Science & Sensibility

When the study titled Elective birth at 37 weeks of gestation versus standard care for women with an uncomplicated twin pregnancy at term: the Twins Timing of Birth Randomised Trial came out on June 13, 2012 both the BJOG:An International Journal of Obstetrics and Gynaecology in their press release: “BJOG release: Elective birth at 37 weeks gestation safer for mothers carrying uncomplicated twins, new research suggests” and Science Daily: “Earlier Birth, at 37 Weeks, Is Best for Twins, Study Suggests” reported the findings as strong evidence to support NICE’s (National Institute for Health and Clinical Excellence) guidelines.

“The findings of our randomised trial support the recent NICE recommendations. For women with an uncomplicated twin pregnancy at 37 weeks of gestation, elective birth was associated with a significant reduction in the risk of birthweight below the third centile, with no identified increase in the risks associated with early birth for either women or their infants.”

So what are the NICE recommendations?

• 1.7.1.5 Inform women with uncomplicated monochorionic twin pregnancies that elective birth from 36 weeks 0 days does not appear to be associated with an increased risk of serious adverse outcomes, and that continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk of fetal death.
•  1.7.1.6 Inform women with uncomplicated dichorionic twin pregnancies that elective birth from 37 weeks 0 days does not appear to be associated with an increased risk of serious adverse outcomes, and that continuing uncomplicated twin pregnancies beyond 38 weeks 0 days increases the risk of fetal death.

Photo by www.photographybyjoelle.com licensed under Creative Commons

Let’s take a more in-depth look at the study. This is a randomized control trial where women with twin pregnancies were selected by phone to either be placed in the “standard care” bucket or the “elective birth” bucket. The goal of the study was to determine if an uncomplicated twin pregnancy delivered at 37 weeks gestation reduced the risk of death or serious outcomes for babies without increasing harm.

We do know that multiple pregnancies come with unique complications that singletons do not, such as high rates of prematurity, cerebral palsy, developmental delays and intrauterine growth restriction (IUGR) among others. Credit where credit is due, this study does not compare twins to singletons.  The authors maintain an apples-to-apples comparison by only looking at twins.  The researchers were specifically looking to see if elective birth (both induction and cesarean section) would reduce the risks of perinatal mortality, birth trauma, lung immaturity and admission to the NICU, necrotizing enterocolitis and systemic infection.

For the mothers, they looked at pre-eclampsia, eclampsia, protein-uria, renal insufficiency, liver disease, neurological disturbances, hematological disturbances, antepartum hemorrhage and abnormal umbilical artery.  They also looked at a number of labor and birth complications.  However, the focus of the study was primarily the infants, not the mothers.

“Multiple pregnancy is associated with both maternal and fetal complications. While women with a twin pregnancy are more likely to give birth prematurely, approximately 46% will give birth after 37 weeks’ gestation. For women whose twin pregnancy continues beyond 37 weeks’ gestation, there is a higher risk of perinatal mortality and morbidity with advancing gestational age. 

The Australian study looked at 235 women with an uncomplicated twin pregnancy at 36 weeks gestation. They were divided into women who planned an elective birth from 37 weeks (elective birth group) and women who planned birth from 38 weeks (standard care group).”

One problem I encountered was the relatively small sample size of 235 women.  The authors admit there should have been closer to 1100 mothers to validate their findings:

“There are several limitations to our findings. The current trial was stopped before completion of the estimated sample size for a lack of ongoing funding. We are therefore relatively underpowered to assess our primary outcome of serious adverse outcome for the infant, as well as uncommon maternal labour and birth complications. To detect  a 66% reduction in adverse outcome at term as suggested using plurality-specific data would require a sample size of approximately 1100 women with an uncomplicated twin pregnancy at term.”

Another problem I encountered while looking at the data was that the gestational age of the “Elective Birth” babies was roughly the same as the “Standard Care” babies, differing by only 0.5 weeks.

