The blog-o-sphere is buzzing right now about a practice called “Pit to Distress.” Apparently Keyboard Revolutionary started it all with her post, which was quickly followed by Unnecesarean the same day. Now both of these blogs are written by “lay women”–that is, “JUST” moms, not medical professionals. So I was quite happy to see one of my favorite L&D nurse blogs jump into the fray–Nursing Birth. The Nursing Birth piece should be required reading for ANY woman who is planning a hospital birth, so that she doesn’t let this happen to her.
Pitocin seems to be almost synonomous with hospital labors anymore. I wonder how many women who labor actually manage to get through without using it at some point. One client I had switched OB practices because she had been informed that when she arrived at the hospital in active labor she would be put on Pitocin. No waiting to see how labor was progressing and if it was really needed…it was just the policy of this practice to use Pitocin on all laboring women. Medical staff will often explain away any concerns with the use of Pitocin by saying that it is just a synthetic form of the same medication that your body produces. Which is true. But that doesn’t mean that putting it into an IV is the same as letting your body produce it!
I’ve seen some “interesting” things happen with Pitocin in my doula experience.
* One mom was induced with Pitocin, and just when she seemed to be making progress, the Pitocin was turned off, and she was eventually taken for a cesarean for “failure to progress.” At that point she was only 12 hours into her induction, which started at 0 cm, and she was 9 cm dialated. I never did figure out how that was failure to progress.
* One mom asked for her Pitocin to be turned off until after her epidural was in place (anesthesiologist was with another woman, and my client just didn’t know how much longer she could handle the Pit), and the nurse said that she couldn’t do that without the Dr’s consent. Funny, but I thought in America mentally competent adults could refuse any medication.
* One mom told her nurse that she didn’t want the Pitocin drip turned up any further, the nurse said something to the effect of “yeah, it’s rough stuff,” and then went over to the IV pump and began upping the dose. The father stepped up and said “she said she didn’t want it raised anymore,” and the nurse got a shocked look on her face and said “oh, I thought you were just joking.”
* One mom had not responded to multiple attempts to induce labor with prostaglandins, so was put on an IV drip of Pitocin. Her drip rate was doubled every 15 minutes, until I went out to the nurse’s station and commented to the care provider about the intensity of her contractions. The care provider said “this is what labor is” without even observing the woman’s contractions. She did come into the labor room a few minutes labor, observed a contraction, and then quietly turned the drip down. The woman went from 4 cms to 10 cms in less than 2 hours. This inspired me to research recommended Pitocin dosing, and I learned that this woman had been started on 2-4 times the recommended starting dosage, and the dose she was at when I commented to the care provider was actually 160% higher than the level of oxytocin that would “mimic natural labor.” Even the dose that it was turned back to was 20% above the level that was described as “rarely needed.” This woman also had a post-partum hemorhage.
* I’ve only had two clients have cesareans for fetal distress. Both were on Pitocin at the time.
One of the major problems I have with the use of Pitocin is how strongly it is generally used. It is usually used at strengths MUCH greater than what the body would naturally produce. In the case of my client, it got to nearly 3 times the strength the body would naturally produce. Here is an excerpt from the 3rd page of the package insert on Pitocin:
The initial dose should be 0.5 – 1 mU/min (equal to 3-6 ml of the dilute oxytocin solution per hour [10 units oxytocin in 1000 ml saline was suggested a few paragraphs earlier “piggy backed” with plain saline]). At 30-60 minute intervals the dose should be gradually increased in increments of 1-2 mU/min…[. Once] the desired frequency of contractions has been reached and labor has progressed to 5-6 cm dilation, the dose may be reduced by similar increments.
Studies of the concentrations of oxytocin in the maternal plasma during oxytocin infusion have shown that infusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor. At term, higher infusion rates should be given with great care, and rates exceeding 9-10 mU/min are rarely required. Before term, when the sensitivity of the uterus is lower because of lower concentration of oxytocin receptors, a higher infusion rate may be required.
Water intoxication with convulsions, which is caused by the inherent antidiuretic effect of oxytocin, is a serious complication that may occur if large doses (40 to 50 milliunits /minute) are infused for long periods.
Note: I have a Word document explaining how to figure out what dosage of Pitocin is being administered. Ask, and I’ll e-mail it to you. If you are “lucky” the Pitocin is mixed as 30 Units in 500 mls of saline, then you can just read the IV pump to directly get the mU/minute. But if a different mix is used (such as the 10 Units in 1000 mls of saline that is recommended on the package insert), then the charts I have in the Word document will help you to quickly find what dosage is being used. I STRONGLY urge pregnant women to take a copy of it and the package insert for Pitocin with them to the hospital in labor. If Pitocin is going to be used, ask the care provider if the dosing guidelines in the package insert are going to be followed, and if not, why not. Sometimes a “quick” labor is not as safe as a slow labor. Especially if your baby is thought to be compromised already, it may not really make sense to be trying to blast the baby out.
