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On Our Radar

News, new research and interesting tidbits…

 

Saving Pregnant Women One Device at a Time
Of course the blogosphere lit up last week with the release of yet another study about a piece of technology pegged to “save” women from the dangers of childbirth.  This new device, a compilation of MRI screening and computer software entitled, Predibirth, was designed Dr. Olivier Ami and colleagues at the Antoine Béclères Hospital at Université Paris Sud, France.  The promise of being able to detect whether or not a fetus will successfully navigate the confines of his mother’s pelvis during labor and delivery come from a study including 24 pregnant women upon whom Predibirth’s technology was employed.  Interestingly, of those 24 women, a little over half—13—ultimately underwent a cesarean delivery.

The creation of such a device, I think, is based on the age-old anthropological understanding we have of pelvic tight quarters.  In short, when humans began walking upright some eons ago, our pelvic structures had to change to maintain our balance—thus creating a tighter space through which the large-headed fetus must pass during the birth process.  If you want an in-depth read about this process, go here.

That being said, I’m not sure how well the Predibirth takes into account factors such as hormonal fluctuations that influence pelvic diameters during the labor process and labor and birth positions which work to expand (or reduce) the pelvic inlet and outlet.  The other elephant in the room for this topic is the questionable effect of the magnetic fields and radiofrequencies associated with this type of imaging upon the fetus—for which very little research data is available.

Web-based Buzz on Labor Inductions
With the Lamaze International webinar on labor induction happening next week ( December 12), you may find interest in referring your patients and clients to the related discussion on Henci Goer’s, Ask Henci forum, in which induction for a woman aged 40 or above is addressed.

 

Forceps = Safe(?)
Reuter’s
recently covered a new study released in the American College of Obstetricians and Gynecologists’ Green Journal,  suggesting that forceps-assisted delivery is safer for the neonate, when looking at long term neurological outcomes, compared to vacuum extraction or cesarean delivery.  Data was pulled from over 1 million births that occurred in New York City between 1995 – 2003, with 122,507 vaginal surgical births ultimately analyzed.  Interestingly, births included in the study went down to 34 weeks gestation for nulliparous women delivering singleton babies between 500-5,000g, and excluded breech births, birth weights greater than 5,000g and cases of placenta previa.  Significant outcomes were considered to be: neonatal subdural hemorrhage, intraventricular hemorrhage, seizures, scalp laceration or cephalohematoma, fracture, facial nerve palsy, brachial plexus injury, or 5-minute Apgar score of less than 7.

A remark I read from a seasoned obstetrician and Director of Maternal Fetal Medicine in a Canadian facility suggested that these outcomes may be congruent with the limited use of forceps by (older and more experienced) clinicians who were once heavily trained in their use.  As forceps skills seem to have fallen out of the repertoire of many newer OBs (perhaps a “young” obstetrician will write in and correct any inaccuracy in this statement, if it exists) forceps usage in this study may have occurred in particularly adept hands while vacuum extraction and cesarean delivery were distributed more evenly.

Regardless, the findings of this large study are interesting—if not a bit chilling.  Last time I spoke with a woman who endured a forceps delivery, her description was a ghastly one, in exchange for a 4th degree perineal tear and a healthy baby.  What are your thoughts??? (HINT:  this is an invitation for YOU, the reader, to weigh in on this.)

 

Down into the Water, Baby.
University of Minnesota  and Twin Cities hospitals have been adding water birth to their compendium of birthing options with Amplatz Children’s Hospital being the latest to get on board.

Transform
Childbirth Connection has recently launched a new video on their Transforming Maternity Care Site, encouraging all of us to join in the process of ensuring childbearing women are cared for using best practices and the most up-to-date evidence.

 

What’s on YOUR radar?
Feel free to share (respectfully) what you’ve been reading with interest lately.

 

 

Posted by:  Kimmelin Hull, PA, LCCE, FACCE

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  1. avatar
    Melinda Delisle
    December 8th, 2011 at 20:10 | #1

    I am responding to the invitation to comment on the use of forceps. I have heard some experiences that support the study authors’ conclusion that forceps, when used judiciously in experienced hands, is safer than vacuum extraction. Some years ago, I had a student couple who had a very long second stage, and was getting extremely tired. In addition, baby had not progressed for some time. This couple was lucky to have an OB skilled in forceps, and she offered them the option of doing a high forceps to move the baby down, then removed them and had mom push the baby out on her own for a normal birth. This was all accomplished with only some bruising on baby, and a few small tears on mom.

