childbirth

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Wide Hips? Take Heart: Study Finds You Can Run Just As Efficiently

As a woman who describes herself — matter-of-factly, not self-hatingly — as shaped like a cello, I’m deeply pleased by this fascinating marathon-season report from our friends over at Boston University’s Research Website, headlined “In Defense of Wide Hips.” Re-posted with their permission:

Biological anthropologist and evolutionary anatomist Kristi Lewton of BU School of Medicine. (Jackie Ricciardi for BU)

Biological anthropologist and evolutionary anatomist Kristi Lewton of BU School of Medicine. (Jackie Ricciardi for BU)

By Kate Becker

What can you learn from a pelvis? Among the qualities that make humans unique are two physical features: our way of walking and running upright on two legs, and our newborn babies’ very large heads. Those two traits of humanity meet at the pelvis, a set of bones that includes the ilium, ischium, pubis, and sacrum.

For more than 50 years, anthropologists thought that the human pelvis was shaped by an evolutionary tug-of-war between the competing demands of bipedalism and childbirth. Now, a team of scientists that includes Kristi Lewton, an assistant professor in the department of anatomy and neurobiology at Boston University School of Medicine, and colleagues at Harvard University and Hunter College has shown that this so-called “obstetric dilemma” might not be a dilemma at all.

They found no connection at all between hip width and efficiency: wide-hipped runners moved just as well as their narrow-hipped peers.

Humans give birth to very large (“ginormous!”) newborns, says Lewton. While chimps and other nonhuman primate babies emerge from the birth canal with room to spare, human infants must perform a complicated series of rotations to make their way into the world, and the pelvic opening is just barely big enough. If something goes wrong, the lives of both mother and baby are at risk. So, why hasn’t the human body evolved a wider pelvis? Anthropologists have long believed that an evolutionary trade-off was at work; they assumed that a wide pelvis was “bad for bipedalism,” says Lewton. Yet, until now, no one had rigorously tested this assumption.

Lewton and her colleagues set out to discover whether wide hips really do make running and walking less efficient. They recruited 38 undergraduates, including both men and women, and had them walk and run on a treadmill while gauging how hard they were working by measuring their oxygen consumption. While the participants exercised, their motion was tracked by eight cameras trained on infrared markers attached to the participants’ hips, knees, ankles, thighs, and shanks. Lewton and her colleagues estimated the subjects’ hip width using the results from the infrared trackers, and later combined their data with results from a Washington University in St. Louis research team that used MRI to get a direct measure of hip width. (True hip width is defined as the distance between the hip joints, points out Lewton, and is different from what you would measure with a tailor’s tape.)

If the basic assumptions of the obstetric dilemma are right, says Lewton, participants with wider hips should run and walk less efficiently than those with narrow ones. But that wasn’t what Lewton and her team found. Continue reading

Viewpoint: Doctors Respond To Home Births That End Up In Hospital

By Shirie Leng, M.D. and Cindy Ku, M.D.

As physicians we are concerned about a recent post on CommonHealth — “What to Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)” — that focuses on planned home births that end up in the hospital.

While we respect the right of women to labor and deliver in the environment of their choosing, requiring medical intervention in childbirth is neither shameful nor a moral failing. Life-threatening complications which, 100 years ago, would have meant a death sentence for mothers and babies, are now treatable and even preventable in the modern hospital maternity ward. Suggesting that women are unduly traumatized by transfer to and treatment in a medical facility does a disservice to the obstetricians, nurses, anesthesiologists, and neonatologists who work so hard to save these lives.

Here’s an example of the kind of case that could possibly result from a home birth that goes awry. While on a routine morning on the obstetrics unit, the usual routine was interrupted by a phone call from the emergency room. A laboring mother was in distress and needed an emergency caesarean, and she was about to arrive into the trauma OR. Since caesareans are not normally performed in the emergency room trauma room, everyone dropped their plans and hurriedly prepared the trauma OR. One minute later a petite young woman on a stretcher crashed through the door along with the obstetrician. “Get the baby out of me!” she screamed, writhing and crying in agony as the team transferred her to the operating table. Between her moans and her desperate outbursts, she could barely understand the questions as the anesthesiologist tried to ascertain three things: did she have heart or lung problems, did she have allergies, and did she have any potential problems with her airway?

