Archive for August, 2009

A new era of home birth research

August 31st, 2009 by avatar

In preparing the Home Birth chapter for the forthcoming second edition of Obstetric Myths versus Research Realities, I have literally just finished reading the entire body of literature on planned home birth. Just last week, I said to my co-author, Henci Goer, “frankly, I’m pretty underwhelmed by the quality of most of the studies.” (Though, don’t get me wrong, I still believe that the preponderance of the evidence strongly favors the choice of planned home birth.) But for the second time this year, an exemplary study on planned home birth has been released. Together with the Dutch study released in April, the current study ushers in a new era of home birth evidence that addresses many of the methodological limitations of previous home birth research. Seriously, folks, these two studies raise the bar.

Researchers in Canada analyzed the outcomes of all women who were intending to give birth at home at the onset of labor in British Columbia between 2001-2004 (n=2899 women). Data were obtained from the provincial database that collects information on all births and is cross-referenced with the national vital statistics (birth/death certificates) database. The researchers compared outcomes in the planned home birth group with those of two groups of women who met eligibility requirements for home birth but planned to give birth in hospitals instead. One of the two comparison cohorts had planned hospital births with midwives (n=4752); the other with physicians (n=5331).

Consistent with many other studies comparing planned home with planned hospital birth, the results showed comparable perinatal mortality rates, less serious morbidity for both women and infants, and lower use of obstetric technology in planned home births. Here are the results, as presented in the study’s abstract:

The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Women in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife-attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85).

What makes this study stand out from most  of the rest:

1. Planned home births occurred in a context with relatively rigid guidelines for eligibility (see the full-text of the article to view the guidelines). These guidelines, determined by the Ministry of Health, were applied to women planning hospital births in order to construct the comparison cohorts. This increases the likelihood that, medically at least, the populations were similar. In addition, participants in the home birth group were matched with participants in the physician-attended hospital birth for the following parameters: year of birth, parity, single parent (yes or no), maternal age, and the hospital where the midwife conducting the index home birth had hospital privileges.

2. The authors made the cohorts more similar with statistical analysis – first, controlling for confounding variables and second, testing and retesting their data with different assumptions and exclusions. (Referred to as “sensitivity analysis,” this is a mechanism used by researchers to make sure their findings hold up under various circumstances and are unlikely therefore to be biased.)

3. The researchers isolated the effect of the birth setting itself by comparing midwife-attended home birth with midwife-attended hospital birth. In fact, the same group of midwives cared for women in both settings, so differences are likely to be related to the setting and its protocols and technological accoutrements (or lack thereof) rather than differences in the providers who actually provide the care.

4. According to the study authors, midwives in British Columbia are required to offer medically eligible women a choice of planned home or hospital birth. While women still must self-select to one choice or another, this certainly mitigates some bias. Self-selection bias refers to the possibility that individuals who, in this case, select different birth settings or providers, may be different in ways that are not measured but that nonetheless affect the likelihood of important outcomes. For example, women who choose home birth may have better nutrition, stronger family support systems, or a more positive outlook on labor and birth. But these differences may be less pronounced when the group selecting home birth showed up at the same prenatal clinic as all of the rest of the women and were (perhaps enthusiastically) presented the option of birthing at home. Contrast this with the population of women in parts of the United States who must actively seek out home birth, pay out of pocket, and be told that no physician will willingly consult if medical problems arise so they must settle for the emergency room, whether or not the transfer to the hospital is urgent. (The vast majority of transfers from home to hospital are not.) Only the most dedicated are likely to choose such an option.

5. Although the study was retrospective (meaning data were collected after the fact), data were obtained from province-wide databases to which care providers are obligated to enter data on each and every birth. In addition, these databases have been tested for the reliability of the data (to detect the possibility that certain outcomes are systematically underreported or overreported). Reliability was above 97% for all outcomes. Fewer than 1 in 10,000 records were missing. *

The only thing I did not see in the report that I would have liked to is a detailed description of the circumstances of each fetal or newborn death. These descriptions often provide clues as to whether small differences in perinatal mortality could have been attributed to the planned place of birth and whether and how they might have been averted.

