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Why Pediatricians Fear Waterbirth – Barbara Harper Reviews the Research on Waterbirth Safety

March 27th, 2014 by avatar

By Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE

On March 20th, 2014, the American Academy of Pediatrics Committee on Fetus and Newborn and the American College of Obstetricians and Gynecologists Committee on Obstetric Practice released a joint clinical report entitled Immersion in Water During Labor and Delivery in the journal Pediatrics.  While not substantially different than previous statements released by the AAP, quite a stir was created.  Today, Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE, of Waterbirth International provides a research summary that supports waterbirth as a safe and reasonable option for mothers and babies.  Barbara Harper has been researching and teaching about safe waterbirth protocols for several decades and is considered an expert on the practice.  I am glad Barbara was able to share her knowledge with Science & Sensibility readers all the way from China, where she just finished another waterbirth workshop for Chinese hospital programs. – Sharon Muza, Community Manager, Science & Sensibility

In a candle lit room in Santa Barbara, California, in October of 1984, my second baby came swimming out of me in a homemade tub at the foot of my bed.  As soon as he was on my chest, I turned to my midwife and exclaimed, “We have got to tell women how easy this is!”

Earlier that month I sat in my obstetrician’s office with my husband discussing our plans, which had changed from an unmedicated hospital birth to a home waterbirth.  The OB shook with anger and accused me of potential child abuse, stating that if I did anything so selfish, stupid and reprehensible he would have no choice but to report me to the Department of Child Welfare.  I never stepped foot in his office again, but I did call his office and share the news of my successful home waterbirth.

Before setting up my homemade 300 gallon tub, I had researched through medical libraries for any published data on waterbirth, but could not find a single article, until a librarian called me and said she was mailing an article that came in from a French medical journal.  The only problem was that it was quite old. It had been published in 1803!  The next article would not come out until 1983, the very year that I was searching.[i]

The objections to waterbirth have always come from pediatricians, some with vehement opinions similar to those expressed by my former obstetrician.  The current opinion of the American Academy of Pediatrics Committee on Fetus and Newborn is nothing new.  It was issued in 2005, restated in November 2012 and it is showing up again now.  There are many obstetricians and pediatricians who are perplexed and angered over the issuing of this statement.  Especially, doctors like Duncan Neilson of the Legacy Health Systems in Portland, Oregon. [ii]  Dr. Neilson is chair of the Perinatology Department and VP of both Women’s Services and Surgical Services at the Legacy Emanuel Hospital in downtown Portland.

In 2006, Dr. Neilson did an independent review of all the literature on waterbirth, including in obstetric, nursing, midwifery and pediatric journals. He concluded, “there is no credible evidence that waterbirth is a potential harm for either mothers or babies.” He reported that the majority of the waterbirth studies have been done and published in Europe with large numbers in retrospective analyses.[iii], [iv], [v], [vi] What has been published in the US is largely anecdotal and has involved very small numbers of case reports from home birth or birth center transfers into NICU. [vii], [viii], [ix] Dr. Neilson even pointed out that Jerold Lucy, M.D., the editor of the American Journal of Pediatrics put the following commentary in a sidebar in a 2002 issue of this respected research journal, “I’ve always considered underwater birth a bad joke, useless and a fad, which was so idiotic that it would go away. It hasn’t! It should!” [x]

The publication of such prejudicial statements makes it difficult for pediatricians to look at the European research without skepticism. Dr. Neilson concluded that American doctors were not getting the complete picture.  After this comprehensive review of waterbirth literature, Dr. Neilson believed that waterbirth is a safe birth option that provides other positive obstetric outcomes. He helped set up a Legacy research committee and the parameters for waterbirth selection were created, using current recommended selection criteria followed by other Portland hospitals offering waterbirth.

Upon Dr. Neilson’s recommendations, the entire Legacy system has adopted waterbirth. The most recent hospital to begin waterbirth was Good Samaritan in Portland, which conducted their first waterbirth in February of 2014.

Women seeking waterbirth and undisturbed birth have usually considered the consequences of interference with the birth process on the development, neurology and epigenetics of the baby.  The goal of the pediatrician and the goal of mothers who choose undisturbed birth is really exactly the same.  The use of warm water immersion aids and assists the mother in feeling calm, relaxed, nurtured, protected, and in control, with the ability to easily move as her body and her baby dictate.  From the mother’s perspective, using water becomes the best way to enhance the natural process without any evidence of increased risk.  A joint statement of the Royal College of Obstetricians, the Royal College of Midwives and the National Childbirth Trust in 2006 agreed.  They sat down together to explore what would increase the normalcy of birth without increasing risk and the very first agreement was that access to water for labor and birth would accomplish that task.[xi]

Framework for Maternity Services Protocol

The UK National Health Service and the National Childbirth Trusts formed a Framework for Maternity Services that includes the following statements:

  • Women have a choice of methods of pain relief during labour, including non pharmacological options.
  • All staff must have up-to-date skills and knowledge to support women who choose to labour without pharmacological intervention, including the use of birthing pools.
  • Wherever possible women should be allowed access to a birthing pool in all facilities, with staff competent in facilitating waterbirths.

There is a concerted effort to educate midwives and physicians in all hospitals in the UK on the proper uses of birthing pools and safe waterbirth practices. [xii]

The baby benefits equally from an unmedicated mother who labors in water and has a full complement of natural brain oxytocin, endorphins and catecholamines flowing through her blood supply. The mother’s relaxed state aids his physiologic imperative to be born.  The descent and birth of the baby is easier when the mother can move into any upright position where she can control her own perineum, ease the baby out and allow the baby to express its primitive reflexes without anyone actually touching the baby’s head.  The birth process is restored to its essential mammalian nature.

The true belief in the safety of waterbirth is a complete understanding of the mechanisms which prevent the baby from initiating respirations while it is still submerged in the water as the head is born and then after the full body has been expelled.  When Paul Johnson, M.D., of Oxford University, explained these mechanisms at the First World Congress on Waterbirth at Wimbledon Hall, in 1995, there was a collective nod of understanding from more than 1100 participants.  With this information, more waterbirth practices were established all over the UK and Europe.  Dr. Johnson went on to publish his explanations in the British Medical Journal in 1996.[xiii]

Johnson’s 1996 review of respiratory physiology suggests that, in a non-stressed fetus, it is unlikely that breathing will commence in the short time that the baby’s head is underwater. Johnson sees no reason to prevent this option being offered to women.

A Cochrane Review[xiv] of women laboring in water or having a waterbirth gives no evidence of increased adverse affects to the fetus, neonate, or woman.

American Academy of Pediatrics’ Misleading Committee Commentary

Despite this review, the 2005 American Academy of Pediatrics committee on Fetus and Newborn commentary raised concerns regarding the safety of hospital waterbirth. The committee commentary was not a study itself, but rather an opinion generated upon the review of research.

A review of the commentary and the sources cited, revealed irregularities. The commentary often paraphrased text from the references, redacted crucial words and sentences from the texts, and sometimes re-interpreted the authors’ conclusions.  Anecdotal case studies were referenced without being part of an empirical study.