“Despite our trial protocol specifying birth for women in the Standard Care Group being after 38 weeks of gestation, and as close to 39 weeks as possible, 45% of women in this group gave birth between 37 and 38 weeks of gestation, reflecting the practicalities of scheduling induction of labour and caesarean section procedures in a busy maternity environment at close to 38 weeks of gestation. The resultant mean difference of 4 days in gestational age at birth is consistent with the identified difference of 90 g in mean birthweight. However, these identified differences do not explain the significant reduction in the risk of birthweight less than the third centile observed in the Elective Birth Group, raising the possibility that this was a chance finding.” (emphasis mine)

But, yet, one of the main reasons they suggest elective birth at 37 weeks is due to IUGR or small for gestational age. Out of the “Elective Birth” group, 7 babies were in the third percentile or less (3%), the “Standard Care” group had 24 babies (10.1%). On the surface, that is much higher.  However, the “Standard Care” numbers also accounts for emergency cesarean sections and induced labors for medical reasons.  For ethical reasons unplanned inductions and cesarean sections needed to occur.

The questions I have are:  how badly did that skew the data?  How accurate is the gestational age of the babies? There is no indication in the study to tell us that these pregnancies were accurately dated via early ultrasound, etc. so some amount of variability in gestational ages may have impacted results.

How is elective twin birth managed here in the U.S.?

ACOG

In the American Congress of Obstetricians  and Gynecologists’ ACOG Practice Bulletin #56, 2004, reaffirmed in 2009

“The nadir of perinatal mortality for twin pregnancies occurs at approximately 38 completed weeks of gestation and at 35 completed weeks of gestation for triplets; the nadir for quadruplet and other high-order multiple gestations is not known. Fetal and neonatal morbidity and mortality begin to increase in twin and triplet pregnancies extended beyond 37 and 35 weeks of gestation, respectively.  However, no prospective randomized trials have tested the hypothesis that elective delivery at these gestational ages improves outcomes in these pregnancies.”

At this time, ACOG is not recommending elective birth at 37 weeks for twins.  The data that ACOG provides reflects the same information as NICE and as in the BJOG study. So the data set is the same, it’s the recommendations for scheduled birth at 37 weeks that differ.

The March of Dimes

The March of Dimes makes no distinction between singleton and multiple gestation pregnancy with regards to their campaign, Healthy Babies are Worth the Wait™  to prevent prematurity. “In 2010, the Joint Commission established a new perinatal care core measure set that includes the number of elective deliveries (both vaginal and cesarean) performed at > 37 and < 39 weeks of gestation completed.”   I speculate that is because of the relative rarity of twin births in relation to singletons. Although I’d like to see a future statement specifically on twins in this regard.

Lamaze

“Lamaze Healthy Birth Practice #1 – Let Labor Begin on Its Own” would appear to be in conflict with the BJOG study and NICE’s recommended practices. However, there is always an exception for a true medical need. Induction and scheduled cesarean sections, when used judiciously, are lifesaving for both mother and baby.  Professor Jodie Dodd, one of the researchers in the BJOG study, believes strongly in her results. So much so, that she and the Univeristy of Adelaide put out this video regarding her findings.

Even with a smaller sample size than required for a full analysis, this study, plus previous others, as cited in the references, shows a correlation between birth at 37 weeks for twins and reduced risk for low birth weight and perinatal mortality. As a Lamaze educator, I feel an internal conflict with the March of Dimes information, Lamaze’s Healthy Birth Practice #1 and the study results. My belief is that all babies know their best time to be born, including twins. I think that every twin pregnancy should be taken on a case by case basis. Truly, there are increased risks with any twin pregnancy. However, the risks always need to be explained in context of the long term effects of a scheduled birth on breastfeeding; cesarean section complications; and long term complications of prematurity on the babies. As long as the mother has the full set of information she can make an appropriate decision with her individual care provider regarding scheduling the elective birth of her twins.

This post was written by regular contributor, Deena Blumenfeld, RYT, RPYT, LCCE  To read more about Deena or to contact her, please see our contributor page.

Deena Blumenfeld Babies, Cesarean Birth, Childbirth Education, Evidence Based Medicine, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternal Quality Improvement, Maternity Care, Medical Interventions, Newborns, NICU, Practice Guidelines, Pre-term Birth, Pregnancy Complications, Twins, Uncategorized ACOG, BJOG, Deena Blumenfeld, guest posts, Healthy Birth Practices, labor induction, Lamaze International, multiples, NICE, twins

[Editor's note: This is the final post of  a two-part series.  In this series I interview Jannette Fesitval, RN, IBCLC, and Founder of the Calgary Mothers' Milk Bank].