Friday, July 10, 2009
Tuesday, July 07, 2009
Items of InterestShare
Today at 10:07am
On the Mindful Mama website this past week I was interested to read an article called Five Things Every Woman Should Know Before Giving Birth.
Written by the author of a fairly new book titled Homebirth in the Hospital, she suggests 6 "C's" for having a "homebirth in the hospital":
First, take responsibility for your choices.
Expect communication to be open and flowing both ways
Pay attention to continuity of care
The confidence you have in your provider and in your birth team is essential.
In any hospital, there must be control of protocols...I can not stress this point strongly enough: Protocols are the most disempowering aspect of modern maternity care, giving the message that our bodies don’t really know how to have babies without someone else managing the process for us.
Finally, the sixth C to consider, the one that should never be allowed into a birth: conflict. Conflict releases stress hormones that work against the powerful hormones that facilitate birth. Humans are mammals, and no mammal gives birth easily when fearful or in an unsafe situation. If you resolve most issues long before your first contraction, you shouldn’t have to fight for your choices while you are in labor.
The author is also interviewed in a video clip on the site about Finding Your Power in Birth:
Also from Mindful Mama is another short Penny Simkin video called Alternative Ways to Relieve Labor Pain (she teaches a hand massage technique):
Finally, I'm a little behind in mentioning this, but a Letter to the Editor from OBOS director Judy Norsigian regarding Evidence-Based Labor and Delivery Management was published in the American Journal of Obstetrics and Gynecology in May. The conclusion of the letter was: "In the absence of adequate evidence, we believe that the American College of Obstetricians and Gynecologists should retract its strong opposition to home births."
--
Molly
CfM Blogger
On the Mindful Mama website this past week I was interested to read an article called Five Things Every Woman Should Know Before Giving Birth.
Written by the author of a fairly new book titled Homebirth in the Hospital, she suggests 6 "C's" for having a "homebirth in the hospital":
First, take responsibility for your choices.
Expect communication to be open and flowing both ways
Pay attention to continuity of care
The confidence you have in your provider and in your birth team is essential.
In any hospital, there must be control of protocols...I can not stress this point strongly enough: Protocols are the most disempowering aspect of modern maternity care, giving the message that our bodies don’t really know how to have babies without someone else managing the process for us.
Finally, the sixth C to consider, the one that should never be allowed into a birth: conflict. Conflict releases stress hormones that work against the powerful hormones that facilitate birth. Humans are mammals, and no mammal gives birth easily when fearful or in an unsafe situation. If you resolve most issues long before your first contraction, you shouldn’t have to fight for your choices while you are in labor.
The author is also interviewed in a video clip on the site about Finding Your Power in Birth:
Also from Mindful Mama is another short Penny Simkin video called Alternative Ways to Relieve Labor Pain (she teaches a hand massage technique):
Finally, I'm a little behind in mentioning this, but a Letter to the Editor from OBOS director Judy Norsigian regarding Evidence-Based Labor and Delivery Management was published in the American Journal of Obstetrics and Gynecology in May. The conclusion of the letter was: "In the absence of adequate evidence, we believe that the American College of Obstetricians and Gynecologists should retract its strong opposition to home births."
--
Molly
CfM Blogger
Monday, July 06, 2009
Labor Doula Training Workshop
A Special Touch Presents A Cappa Approved Labor Doula Training In West Memphis, Arkansas
5 Sets Left
3 day workshop
Dates: July 24, 25, & 26th, 2009
Friday, Saturday 9a—4p --Sunday 9a—1p
Location: Glenn P Scheottle Medical Education Center
200 W. Tyler St.
West Memphis, Arkansas 72301
Cost: $275.00
Sign Up By July 10, 2009 and the cost is $250.00
Trainer: Angie Whatley, RN, CCCE, CLD
Cappa Approved Labor Doula Faculty Member
Doula Training will cover
CAPPA Scope of Practice
Benefits of a Doula
Birth Options and writing a Birth Plan
Stages of Labor
Comfort Measures for each stage
Medical Interventions
Unmedicated/Medicated Births
Informed Consent
Advocacy and Communication Skills
Difficult Labor Situations
Unexpected Outcomes
Postpartum and Breastfeeding
Getting Started in your career as a Doula and Marketing
The prenatal Interview
And much, much more!!!
Teaching Techniques Used
Videos/DVDs
Power Point
Role Play
Modeling
Hands On
Scenarios
Tools Used
Birth Ball
Rebozo
Massage
Relaxing Techniques and Breathing
Comfort tools
With today’s economy this is a great opportunity for extra income.
If you love working with women and babies and are compassionate you will love this opportunity.
You can register through the CAPPA website at www.cappa.net under workshop trainings
For more information or assistance please call 870-735-5527 ext 225
For lodging information, or with questions, please email arwhatley@uams.edu.