Example:

Committee text: “All mothers used water immersion during labor, but only a limited and unspecified number of births occurred under water.” 2 infants required positive pressure support, but little additional data were provided.

From cited reference: 100 births occurred under water. Only 2 infants out of 100 needed suction of the upper respiratory tract and a short period of manual ventilatory support. [xv]

Committee text: “Alderdice et al performed a retrospective survey of 4494 underwater deliveries by midwives in England and Wales. They reported 12 stillbirths or neonatal deaths”

From cited reference: “Twelve babies who died after their mothers laboured or gave birth in water, or both, in 1992 and 1993 were reported. None of these cases was reported to be directly related to labour or birth in water.”[xvi]

Committee text: “In a subsequent survey of 4032 underwater births in England and Wales, the perinatal mortality rate was 1.2 per 1000 live births (95% confidence interval: 0.4–2.9) and the rate of admission to a special care nursery was 8.4 per 1000 live births (95% CI: 5.8–11.8) The author of this survey suggested that these rates may be higher than expected for a term, low-risk, vaginally delivered population.”

From cited reference: “4032 deliveries (0.6% of all deliveries) in England and Wales occurred in water. Perinatal mortality was 1.2/1000 (95% confidence interval 0.4 to 2.9) live births; 8.4/1000 (THEY LEFT OUT THE 2ND CI 5.8 to 11.8) live births were admitted for special care. No deaths were directly attributable to delivery in water….”

The reference also provides that the UK perinatal mortality and special care admission rates for conventional birth ranged from 0.8 to 4.6/1000 for perinatal mortality, and 9.2 to 64/1000 for special care admission—significantly higher than those utilizing waterbirth.

Nowhere in the cited reference can the statement be found that “these rates may be higher than expected for a term, low-risk, vaginally delivered population.” In fact, the study results reflect no effect on fetal outcomes and certainly not an increase in fetal mortality and special-care admissions.[xvii]

Finally, the committee commentary acknowledges the findings of the Geissbühler study[xviii]:

“A prospective observational study compared underwater birth with births using Maia-birthing stools and beds. Although underwater birth was associated with a decreased need for episiotomies and pain medication as well as higher APGAR scores and less cord blood acidosis in newborns, the birthing method was determined by maternal preference, and potential confounding variables were not analyzed.”

The committee does not elaborate on which confounding variables they feel are of concern. It appears this supportive study was automatically discredited without a reason.

While the American Academy of Pediatrics is committed to patient safety and evidence-based medicine, this commentary’s conclusions that hospital waterbirths are of greater risk than other hospital birth options for low risk and carefully screened patients are completely unfounded.

Waterbirth Studies

In 1998, I copied all the medical journal articles about waterbirth that had been published to date and sent the labeled and categorized studies to the Practice Committee of ACOG.  In the cover letter accompanying the rather weighty binders, I asked the Committee if they would review the literature and issue an opinion about actual birth in water.  The letter that arrived a few months later from Stanley Zinberg, MD, then head of the Practice Committee, stated, “until there are randomized controlled trials of large numbers of women undergoing birth in water, published in peer reviewed journals in the US, the committee is not able to issue an opinion.”

Randomized studies of waterbirth are difficult to design and implement for one major reason: women want to choose their own method of delivery and should be able to change their mind at any point of labor. Because of this, it is difficult to design a randomized controlled study without crossover between control and study group. A 2005 randomized trial which was set up in a Shanghai, China hospital was abandoned because the hospital director realized after only 45 births that the study was unethical.  The original goal was to study 500 births, but the results of those first 45 were so good they abandoned the research project, yet continued their commitment to offering waterbirth to any woman who wanted one.  The latest communication from the Changning Hospital in Shanghai indicates that they have facilitated well over 5000 waterbirths since then.

Randomized controlled trials may be few, however, many retrospective and prospective case-controlled studies have been performed, primarily in European countries with a long history of waterbirth. In reviewing published studies, a comparison of the safety of waterbirth to conventional births among low-risk patients can be made. The evidence reveals the option of waterbirth is safe and, looking at certain parameters, has superior outcomes.

European Research

Highlights of the literature:

  • APGAR scores were found to be unaffected by water birth.[xix] One study found a decrease in 1-minute APGAR scores exclusively in a subgroup of women who were in water after membranes were ruptured longer than 24 hours.[xx]
  • A consensus of researchers found that waterbirth had either no effect or reduced cesarean section and operative delivery rates.[xxi]
  • No studies have found an effect on rates of maternal or fetal infection.[xxii]
  • Statistically, waterbirth leads to increased relaxation and maternal satisfaction, decreased perineal trauma, decreased pain and use of pharmaceuticals, and decreased labor time.[xxiii]

Cochrane Collaboration Findings

A Cochrane Collaboration review of waterbirth in three randomized controlled studies (RCTs) show no research that demonstrates adverse effects to the fetus or neonate.[xxiv] Other studies that were not RCTs were included in the conclusion:

“There is no evidence of increased adverse affects to the fetus or neonate or woman from laboring in water or waterbirth. However, the studies are variable and considerable heterogeneity was detected for some outcomes. Further research is needed.”

Conclusion

Waterbirth is an option for birth all over the world. World-renowned hospitals, as well as small hospitals and birthing centers, offer waterbirth as an option to low risk patients. Though some members of the American Academy of Pediatrics and American College of Obstetricians and Gynecologists feel otherwise, the Cochrane Review and many other studies find no data that supports safety concerns over waterbirth.

Women increasingly are seeking settings for birth and providers that honor their ability to birth without intervention. Waterbirth increases their chances of attaining the goal of a calm intervention free birth.

Physicians and midwives are skilled providers who are being trained in waterbirth techniques, safety concerns, the ability to handle complications and infection control procedures.

Carefully managed, waterbirth is both an attractive and low-risk birth option that can provide healthy patients with non-pharmacological options in hospital facilities while not compromising their safety.

In contrast to Dr. Lucy’s statement, waterbirth is not a fad and it is not going away, especially when it is mandated as an available option for all women in the UK and practiced worldwide in over ninety countries. The first hospital that began a waterbirth practice in 1991, Monadnock Community Hospital in Peterborough, New Hampshire, is still offering this service to low risk women 23 years later.  They have been joined since then by just under 10% of all US hospitals including large teaching universities and the majority of all free standing birth centers.  Hospitals have invested in equipment, staff training and are collating data to present to the medical community.  Dr. Duncan Neilson in Portland, Oregon is working on a summary of the data on over 800 waterbirths at only one hospital in the Legacy Health System.

I have dedicated my entire life to changing the way we welcome babies into the world since that October night in 1984, when I told my midwife that we have to tell women about the wonders of waterbirth. Since that night, I have traversed the planet to 55 countries and helped hundreds of hospitals start waterbirth practices.  Birth in water is safe, economical, effective and is here to stay, despite the AAP’s recent statement.

References


[i] Odent, M.,1983. The Lancet, December 24/31, p 1476

[ii] Medical Plaza Bldg. 300 N. Graham St., Suite 100 Portland, OR 97227, (503) 413-3622 dneilson@lhs.org

[iii] Alderdice, F., R., Mary, Marchant, S., Ashiurst, H., Hughes, P., Gerridge, G., and Garcia, J. (April 1995). Labour and birth in water in England and Wales. British Journal of Medicine, 310: 837.