Lisa Baker: What is the potential capacity of the bank?

Jannette Festival: That is really dependant on our supply of milk from donor moms. We anticipate that we will pasteurize 40,000 oz (1200 L) our first year. Our pasteurizer is capable of handling volumes up to 250,000 oz/year or 7500 L/year.

Lisa Baker: Who will receive the donor milk?

Jannette Festival: Because we won’t be able to collect all the milk that is needed we will need to triage it out. The easiest way to do this is to have the milk available by prescription. This will ensure that it will go to the sickest babies first. Our hope is to provide everyone that is in need of human milk.

Lisa Baker: What regions will the bank serve?

Jannette Festival: We would like to try and support Albertans first. But if there was a sick baby out of province who needed milk we would do our best to supply milk to them. If we are collecting milk from donor moms in other provinces then we will reciprocate when needed.

Lisa Baker: How will you recruit donors?

Janette Festival: Recruitment of Donors will be a full time job. Advertising and awareness is huge. There really needs to be a paradigm shift in how people value human milk and this is based on knowledge and education. By educating all health care providers I feel that this will be passed on to moms who will become aware of the importance of breastfeeding and may become potential donors.

 Lisa Baker: What is the screening process for potential donors? 

Jannette Festival: The screening process is very thorough and a bit of work on the donor part. We first start with a verbal interview on the phone that can be done in 20 minutes but usually takes a bit longer than that. This is followed by a written questionnaire, blood tests, and a visit between the donor and her health care provider. Once all the results are gathered and there are no issues we can accept the donor’s milk.

Lisa Baker: Do you anticipate lots of mothers to donate?

Jannette Festival: I don’t think we will have any problem recruiting donors. Donating human milk is one of the most altruistic acts a women can do. It truly is a win-win situation. Where else can you make this type of donation that could have such an impact on a baby’s future quality of life or even, life or death. When a mom has read our website and has decided she wants to donate, she is excited and eager to participate.

Lisa Baker: Where do you see the future of human milk banking?

 Jannette Festival: I think each Province needs to have it’s own milk bank. I believe that once the medical community observes the success of the milk bank and it’s impact on sick and fragile babies– more milk banks will open. I think that community milk banks are accountable and sustainable – they need to be to survive. They also have the ability and responsibility to educate the public about the importance of breastfeeding. Calgary Mothers’ Milk Bank will have free breastfeeding classes for moms prior to their babies being born as well as peer-to-peer support after. We really want to create a place where moms can gather and support each other. Milk banks should exist to support breastfeeding, not the other way around (Arnold, 2010). We would eventually like to participate in research of human milk.Hospital milk banks can work well, if they are valued. But if the hospital has a tight budget period, history has shown that often milk banks can be the first to go or cut back. And that’s what you don’t want to happen. 

 Arnold, Louis D.W. (2010), Human Milk in the NICU Policy into Practice (pg. 397)

For more information on the Calgary Mother’s Milk Bank, please visit their website at www.calgarymothersmilkbank.ca. 

To learn more about HMBANA and how to start a milk bank, please visit their website at www.hmbana.org.

Lisa Baker Authoritative Knowledge, Breastfeeding, Guest Posts, Pre-term Birth breastfeeding, newborns

[Editor's Note: Jannette Festival, RN, IBCLC, is the Founder and Executive Director for the Calgary Mothers’ Milk Bank (CMMB). The CMMB is one of the newest banks affiliated with the Human Milk Bank Association of North America (HMBANA). The bank has begun accepting donations of milk from qualified mothers and will begin distributing donor milk in the very near future. As a means to gather insight on establishing a milk bank from scratch, I had a very insightful conversation with Jannette. The following two posts outline our discussion.]

PART ONE

Lisa Baker: Tell me a little about yourself and how you became involved with the CMMB.

Jannette Festival: I am an RN and an IBCLC. I started my nursing career in Labor and Delivery Unit at the Foothills Hospital in Calgary, Alberta. I was very interested in breastfeeding since I would always be in the room when moms were first latching their newborn babies. I started teaching prenatal classes and a large portion of those classes were centered around breastfeeding. I eventually ended up working in the Postpartuum Unit where I was always working with breastfeeding moms. I became an International Board Certified Lactation Consultant (IBCLC) and started a Lactation Consulting business. As far as how I became involved with the milk bank, I am the founder.