Wednesday, July 01, 2009
Cord Clamping Danger to Babies
By Lucy Johnston HEALTH EDITOR, Daily Express Weekend – Dec, 16, 2007
CLAMPING a newborn baby's umbilical cord too soon after birth can lead to oxygen deprivation and may explain the dramatic rise in autism, scientists have warned.
Groundbreaking research suggests the routine practice of cutting the cord quickly after delivery may reduce an infant's supplies of oxygen and nutrient rich blood in the crucial minutes before they start breathing.
Specialists now believe that in vulnerable infants this is leading to brain hemorrhaging, iron deficiencies and mental impairment, including autism, a mental condition characterized by extreme loneliness and a desire for sameness. Experts say this now affects up to one in 100 children … a sevenfold rise over the past decade.
Last night. David Hutchon, consultant obstetrician at Darlington Memorial Hospital who has studied the effects of cord clamping said: "Babies are being put at risk by clamping the cord too quickly.
"The blood and oxygen supplies in the baby are rapidly decreasing during the minutes after birth. Infants need an increased blood volume to till their lungs and the rest of their organs that are coming into use.
He added: "In susceptible infants, early cord clamping and the lack of blood to the baby increases the risk of brain hemorrhage and breathing problems. This could help explain the rise in autism. Why are we doing it?"
He added that he considered the modern practice of early cord c1amping to be "criminal" in particularly vulnerable and undernourished infants. And he said, "Obstetricians are more likely to clamp early than midwives. It is perhaps significant that autism seems to be more prevalent in babies who were delivered by an obstetrician.”
Umbilical cords are now clamped almost immediately ... before 30 seconds in many hospitals because over the last 20 years doctors have increasingly believed this could reduce the risk of mothers bleeding to death.
However: a growing number of experts, including Mr Hutchon, believe the risks to the baby outweigh the potential harm to the mother. They say at least three minutes should elapse before the cord is cut to allow the mother's blood from the placenta to continue to flow into the baby until its breathing is more established.
Their theory is borne out by recent research. In one major study, involving more than 1,900 newborns and published in the Journal of the American Medical Association, delaying cord clamping for two minutes reduced the risk of anemia by half and low iron levels in the blood by a third.
Eileen Hutton, assistant dean of midwifery at McMaster University in Hamilton, Canada, who carried out the research, said: "These benefits extend beyond the early neonatal period."
Another study carried out by Andrew Weeks, and published in the British Medical .Journal had similar findings: Dr Weeks, senior lecturer in Obstetrics at the University of Liverpool and practicing obstetrician at Liverpool Women's Hospital, told the Sunday Express: "I delay the cutting of the cord. This is especially important for premature babies who have fragile blood vessels. The lack of blood supply could theoretically lead to autism.
"There is evidence to show it [immediate clamping] can damage a baby but none to show it can benefit."
Patrick O'Brien, spokesman for the Royal College of Obstetricians and Gynecologists said: “The latest research does suggest parents should be given a choice and it should be discussed routinely in antenatal classes.”
Birth injuries caused by immediate clamping of the umbilical cord are explained and discussed fully at the following web sites:
www.autism-end-it-now.org
www.birth-brain-injury.org
www.cordclamp.com
CLAMPING a newborn baby's umbilical cord too soon after birth can lead to oxygen deprivation and may explain the dramatic rise in autism, scientists have warned.
Groundbreaking research suggests the routine practice of cutting the cord quickly after delivery may reduce an infant's supplies of oxygen and nutrient rich blood in the crucial minutes before they start breathing.
Specialists now believe that in vulnerable infants this is leading to brain hemorrhaging, iron deficiencies and mental impairment, including autism, a mental condition characterized by extreme loneliness and a desire for sameness. Experts say this now affects up to one in 100 children … a sevenfold rise over the past decade.
Last night. David Hutchon, consultant obstetrician at Darlington Memorial Hospital who has studied the effects of cord clamping said: "Babies are being put at risk by clamping the cord too quickly.
"The blood and oxygen supplies in the baby are rapidly decreasing during the minutes after birth. Infants need an increased blood volume to till their lungs and the rest of their organs that are coming into use.
He added: "In susceptible infants, early cord clamping and the lack of blood to the baby increases the risk of brain hemorrhage and breathing problems. This could help explain the rise in autism. Why are we doing it?"
He added that he considered the modern practice of early cord c1amping to be "criminal" in particularly vulnerable and undernourished infants. And he said, "Obstetricians are more likely to clamp early than midwives. It is perhaps significant that autism seems to be more prevalent in babies who were delivered by an obstetrician.”
Umbilical cords are now clamped almost immediately ... before 30 seconds in many hospitals because over the last 20 years doctors have increasingly believed this could reduce the risk of mothers bleeding to death.