[iv] Geissbuehler, V., Stein, S., & Eberhard, J. (2004). Waterbirths compared with landbirths: An observational study of nine years. Journal of Perinatal Medicine, 32, 308-314

[v] Gilbert, Ruth E., Tookey, Pat A. (1999) Perinatal mortality and morbidity among babies delivered in water: surveillance study and postal survey. British Medical Journal ;319:483-487 (21 August)

[vi] Zanetti-Dallenback, R., Lapaire, O., Maertens, A., Frei, F., Holzgreve, W., & Hoslit, I. (2006). Waterbirth:, more than a trendy alternative: A prospective, observational study. Archives of Gynecology and Obstetrics, 274, 355-365

[vii] Bowden, K., Kessler, D., Pinette, M., Wilson, D Underwater Birth: Missing the Evidence or Missing the Point? Pediatrics, Oct 2003; 112: 972 – 973.

[viii] Nguyen S, Kuschel C, Reele R, Spooner C. Water birth—a near –drowning experience. Pediatrics. 2002; 110:411-413

[ix] Schroeter, K., (2004). Waterbirths: A naked emperor (commentary) American Journal of Pediatrics, 114 (3) Sept, 855-858

[x] Neilson, Duncan  Presentation at the Gentle Birth World Congress, Portland, Oregon, Setpember 27, 2007

[xi] RCOG/The Royal College of Midwives (2006) Joint Statement no 1: Immersion in Water During Labour and Birth. London: RCOG

[xii] Johnson P (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynaecology 103(3): 202-8

[xiii] ibid

[xiv] Cluett, E.R., Burns, E. Water in Labor and Birth(review) Cochrane Database of Systematic Reviews 2012, Issue 2 Art. No.: CD000111.DOI: 10:1002/14651858.CD000111.pub3

[xv] Odent, M.,1983. The Lancet, December 24/31, p 1476

[xvi] Alderdice, F. et.al.1995. British Journal of Midwifery 3(7), 375-382

[xvii] ibid

[xviii] Geissbühler V, Eberhard J, 2000

[xix] Aird, et al, 1997; Cammu, et al, 1994; Eriksson, et al, 1996; Lenstrup et al, 1987; Ohlsson et al, 2001, Otigbah et al, 2000; Rush, et al, 1996, Waldenstrom & Nilsson, 1992.

[xx] Waldenstrom & Nillson, 1992

[xxi] Aird, Luckas, Buckett, & Bousfield, 1997; Cammu et al, 1994; Cluett, Pickering, Getliffe, & St. George, 2004; Eckert, Turnbull, & MacLennon, 2001; Lenstrup, et al, 1987, Ohlsson, et al, 2001, Rush, et al, 1996)

[xxii] Cammu, Clasen, Wettere, & Derde, 1994; Eriksson, Lafors, Mattson, & Fall, 1996; Eldering, 2005; Lenstrup, Schantz, Feder, Rosene, & Hertel, 1987; Geissbuhler & Eberhard, 2000; Rush, et al, 1996; Schorn, McAllister, & Blanco, 1993, Thöni A, Mussner K, Ploner F, 2010; Waldenstrom & Nilsson, 1992.

[xxiii] Mackey,2001; Benfield et al, 2001

[xxiv] Cluett, E.R., Burns, E. 2012

About Barbara Harper

© Barbara Harper

© Barbara Harper

Barbara Harper, RN, CLD, CCE, DEM, CKC, CCCE,  loves babies and has been a childbirth reform activist since her first day at nursing school over 42 years ago. She is an internationally recognized expert on waterbirth, a published author and she founded Waterbirth International in 1988, with one goal in mind – to insure that waterbirth is an available option for all women. During the past four decades, Barbara has worked as a pediatric nurse, a childbirth educator, home birth midwife, midwifery and doula instructor and has used her vast experience to develop unique seminars which she teaches within hospitals, nursing schools, midwifery and medical schools and community groups worldwide. She was recognized in 2002 by Lamaze International for her contributions in promoting normal birth on an international level. Her best selling book and DVD, ‘Gentle Birth Choices’ book has been translated into 9 languages so far. Her next book ‘Birth, Bath & Beyond: A Practical Guide for Parents and Providers,’ will be ready for publication at the end of 2014. Barbara has dedicated her life to changing the way we welcome babies into the world. She considers her greatest achievement, though, her three adult children, two of whom were born at home in water. She lives in Boca Raton, Florida, where she is active in her Jewish community as a volunteer and as a local midwifery and doula mentor and teacher. Barbara can be reached through her website, Waterbirth International.

ACOG, American Academy of Pediatrics, Babies, Evidence Based Medicine, Guest Posts, Home Birth, informed Consent, Midwifery, New Research, Newborns, Research, Second Stage, Uncategorized , , , , , , , ,

Evidence for the Vitamin K Shot in Newborns – Exclusive Q&A with Rebecca Dekker on her New Research

March 18th, 2014 by avatar

 Evidence Based Birth , a popular blog written by occasional Science & Sensibility contributor Rebecca Dekker, PhD, RN, APRN, has just published a new article, “Evidence for the Vitamin K Shot in Newborns that examines Vitamin K deficiency bleeding (VKDB)- a rare but serious consequence of insufficient Vitamin K in a newborn or infant that can be prevented by administering an injection of Vitamin K at birth.  I had the opportunity to ask Rebecca some questions about her research into the evidence and some of her conclusions after writing her review. – Sharon Muza, Science & Sensibility Community Manager.

Note:  Evidence Based Birth website may be temporarily unavailable due to high volume loads on their server.  Please be patient with the site, I know the EBB team is working on it.

Sharon Muza: Why was the topic of Vitamin K an important one for you to cover and why now?

Rebecca Dekker: Well, I try to pick my articles based on what my audience wants me to cover. I heard over and over again that people were confused and concerned about Vitamin K. A lot of parents told me they weren’t sure if they should consent to the injection or not. There was just so much confusion, and even I didn’t understand what the Vitamin K shot was all about. I didn’t know what I was going to do at the birth of my own child last December. It seemed like there was a need for an evidence-based blog article to clear up all the confusion once and for all.

So as usual, I dove in head first into the research, with no up-front biases one way or the other. I just wanted to get to the bottom of this mess!

SM: Were you surprised by what the current research showed about the rates of VKDB, and the apparent significant protection offered by the Vitamin K shot?

RD: I knew that Vitamin K deficiency bleeding (VKDB) was rare, but I didn’t realize—until I started reading the research—how effective the shot is at basically eliminating this life-threatening problem.

I was surprised by how low the rates of VKDB are in European studies, and by how VKDB is more common in Asian populations. I was also surprised by the fact that we don’t track VKDB in the U.S. and we have no idea how many infants in the U.S. would develop VKDB if we stopped giving the shot.

The number of infants in Tennessee last year who developed VKDB is very concerning to me. They had 5 cases of life-threatening VKDB in Nashville during an 8 month period—7 if you count the infants who were found to have severe Vitamin K deficiencies but didn’t bleed. None of these infants received Vitamin K, mostly because their parents thought it was unnecessary and weren’t accurately informed about the risks of declining the shot.