    We have all heard horrow stories about forceps deliveries. I could also say that for just about every other possible birth intervention and non-intervention. Yes, I have heard descriptions of traumatizing unmedicated births, as well. How a birth, or an intervention at a birth, turns out seems to have a lot to do with preparation and control (in this case, of both the parents and the practitioner).

    My understanding has always been that forceps in the hands of an experienced user carries less risk than vacuum extraction. Perhaps it is because it is harder to sense exactly what is going on with the vacuum? Of course, it is entirely possible that the difference in safety noticed between forceps and vacuum is entirely due to the skill of the practitioner. I once observed a very careful vacuum extraction that seemed to just “give a little help” without much negative effect on baby. Perhaps if vacuum extraction were practiced with as much patience and skill as the forceps births, the differences would not be so pronounced.

  2. December 8th, 2011 at 21:41 | #2

    What concerns me about the Predibirth is the static nature of the evaluation it provides. In contrast, one of the most impressive demonstrations I remember from my early days in the birthing field was a lecture during which the speaker showed us 2 red rubber rain boots at the beginning. One was hers and the other belonged to her 8 year old daughter. Initially, she had no problem fitting her foot into her own boot, but her daughter’s boot was clearly too small for her foot. But, by the end of the hour, she had slowly and gently worked her entire foot into the smaller boot. The foot – like the pelvis and the fetal skull – is made up of a number of bones connected by elastic tissue. These bones can be realigned when this connective tissue is warmed up.

  3. avatar
    JudyC
    December 10th, 2011 at 22:38 | #3

    About the Predibirth: what can one say that has not been said about the CTG. Technology with no evidence base which will cause more CS and cost the country and consumers more dollars. Bound to be heaps of side effects for mum and baby from the MRI.
    About the forceps, the study should have been with low risk women/babies at term. It doesn’t account for operator experience as mentioned, nor does it account for the reasons for caesarians such as fetal distress. I am sure there is more but haven’t read it yet. And, as already mentioned it doesn’t mention the trauma to the mother.

  4. December 11th, 2011 at 10:05 | #4

    The following is a comment submitted anonymously from one of our readers. I thank her, whole-heartedly, for sharing this story:

    “My forceps delivery was excruciating. I was unmedicated and screaming for the OB to stop. Looking back, I had only been in labor for a few hours, and it was progressing well, but it was 3:00 on a Sunday night, and the OB was eager to go home and sleep. I ended up with deep tears and stitches all the way to my rectum, crying every time I had a bowel movement. I felt deeply violated, and that affected my relationship both to my husband (for not protecting me), and my baby that I associated with such misery. I never was able to have orgasm in the same way because my vaginal wall was scarred. Now, years later, I have deep hip and thigh pain on the side of the cut that I attribute to the serious cutting and tearing I went through.”

  5. December 12th, 2011 at 19:33 | #5

    My appreciation to the reader’s courage to reach out and share. I would like to offer that these deeply intrusive physical interventions and the subsequent distress caused by them merits looking at posttraumatic stress disorder secondary to childbirth that unfortunately was not recognized, nor treated. A therapist or care provider trained in PTSD in her area might be of tremendous value. Also, the website http://www.solaceformothers.org has an online support group and resources that might be beneficial.

    My heart broke when I read this, however it is an un-recognized diagnosis so often.

  6. avatar
    Emalee Danforth, CNM
    December 13th, 2011 at 19:08 | #6

    There was a great article in the New Yorker by Atul Gawande a couple years ago about the increasing use of cesarean section being due in part to the easy reproduction of the skill. Teaching and performing cesarean surgery is quite similar from one delivery to the next, whereas the use of vacuums and particulary forceps is a truly advanced skill with greater potential variation in outcome. Many doctors, midwives and birthing women, especially in an age when birthing one or two children is the norm, will opt for the more predictable intervention when the birth is difficult.

    I for one would like to see forceps re-employed in delivery as a way to increase the opportunity for vaginal birth for some women. Using forceps rather than C/S for second stage arrest or true maternal exhaustion can make a primip into a multip, rather than a primip into a future repeat C/S. I think this would be especially useful for women who think they may have more than two children.

    The primary problem with this is that most training institutions no longer teach forceps, or even those OBs who might initially be trained in residency end up working at hospitals to do not encourage the maintenance of those skills. I hope that there will be a reverse in this trend, though so far I hear little word of it even with the growing awareness that the continually climbing C/S rate is not benefiting anyone.

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