However: a growing number of experts, including Mr Hutchon, believe the risks to the baby outweigh the potential harm to the mother. They say at least three minutes should elapse before the cord is cut to allow the mother's blood from the placenta to continue to flow into the baby until its breathing is more established.
Their theory is borne out by recent research. In one major study, involving more than 1,900 newborns and published in the Journal of the American Medical Association, delaying cord clamping for two minutes reduced the risk of anemia by half and low iron levels in the blood by a third.
Eileen Hutton, assistant dean of midwifery at McMaster University in Hamilton, Canada, who carried out the research, said: "These benefits extend beyond the early neonatal period."
Another study carried out by Andrew Weeks, and published in the British Medical .Journal had similar findings: Dr Weeks, senior lecturer in Obstetrics at the University of Liverpool and practicing obstetrician at Liverpool Women's Hospital, told the Sunday Express: "I delay the cutting of the cord. This is especially important for premature babies who have fragile blood vessels. The lack of blood supply could theoretically lead to autism.
"There is evidence to show it [immediate clamping] can damage a baby but none to show it can benefit."
Patrick O'Brien, spokesman for the Royal College of Obstetricians and Gynecologists said: “The latest research does suggest parents should be given a choice and it should be discussed routinely in antenatal classes.”
Birth injuries caused by immediate clamping of the umbilical cord are explained and discussed fully at the following web sites:
www.autism-end-it-now.org
www.birth-brain-injury.org
www.cordclamp.com
CAPPA and the Economy
Childbirth and Postpartum Professional Association
July 1, 2009
Dear Childbirth Educators and Doulas,
As a Childbirth Educator or Doula, you may be thinking of broadening your education and certification options in order to keep your business running successfully in the current economy. CAPPA has many options that may appeal to you!
CAPPA would like to introduce our organization to you and take a moment to tell you about our certification programs for childbirth educators and doulas. Many educators and doulas from other organizations have obtained dual certification with CAPPA as a way to increase their marketing audience, thus growing their businesses. Over the last few months, you may have heard that some childbirth organizations have been struggling financially and have even closed. CAPPA wants to assure you that our organization is thriving, financially sound and debt free. With this assurance you can feel comfortable that CAPPA will be there to support you long term.
Childbirth and Postpartum Professional Association (CAPPA) is an internationally known and respected childbirth organization, offering training and certifications for childbirth educators and doulas all over the world for over 10 years. CAPPA has over 2000 members. CAPPA offers professional training, certification and support to Childbirth Educators, Lactation Educators, Labor Doulas, and Postpartum Doulas.
CAPPA has a unique program that fits the needs of childbirth educators and/or doulas seeking to transfer their certification or obtain a dual certification with CAPPA.
For the Childbirth Educator
This CAPPA program is called the DUAL Transfer Childbirth Education Program.
For the Doula
This CAPPA program is called the DUAL Transfer Labor Doula Program.
These programs are only available through CAPPA.
CAPPA is offering a substantial discount to Childbirth Educators and Doulas for a limited time.
These CAPPA programs are designed for those educators and doulas who have previous certification and experience. CAPPA will recognize your experience so that you do not have to begin the entire certification process again.
These programs allow educators and/or doulas to take the CAPPA open book exam, and earn your CAPPA certification as a childbirth educator (CCCE) and/or labor doula (CLD) at a very low cost.
Here are the details:
For the Childbirth Educator
Become a member of CAPPA (45.00)
Enter certification program by purchasing the dual childbirth educator certification program, available in our shop (150.00)
Submit proof of your childbirth educator certification by turning in a copy of your certificate with your completed CAPPA open book test.
Read three books from the required reading list, this is a very large list of popular childbirth and pregnancy books. If you have previously read any 3 on the list, you may use those books.
Pass the test on childbirth education topics included in your packet. The test is an open book test.
Total Cost is:
45.00 membership fee
150.00 Exam fee
Total : 195.00
CAPPA has waved the usual 75.00 processing fee for a limited time.
For the Labor/Birth Doula
Become a member of CAPPA (45.00)
Enter certification program by purchasing the dual labor doula certification program, available in our shop (150.00)
Submit proof of your labor doula certification by turning in a copy of your certificate with your completed CAPPA open book test.
Read three books from the required reading list, this is a very large list of popular childbirth and pregnancy books. If you have previously read any 3 on the list, you may use those books.
Pass the test on childbirth topics included in your packet. The test is an open book test.
Total Cost is:
45.00 membership fee
150.00 Exam fee
Total : 195.00
CAPPA has waved the usual 75.00 processing fee for a limited time.
If you have any questions please feel free to call the CAPPA office at 1-888-692-2772 A CAPPA faculty member will be happy to answer all your questions.
We invite you to join CAPPA and become a valued member of the CAPPA organization. CAPPA members also enjoy our FREE yearly childbirth conference. CAPPA is proud to offer excellent training and support to childbirth professionals world wide. Please visit the CAPPA web site and get acquainted with CAPPA.