So the Tennessee situation makes me worry that maybe there is something about our diets in America, or our genetics, that makes us at higher risk for VKDB if we decline the Vitamin K shot for our newborns. But we don’t know our underlying risk, because we don’t track these numbers on a nationwide scale.

SM: What was the most surprising finding to you in writing this article?

RD: That the research on Vitamin K for newborns goes back as far as the 1930’s and 1940’s… that we have literally eight or nine decades of research backing up the use of Vitamin K for newborns. I was under the impression that we were using the shot without any supporting evidence. That turned out not to be the case.

I even forked out the money to buy the landmark 1944 study in which a Swedish researcher gave Vitamin K to more than 13,000 newborns. He observed a drastic decrease in deaths from bleeding during the first week of life. I am usually able to read all of my articles through my various subscriptions, but this article was so old the only way I could read it was to buy it. It was pretty eye-opening. There was some really good research going on back then on Vitamin K. About 15 years later, the American Academy of Pediatrics finally recommended giving Vitamin K at birth. We know that it takes about 15 years for research to make its way into practice. It looks like the same was true back then.

But there is this misconception that “Vitamin K doesn’t have any evidence supporting its use,” and I found that belief is totally untrue. There is a lot of evidence out there. People have just forgotten about it or not realized it was there.

SM: What was the most interesting finding to you in writing this article?

RD: That the two main risk factors for late Vitamin K deficiency bleeding (the most dangerous kind of VKDB that usually involves brain bleeding) are exclusive breastfeeding and not giving the Vitamin K shot.

Parents who have been declining the shot are the ones who are probably exclusively breastfeeding. So their infants are at highest risk for VKDB.

SM: What do you think is the biggest misconception around the Vitamin K shot?

RD: How do I choose which one? There are so many misconceptions and myths. I’ve heard them all. The scary thing is, I’ve heard these misconceptions from doulas and childbirth educators—the very people that parents are often getting their information from. I’ve heard: “You don’t need Vitamin K if you aren’t going to circumcise.” “Getting the shot isn’t necessary.” “Getting the shot causes childhood cancer.” “Getting the shot is unnatural and it’s full of toxins that will harm your baby.” “You don’t need the shot as long as you have delayed cord clamping.” “You don’t need the shot if you had a gentle birth.”

Informed consent and refusal isn’t truly informed if you’re giving parents inaccurate information.

SM: What do you think are the sources of information that families are using to make the Vitamin K decision and where are they getting this information from? Do you think families trust the evidence around this?

RD: This is what I did—I googled “Vitamin K for newborns” and read some of the blog articles that pop up on the front page of results. It is truly alarming the things that parents are reading. “Vitamin K leads to a 1 in 500 chance of leukemia.” “Vitamin K is full of toxins.” Most of the articles on the front page of results are written by people who have no healthcare or research background and did not do any reference checking to see if what they were saying was accurate. It’s appalling to me that some bloggers are putting such bad information out there.

If parents don’t trust the evidence, it may be because they have read so many of these bad articles that it’s hard to overcome the bias against Vitamin K. All I can say is, given the number of bad articles on the internet about Vitamin K, I can totally understand the confusion people have.

I mean, even I was confused before I started diving into the research! I truly went into this experience with no pre-existing biases. I just wanted to figure out the truth. If even I—the founder of Evidence Based Birth—didn’t know all the facts about Vitamin K, then I think that’s a pretty good sign that most other people don’t know the facts, either!

To help remedy the amount of misinformation out there, I’d like for the new Evidence Based Birth article to make it towards the top of the Google results so that parents can read evidence-based information on Vitamin K and check out the references for themselves.

SM: In your article, you state “The official cause of classical VKDB is listed as “unknown,” but breastfeeding and poor feeding (<100 mL milk/day) are major risk factors.” – Why, if breastmilk offers little to no protection against VKBD, is “poor feeding” seen as a risk factor?  What should it matter?

RD: Poor feeding is a risk factor for classical VKDB, which happens in the first week of life. There are limited amounts of Vitamin K in breastmilk overall, but there is more Vitamin K in colostrum than in mature milk. So infants who don’t receive enough milk in those first few days may be at higher risk. This connection was first observed by Dr. Townsend in Boston in the 1890’s. He figured out that he could help some infants with early bleeding by getting them to a wet nurse. These infants weren’t getting enough milk from their biological mothers, for whatever reasons.

SM: Are families in the USA receiving proper informed consent around the issue of Vitamin K and the risks and benefits of the different options available to their children at birth (injection, oral,  or declination of both?)

RD: I’m not sure, but my gut reaction is that I don’t think parents are giving informed consent. In my case, when my first child received the shot, I wasn’t even told that she got it! They just did it in the nursery when they separated me from my daughter after birth. It would have been nice to receive some education on it and be given the chance to consent. Maybe if healthcare providers had been properly consenting parents all along, we wouldn’t have so much misinformation out there! By taking parents out of the equation and doing the shot in the nursery without their knowledge, that certainly doesn’t help educate the public!

I don’t think we are doing a very good job with the parents who decline the shot, either. If you read the part of my article where I wrote about the epidemic in Nashville, all of the parents refused the shot, but none of the parents gave informed refusal. All of them had been given inaccurate information about the shot, so they couldn’t make a truly informed decision. Can you imagine what it must be like for the people who gave them the inaccurate information? That would be so terrible to know that your misinformation may have led to the parents making the choice that they did. 

SM: What should the information look like during the consent process so that families can make informed decisions about having their newborns receive Vitamin K in injection or oral form.

RD: I think the CDC has a really great handout that can be used for informed consent. If parents want more detailed information and references, or if they have concerns that the CDC handout doesn’t answer, then the Evidence Based Birth blog article covers most of the research out there. 

Also, here is a link to a peer-reviewed manuscript that is free full-text, and although it is written at a higher level, it does a good job addressing the myths about the Vitamin K shot.

SM: Are you aware of any adverse effects from either the injection or the oral administration of Vitamin K, other than bruising, pain and bleeding at the injection site if an injection pathway is chosen?

RD: Not if given via the intramuscular method. Some bloggers out there look at the medication information sheet and immediately start pointing out some scary sounding side effects. It’s important to realize that those side effects refer to intravenous administration. Giving a medication intravenously (IV) is a whole different ballgame than giving an intramuscular shot (IM). In general, medications have the potential to be a lot more dangerous if they are given IV—because when medications are given IV they go straight to the heart and all throughout the circulation in potent quantities. For newborns, the Vitamin K is given IM, not IV, which is a much safer method of giving medications in general.

SM: In a childbirth education class, with limited time and a lot of material to cover, what message do you think educators should be sharing about the Vitamin K options.

RD: If I had to sum it up in a minute or less, I would share that babies are born with limited amounts of Vitamin K, and Vitamin K is necessary for clotting. Although bleeding from not having enough Vitamin K is rare, when it happens it can be deadly and strike without warning, and half of all cases involve bleeding in the baby’s brain.

