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What is the Evidence for Induction for Low Amniotic Fluid in a Healthy Pregnancy?

August 30th, 2012 by avatar

By Rebecca L. Dekker, PhD, RN, APRN

Today’s post on the Evidence for Induction for Low Amniotic Fluid in a Healthy Pregnancy is a guest post by blogger Rebecca Dekker, owner of  the fairly new blog in the birth world, Evidence Based Birth that has been  very well received and enjoyed by many.  Look for an interview with Rebecca in an upcoming post where we will learn how this Assistant Professor of Nursing who teaches pathopharmacology and studies depression in patients with heart failure ended up writing the Evidence Based Birth blog appreciated by birth professionals.  I look forward to future posts and collaboration with Rebecca and thank her for her contribution today.- SM

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This question came from one of my readers:

“Low fluid seems to be the new “big baby” for pushing for induction. What does the research say about low fluid at or near term? From what I’ve been able to see in research summaries at least, there appears to be no improved outcome for babies, but I’d love to see the research really hashed out. I’m also curious about causes of low fluid (theorized or known), risks of low fluid, and perhaps as important if not more so, measurements of low fluid.”

This is a great question and I felt like it was a perfect topic for my first article for Science and Sensibility. Standard of practice in the U.S. is to induce labor at term if a mother has low amniotic fluid in an otherwise healthy pregnancy. In fact, 95% of physicians who practice maternal-fetal medicine feel that isolated oligohydramnios—low amniotic fluid in an otherwise healthy pregnancy—is an indication for labor induction at 40 weeks (Schwartz, Sweeting et al. 2009).

But what is the evidence for this standard birth practice? Let’s take a look at the evidence together.

First of all, what is oligohydramnios?

Oligohydramnios means low fluid inside the amniotic sac.

(oligo = little, hydr = water, amnios = membrane around the fetus, or amniotic sac).

Not sure how to pronounce oligohydramnios? Click here.

It is standard of care in the U.S. to induce women with isolated oligohydramnios at term.
Image Source drewesque 

What is amniotic fluid, and what does it do?

During pregnancy, the baby is surrounded by a liquid called amniotic fluid. Amniotic fluid helps protect the baby from trauma to the mother’s abdomen. Amniotic fluid cushions the umbilical cord, protects the baby from infection, and provides fluid, space, nutrients, and hormones to help the baby grow (Brace 1997).

During the second half of pregnancy, amniotic fluid is made up of the baby’s urine and lung secretions. This liquid originally came from the mother, and then flowed through the placenta, to the baby, and out through the baby’s bladder and lungs (Brace 1997).

This same amniotic fluid is then swallowed by the baby and re-absorbed by the lining of the placenta. Because the mother’s fluid levels are the original source of amniotic fluid, changes in the mother’s fluid status can result in changes in the amount of amniotic fluid. Amniotic fluid levels increase until the mother reaches about 34-36 weeks, and then levels gradually decline until birth (Brace 1997).

What can cause low amniotic fluid at term?

Both mother and baby factors can contribute to low amniotic fluid at term.

Mother factors:

  • If the mother is dehydrated, this may lower the amniotic fluid levels. (Patrelli, Gizzo et al. 2012)
  • Women are more likely to be diagnosed with low amniotic fluid levels during the summer, possibly because of dehydration. (Feldman, Friger et al. 2009)
  • If a woman with low amniotic fluid levels at term drinks at least 2.5 Liters of fluid per day, she increases the likelihood that her amniotic fluid levels will be back up to normal by the time of delivery. (Patrelli, Gizzo et al. 2012)
  • If the mother rests on her left side before or during the fluid measurement, this can increase amniotic fluid levels. (Ulker, Temur et al. 2012)
  • If the mother’s water has broken (membranes ruptured), this will lead to a decrease in amniotic fluid. (Brace 1997)
  • If the mother’s placenta is not acting sufficiently anymore, this may lead to a decrease in amniotic fluid. When this happens, it may be because the mother has a serious condition such as pre-eclampsia or intrauterine growth restriction. (Beloosesky and Ross 2012)

Baby factors:

  • If the baby has a problem with the urinary tract or kidneys, this may decrease the flow of urine. (Brace 1997)
  • In the 14 days before the start of spontaneous labor, the baby’s urine output starts to decrease. (Stigter, Mulder et al. 2011)
  • As the baby gets closer to term, the baby swallows more amniotic fluid, thus leading to a decline in fluid levels. (Brace 1997)
  • If the baby is post-term (after 42 weeks), he or she begins to swallow significantly more fluid, contributing to a decline in amniotic fluid. (Brace 1997)
  • If the baby has a birth defect, he or she may swallow significantly more fluid, leading to low amniotic fluid levels. (Beloosesky and Ross 2012)

What is the best way to measure amniotic fluid levels?

The gold-standard method is to inject the amniotic sac with dye and then take samples of the amniotic fluid to check the dilution. However, this method is very invasive. So the most commonly used methods instead are 2 ultrasound techniques:  the amniotic fluid index (AFI) and the single deepest pocket (Gilbert 2012).

To calculate the AFI, the technician divides the uterus into 4 areas. The largest fluid pocket in each area is measured, and then these 4 numbers are added make up the AFI. An AFI value of 5 cm or less is considered oligohydramnios. With the single deepest pocket method, the technician looks for the largest pocket of amniotic fluid in the uterus. If the largest pocket is less than 2 cm by 1 cm, then that is considered a diagnosis of oligohydramnios (Nabhan and Abdelmoula 2009).

It is important to understand that amniotic fluid levels exist on a continuum and that there is no agreement among researchers about the cut-off value that predicts poor outcomes—the AFI level of 5 was arbitrarily chosen to define oligohydramnios (Nabhan and Abdelmoula 2009). Furthermore, a large body of research has shown that both AFI and single deepest pocket are poor predictors of true amniotic fluid volume. For example, the AFI catches only 10% of all cases of true oligohydramnios (10% sensitivity)(Gilbert 2012).

