childbirth

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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.”

Ban On Handcuffing Pregnant Inmates In Labor Clears Hurdle In Mass. Legislature

A proposal to prohibit the scary practice of handcuffing pregnant inmates during labor has cleared its first hurdle through the Massachusetts Legislature. If passed, the so-called “anti-shackling bill” would “create uniform laws in 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,” according to an earlier WBUR report.

(MOZ278/flickr)

(MOZ278/flickr)

“This bill has been on file for over a decade — the language has changed a bit — but it’s never seen the light of day,” says Megan Amundson, executive director of NARAL Pro-Choice Massachusetts. The bill was reported out of committee on Friday, and now it will be given a new number and then most likely go to the House Ways and Means Committee, Amundson says.

Here’s more from the NARAL Pro-Choice Massachusetts news release:

In a step toward joining the 18 states that have passed legislation banning the shackling of pregnant incarcerated women, the Massachusetts Joint Committee on Public Safety has released the Anti-Shackling Bill, a bill the prohibits the practice of shackling pregnant women in our jails and prisons, sponsored by Senator Karen Spilka. The bill has now passed the first hurdle to passage.

“As hard as this is to believe, it is not unusual for pregnant women in Massachusetts jails to be handcuffed to the hospital bed even while in labor,” said Megan Amundson, Continue reading

Bundle Of Edible Joy: Why New Moms Are Bringing Their Placentas Home

Ground Placenta (danoxster/flickr)

Ground Placenta (danoxster/flickr)

By Kira Kim
Guest contributor

I recently got an email with the subject line: “Placenta.”

I work with a lot of pregnant women and new mothers, so this particular tag didn’t faze me. But the note wasn’t about a client; it was about a new law in Oregon that allows mothers to take their placentas home from the hospital after childbirth.

Some hospitals already allowed this practice, but it was technically against Oregon’s law prohibiting medical facilities from releasing medical waste, reports The Oregonian.

Amanda Englund of Placenta Power in Portland told me in an email that momentum is “building” for mothers to take their placentas home with them for therapeutic use. “I have seen the number of clients I serve double every year. More folks are learning about it through media sources and more mothers are sharing their experiences about how positive the effects have been on their recovery. The new law cements…this growing trend.” (Want more proof? Kim Kardashian is considering it. And mean “Glee” cheerleading coach Sue Sylvester took her placenta home.)

OK, so now it’s legal: power to the placenta in Oregon.

But why, you may ask, would anyone want to take home their placenta in the first place?

The answer is broad: sometimes it’s a cultural thing, part of a long tradition, and sometimes it’s extremely intimate and health-related.

A 2013 survey published in the journal Ecology, Food and Nutrition by anthropologists at the University of Las Vegas, Nevada asked 189 women who ate their placentas after birth (a practice known as placentophagy) “why they did it, how they preferred to have the placenta prepared, and if they would do it again. (An interesting side note on demographics: in this study, the majority of women who ate their placentas were “American, Caucasian, married, middle class, college-educated and were more likely to give birth at home.”)

Researchers report that the top three positive effects of placenta consumption, according to participants, were:

•Improved mood
•Increased energy
•Improved lactation

(For the record, the top three negative side effects of placentophagy were: “Unpleasant burping, headaches, unappealing taste or smell.”)

I was first introduced to placentophagy while living in China. A Traditional Chinese Medicine practitioner wrote me a prescription after I miscarried to balance my qi. As a Westerner I looked at him with a mix of sarcasm and confusion. He then explained that the medicine was actually placenta, dried, ground and taken in pill form. (This is called encapsulation — more later.)

I was not convinced about taking someone else’s placenta, but he had me interested. Could my own placenta from future pregnancies be used for my benefit? It was then that I learned about the art of placentophagy and began to learn the ins and outs of this ancient practice, as well as it’s benefits.