Breastfed babies are at higher risk for Vitamin K bleeding because there are very low levels of Vitamin K in breastmilk. Giving a breastfed infant a Vitamin K shot virtually eliminates the chance of life-threatening Vitamin K deficiency bleeding. The only known adverse effects of the shot are pain, bleeding, and bruising at the site of the injection.

Right now there is no FDA-approved version of oral Vitamin K, although you can buy a non-regulated Vitamin K supplement online. A regimen of three doses of oral Vitamin K1 at birth, 1 week, and 1 month reduces the risk of bleeding. Although oral Vitamin K1 is better than nothing, it is not 100% effective. It is important for parents to administer all 3 doses in order for this regimen to help lower the risk of late Vitamin K deficiency bleeding.

If parents want to use the oral method, or decline the Vitamin K altogether, I would encourage them to do their research and talk with their healthcare provider so that they truly understand the risks of declining the injection. I would tell them to take caution when reading materials online because there is a lot of misinformation out there and you don’t want them making important healthcare decisions based on faulty information.

 SM: How should a childbirth educator (or other professional who works with birthing women) respond when asked  by parents “Why does breastmilk, the perfect food for babies, not offer the protection that babies need? It doesn’t make sense?”

RD: Breastmilk is the perfect food for babies! But for some reason—we don’t know why—Vitamin K doesn’t do a very good job of going from the mom to the baby through breastmilk. Our diets today are probably low in Vitamin K (green leafy vegetables), which doesn’t help matters, either.

It’s possible that maybe there is some reason we don’t know of that could explain why Vitamin K doesn’t cross the placenta or get into breastmilk very well. Maybe the same mechanism that keeps Vitamin K out of breastmilk is protecting our babies from some other environmental toxin. Who knows?

If it helps, look at it this way—don’t blame it on the breastmilk! Blame it on the Vitamin K! That pesky little molecule doesn’t do a good job of getting from one place to the other. So we have to give our infants a little boost at the beginning of life to help them out until they start eating Vitamin K on their own at around 6 months.

SM: If formula feeding is protective, because of the addition of Vitamin K in the formula, why wouldn’t oral dosing of Vitamin K be effective for the exclusively breastfed infant  – is it just a compliance issue?

RD: Part of the failure of oral Vitamin K is compliance—not all parents will give the full regimen of oral doses, no matter how well-intentioned they are. But research from Germany shows that half of the cases of late VKDB occur in infants who completed all 3 doses. It’s thought that maybe some infants don’t absorb the Vitamin K as well orally. Vitamin K is a fat-soluble vitamin, and it needs to be eaten with fatty foods or fatty acids in order for it to be absorbed. So maybe some of those infants had the Vitamin K on an empty stomach. Or maybe they spit it up!

SM: Do you expect a strong reaction from any particular segment of professionals or consumers about your findings?

RD: No more so than when I published the Group B Strep article!

I anticipate that some people may think that the shot is too painful for newborns, and they may theorize that this pain will cause life-long psychological distress. Unfortunately there really isn’t any evidence to back that claim up, and so I can’t really address this theory. But I have spoken with parents and nurses, and they say that having the baby breastfeed while the shot is administered can drastically reduce the pain of the shot.

I would encourage parents who are worried about pain to weigh these two things: the chance of your infant experiencing temporary pain with an injection, versus the possibility of a brain bleed if you don’t get the shot.

 SM: Any last thoughts that you  would like to share with Science & Sensibility readers on this topic?

RD: You can be a natural-minded parent… interested in natural birth and naturally healthy living, and still consent to your newborn having a shot with a Vitamin K to prevent bleeding. These things are not mutually exclusive. One hundred years ago, infants with Vitamin K deficiency bleeding would have died with no known cause. But today, we have the chance to prevent these deaths and brain injuries using a very simple remedy. The discovery of Vitamin K and its ability to prevent deadly bleeds is a pretty amazing gift. I am thankful to all of the researchers and scientists who used their talents and gifts and got us to this point, where we now have the power to prevent these tragedies 100% of the time.

I want to thank Rebecca Dekker for taking the time to answer my questions  I always look forward to Rebecca’s new articles, and appreciate the effort she puts into preparing them,  Have you had a chance to read Rebecca Dekker’s new post on the Evidence for Vitamin K Shots in Newborns?  Will you be changing what you say to your clients or patients based on what you read or based on this interview with Rebecca?  What are your thoughts on this information?  Are you surprised by anything you learned?  I am very interested in your thoughts – please share in our comments section. – SM

Babies, Childbirth Education, Evidence Based Medicine, informed Consent, New Research, Newborns, Research, Vaccinations , , , , , , , ,

Research Review: Are There Any Benefits to Performing an Early Frenotomy on Newborns?

December 10th, 2013 by avatar

By Elias Kass, ND, LM, CPM

Breastfeeding is often considered the next big challenge after childbirth. New mothers and babies work together to establish a successful breastfeeding relationship. Sometimes, there are complications that can make things harder than they should be.  Tongue tie is one of the circumstances that can interfere with getting the breastfeeding relationship off to a good start. Please welcome Dr. Elias Kass, to Science & Sensibility as he reviews a recent study on early frenotomy (tongue tie clipping) in newborns and shares his thoughts on the study results. – Sharon Muza, Community Manager

With tongue tie seemingly on the rise, it’s always nice to see new literature approach the issue. “Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie” (Emond et al) compares releasing the tongue tie (frenotomy) immediately versus waiting and providing standard breastfeeding support.

What is tongue tie?

Tongue tie describes the presence of a frenulum that restricts the tongue’s ability to reach out and grasp the breast for successful breastfeeding.

Anterior tongue tie Image Source: Melissa Cole, IBCLC, RLC

Anterior tongue tie
Image Source: Melissa Cole, IBCLC, RLC

The most profound anterior tongue tie is one that connects the tip of the tongue to the edge of the gum. These babies have a V- or heart-shaped tongue when they cry, cannot extend their tongue at all, cannot follow a finger tracing along their bottom gum, and cannot generally latch well. Tongue ties can occur all along the spectrum of the tongue and the floor of the mouth, and some are hidden under the surface layer of skin, which we call “posterior tongue tie.”

The role of the tongue in breastfeeding

The tongue is incredibly important in breastfeeding. The baby must reach out with his tongue and grasp the breast. The tongue forms the primary seal, preventing milk loss and air intake. The movement is intrinsic to the tongue. Rather than sawing the tongue in and out, the muscular impulse starts at the tip of the tongue and moves inward, moving milk from the breast into the mouth. The middle of the tongue acts to form the milk into a ball, and the back of the tongue is responsible for coordinating swallowing, raising the larynx so that milk is directed down the esophagus and not down the trachea into the lungs.

What happens when a baby is tongue tied?

Tongue tie interferes with this intricate coordination in many ways. Some babies cannot extend their tongue. Those babies will have difficulty finding and attaching to the breast, but they may be able to nurse if the nipple is placed in their mouth just right. These babies come off the breast easily and become frustrated because they cannot adjust the position of the nipple in the mouth. The babies who are so tied they cannot extend their tongue over their bottom gum will reflexively clamp their gums. To the nursing parent, this pressure can feel like biting, and can damage nipples incredibly quickly, causing cracking, bleeding, pain, and because the skin is now broken, infection. 