No study of home birth will be perfect, but large perinatal databases and systems that integrate rather than marginalize home-birth midwifery have helped to achieve the “scientific rigor” that the American College of Obstetricians and Gynecologists has called for. And the results are looking very good indeed.

* denotes edited text. Click “read more” to view the original version. Read more…

Lamaze News, New Research, Practice Guidelines, Science & Sensibility, Systematic Review, Uncategorized , , , ,

The ethics of birthing babies

August 31st, 2009 by avatar

[Editor’s Note: This is our third installment of guest posts from Lamaze International’s 2009 Annual Conference speakers. You can read all of our conference previews by clicking on the Lamaze 2009 Annual Conference tag. We hope to see you October 1-4 in Orlando at the Lamaze International 2009 Annual Conference. – AMR]

Jennifer Torres

Jennifer Torres

It is late summer and nearly all media outlets in the US are abuzz with news of town hall shouting matches over health reform.  Americans – whose health system has the distinction of being the most expensive in the world (measured in dollars spent per capita) while leaving over 45 million people with no or limited access to care – are rightly fearful of change.  It is a case of choosing “the devil you know” over the uncertainty of reform.  Senators and members of congress are hearing stories of “death panels” that will deny care to the elderly and infirm, of benefits being taken away from medicare recipients and given to (illegal) immigrants.

Where are the ethicists?  Clearly questions about who should have access to what kind of health care is an ethical question, but if you look closely at the debates over health reform, ethicists show up only when the issues are related to the beginning and end of life.

It is a sad fact that the rise of bioethics as a profession has served to limit the range of issues that are considered “ethical.”  Ethical questions are restricted to those debated by “experts” — on television, radio, and on the pages of our newspapers — questions about stem cell research, cloning, and the end of life.

Those of us who work in and around childbirth know that questions of ethics and morality are not limited to the special issues taken up by bioethicists (the “experts”).  Think, for example, about the debates between hospital birthers and home birthers.  You are unlikely to see a bioethicist wade into this controversial topic, in spite of the fact that the conversation is rife with moral terms.  “Good mothers” give birth at home (or in the hospital), only a “bad mother” would consider subjecting her baby to all that technology (or the care of a midwife).   Good and bad.  The debate over where to give birth is framed in moral terms.  This is where the ethical rubber meets the road, in the moral aspects of mundane life.  The ethics of everyday life – more common and more important than cloning, stem cells, and pre-implantation genetic diagnosis to most of us – gets ignored by professional bioethicists.

So why do bioethicists ignore the ethics of everyday life? It has a lot to do with their academic approach to the subject.  When asked to consider the ethical problems associated with prenatal testing, most ethics pros will focus on the process of informed consent. Have the parents been told the risks and benefits of the procedure?  Have they given their free and informed consent?  The academic ethicist wants to be sure that the autonomy of the parents has been respected – if it has, there is nothing more to be done.

What’s missing here?  The ethicist has not asked how our culture (and economy) shapes our attitude about disability (and the possibility of parenting a disabled child) or how the way we pay (or don’t pay) for health care influences parents’ choices.  These everyday aspects of life play an important role in parents’ decisions about prenatal testing, yet the informed consent process does not address them. As long as parents make a “free” decision there are no ethical issues.

Come to the Research Papers session at the 2009 Lamaze International Annual Conference to hear more about the importance of everyday ethics.  Raymond DeVries and I will consider issues much on the mind of childbirth educators, from elective cesareans to epidurals to male infant circumcision to the use of educational materials paid for by manufacturers of baby products. We’ll talk about the standard bioethical approach to these issues and, more importantly, what this approach leaves out. You will go away with an entirely new perspective on the ethics of childbirth.

Jennifer Torres is a doctoral student in the department of Sociology at the University of Michigan. Her dissertation is an historical examination of breastfeeding discourse and how this changing discourse affects women’s decisions about and experiences of breastfeeding.