 (meme_mutation/flickr)

(meme_mutation/flickr)

We had no other information to go by – no laboratory data, no history, not even her name. All we knew was the baby was in breech position (legs down, not head down) and was in distress. We had five seconds to decide how we would help to save the two lives in front of us. We told her as gently as we could (though it likely didn’t register with her at all) that she needed to breathe in oxygen for herself and her unborn child, that she would be unconscious for about an hour, and we would see her and her baby in the recovery room. Vaginal delivery is not the standard of care for breech presentations because of the significantly elevated risk of shoulder entrapment in the birth canal and stillbirth. Months after this case we all still wonder how we could have done better and what would’ve happened if she hadn’t arrived in time.

Thankfully, our team — the obstetricians, anesthesiologists, nurses and neonatologists — worked together successfully and both mother and child did well. We don’t know for sure if this case began as a home birth, but it does represent the sorts of difficulties that we medical staffs wrestle with when a home birth becomes complicated and ends up at the hospital.

Childbirth always brings with it an element of danger. While everything usually goes right, when it goes wrong it usually does so quickly and seriously. To expect the idealized experience in every case is to deny reality. In 1900, when women were having the arguably blissful natural birth experience home birthers seek, the maternal mortality rate was more than 800 deaths per 100,000 births. According to the CDC, in 1997 that number was 7 per 100,000. This statistic, an upwards of 99 percent decrease in mortality rate, was not achieved by midwives and doulas with the latest technology in birthing balls and labor tubs. It was achieved through advances in science and medicine. Continue reading

What To Expect When You’re Birthing At Home: A Hospital C-Section (Possibly)

Screen shot 2015-03-20 at 9.07.11 AM

By Ananda Lowe
Guest Contributor

The term “homebirth cesarean” didn’t exist before 2011, when Oregon mother and student midwife Courtney Jarecki coined it. But now, a Google search returns almost 2,000 entries on the topic.

The term refers to a small but emerging community of mothers who have experienced the extremes of birth: They’d planned to have their babies at home, but ended up in a hospital, most often in the operating room having a cesarean section, major abdominal surgery. Needless to say, the effect of such a dramatic course change takes a toll, and can often be overwhelming.

(“Homebirth cesarean” can also refer to births that were planned to occur at a freestanding birth center outside of a hospital, but eventually were transferred to the hospital for a cesarean.)

How often does this happen?

Home births, though a small fraction of the approximately 3.9 million births a year in the U.S., are on the rise. Based on the most recent birth data from the National Center for Health Statistics, “the 36,080 home births in 2013 accounted for 0.92% of all U.S. births that year, an increase of 55% from the 2004 total.”

Eugene Declercq, a professor of community health sciences at Boston University School of Public Health, studies national birth trends. He said in an email that while there are no nationwide numbers on homebirth transfers to the hospital, “the studies that have been done usually report about a 12% intrapartum transfer rate.”

But beyond the numbers, what happens emotionally when your warm and fuzzy image of natural childbirth in the comfort of home suddenly morphs into the hard reality of a surgical birth under fluorescent lights?

A woman who'd planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

A woman who’d planned a homebirth but ended up having a cesarean in the hospital. (Photo courtesy: Courtney Jarecki)

Jarecki founded the homebirth cesarean movement to figure that out. She connected women who, like herself, shared the experience of giving birth through full surgical intervention, despite their original plans of having their babies at home or outside of the established medical system.

In Jarecki’s case, she labored at home for 50 hours until her midwives detected a rare complication known as a constriction ring, or a thickened band of tissue in her uterus that was impeding progress. Shortly after this, meconium appeared, and Jarecki knew it was time to go to the hospital. Her emotional response to the intensity of the situation, however irrational, was one of anger, shame and failure at her ability to give birth normally. A cesarean followed.

Over the next several years, Jarecki began helping other homebirth cesarean mothers emerge from the silence and shame they felt confronting their unexpected surgeries. Some of these women also report that their postpartum recovery was tougher because their unique needs were not adequately addressed by their home birth midwives or their hospitals.

Jarecki started by launching a (now busy) Facebook page as a support group for these mothers and their health care providers.