Some babies can extend their tongue against the “rubber band” of the tongue tie, but their tongues “snap back” frequently. This can feel like a sawing against the underside of the nipple, and that friction can also damage nipples. These babies tire easily, because their feeding is made more difficult by the resistance of the rubber band. Snap back can sound like clicking. Clicking can also be caused by loss of suction from the underside of the breast. The tongue should stay mostly in the middle of the mouth when breastfeeding, with the jaw opening to create suction in the middle and back of the mouth. If, when baby opens her jaw, the tongue is tied to the bottom of the mouth, her tongue will snap away from the breast, losing suction.

Some babies can extend but not cup their tongues. These babies generally mash the nipple against the roof of the mouth, causing flattened, ridged nipples. Others thrust their tongue against the nipple instead of reaching under it, which leaves the nipple looking like a lipstick applicator.

What is a frenotomy?

Frenotomy refers to the procedure where this tongue tie is released (or in some places, “revised”). Though not all providers perform this procedure, providers from many different specialties have been known to offer it: pediatricians, family practice doctors, ear nose and throat specialists, dentists, and some midwives. For most, it is a simple, in-office procedure.

What did this study look at?

The researchers determined which babies were tongue tied based on the Hazelbaker Assessment Tool for Lingual Frenulum Function and the LATCH score (Latch, Audible swallowing, nipple Type, Comfort, Hold ). Those who had mild-moderate tongue tie according to the Hazelbaker score, as well as a LATCH score less than 8 out of 10 were eligible for the study. Those babies with severe tongue tie according to the Hazelbaker score were not randomized, and were instead offered immediate frenotomy; their outcomes were not considered as part of the study. Some parents of babies who otherwise qualified for the study refused to be randomized because they felt strongly about receiving frenotomy upon diagnosis.

When considering whether to intervene for tongue tie, it’s important to consider appearance as well as functionality. Some tongue ties are not readily visible but interfere greatly with functionality. Some tongue ties appear dramatic, but breastfeeding is not affected. (There are other long-term considerations, like speech and oral health, in deciding whether or not to release a tongue tie that is not affecting breastfeeding.) The Hazelbaker score is a good way to evaluate functionality because it takes into account whether baby can extend her tongue, cup it into the appropriate shape, moved it appropriately, and maintain suction, as well as the severity in appearance. The Hazelbaker score has good inter-scorer correlation, meaning that different professionals using the tool will arrive at the same conclusion (whether or not the baby should have a frenotomy) nearly 90% of the time. Using a consistent tool can help the individual provider get a better sense of who needs the procedure, but it can also help us as readers to know whether the study population was appropriate, and whether the study’s conclusions can inform our own practice.

V-shaped tongue Image Source: Osama Moshet, MD, FAAP

V-shaped tongue
Image Source: Osama Moshet, MD, FAAP

The LATCH score is a very broad evaluation of how breastfeeding is going, and despite its name, only barely addresses latch itself. Using such a general assessment in conjunction with the Hazelbaker score may have helped the researchers isolate the babies who were both tongue tied and having difficulties breastfeeding, as opposed to those who were tongue tied but doing okay.

In measuring outcomes, they used these two measures again, and added several more measures concerning breastfeeding behavior of newborns, breastfeeding self-efficacy (how confident mom felt in her ability to feed her baby, as well as an observer’s evaluation of breastfeeding effectiveness), and pain.

Conclusion

The primary outcome was LATCH score at 5 days. Secondary outcomes were LATCH score at 8 weeks, and the other measures listed above at 5 days and 8 weeks. The Hazelbaker score was another “outcome of interest” at 5 days, as was infant weight at 8 weeks. At 5 days, parents could choose to have frenotomy regardless of whether they had been randomized to the control arm or the intervention arm.

The researchers concluded “Early frenotomy did not result in an objective improvement in breastfeeding but was associated with improved self-efficacy. The majority in the comparison arm opted for the intervention after 5 days.”

Discussion

Though the study is structured fairly soundly, it doesn’t really answer its own question of whether frenotomy helps improve breastfeeding, largely because of the outcomes they chose to study. The LATCH score is not an indication of tongue functionality, success of frenotomy, or long-term breastfeeding success. Five days is also probably too soon to pass final judgement on whether the frenotomy helped; babies and nipples are still healing. The study also excluded those with severe tongue tie, and it’s safe to assume these babies would have significant improvement when their tongue ties were corrected.

Mothers did feel significantly more effective in their feeding when their babies had received frenotomy (which is correlated with duration of breastfeeding), and more of those who didn’t receive frenotomy were feeding by bottle. It’s unclear whether this bottle feeding was because of the pain associated with breastfeeding or because of inadequate milk transfer or nutrition, but it’s possible that some of those parents have been helped by immediate frenotomy. Indeed, some of the mothers who had been randomized to the control group requested early frenotomy because their feeding was so painful. There were statistically significant improvements in the Hazelbaker score, representing improvement in both appearance and functionality.

Very thick  submucosal/posterior tongue tie. {link url="http://www.bayareabreastfeeding.net"}Bay Area Breastfeeding & Education, LLC{/link} Image Source: Bay Area Breastfeeding & Education, LLC

Very thick submucosal/posterior tongue tie.
Image Source: Bay Area Breastfeeding & Education, LLC www.bayareabreastfeeding.net

Many features of this study mirror how I treat tongue tie in my practice. Almost all babies are referred by lactation consultants or their own pediatricians because they are having difficulty breastfeeding, or because their tongue ties are so profound that we can anticipate speech and oral health problems if it’s not corrected. I use both the Hazelbaker score and the scoring tool in the appendix of RL Martinelli’s “Lingual frenulum protocol with scores for infants” to capture the infant’s feeding history, anatomy, and functionality on both the gloved finger and at the breast. These scores help support a systematic approach to these infants, and helps communicate back to their referring provider what I’m looking for when I decide whether or not to recommend frenotomy. Though most babies referred do need frenotomy, some need other kinds of support instead, and some just need reassurance around normal feeding patterns.

The article didn’t go into much detail about the aftercare. Aftercare is a crucial variable in improving breastfeeding and maximizing success of the procedure. Seattle area practices who perform significant numbers of frenotomy have collaborated to create a list of exercises we ask parents to do with their babies 5 times daily for a week to keep the area open, reduce reattachment, and help baby learn to maximize their new freedom of movement. We also generally recommend craniosacral therapy to help release tight muscles and retrain movement patterns. Many families have incorporated other feeding tools or accessories into their regimens, whether that’s nipple shields, bottles, supplemental nursing systems, or formula. With frenotomy, most will be able to start to move away from those tools, and need continued support from a lactation consultant to relearn how to nurse at the breast. Though most mothers feel that baby nurses differently immediately, some babies take longer to change their approach, and some do not benefit at all.

Releasing tongue ties is a very satisfying part of my practice. I love when breastfeeding parents nurse immediately after the procedure and their faces light up because for the first time it doesn’t hurt to feed. These parents have been working very, very hard to breastfeed, and I feel strongly that this procedure removes a significant obstacle. The more I work with breastfeeding families, the more in awe I am of the complexity of breastfeeding, and importance of excellent breastfeeding support.