Sincerely,
The CAPPA Faculty
CAPPA
--------------------------------------------------------------------------------
email: info@cappa.net
phone: 1-888-MY-CAPPA
web: http://www.cappa.net
July 1, 2009
Dear Childbirth Educators and Doulas,
As a Childbirth Educator or Doula, you may be thinking of broadening your education and certification options in order to keep your business running successfully in the current economy. CAPPA has many options that may appeal to you!
CAPPA would like to introduce our organization to you and take a moment to tell you about our certification programs for childbirth educators and doulas. Many educators and doulas from other organizations have obtained dual certification with CAPPA as a way to increase their marketing audience, thus growing their businesses. Over the last few months, you may have heard that some childbirth organizations have been struggling financially and have even closed. CAPPA wants to assure you that our organization is thriving, financially sound and debt free. With this assurance you can feel comfortable that CAPPA will be there to support you long term.
Childbirth and Postpartum Professional Association (CAPPA) is an internationally known and respected childbirth organization, offering training and certifications for childbirth educators and doulas all over the world for over 10 years. CAPPA has over 2000 members. CAPPA offers professional training, certification and support to Childbirth Educators, Lactation Educators, Labor Doulas, and Postpartum Doulas.
CAPPA has a unique program that fits the needs of childbirth educators and/or doulas seeking to transfer their certification or obtain a dual certification with CAPPA.
For the Childbirth Educator
This CAPPA program is called the DUAL Transfer Childbirth Education Program.
For the Doula
This CAPPA program is called the DUAL Transfer Labor Doula Program.
These programs are only available through CAPPA.
CAPPA is offering a substantial discount to Childbirth Educators and Doulas for a limited time.
These CAPPA programs are designed for those educators and doulas who have previous certification and experience. CAPPA will recognize your experience so that you do not have to begin the entire certification process again.
These programs allow educators and/or doulas to take the CAPPA open book exam, and earn your CAPPA certification as a childbirth educator (CCCE) and/or labor doula (CLD) at a very low cost.
Here are the details:
For the Childbirth Educator
Become a member of CAPPA (45.00)
Enter certification program by purchasing the dual childbirth educator certification program, available in our shop (150.00)
Submit proof of your childbirth educator certification by turning in a copy of your certificate with your completed CAPPA open book test.
Read three books from the required reading list, this is a very large list of popular childbirth and pregnancy books. If you have previously read any 3 on the list, you may use those books.
Pass the test on childbirth education topics included in your packet. The test is an open book test.
Total Cost is:
45.00 membership fee
150.00 Exam fee
Total : 195.00
CAPPA has waved the usual 75.00 processing fee for a limited time.
For the Labor/Birth Doula
Become a member of CAPPA (45.00)
Enter certification program by purchasing the dual labor doula certification program, available in our shop (150.00)
Submit proof of your labor doula certification by turning in a copy of your certificate with your completed CAPPA open book test.
Read three books from the required reading list, this is a very large list of popular childbirth and pregnancy books. If you have previously read any 3 on the list, you may use those books.
Pass the test on childbirth topics included in your packet. The test is an open book test.
Total Cost is:
45.00 membership fee
150.00 Exam fee
Total : 195.00
CAPPA has waved the usual 75.00 processing fee for a limited time.
If you have any questions please feel free to call the CAPPA office at 1-888-692-2772 A CAPPA faculty member will be happy to answer all your questions.
We invite you to join CAPPA and become a valued member of the CAPPA organization. CAPPA members also enjoy our FREE yearly childbirth conference. CAPPA is proud to offer excellent training and support to childbirth professionals world wide. Please visit the CAPPA web site and get acquainted with CAPPA.
Sincerely,
The CAPPA Faculty
CAPPA
--------------------------------------------------------------------------------
email: info@cappa.net
phone: 1-888-MY-CAPPA
web: http://www.cappa.net
Tuesday, June 30, 2009
Indications for induction of labour
a best-evidence review
E Mozurkewich,a J Chilimigras,a E Koepke,a K Keeton,a VJ Kingb
a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
b Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
Correspondence: Dr E Mozurkewich, F4835, PO Box 0264, Mott Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0264, USA.
Email mozurk@umich.edu
Accepted 2 November 2008. Published Online 4 February 2009.
Background Rates of labour induction are increasing.
Objectives To review the evidence supporting indications for
induction.
Search strategy We listed indications for labour induction and
then reviewed the evidence. We searched MEDLINE and the
Cochrane Library between 1980 and April 2008 using several terms
and combinations, including induction of labour, premature
rupture of membranes, post-term pregnancy, preterm prelabour
rupture of membranes (PROM), multiple gestation, suspected
macrosomia, diabetes, gestational diabetes mellitus, cardiac disease,
fetal anomalies, systemic lupus erythematosis, oligohydramnios,
alloimmunization, rhesus disease, intrahepatic cholestasis of
pregnancy (IHCP), and intrauterine growth restriction (IUGR). We
performed a review of the literature supporting each indication.