There are several factors that make it difficult to get an accurate ultrasound measurement. As fluid levels decrease, ultrasound results become less accurate. Inexperience on the part of the technician can reduce the accuracy of the test results, as well as the amount of pressure that the technician puts on the ultrasound probe. The position of the baby can also affect the accuracy of the results. (Nabhan and Abdelmoula 2009; Gilbert 2012).

So which is the best way to measure amniotic fluid?

In a Cochrane review, researchers combined the results from 5 randomized controlled trials with more than 3,200 women. In these studies, women were randomized to either the AFI method or the single deepest pocket method. Researchers found that when the AFI is used to measure amniotic fluid, women were 2.4 times more likely to be diagnosed with oligohydramnios, 1.9 times more likely to be induced, and 1.5 times more likely to have a Cesarean for fetal distress without any corresponding improvement in infant outcomes. The researchers concluded that the single deepest pocket measurement has fewer risks and should be the preferred way to measure amniotic fluid (Nabhan and Abdelmoula 2009).

What is the clinical significance of low amniotic fluid when a mother reaches 37 or more weeks?

In 2009, 91% of physicians believed that isolated oligohydramnios, or low amniotic fluid in an otherwise healthy pregnancy at term, was a risk factor for poor outcomes (Schwartz, Sweeting et al. 2009).

In the U.S., 91% of maternal-fetal physicians believe that isolated oligohydramnios at term is a risk factor for poor outcomes, and 95% will recommend labor induction.
Image Source robenjoyce

However, this belief is not accurate. In early studies on amniotic fluid and outcomes, researchers included babies with congenital defects , women with pre-eclampsia or intrauterine growth restriction (IUGR), and women who were post-term (past 42 weeks) in their samples. These women and babies are more likely to have low amniotic fluid, and they are also much more likely to have poor outcomes. So although early researchers found that babies born to women with low amniotic fluid had higher perinatal mortality rates (Chamberlain, Manning et al. 1984), higher Cesarean rates for fetal distress, and lower Apgar scores (Chauhan, Sanderson et al. 1999), the poor outcomes were due to the complications—not the low amniotic fluid (Gilbert 2012).

So, if a woman has TRUE ISOLATED oligohydramnios at term, meaning low amniotic fluid in a healthy pregnancy with a healthy baby at term (between 37 and 42 weeks), what are the risks?

There is no evidence that isolated oligohydramnios at term is a risk factor for poor outcomes. However, induction for isolated oligohydramnios leads to higher Cesarean rates. In a systematic literature review, I found 5 studies from the last 10 years. I will discuss the 3 highest quality studies here. For results from all 5, you can see my findings summarized in this Google document table here.

  1. Locatelli et al. (2003) studied 3,049 healthy pregnant women who were between 40 and 41.6 weeks pregnant. The purpose of this study was to find out if low amniotic fluid (defined as AFI ≤ 5) led to poor outcomes. Eleven percent of women had low amniotic fluid, and these women had higher induction rates (83% vs. 25%), higher Cesarean rates (15% vs. 11%), and higher Cesarean rates for non-reassuring fetal heart rates (8% vs. 4%). Babies born to women with low amniotic fluid were more likely to have birth weights beneath the 10th percentile (13% vs. 6%). There were no differences between groups with meconium staining, meconium aspiration, umbilical artery pH <7, or Apgar scores. There was only one stillbirth (in the normal fluid group) for a true knot in the umbilical cord.

After controlling for the fact that some women were induced and some women were having their first baby, the researchers found no association between Cesarean for non-reassuring heart rate and amniotic fluid. This means that the inductions were probably responsible for the higher Cesarean rates in the low amniotic fluid group. However, when the researchers controlled for gestational age, they found that the association between low birth weight and low amniotic fluid remained significant. This means that women with low amniotic fluid were 2 times more likely to have a baby that is born beneath the 10th percentile. These babies may have had undiagnosed fetal growth restriction (IUGR), which is a separate risk factor for poor outcomes.

  1. Manzaneres et al. (2006) compared outcomes from 206 healthy pregnant women who were induced for isolated oligohydramnios at term and 206 healthy pregnant women with normal amniotic fluid levels who went into spontaneous labor.  The women in both groups delivered between 37 and 42 weeks. The researchers found that the low amniotic fluid group was more likely to require forceps or vacuum delivery (26% vs. 17%), Cesarean delivery (16% vs. 6%), and have non-reassuring fetal status during labor (8% vs. 2%). The non-reassuring fetal status may have been due to the induction medications, but this explanation was not proposed by the authors. There were no differences between groups with birth weight, Apgar scores, meconium staining, neonatal admissions, or umbilical cord pH. In summary, the authors found that inducing labor for isolated oligohydramnios at term increased Cesarean and operative vaginal delivery rates without any improvement in newborn outcomes.
  1. There was one small pilot study done in which researchers randomized women with isolated oligohydramnios at term to induction or watchful waiting. The researchers randomly assigned 54 women who were 41 weeks pregnant to either induction or watchful waiting. There were no differences between groups in any outcomes, including birth weight, Cesarean delivery, Apgar scores, or neonatal admission. This study was limited by its small sample size and the fact that it only included women who were 41 weeks pregnant (Ek, Andersson et al. 2005).

So what is the evidence for induction because of low amniotic fluid (without any other complications) at term?

There is no evidence that inducing labor for isolated oligohydramnios at term has any beneficial impact on mother or infant outcomes. Based on the lack of evidence, any recommendation for induction for isolated oligohydramnios at term would be a weak recommendation based on clinical opinion alone.