Childbirth  and breastfeeding educators should be sharing that painful breastfeeding sessions are not normal and should be evaluated by a lactation consultant.  Educators should provide resources for qualified LCs in their communities to families in need.  For those that work with breastfeeding dyads, what are you seeing in terms of tongue tie and treatment success? Please share your experiences.- SM

References

Ballard, J. L., Auer, C. E., & Khoury, J. C. (2002). Ankyloglossia: assessment, incidence, and effect of frenuloplasty on the breastfeeding dyad.Pediatrics, 110(5), e63-e63.

Emond, A., Ingram, J., Johnson, D., Blair, P., Whitelaw, A., Copeland, M., & Sutcliffe, A. (2013). Randomised controlled trial of early frenotomy in breastfed infants with mild–moderate tongue-tie. Archives of Disease in Childhood-Fetal and Neonatal Edition, fetalneonatal-2013.

Martinelli RL de C, Marchesan IQ, Berretin-Felix G. Lingual frenulum protocol with scores for infants. Int J Orofacial Myology. 2012;38:104–112.

About Dr. Elias Kass

elias kass head shot

Elias Kass, ND, LM, CPM

Elias Kass, ND, LM, CPM, is a naturopathic physician and licensed midwife practicing as part of One Sky Family Medicine in Seattle, Washington. He provides integrative family primary care for children and their parents, including prenatal, birth and pediatric care. He loves working with babies! Practice information and Dr Kass’s contact info is available at One Sky Family Medicine.

Babies, Breastfeeding, Guest Posts, New Research, Newborns, Parenting an Infant, Research , , , , , ,

Safe at Home? New Home Vs. Hospital Birth Study Reviewed by Henci Goer

November 26th, 2013 by avatar

 Regular contributor Henci Goer examines the most recent study on the safety of home birth in the United States.  When taking a closer look at the data analysis done by the authors, there are concerns not addressed in the study, that raise issues that cause the study’s conclusions to be questioned. Henci shares some other studies that do not reach the same results about the safety of home birth. Have you read this study?  If you had read this study too, did you find more questions than answers when you were done? – Sharon Muza, Community Manager, Science & Sensibility.

“Researchers have already cast much darkness on the subject, and if they continue their investigation, we shall soon know nothing at all.” – Mark Twain

flickr.com/photos/vestfamily/2591899412/

The latest contender in the long list of studies attempting to compare the safety of home and hospital birth, “Selected perinatal outcomes associated with planned home births in the United States,” was published last month (Cheng 2013). Let’s start by summarizing the study:

Using data compiled from the U.S. birth certificate, Cheng and colleagues compared outcomes between 12,039 women “planning” home births with 2,081,753 women having hospital births. All women were at term (between 37 and 43 weeks) and carrying one head-down baby. Women with prior cesarean were not excluded. After adjustment for numerous factors including number of prior births, medical conditions (hypertension, diabetes), risk factors (smoking), and social and demographic factors (race/ethnicity, age, marital status), women having home births were much less likely to have an instrumental vaginal delivery (0.1% vs. 6.2%; odds ratio 0.1), induced labor (1.4% vs. 25.7%; odds ratio 0.2), or labor augmentation (2.1% vs. 22.2%; odds ratio 0.3). They were also, however, twice as likely to have a baby with a 5-minute Apgar less than 4 (0.24% vs. 0.37%; odds ratio 1.9), three times as likely to have a baby experience neonatal seizure (0.06% vs. 0.02%; odds ratio 3.1), and more than twice as likely to have a baby with 5-minute Apgar less than 7 (2.42% vs. 1.17%; odds ratio 2.4). On the other hand, similar percentages of babies needed more than 6 hours of ventilator support, and babies born at home were much less likely to be admitted to intensive care (0.57% vs. 3.03%; odds ratio 0.2). In the discussion, the investigators note that removing the 489 women with previous cesareans who had planned home birth and women with medical or obstetric conditions did not alter that infants of women with prior births who planned home birth were more likely to have a low Apgar score. They don’t specify whether this was 5-minute Apgar less than 4 or less than 7 nor do they report the occurrence rate in this higher-risk subgroup.

There is more. To evaluate the effect of birth attendant qualifications, the investigators excluded births attended by doctors or unknown birth attendant and stratified the remaining home birth population into those attended by professional midwives and those attended by “other midwives.” (Confusingly, study authors state that Certified Professional Midwives [CPMs] were categorized as Certified Nurse-Midwives in the birth certificate data yet go on to refer solely to “CNMs” in the rest of the analysis.) In the subset attended by professional midwives, newborn outcomes were similar except that hospital-born infants were more likely to be admitted to intensive care (0.37% vs. 3.03%; odds ratio 0.1).

Cheng and colleagues conclude that while women planning home births are less likely to experience obstetric intervention, their babies are more likely to be born in poor condition. Do their data warrant that conclusion?

To begin with, the relevant question isn’t the tradeoffs between planned home birth per se and hospital birth. It is: “What are the excess risks for healthy women at low risk of urgent complications who plan home birth with qualified home birth attendants compared with similar women planning hospital birth?” This study can’t answer that question. Here’s why:

The study only includes women actually delivering at home, but you can’t make a meaningful comparison unless you have the outcomes of women transferred to hospital. “Planning” in this study meant only that birth at home wasn’t accidental, not the more usual meaning that birth may be planned at home but problems during labor may alter that plan. I discovered this when I wrote the lead author to request cesarean rates, which, oddly, to me, were not reported in the study. She responded that this was because cesareans aren’t performed at home. Puzzled by this explanation, I wrote back that neither are instrumental vaginal delivery, induction, nor labor augmentation, which were reported. She responded that birth certificate data don’t state how labor was induced or augmented but that perhaps at home births it was by rupturing membranes and that “apparently some midwives or birth attendants do perform vacuum extraction at home,” but it is rare since only 10 were reported.

Not all women planning home birth were low-risk. For one thing, women with prior cesareans were included. For another, the methods section states that the analysis adjusted for medical risk, and the discussion notes that women with prior children in the home birth group were more likely to have babies with low Apgar scores even after removing women with medical risk, which implies that some of them had medical problems.

Not all women in the home birth group had qualified home birth attendants. Outcome data on the overall population came from women recorded as being attended by MDs, DOs, “other midwife,” “others,” and “unknown/not stated” as well as by professional midwives.

Rates of neonatal seizure and 5-minute Apgar less than 4 were very low, and the study doesn’t report on perinatal death or permanent disability. As concerning as an excess in low Apgar scores and seizures may be, the real question is excess incidence of permanent harm. Even without limiting the population to low-risk women with qualified care providers, only 1 more baby per 1000 born at home experienced very low 5-minute Apgar, and only 4 more babies per 10,000 experienced neonatal seizure, and while babies born in poor condition are more likely to incur permanent neurologic damage or die, most will recover. Also, as we saw, differences in rates of these adverse outcomes disappeared with a qualified provider.