Lisa Baker: How did the Calgary Mothers’ Milk Bank come to be? 

Jannette Festival: Back in November 2011 the Canadian Pediatric Society issued a statement: “The preferred nutrition for the newborn is his/her own mother’s milk. When this is not available or is limited, pasteurized human donor breast milk is a recommended alternative for hospitalized neonates.” At this point I had felt that if I couldn’t start a milk bank right now, it just might never happen. I first contacted Maureen Fjeld and asked her “can I start a community-based milk bank?” Her response was “absolutely”. I was able to get a lot of help from a friend who was the former CFO of STARS helicopters. Ann Marie had all the business and not-for-profit experience that I was missing. We were really a perfect pair to tackle this. She just happened to retire, and I was able to convince her that she was too early for retirement.

Lisa Baker: How long has the project been underway?

Jannette Festival: It has been 15 months of 2 people working full time. We also have several part-time people who have been able to offer their expertise from architecture to computers and creating brochures.

Lisa Baker: What has been the biggest challenge in starting the bank?

Jannette Festival: When we first started discussions with HMBANA, they are our professional organization, they had told us that money and space are the two largest challenges for milk banks. They were right. We had the finances taken care of but we looked at and evaluated 12 different locations. There are a lot of items that needed to be considered. That took a lot of our time.

Lisa Baker: Who or what has been the project’s biggest source of support? 

Jannette Festival: We have had several sources of support. When I first presented this project to a physicians group they bought into it right away. Dr. Chen Fong was at this meeting and he was able to put me in contact with other physicians in Calgary who he felt might be interested. Our Medical Director Dr. Doug Caine was at this original meeting. Dr. Caine and I went to present to Dr. Doug Wilson. Dr. Wilson is an obstetrician and he was very aware of the benefits of breast milk and volunteered to help us. It literally just snow balled from there.

Lisa Baker: How did you obtain funding for this project?

Jannette Festival: Funding for the project started with a single donor who wishes to remain anonymous. We are a charitable, not-for-profit organization. Since we obtained this status other individuals have stepped forward and have been able to support us with donations or their offer of help in their area of expertise. While looking for a contractor I talked to friends of mine who decided to donate the funds required to build our office and pasteurizing room. Our Treasurer Anne Marie and her partner purchased the pasteurizer. We’ve been receiving small on-line donations. This all helps us tremendously.

Lisa Baker: How will you continue to fund the Milk Bank? 

Jannette Festival: Calgary Mothers’ Milk Bank is a charitable, not-for-profit organization. There is a fee for the milk and it’s based on cost recovery. We also intend to approach individuals for donations. In the near future we will look at a fundraiser. Because we are not based in the hospital we can take advantage of using volunteers. There is a lot of talent out there and people are more than happy to volunteer. This will help keep our costs down.

Stay tuned for part two of our interview, where Jannette will discuss the logistics of collecting and distributing donor milk and her vision of the future of milk banking in Canada.

Lisa Baker Babies, Breastfeeding, Evidence Based Medicine, Guest Posts, Pre-term Birth breastfeeding, newborns

[Editor's Note: A big hello to Science and Sensibility readers! As this is my first post, I would like to take a minute to thank Deena for the wonderful job she did on Science and Sensibility in February. I look forward to spending the month of March with you. Enjoy! - Lisa Baker]

As discussed in last week’s post, the American Academy of Pediatrics (AAP) revised policy statement on Breastfeeding and the Use of Human Milk reaffirms the recommendation of exclusive breastfeeding for six months and a continuation of breastfeeding for 1 year or longer (1). It has been well established that the act of breastfeeding and the consumption of human milk has numerous benefits to infant, mother, and society.  As outlined in the policy statement, the benefits of human milk consumption for the preterm infant are significant and include:

• lower rates of necrotizing enterocolitis (NEC) and sepsis
• fewer readmissions to hospital
• higher intelligence testing scores and higher total brain volume
• lower rates of retinopathy of prematurity
• lower blood pressure and low-density lipoprotein concentrations
• improved leptin and insulin metabolism

The benefits of human milk to the preterm infant are so significant that the AAP recommends, “If mother’s own milk is unavailable despite significant lactation support, pasteurized donor milk should be used”(1). This week’s posts will further explore the topic of donor human milk for the premature infant.