Childbirth Expectations vs. Reality

Rule number one in childbirth is that it rarely unfolds as you expect. Continue reading

Falling Into The Postpartum Mood Disorder Abyss: A Personal Story

By Deb Wachenheim
Guest Contributor

Over the past two days, The New York Times published a series of articles about postpartum depression and other related mood disorders. The first article looked at the science and policy on this topic and highlights a few women’s stories.

Today’s article is about my sister, Cindy Wachenheim, who took her own life in March of 2013 after struggling for six months with postpartum mood disorders. I say mood disorders because it was not just depression (and the fact that there are other postpartum mood disorders in addition to postpartum depression was something about which I was previously completely unaware). She had extreme anxiety about, and obsession with, her baby’s health and she was depressed because she believed she caused him to have serious health problems. Also, according to what I have been told by experts, she may have been psychotic: she was so convinced that something was seriously wrong with her baby — despite doctors telling her otherwise — that she strapped him to her chest when she jumped out of her apartment window, believing, I can only assume, that this was what was best for him. Thank goodness, he survived and is thriving.

Beyond what is written in the article, I think it is important to give more detail and information on some resources and policy activities in Massachusetts, in the hope that this could possibly help others who are facing similar struggles. As is mentioned in the article, I reached out to Cindy’s son’s pediatrician after Cindy had gone to see her multiple times about her concerns.

Pediatricians are key to screening for postpartum mood disorders and making referrals for needed treatment. Most women see their OB a few weeks after giving birth and if everything seems okay at that point then they are sent on their way until the following year’s annual exam.

However, woman bring their infants to see the pediatrician many times over that first year. It is pediatricians who could notice if something seems to not be right with the mother. Continue reading

Anti-Shackling Bill, With More Medical Care For Pregnant Inmates, Poised To Become Law

A bill that would ban the use of restraints on pregnant inmates in labor (except in “extraordinary circumstances”) and also require more pre- and post-natal medical care for incarcerated women is about to become law in Massachusetts.

Here’s the specific language from the bill:

An inmate who is in labor, as determined by a licensed health care professional, delivering her baby or who is being transported or housed in an outside medical facility for the purpose of treating labor symptoms, shall not be placed in restraints.

An inmate in post-delivery recuperation, as determined by the attending physician, shall not be placed in restraints, except under extraordinary circumstances.

For the purposes of this section, “extraordinary circumstances” shall mean a situation in which a correction officer makes an individualized determination, approved by a superintendent, that the inmate presents an immediate, serious threat of hurting herself or others or in which the inmate presents an immediate and credible risk of escape that cannot be reasonably contained through other methods. In the event the correction officer determines that extraordinary circumstances exist, the officer shall document, in writing, the reasons for the determination and the specific type of restraints used.

Here’s more on the anti-shackling legislation from the NARAL Pro-Choice Massachusetts news release:

After over a decade of advocacy, members of the Massachusetts Anti-Shackling Coalition are celebrating unanimous votes in both the Massachusetts House of Representatives and State Senate that will send the Anti-Shackling Bill to the Governor’s desk for his signature.

“I was handcuffed by both my wrist and my ankle to the hospital stretcher for over eighteen hours while I was in labor,” said Michelle Collette, who was incarcerated at MCI-Framingham. “Today, the legislature moved us one step closer to making sure that no woman in Massachusetts will ever again experience what I went through when giving birth to my son.”

The.Comedian/flickr

The.Comedian/flickr

Representative Kay Khan (D-Newton) has filed some version of the Anti-Shackling Bill since 2001. In 2013, Senator Karen Spilka (D-Framingham) filed a companion bill in the Senate. Earlier this year, Governor Deval Patrick filed 90-day emergency regulations to immediately prohibit the practice of shackling pregnant women as a stopgap measure until the legislature passed the Anti-Shackling Bill. Last month, both the State Senate and State House unanimously passed versions of the bill. Differences between the two versions have now been reconciled and the final language has been enacted in both chambers….Since the emergency regulations were filed in February, advocates have heard reports of two incarcerated women who have gone into labor. Both were shackled during transport, and one was not unshackled when requested by medical personnel. Further, one was shackled in the hospital during labor and during postpartum recuperation without an individualized determination that “extraordinary circumstances” justified it. Continue reading

OBs: No Link Between Labor Induction And Autism

The nation’s most influential group of obstetrician-gynecologists concludes that there’s no connection between labor induction and autism. Earlier reports suggested that there’s was a possible link, but even that research, published in JAMA Pediatrics, was complicated and somewhat murky.