The proof of the pudding lies in studies free of these weaknesses. A study of 530,000 low-risk Dutch women found no difference in deaths during labor or newborn death rates between women planning, but not necessarily having, home birth and those planning hospital birth (de Jonge 2009). A Canadian study comparing outcomes of 2900 women eligible for home birth with women equally eligible but planning hospital birth reported worse newborn outcomes (more required resuscitation at birth or oxygen for more than 24 hrs and more birth injuries), worse maternal outcomes (more anal sphincter tears and postpartum hemorrhage), and more use of instrumental and cesarean delivery in the hospital population (Janssen 2009).

What can we take away from Cheng and colleagues analysis? First, care provider qualifications matter. Women desiring home birth should have access to professional midwifery care, which argues for making CPMs legal in all 50 states. Second, less than optimal candidates are birthing at home, and some women may be continuing labor at home who shouldn’t. Why might that be? Women may choose home birth because they want control over what happens to them, they have had a prior negative hospital experience, or they want to avoid unnecessary medical intervention (Boucher 2009), the last of which will include women denied hospital VBAC. Women may resist hospital transfer for the same reasons or because they know that at best, hospital transfer means losing the care and advice of the care provider they trust and at worst, they will be treated badly by disapproving hospital staff. If we want to reduce their numbers, hospital-based practitioners need to address the behaviors, practices, and policies that drive women away from hospital birth. This would have the added benefit of improving care for the 99% of American women who would never consider birthing at home.

References

Boucher, D., Bennett, C., McFarlin, B., & Freeze, R. (2009). Staying home to give birth: why women in the United States choose home birth. J Midwifery Womens Health, 54(2), 119-126. http://www.ncbi.nlm.nih.gov/pubmed/?term=boucher+2009+home+birth

Cheng, Y. W., Snowden, J. M., King, T. L., & Caughey, A. B. (2013). Selected perinatal outcomes associated with planned home births in the United States. Am J Obstet Gynecol, 209(4), 325 e321-328. doi: 10.1016/j.ajog.2013.06.022 http://www.ncbi.nlm.nih.gov/pubmed/23791564

de Jonge, A., van der Goes, B. Y., Ravelli, A. C., Amelink-Verburg, M. P., Mol, B. W., Nijhuis, J. G., . . . Buitendijk, S. E. (2009). Perinatal mortality and morbidity in a nationwide cohort of 529,688 low-risk planned home and hospital births. BJOG 116(9), 1177-1184. http://www.ncbi.nlm.nih.gov/pubmed/?term=de+jonge+2009+planned+home

Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee, S. K. (2009). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ, 181(6-7), 377-383. http://www.ncbi.nlm.nih.gov/pubmed/19720688

 

Guest Posts, Home Birth, Maternity Care, Medical Interventions, New Research, Newborns, Research , , , , , , ,

The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

Click image to see full size

The health concerns that affect preterm babies are well documented and much is known about the impact of an early birth on the long term health of children.  Some of these issues were discussed in a recent post on Science & Sensibility highlighting World Prematurity Day.  The issue of babies being born too soon was highlighted by the American College of Obstetricians and Gynecologists (ACOG) in a new committee opinion recently published in the November issue of Obstetrics and Gynecology.

In a joint committee opinion, “The Definition of Term Pregnancy” released by ACOG and the Society for Maternal Fetal Medicine, these organizations acknowledge that previously it was believed that ”the period from 3 weeks before until 2 weeks after the estimated date of delivery was considered ‘term’ with the expectation that neonatal outcomes from deliveries in this interval were uniform and good.”  More recent research has demonstrated that this is not the case.  The likelihood of neonatal problems, in particular issues related to respiratory morbidity, has a wide variability based on when during this five week “term” window baby is born.

ACOG has released four new definitions that clinicians and others can use when referring to gestational age; early term, full term, late term and postterm.

  1. Early term shall be used to describe all deliveries between 37 0/7 and 38 6/7 weeks of gestation.
  2. Term shall indicate deliveries from 39 0/7 and 40 6/7 weeks of gestation.
  3. Late term refers to all delivers rom 41 0/7 to 41 6/7 weeks of gestation.
  4. Postterm indicates all births from 42 0/7 weeks of gestation and beyond.

These new definitions should be put into practice by all those who work with birthing women, including researchers, clinicians, public health officials and organizations AND childbirth educators. We can and should be teaching and using these terms with our students.

As we move forward, we can expect to see these terms applied and research defined by the new categories, which will yield rich and useful information for those working in the field of maternal-infant health.

Lamaze International has long been focused on evidence based care during the childbearing year and continues to support childbirth educators, consumers and others by providing useful and fact based information that women and their families can use to make informed choices about their maternity care.  As part of this continued effort, Lamaze is pleased to share a new induction infographic created by the Lamaze Institute for Safe & Healthy Birth committee. This easy to read infographic is designed to highlight the facts about induction and encourage women to carefully consider all the information before choosing a non-medically indicated induction.  More than one in four women undergo an induction using medical means, and 19% of those inductions had no medical basis.

Since many women are pressured by providers or well-meaning but misguided friends and family to be induced, Lamaze encourages women to learn what are the important questions to ask during conversations with their providers and to get the facts about their own personal situation.  It is also recognized that a quality Lamaze childbirth education class can provide a good foundation for understanding safe and healthy birth practices.

Lamaze International is proud of their Six Healthy Birth Practices for safe and healthy birth, and this infographic supports the first birth practice; let labor begin on its own.  Women need to be able to gather information to discern between a medically indicated induction, which protects the baby, the mother or both from those induction that are done for a social or nonmedical reason which increases the risk of further interventions, including cesarean surgery for mothers and NICU stays for babies who were not ready to be born. This infographic can be shared with students, clients and patients.  It can be hung in classrooms and offices.  Educators can use it in creative ways during teaching sessions, when discussing the topics of inductions, informed consent and birth planning.

As the benefits of a term baby are more clearly understood, and research is revealing how critical those last days are for a baby’s final growth and development, it is perfect timing for Lamaze to share this infographic.  This tool will reduce unneeded inductions and help women learn how important it is to allow their babies to receive the full benefit of coming when the baby is ready.  There has been a huge push to stop inductions before at least 39 weeks.  March of Dimes has their “Healthy Babies are Worth the Wait” campaign. The new induction infographic provides an accessible and easy to use information sheet to help families reduce non-medical inductions. Many organizations, including Lamaze are joining together to make sure that babies are born as healthy as possible and women go into labor naturally when baby is ready.

You can find and download the full version of the Induction infographic on the Let’s Talk Induction page of Lamaze’s Push for Your Baby campaign website.  Alternately, if you are a Lamaze member, you can also download the infographic and many other useful handouts from the Teaching Handouts Professional Resource Page from Lamaze International.

Please take a moment to read over this great, new infographic and share in the comments below, both your thoughts on the finished product and how you might use this to help mothers to push for the best care. Lamaze International and its members are doing their part to help reduce the number of early term babies who arrive before they are ready.  I look forward to hearing your thoughts and your ideas for classroom use.

References

The American College of Obstetricians and Gynecologists Committee on Obstetric Practice Society for Maternal-Fetal Medicine. Committee Opinion No 579: Definition of Term Pregnancy. Obstet Gynecol 2013; 122:1139.

Declercq, E. R., & Sakala, C. (2013). Listening to mothers III: Pregnancy and childbirth.”. 

 

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