Donor human breast milk vs cow’s milk-based formula

When a mother’s breast milk is not available, preterm infants can be given either donor breast milk or commercially made formula. Feeding preterm infants pasteurized donor milk over formula is the recommendation expressed by a long list of organizations.  Such groups include the AAP, Canadian Pediatric Society, United States Breastfeeding Committee, Breastfeeding Committee for Canada, and La Leche League International (1-5).  Evidence to support this recommendation largely comes from a 2007 systematic review by Quigley et al. (6) and a 2010 trial by Sullivan et al. (7). In both cases the rates of NEC were significantly higher in preterm infants fed cow’s milk-based formula products versus those fed only human milk.

The review performed by Quigley et al. compared formula feeding to donor breast milk in eight separate studies, involving a total of 1,017 infants. The authors concluded, “feeding with formula milk, compared with donor breast milk, leads to higher rates of short-term growth in preterm or low birth weight infants, but is associated with an increased risk of developing necrotizing enterocolitis” (6). The results of short-term growth should be taken with caution, however, as only one of the eight trials included nutrient-fortified breast milk (a common practice in today’s NICU).  Fortifying human milk has been shown to increase short-term growth rates, but does not appear to affect growth beyond infancy (8).

The study by Sullivan et al. included 207 extremely premature infants and showed a 77% reduction in the odds of developing NEC (odds ratio of 0.23 (95% CI=0.08,0.66), P=. 007) in infants that consumed only human milk and human milk-based fortifiers compared to infants that consumed cow’s milk-based products (7).

Pasteurization of donor breast milk

In accordance with recommendations from the AAP and Canadian Pediatric Society (CPS), as well as the remaining aforementioned organizations, donor human milk offered to premature infants must be pasteurized (1-5). As a human body substance, breast milk must be properly collected and stored, subject to screening and testing, pasteurized, and cultured.  Pasteurization involves heating breast milk to inactivate bacterial and viral contaminants. The heating process can also alter the breast milk itself. The CPS policy statement on milk banking provides a summary of the alterations caused by a common form of pasteurization in milk banks (heating milk to 62.5^oC for 30 minutes; the Holder method):

• Carbohydrates, fats and salts are unchanged.
• Thirteen per cent of the protein content is denatured.
• Fat-soluble vitamins are unchanged.
• While not all of the water-soluble vitamins have been studied, some have been shown to degrade following pasteurization.
• All beneficial immune cells are also inactivated.
• Secretory immunoglobulin IgA, which binds microbes within the digestive tract, is found at 67% to 100% of its original activity.
• Targeted IgG antibodies are reduced at 66% to 70%.
• IgM antibodies are completely removed.
• Lactoferrin, which binds iron required by many bacteria, thus reducing their growth, is reduced to 20% of its original level.
• Lysozyme enzyme, which attacks bacterial cell walls, drops to 75% activity.

Despite these alterations, pasteurized breast milk still contains far more beneficial elements than formula and is the preferential alternative to mother’s own fresh breast milk.

Supply of pasteurized donor breast milk in Canada

To meet the recommendation of properly pasteurized milk, Canadian hospitals receive their donor milk from one of the milk banks associated with the Human Milk Bank Association of North America (HMBANA).  The HMBANA is a non-profit association of donor human milk banks established to set standards for and facilitate establishment and operation of milk banks in North America. These banks have rigorous screening methods for all donors and stringent protocols for pasteurization and handling of breast milk.  The milk is sold to hospital NICU’s on a cost-recovery basis. As of 2011 there were 11 accredited HMBANA milk banks in North America. Only one of those banks is located in Canada (British Columbia). HMBANA banks are being developed in Ontario and Alberta and the Calgary Mothers’ Milk Bank (Alberta) is already accepting milk donations. Despite this recent development, Canadian hospitals are still critically short on donated breast milk.  Milk that is available is reserved for the most critical preterm infants or newborns that require gastrointestinal surgery (2).  There is certainly room for more banks to supply the large demand of breast milk to preterm and critically ill newborns.