In summary, this is what I found about low amniotic fluid in an uncomplicated pregnancy at term (37-42 weeks):

  • Ultrasound measurement is a poor predictor of actual amniotic fluid volume
  • The single deepest pocket method of measurement has fewer risks than the AFI
  • Poor outcomes seen with low amniotic fluid are usually due to underlying complications such as pre-eclampsia, birth defects, or fetal growth restriction
  • The main risk of low amniotic fluid at term in a healthy pregnancy is induction (and Cesarean delivery as a result of the induction) and potentially the risk of lower birth weight
  • Current evidence does not support induction for isolated oligohydramnios at term

Are women in your local areas being induced for isolated oligohydramnios at term? Are consumers and clinicians aware of this evidence? What is the standard of practice for evaluating amniotic fluid in your local facilities, AFI or Single Deepest Pocket? How do you discuss this in your classes and with your patients, clients and students?

References

  1. Beloosesky, R. and M. G. Ross. (2012). “Oligohydramnios.”   Retrieved 8/20/12, 2012, from www.UpToDate.com
  2. Brace, R. A. (1997). “Physiology of amniotic fluid volume regulation.” Clin Obstet Gynecol 40(2): 280-289.
  3. Chamberlain, P. F., F. A. Manning, et al. (1984). “Ultrasound evaluation of amniotic fluid volume. I. The relationship of marginal and decreased amniotic fluid volumes to perinatal outcome.” Am J Obstet Gynecol 150(3): 245-249.
  4. Chauhan, S. P., M. Sanderson, et al. (1999). “Perinatal outcome and amniotic fluid index in the antepartum and intrapartum periods: A meta-analysis.” Am J Obstet Gynecol 181(6): 1473-1478.
  5. Ek, S., A. Andersson, et al. (2005). “Oligohydramnios in uncomplicated pregnancies beyond 40 completed weeks. A prospective, randomised, pilot study on maternal and neonatal outcomes.” Fetal Diagn Ther 20(3): 182-185.
  6. Feldman, I., M. Friger, et al. (2009). “Is oligohydramnios more common during the summer season?” Arch Gynecol Obstet 280(1): 3-6.
  7. Gilbert, W. M. (2012). Amniotic Fluid Disorders. Obstetrics: Normal and Problem Pregnancies. S. G. Gabbe. Philadelphia, PA, Elsevier. 6.
  8. Locatelli, A., P. Vergani, et al. (2004). “Perinatal outcome associated with oligohydramnios in uncomplicated term pregnancies.” Arch Gynecol Obstet 269(2): 130-133.
  9. Nabhan, A. F. and Y. A. Abdelmoula (2009). “Amniotic fluid index versus single deepest vertical pocket: a meta-analysis of randomized controlled trials.” International journal of gynaecology and obstetrics: the official organ of the International Federation of Gynaecology and Obstetrics 104(3): 184-188.
  10. Patrelli, T. S., S. Gizzo, et al. (2012). “Maternal hydration therapy improves the quantity of amniotic fluid and the pregnancy outcome in third-trimester isolated oligohydramnios: a controlled randomized institutional trial.” J Ultrasound Med 31(2): 239-244.
  11. Schwartz, N., R. Sweeting, et al. (2009). “Practice patterns in the management of isolated oligohydramnios: a survey of perinatologists.” J Matern Fetal Neonatal Med 22(4): 357-361.
  12. Stigter, R. H., E. J. Mulder, et al. (2011). “Fetal urine production in late pregnancy.” ISRN Obstet Gynecol 2011: 345431.
  13. Ulker, K., I. Temur, et al. (2012). “Effects of maternal left lateral position and rest on amniotic fluid index: a prospective clinical study.” J Reprod Med 57(5-6): 270-276.
About Rebecca Dekker
Rebecca Dekker, PhD, RN, APRN, is an Assistant Professor of Nursing at a research-intensive university and author of www.evidencebasedbirth.com. Rebecca’s vision is to promote evidence-based birth practices among consumers and clinicians worldwide. She publishes summaries of birth evidence using a Question and Answer style. You can contact Rebecca via email here.

 

 

 

Evidence Based Medicine, Fetal Monitoring, Guest Posts, Healthy Birth Practices, Healthy Care Practices, informed Consent, Maternity Care, Medical Interventions, Systematic Review, Uncategorized , , , , , , , , ,

Join Our Virtual Book Club and Read “The Midwife of Hope River” by Patricia Harman

August 28th, 2012 by avatar

As summer draws to a close, each day becoming a little bit shorter and the nights just a little bit cooler, many of us are remembering recent fun summer events, vacations, and relaxing times with families and friends.  Labor Day is looming next weekend, offering a long weekend for many of us and a last taste of summer for a while.  I always feel that the Labor Day holiday weekend is the closing bookend of summer, as my family’s attention and energy turn to school, sports and all that fall brings. As I say good bye to the “lazy” days of summer, reading a good book on the deck with a cold drink, I thought our “family” here on Science & Sensibility could participate in a Virtual Book Club, and maybe enjoy some of the long weekend by digging into a captivating new novel about midwives and birth by exploring Patricia Harman’s just released book, “The Midwife of Hope River.”

Author and Midwife Patricia Harman

Patricia Harman is a certified nurse midwife who lives in Morgantown, West Virginia where she works with her OB/Gyn husband, Tom Harman to provide woman centered care at all stages of a woman’s life as well as prenatal care to women in the early stages of pregnancy.  The Harmans stopped catching babies in 2003, and Patricia decided that she would use some of her “free” time to do some writing.  Her first book, The Blue Cotton Gown: A Midwife’s Memoirshared the stories of her midwifery patients, who came from all walks of life, to sit in her office, offering their intimate stories of challenge, laced with her own personal struggles with her health, the task of running a business and the stress it placed on relationships with those she loves.

In Patricia’s second non-fiction work, Arms Wide Open: A Midwife’s Journeythe prequel to her first book, readers are offered insight into the journey that Patricia Harman took to become a midwife. We read about her first exposure to helping women birth their babies, her exploration into living a life more in line with nature, community and supporting causes in line with her philosophy and her heart during a turbulent period of time in America’s history. Patricia shares how she, along with other women, stretched their wings and stood up for what they believed in, even if it veered from the mainstream culture and norms of the time.