Upon returning to the U.S., I was surprised that so many American women were open to the practice. For the past two years, I’ve helped more than 100 mothers through this process. Continue reading

Comparing Quality In Childbirth: Key Questions For Doctors And Hospitals

I’ve heard from a lot of moms this week about our new online tool for Comparing Childbirth in Massachusetts. It offers a side-by-side review of hospitals using five quality measures.

photo: Matha Bebinger

photo: Matha Bebinger

OK, these mothers say, quality measures are important, but I don’t want to make a decision based on stats alone.

So here’s a way to translate these measures (which experts say are good ways to assess quality) into an action plan. It’s a list of questions you can use when choosing the doctor or midwife who will help deliver your baby. Please add your own below!

Question: What is your C-section rate?
Background: Many childbirth experts say 15 percent is a good target rate. If the rate for your doctor or the hospital where he or she works is higher, have a conversation about why.

Question: When you are called to the labor floor, do you still have responsibilities in the office?
Background: Some hospitals have or are moving to scheduled hours for OBs in Labor and Delivery units. But in many places an OB is pulled between office hours, labor and sometimes surgery as well. Some childbirth experts say these time pressures push doctors to opt for more C-sections that are medically necessary.

Question: What is your practice regarding elective inductions? Do you induce women before 39 weeks if everything is going well? How long do you suggest women wait, past their due date, to be induced?
Background: Many childbirth experts say babies should not be delivered before 39 weeks to avoid complications, and because babies need the last two weeks for brain, lung, and other vital organ development. Some hospitals wait until two weeks after a mom’s due date to induce because waiting for labor to begin naturally can help women avoid a C-section. But inductions are needed in cases where the mom or baby are in distress.

Question: Once you find a doctor you like, if he or she is part of a larger practice, ask…Do all the doctors in your practice share the same philosophy about: inductions, epidurals, when to declare a mom is no longer making progress in labor? Continue reading

Moms Speak Out: On Improving Childbirth In Boston-Area Hospitals

When we opened up the “lines” for an online chat about quality and childbirth, moms dove in with comments and questions about induction, malpractice and worse results for black women as compared to whites.

We had help answering questions from:
Gene Declercq, a Boston University School of Public Health professor who has studied childbirth practices for more than 20 years.
Dr Jeff Ecker, an OB/GYN at Massachusetts General Hospital and a member of the Massachusetts Perinatal Quality Collaborative Advisory Committee.
Betsy Deitte, a mom from Needham who had her third child, a boy, in September.
And Rebecca Loveys of Watertown, who delivered her second son in August.

Livechat

First question, from Agnes…
Is there a way we can improve these measures of childbirth by focusing not just on the labor-and-delivery part, whose benchmarks mostly are set by hospital birth, but on childbearing? On a woman’s experience of her pregnancy and not just the outcome?

Dr. Jeff Ecker responds…
I think it would be difficult to do so, as they are such different experiences. A woman can have a perfectly healthy pregnancy, and have a difficult delivery. One does not necessarily affect the other experience.

I agree that it would be ideal to focus on the whole experience of pregnancy, childbirth and post-delivery care. We have, to date, focused mostly on the process of labor and delivery because that is the point at which we most reliably collect data (think: birth certificate). Increasingly we are turning to evaluate patient satisfaction. But I need to tell you that in my experience, much of satisfaction is driven by outcome.

Question from Katie…
To what extent does the fear of medical malpractice dictate a woman’s birth experience?

Gene Declercq responds…
The research on the effects of fear of malpractice on obstetrician’s behavior is somewhat mixed. In terms of whether things like malpractice premiums are directly related to, say cesarean rates, there is not much support for that link. However, in terms of perception of malpractice concerns on obstetrician attitudes it continues to have an impact since the widespread feeling exists that interventions like cesareans are more easily defensible in court.

Cara responds…
As a labor and delivery RN I know that the fear of lawsuit is a huge driving force in the care we provide. I can’t tell you how often I hear docs and midwives say “Well I really should do (insert intervention) because how would it ‘look’ if we didn’t”…..”look” being the operative word and it means when the lawyers review the chart if a lawsuit did happen.