In light of the need for more banks in North America, HMBANA has established guidelines and best practices for those wishing to start and operate a functional milk bank.  In our next post series we will interview Jannette Festival, Founder and Executive Director for the newly established Calgary Mothers’ Milk Bank, to discuss the process of creating a milk bank and the potential future of milk banks in Canada and North America.

References

1. American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129: e827–e841. Available at http://pediatrics.aappublications.org/content/early/2012/02/22/peds.2011-3552 

2. Canadian Paediatric Society. Position Statement: Human Milk Banking. Paediatrics and Child Health 2010; 15 (9):595-8. Available at http://www.cps.ca/english/statements/N/N10-01.htm.

3. United States Breastfeeding Committee. Statement on the Safe Use of Donor Human Milk. Washington, DC: United States Breastfeeding Committee. 2008. Available at http://www.usbreastfeeding.org/LinkClick.aspx?link=Position-Statements%2fDonor-Milk-Statement-2008-06-18-USBC.pdf&tabid=227&mid=587.

4.  The Breastfeeding Committee of Canada. Breastfeeding Statement of The Breastfeeding Committee of Canada. 2002. Available at http://www.breastfeedingcanada.ca/Publications.aspx.

5.  La Leche League International. Policy regarding the donation of human milk. 2011. Available at http://www.llli.org/release/milksharing.html.

6.  Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants (review). Cochrane Database of Systematic Reviews 2007; 1-41. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002971.pub2/abstract

7.  Sullivan S et al.  An Exclusively Human Milk-Based Diet Is Associated with a Lower Rate of Necrotizing Enterocolitis than a Diet of Human Milk and Bovine Milk-Based Products The Journal of Pediatrics 2010; 156:562-7.

8. Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 1. Available at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000343.pub2/abstract.

Lisa Baker Babies, Breastfeeding, Evidence Based Medicine, Pre-term Birth breastfeeding, Lisa Baker, newborns, preterm infant

In Part 1 we talked about how to help your client choose a prenatal yoga class; in Part 2, we will look at breathing, meditation and relaxation in a prenatal yoga class and how it’s beneficial to the pregnant mother.

We know that learning relaxation and breathing techniques can help a woman better cope with her labor and enhance her birth experience.  A prenatal yoga class should incorporate relaxation (meditation), breathing, physical postures and movements to prepare a woman’s body for labor and birth.  If a woman has a consistent yoga practice for many weeks leading up to her labor and birth, she should be better prepared physically, psychologically and emotionally to cope with her labor.

When most people think of yoga, asana (physical postures) comes to mind.  Preparing the physical body, and to some extent reliving stress by increasing the endorphin levels, is good.  Beyond the physical, however, when a woman is pregnant her hormones can make her feel out of whack; she can have fears about the birth process; she can feel a need for community and friendship in a new way.  A good yoga class should provide for all of the above.

Let’s get to the nitty-gritty of how the non-physical aspects of yoga work for the pregnant woman.

 ”This study provides evidence that regular yoga practice in the last 10–12 weeks of pregnancy improves maternal comfort in labor and may facilitate labor progress. The researchers offer several theories for these effects. First, yoga involves synchronization of breathing awareness and muscle relaxation, which decrease tension and the perception of pain. Second, yoga movements, breathing, and chanting may increase circulating endorphins and serotonin, “raising the threshold of mind-body relationship to pain” (p. 112). Third, practicing yoga postures over time alters pain pathways through the parasympathetic nervous system, decreasing one’s need to actively respond to unpleasant physical sensations.

Prenatal strategies that help women prepare emotionally and physically for labor may help reduce pain and suffering and optimize wellbeing in childbirth by providing coping skills and increasing self-confidence and a sense of mastery. More research is needed to confirm the findings of this study. However, yoga’s many health benefits and the lack of evidence that yoga is harmful in pregnancy or birth provide justification for encouraging interested women to incorporate yoga into their preparations for childbirth.”

 Research Summaries for Normal Birth by Amy M. Romano, MSN, CNM and Henci Goer, BA

 
For more information on breathing techniques try Yoga Journal.
 