I am delighted to announce that Patricia Harman is releasing her first fiction book, The Midwife of Hope River, A Novel of an American Midwife today, August 28th, and I have selected it as the very first book in the Science & Sensibility Virtual Book Club.  I invite all of you to join me in reading this new novel and participate in the events I have planned for our virtual book club in the beginning of October.

The Midwife of Hope River follows along with Patience Murphy, a midwife practicing during the Great Depression, serving the women of Appalachia, establishing trust and relationships with the mothers who struggle with poverty, challenges and hardship on a daily basis.  Midwife Patience’s own intimate secrets and the presence of the Klu Klux Klan add even more intrigue and suspense, as care is provided to the most fragile and deserving of women as they persevere to birth their babies under circumstances that stretch the midwife and risk the lives of all involved.

I hope that you will join me in reading Patricia Harman’s The Midwife of Hope River, and participating in the events I have planned for the beginning of October.  That timeframe will allow everyone time to read it over the next 5-6 weeks.  Here are some of the things you can look forward to in Science & Sensibility’s first Virtual Book Club;

  • An interview with the author, Patricia Harman, to learn more about how she came to write this novel, how she did the historical research needed to capture the personalities and events she created  and and the message she felt that needed to be shared with all of the readers.
  • An engaging discussion between Science & Sensibility readers, myself and book author, Patricia about your thoughts on the book, the challenges faced by the main character, Patience Murphy and the birth climate for the women of Appalachia during the Depression.  I have no doubt that all of us will be impacted by what we read and will appreciate a venue in which to share our thoughts and the emotions that arise from this passionate story.
  • When you participate in our Virtual Book Club by leaving a comment on the Book Club Discussion blog post in early October, your name will be entered in the random drawing to receive an autographed copy of the book personally inscribed to you.

I have always enjoyed reading memoirs and fictional books about birth, some of my favorites have been The Birth House, Monique and the Mango Rains, Midwives, Catching Babies and The Red Tent  and I am looking forward to adding The Midwife of Hope River to the list.  I know that any discussion with the readers of this blog will be interesting, and I look forward to hearing your thoughts and impressions of the book and sharing that discussion with the author.

Won’t you join me in celebrating good bye to summer, hello fall and maybe starting off the Labor Day weekend with this book, jotting down your notes along the way for sharing when I review the book and we share in our discussion with Patricia Harman.

You can find the book at your local library, Amazon, major book retailer or favorite independent bookseller. Grab yourself a copy, settle down with your favorite tea or coffee and start right in.  In the meantime, let me know in our comments section, what your favorite novels or memoirs about birth have been to date, and why.  Then look forward to our vibrant discussion about this newest novel on midwives, mothers and birth, along with an interview with the author. Join in that discussion and you may be chosen to receive your very own autographed copy.  Happy reading!

Home Birth, Maternity Care, Midwifery, Newborns, Science & Sensibility Virtual Book Club , , , , , , ,

American Academy of Pediatrics Releases Revised Policy on Newborn Male Circumcision

August 27th, 2012 by avatar

photo licensed by creative commons handmaidenbymaria

On August 27th, 2012, the American Academy of Pediatrics (AAP) released their updated policy on newborn male circumsion along with their updated technical report reviewing current research. This official statement follows a week or so of speculation in the media that the AAP’s new statement would fall on the side of supporting newborn male circumcision, stating that the benefits outweigh the risks.

The new policy statement replaces the last AAP recommendation on this topic released in 1999 (1). The just released statement makes the following recommendations:

  • Evaluation of current evidence indicates that the health benefits of newborn male circumcision outweigh the risks, and the benefits of newborn male circumcision justify access to this procedure for those families who choose it.

  • Parents are entitled to factually correct, nonbiased information about circumcision that should be provided before conception and early in pregnancy, when parents are most likely to be weighing the option of circumcision of a male child.

  • Physicians counseling families about elective male circumcision should assist parents by explaining, in a nonbiased manner, the potential benefits and risks and by ensuring that they understand the elective nature of the procedure.

  • Parents should weigh the health benefits and risks in light of their own religious, cultural, and personal preferences, as the medical benefits alone may not outweigh these other considerations for individual families.

  • Parents of newborn boys should be instructed in the care of the penis, regardless of whether the newborn has been circumcised or not.

  • Elective circumcision should be performed only if the infant’s condition is stable and healthy.

  • Male circumcision should be performed by trained and competent practitioners, by using sterile techniques and effective pain management.

  • Analgesia is safe and effective in reducing the procedural pain associated with newborn circumcision; thus, adequate analgesia should be provided whenever newborn circumcision is performed.
    • Nonpharmacologic techniques (eg, positioning, sucrose pacifiers) alone are insufficient to prevent procedural and postprocedural pain and are not recommended as the sole method of analgesia. They should be used only as analgesic adjuncts to improve infant comfort during circumcision.

    • If used, topical creams may cause a higher incidence of skin irritation in low birth weight infants, compared with infants of normal weight; penile nerve block techniques should therefore be chosen for this group of newborns.

  • Key professional organizations (AAP, the American Academy of Family Physicians, the American College of Obstetricians and Gynecologists, the American Society of Anesthesiologists, the American College of Nurse Midwives, and other midlevel clinicians such as nurse practitioners) should work collaboratively to:
    • Develop standards of trainee proficiency in the performance of anesthetic and procedure techniques, including suturing;

    • Teach the procedure and analgesic techniques during postgraduate training programs;

    • Develop educational materials for clinicians to enhance their own competency in discussing the benefits and risks of circumcision with parents;

    • Offer educational materials to assist parents of male infants with the care of both circumcised and uncircumcised penises.