Selection criteria We identified 1387 abstracts and reviewed 418
full text articles. We preferentially included high-quality systematic
reviews or large randomised trials. Where no such studies existed,
we included the best evidence available from smaller randomised
trials and observational studies.
Main results We included 34 full text articles. For each indication,
we assigned levels of evidence and grades of recommendation
based upon the GRADE system. Recommendations for induction
of labour for post-term gestation, PROM at term, and premature
rupture of membranes near term with pulmonary maturity are
supported by the evidence. Induction for IUGR before term
reduces intrauterine fetal death, but increases caesarean deliveries
and neonatal deaths. Evidence is insufficient to support induction
for women with insulin-requiring diabetes, twin gestation, fetal
macrosomia, oligohydramnios, cholestasis of pregnancy, maternal
cardiac disease and fetal gastroschisis.
Authors’ conclusions Research is needed to determine risks and
benefits of induction for many commonly advocated clinical
indications.
Keywords Best evidence, indications, induction.
Please cite this paper as: Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King V. Indications for induction of labour: a best-evidence review. BJOG 2009;116:626
E Mozurkewich,a J Chilimigras,a E Koepke,a K Keeton,a VJ Kingb
a Division of Maternal-Fetal Medicine, Department of Obstetrics and Gynecology, University of Michigan, Ann Arbor, MI, USA
b Department of Family Medicine, Oregon Health and Science University, Portland, OR, USA
Correspondence: Dr E Mozurkewich, F4835, PO Box 0264, Mott Hospital, 1500 E. Medical Center Drive, Ann Arbor, MI 48109-0264, USA.
Email mozurk@umich.edu
Accepted 2 November 2008. Published Online 4 February 2009.
Background Rates of labour induction are increasing.
Objectives To review the evidence supporting indications for
induction.
Search strategy We listed indications for labour induction and
then reviewed the evidence. We searched MEDLINE and the
Cochrane Library between 1980 and April 2008 using several terms
and combinations, including induction of labour, premature
rupture of membranes, post-term pregnancy, preterm prelabour
rupture of membranes (PROM), multiple gestation, suspected
macrosomia, diabetes, gestational diabetes mellitus, cardiac disease,
fetal anomalies, systemic lupus erythematosis, oligohydramnios,
alloimmunization, rhesus disease, intrahepatic cholestasis of
pregnancy (IHCP), and intrauterine growth restriction (IUGR). We
performed a review of the literature supporting each indication.
Selection criteria We identified 1387 abstracts and reviewed 418
full text articles. We preferentially included high-quality systematic
reviews or large randomised trials. Where no such studies existed,
we included the best evidence available from smaller randomised
trials and observational studies.
Main results We included 34 full text articles. For each indication,
we assigned levels of evidence and grades of recommendation
based upon the GRADE system. Recommendations for induction
of labour for post-term gestation, PROM at term, and premature
rupture of membranes near term with pulmonary maturity are
supported by the evidence. Induction for IUGR before term
reduces intrauterine fetal death, but increases caesarean deliveries
and neonatal deaths. Evidence is insufficient to support induction
for women with insulin-requiring diabetes, twin gestation, fetal
macrosomia, oligohydramnios, cholestasis of pregnancy, maternal
cardiac disease and fetal gastroschisis.
Authors’ conclusions Research is needed to determine risks and
benefits of induction for many commonly advocated clinical
indications.
Keywords Best evidence, indications, induction.
Please cite this paper as: Mozurkewich E, Chilimigras J, Koepke E, Keeton K, King V. Indications for induction of labour: a best-evidence review. BJOG 2009;116:626
The HUG Your Baby program is coming to Denver!
Join us for one or more events with Jan Tedder, FNP, the HUG's creator. Two days and four events to choose from!
Events at Nourish Family Center (Register at www.nourishfamilycenter.com under Classes or Workshops)
- HUG Your Baby training (Parts 1 & 2) - 9 am to 4 pm on Tuesday, July 7 (5 contact hours) $100
- HUG Your Baby FREE Meet & Greet with Jan Tedder - July 7 @ 6 pm with food, fun and information. FREE
- HUG Your Baby (Part 1) - 10 am to 12 pm on Wednesday, July 8 (1.5 contact hours). $10
Event through The Lactation Program's Journal Club:
- HUG Your Baby @ Journal Club (Part 1) - The Auditorium at Rose Medical Center (2 contact hours) - July 8 from 2:30-5 pm. $25 ($30 for CERPs for IBCLCs)
www.nourishfamilycenter.com
Events at Nourish Family Center (Register at www.nourishfamilycenter.com under Classes or Workshops)
- HUG Your Baby training (Parts 1 & 2) - 9 am to 4 pm on Tuesday, July 7 (5 contact hours) $100
- HUG Your Baby FREE Meet & Greet with Jan Tedder - July 7 @ 6 pm with food, fun and information. FREE
- HUG Your Baby (Part 1) - 10 am to 12 pm on Wednesday, July 8 (1.5 contact hours). $10
Event through The Lactation Program's Journal Club:
- HUG Your Baby @ Journal Club (Part 1) - The Auditorium at Rose Medical Center (2 contact hours) - July 8 from 2:30-5 pm. $25 ($30 for CERPs for IBCLCs)
www.nourishfamilycenter.com
C-section Births Cause Genetic Changes That May Increase Odds For Developing Diseases In Later Life
ScienceDaily (June 29, 2009) — Swedish researchers have discovered that babies born by Caesarean section experience changes to the DNA pool in their white blood cells, which could be connected to altered stress levels during this method of delivery, according to the July issue of Acta Paediatrica.