 
Meditation is taught to varying degrees in a prenatal yoga class, depending on the style of yoga and the individual instructor.  Meditation does not have to mean finding a quiet seat and looking inward.  It doesn’t mean “clearing your mind”.  Meditation can involve movement, breath, mantra, focal points, visualization, etc.  What meditation does is give the person focus.   How does it affect pain management?

“Women practicing mindful yoga in their second trimester reported significant reductions in physical pain from baseline to post-intervention compared with women in the third trimester whose pain increased. Women in their third trimester showed greater reductions in perceived stress and trait anxiety.  Preliminary evidence supports yoga’s potential efficacy in these areas, particularly if started early in the pregnancy.”

The effects of mindfulness-based yoga during pregnancy on maternal psychological and physical distress. 

Beddoe AE, Paul Yang CP, Kennedy HP, Weiss SJ, Lee KA.

“Yoga was associated with reduced pain (mean difference (MD) -6.12, 95% CI -11.77 to -0.47), one trial, 66 women), increased satisfaction with pain relief (MD 7.88, 95% CI 1.51 to 14.25, one trial, 66 women), satisfaction with the childbirth experience (MD) 6.34, 95% CI 0.26 to 12.42, one trial, 66 women), and reduced length of labour when compared to usual care (MD -139.91, 95% CI -252.50 to -27.32, one trial, 66 women) and when compared with supine position (MD -191.34, 95% CI -243.72 to -138.96, one trial, 83 women)…. Relaxation and yoga may have a role with reducing pain, increasing satisfaction with pain relief and reducing the rate of assisted vaginal delivery.”

Relaxation techniques for pain management in labour.

Smith CA, Levett KM, Collins CT, Crowther CA.

So, it would appear that a yoga practice during pregnancy reduces the need for medical interventions, and would also seem to shorten the overall length of labor.

“The experimental group (yoga group) had significantly less pain and more comfort than the control group at each of the three measurement intervals during labor and at the postpartum measurement. This finding was consistent and significant across all three pain-measurement instruments used. The researchers do not present data about mode of birth. However, the length of the first stage of labor and total duration of labor were significantly shorter in the yoga group (mean length of first stage = 520 minutes in yoga group vs. 660 minutes in control group; mean total time in labor 559 minutes in yoga group vs. 684 minutes in control group)….”

Research Summaries for Normal Birth

Amy M. Romano, MSN, CNM and Henci Goer, BA

Yoga also seems to have an impact in the health and well being of the baby.  I would surmise that this is due to the lower levels of stress hormones in the mother’s body having a positive effect on the uterine environment.  When mama is happy, baby is happy.

 “Complications such as pregnancy-induced hypertension with associated intrauterine growth retardation as well as preterm labor and prematurity were less frequent in the yoga group. These effects are difficult to interpret as they could have derived from the physical postures, the breathing, the meditation and/or all components of the yoga sessions.”

…

“In the yoga group, compared with values obtained before a practice session, the high-frequency band of the heartrate variability spectrum (parasympathetic or vagal activity) increased by 64% in the 20th week and by 150% in the 36th week, and both the low-frequency band (sympathetic) and the low-frequency to high-frequency ratio were reduced. Moreover, the low-frequency band remained decreased after deep relaxation in the 36th week in the yoga group, all of these being adaptive autonomic responses to stress.  Thus, yoga reduced perceived stress and improved adaptive autonomic responses to stress in healthy pregnant women.”

Complementary Therapies in Clinical Practice
Volume 17, Issue 1 , Pages 1-8, February 2011

To conclude, yoga has a multifaceted effect on not only the pregnant mother’s body, but also her mind and her baby.  More research needs to be done to further discover why yoga works.  However, since it does work; is a complementary practice to childbirth education; lowers rates of medical intervention; reduces the length of labor; and reduces the likely hood of prematurity, shouldn’t we consider referring our clients to a prenatal yoga class?

Tell me about your experiences with prenatal yoga and better birth outcomes.

Deena Blumenfeld Childbirth Education, Guest Posts, Pre-term Birth, Research, Uncategorized breathing in childbirth, Childbirth Education, lamaze, meditation, Prenatal Yoga, relaxation in childbirth, yoga breathing