  • The preventive and public health benefits associated with newborn male circumcision warrant third-party reimbursement of the procedure.

As a result of research by the AAP Task Force commissioned for the purpose of updating their policy statemen, specific benefits from male circumcision were identified for the prevention of urinary tract infections, acquisition of HIV, transmission of some sexually transmitted infections, and penile cancer. Male circumcision does not appear to adversely affect penile sexual function/ sensitivity or sexual satisfaction. This task force was made up of AAP representatives from specialty areas, including anesthesiology/ pain management, bioethics, child health care financing, epidemiology, fetus and newborn medicine, infectious diseases (including pediatric AIDS), and urology. The Task Force also included members of the AAP Board of Directors and liaisons representing the American Academy of Family Physicians (AAFP), the American College of Obstetricians and Gynecologists (ACOG), and the CDC

Male circumcision consists of the removal of some or all of the foreksin (prepuce) from the penis. It is one of the most commonly performed procedures in the world and in the United States is most commonly done during the newborn period. The current estimated rate of male circumcision in the United States ranges from 42% to 80% among various populations.(2–6)

Circumcision rates were highest in the Midwestern states (74%), followed by the Northeastern (67%) and Southern states (61%). The lowest circumcision rates were found in the Western states (30%) (See Table 1)

Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990

The AAP discussed the ethical issues of newborn male circumcision, recognizing that the law allows parents or guardians to make medical decisions on behalf of the minors that they are responsible for, when provided unbiased information by a health care provider and taking into account cultural, religious, ethnic traditions and medical factors. The parents or guardians should be advised to take this into consideration. The AAP reccomends HCPs counseling families that are choosing to circumcise their male newborns to use a qualified medical provider in a medical facility rather than a traditional/religious provider in a nonmedical environment. There was also discussion on counseling parents about the potential risks of delaying the procedure beyond the newborn period, The AAP Task Force stated that there is less risk to the child when the procedure is done as a newborn.

Prevalence of male circumcision, according to self-report; United States, 1999–2004 Source: http://pediatrics.aappublications.org/content/early/2012/08/22/peds.2012-1990.full.pdf+html

The AAP does acknowledge that this procedure is elective and the parents should be informed that this is considered an elective procedure.

The AAP Task Force, in their technical report, shares their current literature review and research findings that provided for the basis of each of the current recommendations. Additionally, the technical report discusses studies that provide information on risks and complications of this elective procedure. The technical report is a comprehensive review of the information the AAP used to formulate their current recommendations and I encourage you to not only read it for your own information, but to have it available as a resource for parents who are looking for the full statement and the research behind it.

Future Research is Needed

The Task Force identified important gaps in their knowledge of male circumcision and urges the research community to seriously consider these gaps as future research agendas are developed. Although it is clear that there is good evidence on the risks and benefits of male circumcision, it will be useful for this benefit to be more precisely defined in a US setting and to monitor adverse events. Specifically, the Task Force recommends additional studies to better understand:

photo licensed by creative commons Nina Matthews Photography

  • The performance of elective male circumcisions in the United States, including those that are hospital- based and nonhospital-based, in infancy and subsequently in life.
  • Parental decision-making to develop useful tools for communication between providers and parents on the issue of male circumcision.
  • The impact of male circumcision on transmission of HIV and other STIs in the United States because key studies to date have been performed in African populations with HIV bur- dens that are epidemiologically dif- ferent from HIV in the United States.
  • The risk of acquisition of HIV and other STIs in 0- to 18-year-olds, to help inform the acceptance of the procedure during infancy versus deferring the decision to perform circumcision (and thus the procedure’s benefits) until the child can provide his own assent/consent. Because newborn male circumcision is less expensive and more widely available, a delay often means that circumcision does not occur. It will be useful to more precisely define the prevention benefits conferred by male circumcision to inform parental decision-making and to evaluate cost-effectiveness and benefits of circumcision, especially in terms of numbers needed to treat to prevent specific outcomes.
  • The population-based incidence of complications of newborn male circumcision (including stratifications according to timing of procedure, type of procedure, provider type, setting, and timing of complications [especially severe and non- acute complications]).
  • The impact of the AAP Male Circumcision policy on newborn male circumcision practices in the United States and elsewhere.
  • The extent and level of training of the workforce to sustain the availability of safe circumcision practices for newborn males and their families.

The Role of The Childbirth Educator

The decision of whether to circumcise a male newborn is frequently made early in the pregnancy and even before conception.(7-9) In a cross-sectional study of parents of 55 male infants presenting to a family practice clinic for a well-child visit, 80% of parents reported that the circumcision decision was made before a discussion occurred with the clinician about this issue. Only 4% of parents reportedly discussed circumcision with their clinician before the pregnancy.(6) This finding is substantiated by the 2009 AAP survey of 1620 members with a response rate of 57%, in which most respondents reported that parents of newborn male patients generally do not seek their pediatrician’s recommendation regarding circumcision; only 5% reported that “all” or “most” parents “are uncertain about circumcision and seek their recommendation” about the procedure. (10) There is fair evidence that parental decisions about circumcision are shaped more by family and socio- cultural influences than by discussion with medical clinicians or by parental education.(7, 11)

The AAP states that parents are entitled to factually correct, nonbiased information about circumcision and should receive this information from clinicians before conception and/or early in pregnancy, which is when they are making choices about circumcision.

I found it interesting that research indicated that most parents have most likely made a decision on newborn male circumcision prior to participating in any childbirth classes that they may be attending. I also know that talking about circumcision in a childbirth class can be a sticky, uncomfortable and emotional discussion for both attendees and educators. It may be difficult but it is important to share information on this topic in the same way that we share other information about pregnancy, labor, birth and parenting; providing resources, sources of information and avenues for additional information that the parents can access later for information.