Ecker responds…
Cara, you’re right. Those on labor and delivery spend much time (too much time) talking about lawyers and how they might spin our care. But research is split about how such concerns actually affect care and outcomes. It turns out to be difficult, for example, to demonstrate that a recent malpractice settlement drives care in any particular direction. Don’t get me wrong: I’m no fan of lawyers second guessing good care after the fact but they’re not the only things driving cesarean rates up.

Question from Sarah…
How do doctors decide when during a woman’s labor to recommend a Cesarean section? Do most doctors have their own formula or threshold for deciding when the woman is not making progress that will lead to a vaginal delivery?

Dr. Ecker responds…
There’s no one formula for determining when progress isn’t being made and cesarean delivery is best recommended. Continue reading

Opinion: License Professional Midwives For More Childbirth (And Home Birth) Options

Home birth announcement (Courtesy Sarah Whedon)

Home birth announcement (Courtesy Sarah Whedon)

By Sarah Whedon
Guest Contributor

When I was expecting my first baby in 2009, I planned a home birth with a wonderful midwife. My pregnancy was healthy and normal, my prenatal care with my midwife was both empowering and attentive to my health needs and my labor began spontaneously at full term.

Everything was going according to plan, until about 20 hours into active labor at home when my midwife alerted me that my baby’s heart rate indicated a serious problem and we needed urgent medical attention.

In the amount of time it took the ambulance to arrive at my Somerville home, my midwife cut an episiotomy (a skill in which home-birth midwives are trained but don’t practice as a matter of routine) and performed an emergency delivery. My baby had aspirated meconium (the sticky tar-like substance in a newborn’s bowels that is occasionally expelled during birth) and was having trouble breathing even with the aid of the oxygen my midwife carried with her. She needed a transfer to the level III NICU at Children’s Hospital, where she made a complete recovery.

I had a home birth because I wanted the kind of low intervention pregnancy and birth that Certified Professional Midwives (CPMs) offer. But I tell my birth story publicly because it demonstrates something important that people don’t often realize about CPMs: they are skilled professionals who are prepared to handle emergencies, including facilitating transfer to medical care when needed.

CPMs are midwives who are specially trained in out-of-hospital care. They differ from Certified Nurse Midwives (CNMs) who are trained as nurses and typically practice in hospital settings. Currently, Massachusetts licenses CNMs but has no licensing system for CPMs, who provide care for approximately 500 women across the state each year.

So when I recently learned of a petition asking me to support licensing of CPMs in Massachusetts, I immediately wanted to get more involved. I found other moms who want this bill to pass and I’ve had the pleasure of lending my support to this work being carried out by a coalition of advocates from the Massachusetts Midwives Alliance, Massachusetts Friends of Midwives and others. More than 500 Massachusetts residents have now signed the petition.

The bills (HB 2008 and SB 1081) would require all midwives practicing out of hospital to become CPMs, create state licensing requirements for CPMs and establish a Committee on Midwifery under the Board of Registration in Medicine. The nine-member committee will include five CPMs, one obstetrician, one CNM and one consumer of midwifery services.

Supporters of the measures that would license and regulate home birth midwives were energized by an amazing turnout at a Committee on Public Health hearing last month, testifying to the professional skill of these midwives and the valuable ways they serve Massachusetts families. Several moms even brought their charming home birth babies along for the day at the State House.

I have heard from some midwifery supporters who oppose licensing, worrying that new regulations will hamper midwives’ ability to truly practice the midwifery model of care. But midwives themselves will be involved in determining details of regulation. Overall, licensing of our midwives would mean more moms will feel able to choose home birth, because they’d have the security of knowing that in order to hang out her shingle, a midwife must meet state licensing standards.

The Massachusetts Medical Society has also opposed the bills, expressing disapproval of any health care that is delivered outside the team context with immediate M.D. supervision. Continue reading