It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.
Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.
This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.
“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.
“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”
The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.
“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.
“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”
The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.
“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”
Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.
“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.
“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”
The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.
“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.
--------------------------------------------------------------------------------
Journal reference:
1.Schlinzig et al. Epigenetic modulation at birth - altered DNA-methylation in white blood cells after Caesarean section. Acta Paediatrica, 2009; 98 (7): 1096 DOI: 10.1111/j.1651-2227.2009.01371.x
Adapted from materials provided by Wiley - Blackwell, via AlphaGalileo.
It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.
Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.
This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.
“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.
“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”
The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.
“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.
“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”
The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.
“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”
Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.
“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.
“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”
The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.
“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.
--------------------------------------------------------------------------------
Journal reference:
1.Schlinzig et al. Epigenetic modulation at birth - altered DNA-methylation in white blood cells after Caesarean section. Acta Paediatrica, 2009; 98 (7): 1096 DOI: 10.1111/j.1651-2227.2009.01371.x
Adapted from materials provided by Wiley - Blackwell, via AlphaGalileo.
Monday, June 29, 2009
Fetal Monitoring
(MS-Taken from CfM. http://cfmidwifery.blogspot.com/)
Saturday, June 27, 2009
Fetal Monitoring
I started to write about this in my previous post and then realized it actually belonged in its own post!
The author of Bearing Meaning spends an entire chapter analyzing Williams Obstetrics and the language of birth contained therein. In Williams fetal monitoring is referred to as an "elegant means" of "demonstrating the effect of the forces of labor and delivery on the baby's heart rate." However, as the author of Bearing Meaning (Robbie Kahn) notes, "The tracings don't record labor in a generic sense. They record it under specific conditions--the hospital...Thus, monitor tracings hardly are elegant, if elegant means imparting information at high levels of sophistication. Indeed, the monitor may be simply recording responses characteristic of a woman laboring under the conditions imposed in the hospital rather than imparting sophisticated information about childbirth in general." (emphasis mine).
This observation reminded me of Henci Goer's recent post on the Science and Sensibility blog: The Labor Environment: “Many things that count cannot be counted." In this post, she looks at a recent study published in the June issue of Birth, "gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention." The labor environment impacts women's birth experiences in a number of ways (some that cannot be quantified for research studies) and my observation is that fetal monitoring is one of the most significant elements of the labor environment. It creates conditions for laboring women that then alters their normal, physiological, spontaneous responses to labor and thus cannot be seen as accurately reflecting the influence of labor on the baby.
Speaking of fetal monitoring, ACOG just issued new guidelines refining the fetal heart rate monitoring guidelines. The guidelines briefly refer to manual auscultation. Quoted in the release is the following comment: "'Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,' says George A. Macones, MD, who headed the development of the ACOG document. 'Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.'"
--
Molly
CfM Blogger
Saturday, June 27, 2009
Fetal Monitoring
I started to write about this in my previous post and then realized it actually belonged in its own post!
The author of Bearing Meaning spends an entire chapter analyzing Williams Obstetrics and the language of birth contained therein. In Williams fetal monitoring is referred to as an "elegant means" of "demonstrating the effect of the forces of labor and delivery on the baby's heart rate." However, as the author of Bearing Meaning (Robbie Kahn) notes, "The tracings don't record labor in a generic sense. They record it under specific conditions--the hospital...Thus, monitor tracings hardly are elegant, if elegant means imparting information at high levels of sophistication. Indeed, the monitor may be simply recording responses characteristic of a woman laboring under the conditions imposed in the hospital rather than imparting sophisticated information about childbirth in general." (emphasis mine).
This observation reminded me of Henci Goer's recent post on the Science and Sensibility blog: The Labor Environment: “Many things that count cannot be counted." In this post, she looks at a recent study published in the June issue of Birth, "gauging the effects of modifying the labor room to encourage mobility, reduce stress and anxiety, and discourage routine medical intervention." The labor environment impacts women's birth experiences in a number of ways (some that cannot be quantified for research studies) and my observation is that fetal monitoring is one of the most significant elements of the labor environment. It creates conditions for laboring women that then alters their normal, physiological, spontaneous responses to labor and thus cannot be seen as accurately reflecting the influence of labor on the baby.