Her co-presenter, Raymond G. De Vries, Ph. D., is Professor in the Bioethics Program, the Department of Obstetrics and Gynecology, and the Department of Medical Education at the Medical School, University of Michigan.  He is the author of A Pleasing Birth: Midwifery and Maternity Care in the Netherlands (Temple University Press, 2005), and co-editor of The View from Here: Bioethics and the Social Sciences (Blackwell, 2007).  He is at work on a critical social history of bioethics, and is studying: the regulation of science; international research ethics; the difficulties of informed consent; bioethics and the problem of suffering; and the social, ethical, and policy issues associated with non-medically indicated surgical birth.

Lamaze International Annual Conference

Uncategorized ,

When Is Evidence Based Medicine NOT Evidence Based? Inductions for PROM at Term

August 30th, 2009 by avatar

[Editor’s Note: I would like to give a warm welcome to Science & Sensibility’s newest regular contributor, Mayri Sagady Leslie. Mayri has a brilliant mind for making sense of obstetric research and has over a decade of experience putting evidence-based principles into practice as a nurse-midwife, midwifery practice director, and midwifery instructor. You can find out more about Mayri by clicking on the Contributors tab above. And look for more regular contributors joining the Science & Sensibility ranks this fall. – AMR]

Mayri Sagady Leslie

Mayri Sagady Leslie

The release of ACOG Practice Bulletin No. 80, Premature Rupture of Membranes in April of 2007 should be marked as a red letter day in the downfall of evidence-based maternity care in the United States.  The story of this red letter day begins back in June of 1998 with the publication of the ACOG Practice Bulletin Number 1, Premature Rupture of Membranes: Clinical Practice Guidelines for Obstetricians-Gynecologists.  This is the antecedent document which Bulletin 80 replaces.  Both guidelines address the issues, evidence, and suggested management involved when a mother’s  water bag breaks before labor begins  near, at, or beyond her estimated  due date.

All ACOG bulletins address relevant clinical questions, reviewing the current available evidence pertinent to those questions and providing citations to studies referenced.  At the end, specific recommendations are made and graded by letters, with “A” representing recommendations coming from the most trustworthy evidence, usually randomized, controlled trials.

The 1998 version of the bulletin on Premature Rupture of Membranes (PROM) gave the following recommendation, based on Level A evidence:

With term PROM, labor may be induced at the time of presentation or patients may be observed for up to 24-72 hours for the onset of spontaneous labor.

However, the 2007 bulletin, nine years later, again based on Level A evidence, made a significant change in their recommendation as follows:

For women with PROM at term, labor should be induced at the time of presentation, generally with oxytocin infusion, to reduce the risk chorioamnionitis.

What’s wrong with this new recommendation? One might assume nothing. Obviously, in those nine years something changed in the Level A evidence. The problem is – nothing changed. No new significant studies were published that favored induction over observation for mothers who had no medical indications to start labor. In fact, both guidelines cite the exact same study.

It gets worse. The study, published by Hannah et al in 1996, known as the TERMPROM Trial, was a large clinical trial which took place from 1992 to 1995 in 72 medical centers throughout 6 countries.  The study examined the effects of induction after PROM with oxytocin or prostaglandins versus waiting up to 4 days for labor to start on its own or inducing with the same 2 agents if labor still had not begun or of other problems developed (such as a fever or non-reassuring fetal heart rate pattern).  The lowest rate of maternal infection was found in mothers that were induced with oxytocin. Presumably, since the Hannah trial is the only study cited as evidence for ACOG’s Clinical Bulletin 80, this is the source of the evidence that induction “ reduce[s] chorioamnionitis”. Yet, this logic is fraught with issues:

  • There was no study protocol for either screening for or treating Group B Streptococcus (GBS)
  • Only 20% of GBS culture results were available at the time of labor and birth management
  • The majority of GBS+ mothers did not receive treatment
  • 30% of all study mothers had vaginal exams at the time of PROM
  • The group with the fewest infections was also the group with the fewest vaginal exams

(For more about these and other problems with the TERMPROM trial, see Henci Goer’s critique, “When Research is Flawed: Should Labor be Induced Immediately with Term Prelabor Rupture of Membranes?”)

