 36-37 weeks. There are no birth centers in my state, so that is not an option, although even in a birth center, induction would be my only option. I have interviewed all the insurance-covered OBs in my area and this is the consensus, take it or leave it.

2. Plan a midwife-assisted homebirth

Due to the lack of support for midwifery care from the medical maternity model, the nearest midwife to my home is still over an hour away. Were my next birth to go as quickly as my second, it's highly unlikely she would arrive before the baby did. Even if we called from the very first contraction, I doubt there would be enough time for her to get to our house.

So, what to do? Most likely, I will choose a midwife, paying four times as much for her care (since my insurance won't cover midwifery care), all the while knowing she probably won't be present for the birth.



While many would baulk at the thought of an unassisted birth, I accept that, whether I want it or not, this may well be the reality of birthing again. As such, I don't spend time worrying about this fact; rather, I can focus on preparing everything needed to birth as safely as possible at home.


If modern obstetrics truly cared about making birth as safe as possible, then their focus would be on practicing evidence-based medicine and recognizing when intervention was truly necessary. Thus, the midwifery model of care would be the standard, so that women such as I could birth safely with a skilled attendant present no matter what place of birth was chosen.

Mother-Friendly Childbirth Forum to Gather in San Diego

The Coalition for Improving Maternity Services' (CIMS) 2009 Mother-Friendly Childbirth Forum and Annual Meeting will be held March 5-7, in San Diego, California. The program includes 24 sessions that will cover a broad range of issues affecting childbearing women.

The 2009 CIMS Forum will cover topics ranging from "Racial and Ethnic Disparities in Birth Outcomes," to the findings of a new national report, "New Mothers Speak Out," on the physical and mental health challenges faced by new mothers, to "The Case Against Elective Repeat Cesarean Surgery," to "Why Transparency in Maternity Care Matters."

This is sure to be an eye-opening event and one that is truly crucial to affecting change through the modern maternity machine. The key to accomplishing true change in the system is through widespread public awareness, not only of the shortcomings of the current system, but of simple ways it could be changed for the benefit of mothers and babies.

The full press release is available here.

The Pitfalls of Impatience

A new study published in the November, 2008 issue of Obstetrics and Gynecology, conducted by researchers at the University of California, San Francisco, found that over 130,000 cesareans could be avoided each year by simply waiting an extra two hours for labor to progress normally.


The study focused on the all-too-common "failure to progress" c-section. The study was longitudinal over 1991-2001 and examined outcomes for 1,014 women having their first child at the UCSF.


Current ACOG guidelines state that physicians should wait two hours once an active labor arrest, or a period of time when dilation and effacement have ceased, before moving to a c-section. However, the article states that while this is the standard of care, many physicians currently ignore the guideline and move straight to an avoidable, unnecesarean.



Currently, 1/3 of all c-sections performed each year are for "failure to progress".



The study also highlights the dangers of a primary c-section, which are so often overlooked and were well outlined by the head author:

"Cesarean delivery is associated with significantly increased risk of maternal hemorrhage, requiring a blood transfusion, and postpartum infection," Caughey said. "After a cesarean, women also have a higher risk in future pregnancies of experiencing abnormal placental location, surgical complications, and uterine rupture."

Results of the study also found that women who had c-sections had increased rates of postpartum hemorrhage, chorioamnionitis infections and endomyometritis infections.


However, no significant difference in the health outcomes of the infants was found.


The most refreshing factor about this study is that ultimately, it highlights the dangers of primary and repeat c-sections as well as highlighting the role of physician non-compliance with the outlined standard of care.


Ultimately, the study shows that if physicians follow evidence-based guidelines in their practice, maternal outcomes are improved.


Despite the fact that this is a new study, this is not new information. The two hour wait time was already the standard of care when this study was undertaken. The real issue is getting physicians to respect the evidence and stop rushing to a c-section at the earliest convenience.


I have to wonder what will have to happen before physicians start using evidence-based practice in maternity care.


Despite study after study extolling the pitfalls of procedures such as episiotomy, lithotomy position, EFM, failure to progress c-section, restricted movement and arbitrary time limits on labor, these harmful practices are still standard across much of the US.


Perhaps a punitive approach would work: fine physicians for each non evidence-based procedure: $500 for an episiotomy, $1000 for EFM, $3000 for each unnecesarean.


That, I think, would be an effective approach at gaining adherence to evidence-based medicine and focus on maximizing reimbursement for quality care, not convenience.

The MEAC Needs Your Help

Feel free to pass this along and support midwifery across the US. Donations are also tax-deductible.


October 2008

Dear Friend of the Allied Midwifery Organizations,

MEAC needs our help!