Speaking of fetal monitoring, ACOG just issued new guidelines refining the fetal heart rate monitoring guidelines. The guidelines briefly refer to manual auscultation. Quoted in the release is the following comment: "'Since 1980, the use of EFM has grown dramatically, from being used on 45% of pregnant women in labor to 85% in 2002,' says George A. Macones, MD, who headed the development of the ACOG document. 'Although EFM is the most common obstetric procedure today, unfortunately it hasn't reduced perinatal mortality or the risk of cerebral palsy. In fact, the rate of cerebral palsy has essentially remained the same since World War II despite fetal monitoring and all of our advancements in treatments and interventions.'"
--
Molly
CfM Blogger
Thursday, June 25, 2009
Large Study Showing the Safety of Homebirths
Today at 3:33pm
Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births
Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
A de Jonge a , BY van der Goes b , ACJ Ravelli c , MP Amelink-Verburg a,d , BW Mol b , JG Nijhuis e , J Bennebroek Gravenhorst a , SE Buitendijk a
a TNO Quality of Life, Leiden, the Netherlands b Department of Obstetrics and Gynaecology, Amsterdam Medical Centre, Amsterdam, the Netherlands c Department of Medical Informatics, Amsterdam Medical Centre, Amsterdam, the Netherlands d Health Care Inspectorate, Rijswijk, the Netherlands e Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
Correspondence to Dr A de Jonge, TNO Quality of Life, P.O. Box 2215, 2301 CE Leiden, the Netherlands. Email ankdejonge@hotmail.com
Copyright Journal compilation © 2009 RCOG
KEYWORDS
Midwifery • perinatal mortality • pregnancy outcome
Please cite this paper as: de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.02175.x.
ABSTRACT
Objective To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.
Design A nationwide cohort study.
Setting The entire Netherlands.
Population A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown.
Methods Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics.
Main outcome measures Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.
Results No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).
Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
Accepted 26 February 2009. Published Online 15 April 2009.
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1471-0528.2009.02175.x About DOI
Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births
Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
A de Jonge a , BY van der Goes b , ACJ Ravelli c , MP Amelink-Verburg a,d , BW Mol b , JG Nijhuis e , J Bennebroek Gravenhorst a , SE Buitendijk a
a TNO Quality of Life, Leiden, the Netherlands b Department of Obstetrics and Gynaecology, Amsterdam Medical Centre, Amsterdam, the Netherlands c Department of Medical Informatics, Amsterdam Medical Centre, Amsterdam, the Netherlands d Health Care Inspectorate, Rijswijk, the Netherlands e Department of Obstetrics and Gynaecology, Maastricht University Medical Centre, Maastricht, the Netherlands
Correspondence to Dr A de Jonge, TNO Quality of Life, P.O. Box 2215, 2301 CE Leiden, the Netherlands. Email ankdejonge@hotmail.com
Copyright Journal compilation © 2009 RCOG
KEYWORDS
Midwifery • perinatal mortality • pregnancy outcome
Please cite this paper as: de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009; DOI: 10.1111/j.1471-0528.2009.02175.x.
ABSTRACT
Objective To compare perinatal mortality and severe perinatal morbidity between planned home and planned hospital births, among low-risk women who started their labour in primary care.
Design A nationwide cohort study.
Setting The entire Netherlands.
Population A total of 529,688 low-risk women who were in primary midwife-led care at the onset of labour. Of these, 321 307 (60.7%) intended to give birth at home, 163 261 (30.8%) planned to give birth in hospital and for 45 120 (8.5%), the intended place of birth was unknown.
Methods Analysis of national perinatal and neonatal registration data, over a period of 7 years. Logistic regression analysis was used to control for differences in baseline characteristics.
Main outcome measures Intrapartum death, intrapartum and neonatal death within 24 hours after birth, intrapartum and neonatal death within 7 days and neonatal admission to an intensive care unit.
Results No significant differences were found between planned home and planned hospital birth (adjusted relative risks and 95% confidence intervals: intrapartum death 0.97 (0.69 to 1.37), intrapartum death and neonatal death during the first 24 hours 1.02 (0.77 to 1.36), intrapartum death and neonatal death up to 7 days 1.00 (0.78 to 1.27), admission to neonatal intensive care unit 1.00 (0.86 to 1.16).
Conclusions This study shows that planning a home birth does not increase the risks of perinatal mortality and severe perinatal morbidity among low-risk women, provided the maternity care system facilitates this choice through the availability of well-trained midwives and through a good transportation and referral system.
Accepted 26 February 2009. Published Online 15 April 2009.
DIGITAL OBJECT IDENTIFIER (DOI)
10.1111/j.1471-0528.2009.02175.x About DOI
Subscribe to:
Posts (Atom)