To bring these issues into perspective, think about what we now know and how judicious care providers work with women today if their water breaks before labor at term:

  • Unless a woman declines, she is screened for GBS before term, so if her water breaks, we can factor whether she is GBS positive or negative into our recommendation of whether she may be at less risk opting for an induction or waiting.
  • As indicated by guidelines from the Center for Disease Control (CDC), we treat women who are GBS positive with antibiotics prophylatically to reduce the risk of infection for her and her baby.
  • For women who decline screening or whose GBS status is unknown, we follow guidelines from the CDC which suggests that we treat according to the existence of other risk factors such as the length of time the membranes are ruptured, signs of infection in the mother and baby, etc.
  • In either case, we know NOT to do any vaginal exams until we know mom is in active labor and even then to minimize and avoid them until absolutely necessary because vaginal exams themselves are one of the highest risk factors for increasing infections once the water bag has ruptured.

But here’s the tragedy. Bulletin number 80 was released. The recommendation was changed. Based on data that was 11 years old at the time, from one study that had no protocol for screening or treatment regarding maternal infection and was conducted before current guidelines were available or practiced – a new recommendation, focused on preventing infection, was made that represents itself as current and evidenced-based.

Now, this powerful “guideline”  – which drives industry standards, institutional policies and procedures, medical school education, and, potentially, legal judgments – allows for just one option for mothers in this normal physiological condition: induction.

What impact is this having?  As numbers of inductions increase so do the numbers of technological interventions such as electronic monitoring and the mother’s need for pain medications – as these increase her ability to move freely and choose her own positions decline as well. Operative deliveries have also been found to increase with inductions in some studies and with those come increased risks for more severe perineal injuries and lifelong issues with pelvic floor disorders.  While inductions, like all medical interventions have their place and time when indicated – they cannot be justified as a standard procedure for a normal physiological occurrence in a healthy full term pregnancy.

I was giving a talk on this topic recently to a group of providers and a woman’s eyes suddenly lit up with recognition. Here’s what she said:

I was admitting a client recently whose water bag was broken and the attending said we have to induce her. I said why? He said, haven’t you heard, there is new evidence. It’s dangerous now to wait. We have to induce them now. I said no, I hadn’t heard.

When is evidence based medicine NOT based on the evidence?  When one can make opposing recommendations based on the same exact study publication.  When one can use findings that are inappropriately outdated and not applicable to current practice to make clinical recommendations.  When is evidence based medicine NOT based on the evidence?  When it’s not.


American College of Obstetricians and Gynecologists. (1998). ACOG practice bulletin. Number 1, June, 1998. Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. International Journal of Gynaecology & Obstetrics, 63(1), 75-84.

American College of Obstetricians and Gynecologists. (2007). ACOG practice bulletin. Number 80: Premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. Obstetrics & Gynecology, 109(4), 1007-1019.

Hannah M. E., Ohlsson A., Farine D., Hewson S. A., Hodnett E. D., Myhr T. L., et al. (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. The New England Journal of Medicine, 334 (16), 1005-10

Practice Guidelines , , , , , ,

When Research is Flawed: Should Labor Be Induced Immediately with Term Prelabor Rupture of Membranes?

August 30th, 2009 by avatar

[Editor’s Note: Lamaze International is in the process of moving the archives of our When Research is Flawed series to Science & Sensibility. When Research is Flawed is a series of brief critiques of influential studies that have shaped policy and practice, despite having serious flaws, significant limitations, or both. – AMR]

Commentary on: Hannah ME, Ohlsson A, Farine D, Hewson SA, Hodnett ED, Myhr TL, Wang EE, Weston JA, & Willan AR (1996). Induction of labor compared with expectant management for prelabor rupture of the membranes at term. TERMPROM Study Group. The New England journal of medicine, 334 (16), 1005-10 PMID: 8598837

Study design and results: multicenter, multinational randomized controlled trial in developed countries of 5041 women with confirmed PROM at ≥ 37 completed weeks of gestation. Women were not in active labor, had a singleton fetus in cephalic presentation, and had no contraindication to trial participation.