I invite you to share your thoughts on the new AAP recommendation on newborn male circumcision and how you discuss this topic in your childbirth classes. Do you avoid speaking about it altogether because it makes you uncomfortable? How do you bring it up? What do you do when the topic becomes emotional amongst participants? Will you change what you do based on this newly released recommendation? I invite discussion but ask that you follow Science & Sensibility’s policy on participation and keep all comments polite and respectful. – SM

References

  1. American Academy of Pediatrics. Circumcision Policy Statement. Task Force on Circumcision. Pediatrics. 1999;103(3):686– 693. Reaffirmation published on 116(3): 796
  2. Centers for Disease Control and Prevention (CDC). Trends in in-hospital newborn male circumcision—United States, 1999-2010. MMWR Morb Mortal Wkly Rep. 2011;60(34): 1167–1168
  3. Warner L, Cox S, Kuklina E, et al. Updated trends in the incidence of circumcision among male newborn delivery hospitalizations in the United States, 2000-2008. Paper presented at: National HIV Prevention Conference; August 26, 2011; Atlanta, GA
  4. Overview of the Healthcare Cost and Utilization Project (HCUP). Rockville, MD: Agency for Healthcare Research and Quality; 2009. Available at: www.hcup-us. ahrq.gov/overview.jsp
  5. Nelson CP, Dunn R, Wan J, Wei JT. The increasing incidence of newborn circumcision: data from the nationwide inpatient sample. J Urol. 2005;173(3):978–981
  6. Xu F, Markowitz LE, Sternberg MR, Aral SO. Prevalence of circumcision and herpes simplex virus type 2 infection in men in the United States: the National Health and Nutrition Examination Survey (NHANES), 1999-2004. Sex Transm Dis. 2007;34(7): 479–484
  7. Tiemstra JD. Factors affecting the circumcision decision. J Am Board Fam Pract. 1999;12(1):16–20
  8. Walton RE, Ostbye T, Campbell MK. Neonatal male circumcision after delisting in Ontario. Survey of new parents. Can Fam Physician. 1997;43:1241–1247
  9. Ciesielski-Carlucci C, Milliken N, Cohen NH. Determinants of decision making for circumcision. Camb Q Healthc Ethics. 1996;5 (2):228–236
  10. American Academy of Pediatrics. Periodic Survey of Fellows: Counseling on Circumcision. Elk Grove Village, IL: American Academy of Pediatrics; 2009
  11. Binner SL, Mastrobattista JM, Day MC, Swaim LS, Monga M. Effect of parental education on decision-making about neonatal circumcision. South Med J. 2002;95 (4):457–461

American Academy of Pediatrics, Childbirth Education, Circumcision, informed Consent, Newborns, Parenting an Infant, Research , , , , , , , ,

Series: Journey to LCCE Certification: Taking A Lamaze Childbirth Education Seminar

August 23rd, 2012 by avatar

By Cara Terreri, BA, Community Manager for Lamaze International’s Giving Birth With Confidence blog

Today, an occasional series starts on Science & Sensibility, “Journey to LCCE Certification.”   We will follow Cara Terreri as she progresses on the path to become a Lamaze Certified Childbirth Educator.  Her journey starts with her Childbirth Education Seminar and will continue as she develops her own curriculum, teaches her first classes and sits for the exam.  I invite you to cheer her on and offer your support, suggestions and encouragement based on your own experiences on a similar journey.- SM

After having worked for the Lamaze International headquarters office for seven years now (marketing, writing, managing the Giving Birth with Confidence blog), it’s safe to say that I’ve drank the Kool-Aid. Slowly but surely, the words I pored over while editing became part of my own beliefs – even before I began my own birth journey. And until my last birth, I was happy to remain in my role of reaching women through writing. But my most recent, and most amazing birth (first unmedicated and truly empowering experience), ignited my desire to be more directly involved either as a doula or educator. But how? I already have a part-time job in marketing and writing (for clients in addition to Lamaze) on top of three children, a husband, and a dog – when would I find more time to devote to a budding career in birth?

While I still haven’t answered that last question, in the meantime, I attended the Passion for Birth Lamaze Childbirth Educator Seminar as the first step on the path to being a Lamaze Certified Childbirth Educator.  There was going to a workshop in my hometown, and the timing worked with my other obligations.  This workshop was going to be taught by Passion for Birth founder, Teri Shilling and  co-taught by Ann Tumblin.

At the end of day one, I was blown away. Walking into class, the first thing I noticed was how the tables and each seat were meticulously set up with loads of colorful, playful – and questionable (like, balloons and a ping pong ball?) – class materials. It was like walking into an art class! When class began, I was immediately engaged by the teaching techniques. Nearly every activity and exercise was meant to double as something that could be replicated in your own Lamaze class, including some techniques that should not be used. For example, class kicked off with the dreaded PowerPoint slide. Ann reviewed the slide, turned off the projector and asked everyone to write down the six bullet points reviewed. No one could. Why? Because PowerPoint is a horribly ineffective teaching tool! This was just one of countless “aha” moments for me over the next three days.

In spite of a nine-hour day, the instructors excelled at keeping me engaged and involved, and allowing me to learn – and successfully retain – the material. Beyond the teaching, I really enjoyed the community aspect of class. Participants (27 of them!) came from all walks of the maternal-child health arena, which allowed for interesting dialogue with differing but respectful perspectives.

The Lamaze Childbirth Educator Seminar was, in a word, inspiring. I truly believe that if I could mirror my classes using the Passion for Birth techniques I observed and learned, I would be one fantastic educator! Because Teri still actively teaches childbirth classes in her community, I also felt confident knowing that the information in her workshop is not only effective, but relevant to today’s families.

I believe that my biggest hurdles in completing certification and developing a birth business are making the time, given my other professional commitments; and overcoming my dislike of networking. In class, we discussed the need for aspiring educators to develop face-to-face relationships with individuals, groups, organizations, and businesses in the community. While I don’t think of myself as a wallflower, I’m also not a social butterfly and I’ve never liked being in a “sales-y” role. I’d love to hear from other educators who feel the same way – what did you do to overcome your aversion to marketing and promoting yourself and be able to successfully network with peers and potential students?