MEAC is the Midwifery Education Accreditation Council. MEAC promotes excellence in midwifery education by supporting and accrediting midwifery schools around the country that prepare midwives for national certification as CPMs. MEAC is doing exciting, groundbreaking, and vital work for our midwifery movement. Just this month, the Milbank Memorial Fund, a non-partisan institute devoted to health policy analysis, issued a new report titled, “Evidence-Based Maternity Care: What It Is and What It Can Achieve”. The report cites data from the landmark study of CPMs published in 2005 and concludes:


The low CPM rates of intervention are benchmarks for what the majority of childbearing women and babies who are in good health might achieve.


MEAC currently accredits eight free-standing institutions and two programs that reside within universities, providing excellent midwifery education for more than 500 matriculating students.


Why does MEAC need our help now?


This year, the U. S. Secretary of Education deferred a decision to extend recognition of MEAC, requesting that MEAC provide evidence of a stronger financial and volunteer base. It is ESSENTIAL that MEAC satisfies the requirements to continue its recognition by the USED. This appeal to you hopes to accomplish two things:


1. Increase the capacity of MEAC’s Reserve Fund to cover one year’s operating budget ($120,000).

2. Demonstrate to the USED that MEAC has a strong base of support that can be called upon to respond swiftly and effectively in a time of need.


Please help us in this one-time capital campaign. We have come so far in the last decade. We can’t let it slip away. Your support is crucial and so much appreciated at this time! Please give generously. Large donations of $500-$1,000 will provide significant support. Smaller donations will help, step-by-step, to achieve this goal. We can do this together- it is an investment in our future!


Sincerely Yours,

The Leadership of the Allied Midwifery Organizations


*Donations to MEAC are tax deductible!
Make checks payable to MEAC, POB 984, LaConner, WA 98257,
http://www.meacschools.org

Ten Americans

This will give you chills...




Disturbing to say the least.


In this same vein, the Primal Health Research Centre, led by Dr. Michel Odent, is exploring the correlations between the 'primal period' (fetal life, perinatal period and year following birth) and health and personality traits in later life.


On their site, PrimalHealthResearch.com they have compiled the Primal Health Research Databank, which includes studies that focus on the primal period of development. It's a wonderful resource for evidence-based information.


Hopefully, the efforts of such organizations as the Environmental Working Group and the Primal Health Research Centre will affect system-wide change for both our environment...and our babies.

Petition for Preemies

The March of Dimes is sponsoring a Petition for Preemies as part of this October's Prematurity Awareness Month.


Prematurity is the leading cause of infant mortality in the US. The petition consists of 4 calls-to-action:

• Increasing federal government support of research and data collection on prematurity, to discover the causes of prematurity, to test prevention methods, to improve outcomes and treatment options for premature infants, and to better understand the factors in premature birth


• Expanding access to quality healthcare and devoting more resources to smoking cessation programs


• Urging hospitals and physicians to voluntarily assess c-sections and inductions before 39 weeks to examine adherence to professional guidelines


• Calling on businesses to support mother and infant health by respecting the March of Dimes' 14 recommendations.

To date, they have acquired 67961 signatures - what number is yours?

Antibiotics for Preterm Labor Carry Long-Term Risk for Babies

New research shows that antibiotics given during apparent premature labor, without ruptured membranes or detectable infection, provide no benefit and may cause long-term harm to children

Cerebral palsy was present nearly twice as much in children at age 7 whose mothers received erythromycin during spontaneous preterm labor. An increase in risks was also seen with a combination of amoxicillin and clavulanate (co-amoxiclav), although it was lower. Among 1,611 children exposed in utero, 3.3% had cerebral palsy at age 7, compared with 1.7% of children in the control group or those exposed to co-amoxiclav alone.

In addition, the children were also at increased risk of functional impairment, which includes abnormalities such as difficulties with learning, walking, eyesight and other more extensive disabilities. 42.3% of children in the erythromycin group demonstrated some type of functional impairment.

For women with ruptured membranes but no signs of clinical infection, antibiotics neither improved nor increased risks.

The researchers calculated that one child would experience harm for every 64 mothers treated with erythromycin while 1 child would experience harm for every 79 mothers who received co-amoxiclav alone.

In the U.S., guidelines from ACOG recommend a combination of amoxicillin and erythromycin for women with preterm membrane rupture but neither the ACOG nor RCOG guidelines in England address the use of antibiotics for women in preterm labor whose membranes have not ruptured.

In response to the new study, Alison Bedford Russell, M.B.B.S., B.Sc., of Warwick Medical School, and P.J. Steer, M.D., of Imperial College London stated:

"The lessons to be learned seem clear: contrary to popular opinion ('might as well give them, they don't do any harm'), antibiotics are not risk free,".

The moral of the story: interventions should be used with discretion and follow the purpose to which research has shown them to be effective. More isn't always better.