Investigators randomly allocated trial participants to one of four groups: (1) immediate induction with oxytocin, (2) expectant management for 4 days before oxytocin induction or until an indication for induction developed, (3) immediate induction with prostaglandin E2 (PGE2) followed by oxytocin if necessary, or (4) expectant management for 4 days before PGE2 induction or until an indication for induction developed.

Selected background information [Note: These represent ranges in rates reported among the 4 study groups. No significant differences across groups were detected for any of the following:]

  • vaginal exam at trial admission: 35-39% digital, 64-67% speculum
  • number of digital vaginal exams: 49-63% had ≥ 4
  • Group B strep (GBS) status: 9-12% tested positive for GBS
  • median time to active labor in expectant groups: 16-17 h

Selected maternal outcomes:

  • cesarean rate: rates ranged among the 4 groups from 10-11% overall, 14-15% nulliparous women, 4-5% multiparous women
  • any sign of chorioamnionitis:
    – 4.0% induction/oxytocin vs. 8.6 % expectant/oxytocin, p < 0.001 [Absolute difference: 4.6%. Absolute difference for diagnosis based on criteria other than intrapartum fever (fever before labor, elevated white blood cell count, or foul-smelling amniotic fluid): 2.3%.]
    – 6.2% induction/prostaglandin vs. 7.8% expectant/prostaglandin. Difference did not achieve statistical significance, meaning it was likely to be due to chance.

Neonatal outcomes:

  • neonatal infection: rates ranged from 2-3% and were not significantly different across the 4 groups
  • stay in neonatal intensive care unit > 24 h:
    – 7% induction/oxytocin vs. 12% expectant/oxytocin, p < 0.001.
    – 9% induction/prostaglandin vs. 10% expectant/prostaglandin. Difference did not achieve statistical significance
  • antibiotics:
    – 8% induction/oxytocin vs. 14% expectant/oxytocin, p < 0.001.
    – 11% induction/prostaglandin vs. 12% expectant/prostaglandin, p = 0.003.
  • All other neonatal outcomes were similar, including, fetal distress, meconium-stained amniotic fluid, Apgar score < 7 at 1 or 5 min, cord blood pH < 7.1, need for oxygen resuscitation, jitteriness or irritability, seizures, hypotonia, abnormal level of consciousness, apnea, abnormal feeding at 48 h or more, and ventilation after resuscitation.

Problems include but are not limited to the following:

  • Failure to consider the effect of epidural analgesia on intrapartum fever confounds chorioamnionitis results. Most diagnoses of chorioamnionitis were made on the basis of intrapartum fever. At the time of the trial, the association between epidural analgesia and intrapartum fever was not widely known, and no adjustment was made for this factor. Had this been done, an excess probably would remain in the expectant group, but infection rates might have been lower in all groups.
  • Women who were colonized with GBS were not treated in labor. A secondary analysis looked at the effect of GBS status, based on vaginal swabs obtained at trial entry, on outcomes (Hannah, 1997). Calculations using that study’s data reveal that one-third of neonatal infections were in women testing positive for GBS. GBS also caused one of the four deaths in the expectant group in babies without lethal anomalies. Current standard practice—screening for GBS at the end of pregnancy and providing antibiotics in labor to those who are colonized—would have reduced, and might have eliminated neonatal infections in GBS + women, thus reducing infection rates overall, and it might have prevented the death. It is also possible that GBS status would not have been a factor or would have been less of a factor in neonatal infections were it not for women having vaginal exams at trial entry and multiple exams before delivery. (See next bullet points.)
  • Chorioamnionitis rates were confounded by multiple digital vaginal exams. Leaving aside epidural analgesia as a confounding factor in diagnosing chorioamnionitis, yet another secondary analysis reported that chorioamnionitis increased steadily with number of digital vaginal exams independent of other factors (Seaward, 1997). Compared with less than three, the odds ratio climbed from a 2-fold increase for 3 to 4 exams to a 5-fold increase with more than 8. Seaward (1998) reported in their evaluation of risk factors for neonatal infection that chorioamnionitis had the strongest independent association. The rate among infants of women with chorioamnionitis was 16%, a six-fold increase over those not experiencing chorioamnionitis.
  • Neonatal infection rates were confounded by vaginal exams at trial entry. A secondary analysis of trial data found that having a vaginal exam at trial entry increased the risk of neonatal infection by 250%, even after taking into account GBS status (Hannah, 1997). This difference is likely to be greater than appears because the analysis authors chose to combine digital and speculum exams, although only digital exams are believed to increase the risk of infection.
  • Neonatal infection rates were confounded by multiple digital vaginal exams during labor. According to another secondary analysis, the percentage of infections trended upward with the number of vaginal exams independent of other factors, including time from rupture of membranes to labor onset and length of active labor (Seaward, 1998). It rose from 2% in women with 3 to 4 exams to 5% in women with more than 8. The odds roughly doubled compared with women having fewer than 3 vaginal exams, although the difference only achieved statistical significance when 7 to 8 exams were compared with fewer than 3.