So what next? As a new/inexperienced educator on the pathway to certification, the next official step is to be observed in teaching. But before I can do that, I need to create my curriculum and develop a plan for connecting with my local prenatal community. After a group curriculum-building exercise on day one, I gained new respect for the work that educators put into writing, preparing, and refining a class curriculum. That being said, my strongest skills are in writing, researching, and organizing. And with the multitude of tools I acquired through the workshop, I now have the resources create a comprehensive curriculum. Stay tuned for my next update, when I share how that is going.

If you are interested in becoming a Lamaze Certified Childbirth Educator and taking a seminar, please refer to Lamaze International for more information on seminars and the pathways to certification.

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I would like to ask experienced LCCEs and Doulas;

  • How did you get started on this path?  
  • What led you to become a childbirth educator?  
  • What things did you find useful?  
  • How do you enjoy what you do?  
  • What are some of the challenges?  
  • Why did you choose Lamaze as the organization to certify with?
  • Can you share your tips from the trenches with Cara and other people who are interested in working as a childbirth educator or other birth professional?

In the next installment of the Journey to LCCE Certification Series, Cara will share how things are going as she works to develop her own curriculum.  Look for that post in the next few months. In the meantime, share your own experiences so that Cara and others on the same path can benefit – SM

Addendum

In the interest of full disclosure, I want to share that I am a trainer for the PfB organization that presented the workshop Cara attended.  I want to take a moment to share that Lamaze International has many vibrant, creative and well established programs that offer workshops all around the country, and internationally as well,  for men and women interested in becoming childbirth educators.  I encourage each individual to reach out and explore the different programs, talk to the program representatives and select the program that meets their professional needs.  Links to all the programs can be found on the Lamaze International Childbirth Education Training page -SM

About Cara Terreri

Cara began working with Lamaze two years before she became a mother. Somewhere in the process of poring over marketing copy in a Lamaze brochure and birthing her first child, she became an advocate for childbirth education. Three kids later (and a whole lot more work for Lamaze), Cara is the Site Administrator for Giving Birth with Confidence, the Lamaze blog for and by women and expectant families. Cara continues to have a strong passion for the awesome power and beauty in pregnancy and birth, and for helping women to discover their own power and ability through birth. It is her hope that through the GBWC site, women will have a place to find and offer positive support to other women who are going through the amazing journey to motherhood.

 

 

 

 

Childbirth Education, Giving Birth with Confidence, Guest Posts, Lamaze Method, Series: Journey to LCCE Certification, Uncategorized , , , , , , , , , , ,

One in Three Suffers Posttraumatic Stress Disorder: A Look Behind the Headlines

August 21st, 2012 by avatar

by David White, MD CCFP, Associate Professor, Dept of Family & Community Medicine, University of Toronto

Dr. David White reviews the study “Postpartum Post-Traumatic Stress Disorder Symptoms: The Uninvited Birth Companion“ that made news headlines earlier this month.  This post,  is part two of a two part series. (Read part one here, where Penny Simkin discussed how the media created sensationalistic headlines from the study.) Dr. White demonstrates how important it is to go to the source,  and evaluate the study design for oneself.  I appreciate Dr. White sharing his  summary and review of the research behind the study. – SM

________________

Creative Commons Image by Horia Varlan

The dramatic headline caught my eye: “One in Three Post-Partum Women Suffers PTSD Symptoms After Giving Birth: Natural Births a Major Cause of Post-Traumatic Stress, Study Suggests.”[i] As a family doctor who provides maternity care, I was both puzzled and alarmed. Where were all these women? Each year, I care for about 50 women through pregnancy, birth and post-partum. Am I failing to recognize the 16 or 17 who develop PTSD? Are they suffering without proper care?

The article claimed “Of the women who experienced partial or full post-trauma symptoms, 80 percent had gone through a natural childbirth, without any form of pain relief.”

On reflection, I became skeptical. So I read the original research paper.[ii] To their credit, the authors acknowledge, “Controversy remains whether childbirth should be included under the definition of a traumatic event that meets the criteria for post-traumatic stress disorder.” Unfortunately, their own study is so riddled with problems that it can only add confusion.

First, there is the matter of selection: 102 women agreed to participate, 89 completed the two assessments. There is no mention of how many women were approached, or how many women had births at the hospital during the study period. So there is no way to assess possible selection bias. Suspicion is warranted when a crucial methodological detail is omitted.

Then there is the issue of diagnostic criteria. The diagnosis of PTSD requires that the symptoms last more than one month and cause significant impairment in social, occupational, or other important areas of functioning (both DSM-IV-TR and ICD-10). The researchers administered their survey instrument within a few days of birth and again at one month post-partum. The latter just barely meets the criterion for duration. And could there be a cuing effect from administering an initial questionnaire within a few days of birth?

The findings report “full PTSD”, “partial PTSD” and “PTSD symptomatology”. However the tool used by the researchers, a self-administered questionnaire called Posttraumatic Stress Diagnostic Scale (PDS®), indicates only whether someone meets the DSM diagnostic criteria or not.[iii]

Now to the analysis, which piles questionable analysis onto this shaky diagnostic platform.  ”For processing the data we needed to select a group large enough to be statistically significant but homogenous enough to offer meaningful results.” So they lump together those missing one or two symptoms with those who actually have PTSD. The justification for this methodological legerdemain is that others have done it. They reference a study by Stein, Walker et al[iv] that is considerably more careful. It differs substantially in that it used telephone interviews, a different assessment tool and analyzed full and partial PTSD separately.