(popularpatty/flickr)

(popularpatty/flickr)

Here’s ACOG’s latest guidance on the matter, from the news release:

Current evidence does not support a conclusion that labor induction or augmentation causes autism spectrum disorder (ASD) in newborns, according to a new Committee Opinion released by the American College of Obstetricians and Gynecologists (the College).

While some studies have suggested an association between ASD and the use of oxytocin for labor induction or augmentation, available evidence is inconsistent and does not demonstrate causation, according to the opinion, which also found important limitations in study design and conflicting findings in existing research.

Given the potential consequences of limiting labor induction and augmentation, the College’s Committee on Obstetric Practice recommends against changes to existing guidance regarding counseling and indications for, and methods of, labor induction and augmentation.

“In obstetric practice, labor induction and augmentation play an essential role in protecting the health of some mothers and in promoting safe delivery of many babies,” said Jeffrey L. Ecker, MD. Dr. Ecker is chair of the Committee on Obstetric Practice, which developed the new Committee Opinion. “When compared with these benefits, the research we reviewed in assembling this Committee Opinion, relative to the utilization of oxytocin, had clear limitations. Because of this, these studies should not impact how obstetricians already safely and effectively use labor induction and augmentation when caring for their patients.” Continue reading

Water Babies: Docs Challenge Growing Trend — Childbirth In A Tub

Lumina Gershfield-Cordova, after giving birth to her daughter in the water. (Photo: Erica Kershner)

Lumina Gershfield-Cordova, after giving birth to her daughter in the water. (Photo: Erica Kershner)

Earlier this month, Lumina Gershfield-Cordova gave birth to her healthy 8-pound daughter in a large tub of warm water.

And from that portable tub — set up in the bedroom of her Somerville, Mass., condo — came an atypical American birth story: Gershfield-Cordova describes the buoyancy of the water offering her delicious freedom to move, stretch, turn and, sometimes, relax in ways that are generally unavailable to a woman delivering a baby flat on her back in a hospital bed.

“It’s so wonderful the way the water supports your whole body,” she said. “You can assume positions you can’t get into when gravity is pulling down on you — it’s such a relief. You feel like a ballerina, or an athlete…I was able to work with my baby and together we found the right way for her to come out — there were actual moments of pleasure during her descent. It was amazing.”

Gershfield-Cordova, 35, is one data point in a growing trend. Actress Ricki Lake famously gave birth in a bathtub as part of her pro-natural childbirth documentary, “The Business of Being Born;” the movie created a kind of “Lake Effect” with more buzz around home birth in general, and water birth as well. One report recently quoted supermodel Gisele Bundchen saying her own child’s birth in the water was inspired by Lake’s film.

“It’s so wonderful the way the water supports your whole body…You can assume positions you can’t get into when gravity is pulling down on you — it’s such a relief.”

But it’s one thing to labor in the water, and quite another to actually give birth underwater, according to two prominent physician groups.

In a just-released joint opinion, the American College of Obstetricians and Gynecologists and the American Academy of Pediatrics have come out squarely against childbirth in the water.

Their conclusion: laboring in water could be helpful for women as a way to reduce pain (and pain medication) and spend less time in labor, but giving birth underwater is too risky, with no peer-reviewed, randomized controlled trials showing benefits.

Despite such caveats from medical authorities, both water labor and water birth are becoming more popular around the world.

Consider: One percent of all births in the United Kingdom include some kind of immersion in water (one expert put the number closer to 5 percent); and in the U.S., according to a leading water birth advocate, most birthing centers and nearly 10 percent of the nation’s approximately 3,100 hospitals are now offering birthing tubs that allow women to either labor or deliver their babies in water.

Last year, in one private midwifery practice affiliated with a major medical center in Morristown, N.J., 50 percent of the 170 births were in water, says Lisa Lederer, president of the practice, Midwives of New Jersey. “The benefit is the ability to give birth naturally, without medication… it’s true pain relief without the side effects of epidurals or narcotics,” said Lederer, whose practice has been involved in about 1,000 water births since 2000. “Women will labor in the tub, and I ask them to get out to move around, to pee, or just for a change and they’ll beg to get back in and practically dive head first back in the water. This is not just nice or pretty — it actually helps them.”