Birth Summit To Be Held In Chicago

A Historic Birth Summit will be held in Chicago on November 8, 2008 at the O'Hare Hilton, in the hometown of the American Medical Association.


This historical summit was called in response to the ACOG/AMA joint proclamation (resolution 205 A-08), which sought to draft model legislation to outlaw homebirth and purported that "the safest setting for labor, delivery, and the immediate post-partum period is in the hospital, or a birthing center within a hospital complex, that meets standards jointly outlined by the American Academy of Pediatrics (AAP) and ACOG, or in a freestanding birthing center that meets the standards of the Accreditation Association for Ambulatory Health Care, The Joint Commission, or the American Association of Birth Centers".


The summit will bring together birth activists, nurses, physicians, midwives, childbirth educators, doulas, and lactation consultants to will set the evidence-based record straight regarding midwifery care and childbirth in hospital settings in the US.


Despite their strong stand and numerous requests for the reasoning behind their proclamation, the ACOG/AMA could not cite research to support their opinion that hospitals are the safest setting for childbirth, because there is simply no research to support their stance.


At the conclusion of the summit, a joint evidence-based announcement will be made to refute the AMA/ACOG proclamation, highlight its inaccuracies, and the impact that enacting such legislation would have on an expectant mother’s right to choose her caregiver and place of birth.


All I can say is, give 'em hell....

Impact of Initial Miscarriage on Future Pregnancies

A new study from the University of Aberdeen studied the impact that an initial miscarriage can have on a woman's next pregnancy.


Results revealed that a woman is 3.3 times as likely to have preeclampsia and 1.5 times as likely to have a premature baby. Women who previously had a miscarriage were 1.7 times as likely to experience bleeding or other signs of threatened miscarriage and 1.3 times as likely to experience bleeding later than 24 weeks gestation.


In a study of 33,000 women published in the British Journal of Obstetrics and Gynaecology, women who suffered a single miscarriage experienced nearly double the rate of inductions and 6 times as many instrumental deliveries with forceps or vacuum extraction.


Preterm birth after 34 weeks and birthweight less than 2500 grams was 1.6 times as likely.


Professor Philip Steer, BJOG editor-in-chief stated:

"The findings from this research are helpful to healthcare professionals caring for pregnant women.

"They provide us with an idea of the complications that may arise as a result of a previous miscarriage. This will help doctors in the management of the subsequent pregnancy."

One factor not assessed was the span of time between pregnancies, which does not decrease substantially until 1.5-2 years and increases with less than 6 months between pregnancies.


The moral of the story...don't let a care provider dismiss your concerns if you've suffered a past miscarriage. Most women go on to have successful pregnancies, but a past history of miscarriage can increase the risks with subsequent pregnancies.

Birth Trauma Impacts Breastfeeding

A new study shows that up to 1/3 of women reported a traumatic childbirth experience, with up to 9% reportedly experiencing Post Traumatic Stress Disorder (PTSD), which can cause women to limit future reproduction, damage their ability to bond with their babies, and leave them permanently psychologically scarred.


Results showed that women who suffered a traumatic birth experience went down two paths regarding breastfeeding: they either embraced it as a way to "prove" themselves as a good mother after a difficult birth and steeling their resolve to breastfeed, or for others, it caused intrusive flashbacks, detachment, and physical pain that ultimately caused them to cease breastfeeding.


The authors concluded that:

...intensive one-on-one support for traumatized mothers may be necessary to help them establish breastfeeding. Sensitivity and awareness by medical professionals of the traumatized mother’s needs may also be helpful.

It was also suggested that healthcare providers be more aware to the signs of a traumatic birth, including temporary amnesia, remaining detached and poor eye contact/a dazed look.


The research study: “Impact of Birth Trauma on Breastfeeding – A Tale of Two Pathways,” appears in the July/August 2008 issue of Nursing Research and was co-authored by Cheryl Tatano Beck, Board of Trustees Distinguished Professor of Nursing and Sue Watson, chairperson of the Trauma and Birth Stress charitable trust.

New Research on Maternal Diet and Obesity in Babies

High Fat Maternal Diet Linked to Obesity in Babies


In an animal study from the University of Cincinnati and the Medical College of Georgia, researchers found that mice fed high-fat were more likely to have larger-than-average babies, which is a risk factor for being overweight or obese later in life.


They found that a high-fat causes the placenta to go into "overdrive" and sends too many nutrients to the baby developing in utero.


On a positive note, they also theorized that putting women on a high-fat diet may help to reduce the number of low birth weight babies.


In either case, this new research yet again highlights the importance of nutrition during pregnancy and the long-term effects it can have, for better or for worse, on your baby's life. Sadly, most obstetricians pay lip service to providing expectant women with detailed nutritional guidance during their pregnancies. Increased attention to nutrition could be the catalyst to preventing life-long complications for children and subsiding the obesity epidemic in many countries.