The results are reported in a way that even makes it difficult to determine what group they are analyzing. Is it the “full PTSD” (3) + “Partial PTSD” (7) = 10? No, it is 3 (“full) + 4 (“missing 1 or 2 symptoms”) =7. But look at Table 2, showing 5 in the row labeled “PTSD”. Table 3 has it back up to 7.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

The terminology for the groups seems variable. At times it is “PTSD group”, at others it is “women with PTSD symptoms” and the Tables simply apply the label “PTSD.”

Terminology problems continue: “control group” is used regularly to denote those who did not manifest PTSD symptoms, an odd usage for a study in which there is no intervention or randomization.

While studying Table 2, check out the mode of delivery: Natural 45, Cesarean 42 (20 elective), Instrumental 2. That indicates a Cesarean section rate of 47%. Could this be a biased sample?

More fun with numbers: the text reports that 80% of women with PTSD symptoms reported feeling very uncomfortable in the undressed state: Table 3 shows 3 out of 7 reporting this.

Table source: http://www.ima.org.il/imaj/ar12jun-02.pdf

And the figure that 80% of those with PTSD had gone through natural labour? It appears to come from Table 2, showing that 4 out of 5 women in the “PTSD” group had “Natural” childbirth. I scoured the tables and text in vain to find why the PTSD group is 5 in Table 2 and 7 in Table 3.

The definitions of mode of delivery should be more precise. The authors describe natural births as “non-interventional” but we really don’t know about analgesia use in this group. This matters, because they found “A significantly smaller number of women who developed PTSD symptoms received analgesia during delivery compared to the control group.” For this to make sense, it is essential distinguish vaginal births with and without effective pain relief.

This definitional and analytic fog leads to the conclusion that a lot of women have PTSD symptoms following birth. The authors don’t trouble themselves to explain why their numbers don’t square with the excellent community-prevalence study in the references, in which “The estimated prevalence of full PTSD was 2.7% for women and 1.2% for men. The prevalence of partial PTSD was 3.4% for women and 0.3% for men.”4

This study brings discredit to an admittedly difficult field, one in which researchers must address the criticism of medicalizing normal life experiences.

I’m a GP, not an expert in PTSD. But I think I can recognize “significant impairment in social, occupational, or other important areas of functioning.” The important issue for practitioners is whether we identify and help those at risk and who need assistance. Screening for post-partum depression is important. Adding a simple open-ended question such as “tell me about your birth” is likely to yield much more benefit in practice than this study.

I appreciate Dr. White’s analysis and wonder how many other professionals bothered to examine the research behind the headlines, in order to come to their own conclusions about the study design, assumptions and findings.  What do you think of this research?  Did you understand the terms being used or how the results were determined?  Do you think any journalists who wrote the sensational headlines took the time to look at the study themselves?  It is always important to be a critical thinker for yourself, examine the information and ask questions.  Sometimes, the research does not match up with the front page news, or the study may not have been well-designed.  Please share your thoughts, questions and comments here, with Dr. White, Penny Simkin, myself and Science & Sensibility readers. – SM

References

[i] American Friends of Tel Aviv University (2012, August 8). One in three post-partum women suffers PTSD symptoms after giving birth: Natural births a major cause of post-traumatic stress, study suggests. ScienceDaily. Retrieved August 14, 2012, from http://www.sciencedaily.com­ /releases/2012/08/120808121949.htm

[ii] Postpartum Post-Traumatic Stress Disorder symptoms: The Uninvited Birth Companion, Inbal Shlomi Polachek, Liat Huller Harari, Micha Baum, Rael D. Strous: IMAJ 2012; 14: 347–353, accessed at http://www.ima.org.il/imaj/ar12jun-02.pdf

[iii] The actual PDS® tool can be downloaded at (for a price): http://psychcorp.pearsonassessments.com/HAIWEB/Cultures/en-us/Productdetail.htm?Pid=PAg510&Mode=summary

A useful review of the PDS® is at: http://occmed.oxfordjournals.org/content/58/5/379.full.pdf+html

[iv] Stein, M. B., Walker, J. R., Hazen, A. L., & Forde, D. R. (1997). Full and partial posttraumatic stress disorder: Findings from a community survey. The American Journal of Psychiatry, 154(8), 1114-9. Retrieved from http://search.proquest.com/docview/220491145?accountid=14771

A useful overview of PTSD at

http://www.ptsd.va.gov/professional/pages/ptsd-overview.asp

A review of research issues in PTSD following childbirth:

Pauline Slade: Towards a conceptual framework for understanding post-traumatic stress symptoms following childbirth and implications for further research. Journal of Psychosomatic Obstetrics & Gynecology (January 2006), 27 (2), pg. 99-105, accessed at http://resolver.scholarsportal.info.myaccess.library.utoronto.ca/resolve/0167482x/v27i0002/99_tacffucaiffr

About David White

David White is a community-based family doctor in Toronto and Associate Professor of Family & Community Medicine at the University of Toronto. (DFCM, U of T). He currently serves as the Interim Director of UTOPIAN, the practice-based research network comprising all teaching sites affiliated with the Department of Family & Community Medicine at the University of Toronto.

He obtained his medical degree and completed residency in Family Medicine at the University of Toronto. He began clinical practice in 1977 at Sioux Lookout, working at the Zone Hospital and flying into remote First Nations villages in northwestern Ontario. In this setting he began a long-term affiliation with U of T. On returning to Toronto in 1980, he joined the Family Medicine Teaching Unit at Toronto Western Hospital, and later moved to Mount Sinai Hospital. In 1999 he was appointed Chief of Family & Community Medicine at North York General Hospital (NYGH).

His current academic activities include clinical teaching in his community office and in obstetrics, research in health care delivery, and mentoring of junior faculty. Contact Dr. White

Childbirth Education, Depression, Evidence Based Medicine, Guest Posts, Maternal Mental Health, Maternity Care, New Research, Perinatal Mood Disorders, Postpartum Depression, PTSD, Research, Uncategorized , , , , , , , , , , , , , , ,