Comment: Based solely on the TermPROM trial, the American College of Obstetricians and Gynecologists (ACOG) recommends immediate induction, generally with oxytocin, for women with term PROM on the grounds that inducing labor will reduce chorioamnionitis, febrile morbidity, and neonatal antibiotic treatments without increasing cesarean rates (ACOG, 2007). The primary argument for immediate induction has always been reducing neonatal infections, which ACOG acknowledges it does not do, and, as can be seen in this deconstruction, with optimal care other benefits are likely to be smaller than currently appear.

By contrast, a Cochrane systematic review published in 2006 also evaluates term PROM management (Dare, 2006). Despite being heavily dependent on the TermPROM trial—three-quarters of the 6800 participants among the 12 trials in total come from the TermPROM trial—the reviewers reach a more tempered conclusion: “Since differences in outcomes between planned and expectant management may not be substantial, women need to be able to access the appropriate information to make an informed choice (p. 12).”

In summary, in the absence of signs of infection, expectant management remains a viable option. Nonetheless, the secondary analyses have given us a more nuanced picture. While the original trial report found no difference in neonatal infection rates between immediate induction and expectant management overall, the secondary analyses make clear that length of time between rupture and delivery matters. They also found that modifiable factors affected infection rates, which means we do not know what they would have been with optimal care.

For those choosing expectant management, the question arises of how long to wait before inducing labor if one prefers to set a limit. Consider the following: Seaward (1998) reported that time from membrane rupture to labor onset of 24-48 hours versus less than 12 hours was an independent predictor of neonatal infection. Infection rates with 24 hours or more to onset of labor were 4% versus the background 2% rate. Hannah (1996) reported that the median time to active labor, not labor onset, after membrane rupture was 16-17 hours. It therefore seems reasonable to wait about 18 hours before inducing labor. Half the group of women will have achieved active labor by this time, and, if induced, the remaining half are likely to have started labor by the 24-hour cut point.

Women with PROM at term who are GBS + constitute a special subset. The Centers for Disease Control (2002) guidelines for management of GBS + women say nothing about inducing women with ruptured membranes at term, which suggests that awaiting spontaneous labor is acceptable provided that antibiotic therapy is initiated. And given that it takes time to instill the recommended dose of antibiotics, common sense dictates that women who prefer not to wait for labor should delay induction until they have an adequate dose of antibiotics on board.

In any case, regardless of GBS status or decisions around whether or when to induce, to minimize the risk of infection, women should avoid digital vaginal exams until established in labor, and their use should be minimized during labor. Data also suggest that oxytocin is the induction agent of choice. It appears to reduce infection rates compared with PGE2 without any offsetting disadvantages.