Noting that water birth, along with home birth, is a growing trend in the U.S., Dr. George Macones, an obstetrician-gynecologist at Washington University in St. Louis, and chair of the committee that prepared the latest ACOG/AAP opinion, said: “I think there’s an important distinction between laboring in a tub and delivering in a tub. Most of us feel that laboring in a tub is fine, as long as the baby is doing well and mom is doing well. Delivering underwater is where there’s a bit more of a struggle — there isn’t a lot of data on this but there are a number of case reports of really bad things happening.” Mostly, he said, there are “concerns about the baby aspirating water.” Others cite infection as a potential problem.

Still, Macones said, at his hospital, where planning has begun for a new labor and delivery ward, “one of the hot topics is how many rooms will have tubs.”

The new ACOG/AAP opinion (which follows a 2005 AAP commentary on the risks of underwater delivery and 2012 ACOG guidelines on perinatal care) concludes that water birth should be considered an “experimental procedure ” and only performed as part of a clinical trial with informed consent — something that’s unlikely to happen in the U.S., according to Macones.

For comparison, here’s what the U.K. Royal College of Obstetricians and Gynaecologists and the Royal College of Midwives stated back in 2006: “All healthy women with uncomplicated pregnancies at term should have the option of water birth available to them and should be able to proceed to a water birth if they wish.” The groups also also urged hospitals to support women in this pursuit: “…to achieve best practice with water birth it is necessary for organisations to provide systems and structures to support this service.”

Here’s more of the joint ACOG/AAP opinion, published online in the journal Pediatrics, and summarized in a news release:

Undergoing the early stages of labor in a birthing pool may offer some advantages to pregnant women. However, underwater delivery has no proven benefit to women or babies and may even pose a risk of serious health problems for the newborn…

“Many labor and delivery units are equipped with tubs to be used by laboring women, and immersion in water for relaxation and pain relief is appealing to some,” said Jeffrey L. Ecker, MD, chair of the College’s Committee on Obstetric Practice that developed the Committee Opinion. “But it is important to recognize that laboring in water is not the same as delivering underwater. Laboring in water may offer some potential benefits, but delivering underwater does not seem to have clear advantages, and the risk of rare, but serious, consequences to a delivering baby’s health is something women and providers should all be aware of.”

“The members of the committees conducted a thorough review of the literature, and came to the conclusion that there is no evidence to support delivering babies in water has benefits to the baby,” says Tonse Raju, MD, chief, Pregnancy and Perinatology Branch, the National Institute of Child Health and Human Development (NICHD), who served as the NICHD liaison to the AAP Committee on Fetus and Newborn.

The new recommendation acknowledges that there may be some positive effects of water immersion to pregnant women during the early stages of labor, such as decreased pain or use of anesthesia and shorter labors. However, there is no evidence that giving birth underwater improves newborn outcomes…

Potential risks of underwater delivery include a higher risk of maternal and neonatal infections; difficulty in the regulation of the baby’s body temperature; increased chance of umbilical cord damage; respiratory distress resulting from the baby inhaling tub water; and potential for seizures or asphyxiation of baby following birth.

The College and AAP say that underwater delivery should only be performed within the context of an appropriately designed clinical trial with informed consent.

Barbara Harper, an RN who founded the company Waterbirth International in the late 1980s after her two sons were born in water, has been called “the Billy Graham of water birth.” She says she’s personally attended around 600 water births and trained more than 7,000 physicians, nurses, medical students and others around the world — in Mexico, India, Israel, Malaysia, all over Europe, the U.K and U.S — on how to safely and effectively manage childbirth in the water. Based in Fort Lauderdale, Fla., Harper is currently in China conducting water birth training in medical schools and hospitals.

Harper refutes the ACOG assertion that water births are more risky than land births and cites a number of published studies and analyses that support her position, among them a 1999 British report that concluded: “perinatal mortality is not substantially higher among babies delivered in water than among those born to low risk women who delivered conventionally.”