ACOG Committee on Practice Bulletins-Obstetrics (2007). ACOG Practice Bulletin No. 80: premature rupture of membranes. Clinical management guidelines for obstetrician-gynecologists. Obstetrics and gynecology, 109 (4), 1007-19 PMID: 17400872

Schrag S, Gorwitz R, Fultz-Butts K, & Schuchat A (2002). Prevention of perinatal group B streptococcal disease. Revised guidelines from CDC. MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control, 51 (RR-11), 1-22 PMID: 12211284

Dare MR, Middleton P, Crowther CA, Flenady VJ, & Varatharaju B (2006). Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane database of systematic reviews (Online) (1) PMID: 16437525

Hannah ME, Ohlsson A, Wang EE, Matlow A, Foster GA, Willan AR, Hodnett ED, Weston JA, Farine D, & Seaward PG (1997). Maternal colonization with group B Streptococcus and prelabor rupture of membranes at term: the role of induction of labor. TermPROM Study Group. American journal of obstetrics and gynecology, 177 (4), 780-5 PMID: 9369819

Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, Wang EE, Haque K, Weston JA, Hewson SA, Ohel G, & Hodnett ED (1997). International Multicentre Term Prelabor Rupture of Membranes Study: evaluation of predictors of clinical chorioamnionitis and postpartum fever in patients with prelabor rupture of membranes at term. American journal of obstetrics and gynecology, 177 (5), 1024-9 PMID: 9396886

Seaward PG, Hannah ME, Myhr TL, Farine D, Ohlsson A, Wang EE, Hodnett E, Haque K, Weston JA, & Ohel G (1998). International multicenter term PROM study: evaluation of predictors of neonatal infection in infants born to patients with premature rupture of membranes at term. Premature Rupture of the Membranes. American journal of obstetrics and gynecology, 179 (3 Pt 1), 635-9 PMID: 9757963

Uncategorized , , , ,

From the Research Summaries Archives: Care in Second Stage

August 26th, 2009 by avatar

Lamaze International’s popular series, Research Summaries for Normal Birth, was discontinued in 2008 after four years of quarterly round-ups so that we could move to the blog format and launch Science & Sensibility. In order to bring all of our research resources together in one place, we are adding the Research Summaries archive to Science & Sensibility.

This week we are presenting the archive of summaries of research on care in the second stage of labor. Don’t forget that you can find all second stage Science & Sensibility posts (including this archive) by clicking on “second stage” in the tag cloud.

The articles summarized in this archive are listed here. Please click on the extended post to read the summaries.

  1. Digital Rotation When the Baby is OP Decreases Need for Cesarean Section and Instrumental Vaginal Delivery
    Reichman, O., Gdansky, E., Latinsky, B., Labi, S., & Samueloff, A. (2007). Digital rotation from occipito-posterior to occipito-anterior decreases the need for cesarean section. European Journal of Obstetrics, Gynecology, and Reproductive Biology, 10.1016/j.ejogrb.2006.12.025.
  2. Coached Pushing Offers No Benefit to Moms or Babies and May Be Harmful
    Bloom, S. L., Casey, B. M., Schaffer, J. I., McIntire, D. D., Leveno, K. J. (2006). A randomized trial of coached versus uncoached maternal pushing during the second stage of labor. American Journal of Obstetrics and Gynecology, 194, 10-3.
  3. Upright Positions in Second Stage May Decrease Instrumental Deliveries in Women with Epidural Analgesia
    Roberts, C. L., Algert, C. S., Cameron, C. A., & Torvaldsen, S. (2005). A meta-analysis of upright positions in the second stage to reduce instrumental deliveries in women with epidural analgesia. Acta Obstetricia et Gynecologica Scandinavica, 84(8), 794-798.
  4. Delayed, “Physiologic” Pushing Improves Fetal Oxygenation in Women Using Epidural Analgesia
    JSimpson, K. R., & James, D. C. (2005). Effects of immediate versus delayed pushing during second-stage labor on fetal well-being: a randomized clinical trial. Nursing Research, 54(3), 149-157.

Read more…

Uncategorized , , , ,

cheap oakleys fake oakleys cheap jerseys cheap nfl jerseys wholesale jerseys wholesale nfl jerseys