Among water birth’s benefits, Harper says, are that it can speed up labor, give the mother more of a feeling of control, provide pain relief and reduce the need for drugs and inteventions such as epidurals, episiotomies and even cesarean sections. However, Harper says she has very strict criteria regarding who is eligible to give birth in a tub: “Anyone can labor in the water,” she says. “But if your labor goes into the pathology area and wanders out of normal physiology,” water birth should not be an option. She says, for instance, that women with preeclampsia, high blood pressure, abnormal bleeding or untreated infection or fever should not deliver babies in the water. Continue reading

New Home Birth Data: Numbers Rise A Bit, Controversy Remains Unchanged

A new CDC analysis of trends in out-of-hospital births from 1990-2012 found that home births are on the rise — but only a tiny bit.

The federal agency reports that 1.36 percent of U.S. births occurred outside a hospital in 2012, up
from 1.26 percent in 2011. Those new numbers mark the highest level of non-hospital births since 1975, according to the CDC.

In terms of actual births, that means 53,635 births in the U.S. took place out of a hospital in 2012, including 35,184 home births and 15,577 birthing center births, the CDC says.

(Source: CDC)

(Source: CDC)

Here are some more findings from the CDC news release:

• In 2012, 1 in 49 births to non-Hispanic white women were out-of-hospital births;

•The percentage of out-of-hospital births was generally higher in the northwestern United States and lower in the southeastern United States;

•Out-of-hospital births generally had a lower risk profile than hospital births.

Continue reading

Campaign To Reduce Early Births Pays Off — Mass. Now Leads Nation

Most obstetricians agree that babies should not be delivered early, before 39 weeks, unless the health of the mother or her child is at risk. Research shows important brain, lung and vital organ development occurs late in pregnancy. So hospitals across Massachusetts have been working to reduce so-called “early elective deliveries.”

(popularpatty/flickr)

(popularpatty/flickr)

Over the last three years, most hospitals have either stopped scheduling early deliveries, or set a goal of less than 5 percent. Last year, the state’s rate dropped, on average, to 1 percent, the lowest in the country. There is still variation from one hospital to the next. But the numbers, compiled by Leapfrog, a business group that advocates for improved hospital quality and safety, show the significant progress hospitals made in just one year.

The state’s low rate “should decrease some of the complications that newborns may experience from being born electively,” including, “admissions to the intensive care unit and long-term complications,” said Dr. Glenn Markenson, an obstetrician at Bay State Medical Center. Continue reading

Gov. Patrick Issues Emergency Regulations Banning Restraints On Pregnant Inmates In Labor

At a forum on public safety today, Gov. Deval Patrick said the practice of shackling female inmates while they are in labor should end immediately. He said he’s issuing emergency regulations through the state Department of Corrections to ban the practice in all correctional facilities.

Here’s what the governor said (according to a spokesperson, who emailed me his comments):

While on the subject on the use of restraints, let me be clear that we will also end — finally, completely and immediately — the use of restraints on pregnant inmates in labor. Our current regulations prohibit this in state prisons and today the Department of Corrections will issue emergency regulations extending that prohibition to all facilities, including Houses of Correction. Regulation is good but here law would be better. The Legislature is considering a bill that would make this ban the law. I support that bill and I urge the Legislature to send it to my desk for signature this session.

The bill that Patrick referred to has been on file for over a decade, according to Megan Amundson, executive director of NARAL Pro-Choice Massachusetts.

Regarding the governor’s order today, Amundson said: “We applaud the governor for taking this action.”

But, she added, the proposed legislation “is more comprehensive in terms of supporting and also protecting women’s health. The bill protects women’s health throughout pregnancy and labor and postpartum. The regulations ensure that women aren’t shackled during labor but the bill is stronger, and having something in statute is stronger than having something in regulation because it ensures the protection of women’s health going forward.”

In a press release issued after the governor’s announcement, NARAL Pro-Choice Massachusetts said:

…We look forward to seeing the emergency regulations when they are filed later today.

We join the Governor in calling upon the legislature to pass the Anti-Shackling bill (S.2012), currently in Senate Ways and Means, this session to put an end to this practice and ensure that the health of all pregnant women in the Commonwealth is protected. Massachusetts needs to join the 18 states – including Texas and Louisiana – that have already passed laws to ban shackling of pregnant women in jails and state prisons.

The Massachusetts proposal would prohibit the practice and create streamlined laws in both county jails and the state prison system “banning the shackling of pregnant women during childbirth and post-delivery recuperation — unless they present a specific safety or flight risk.”