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The Straight Scoop On Inductions – Lamaze International Releases New Infographic

November 21st, 2013 by avatar

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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.”. 

 

ACOG, Babies, Childbirth Education, Evidence Based Medicine, Healthy Birth Practices, informed Consent, Maternal Quality Improvement, Medical Interventions, New Research, Newborns, NICU, Practice Guidelines, Pre-term Birth, Push for Your Baby, Research , , , , , , , , , , ,

Beyond Downton Abbey: The True Life Trauma of Pre-eclampsia, Eclampsia, and Its Psychological Aftermath—An Interview with Jennifer Carney of The Unexpected Project

February 5th, 2013 by avatar

By Walker Karraa

Regular contributor Walker Karraa interviews Jennifer Carney, a mother of two, who suffered from eclampsia at the beginning of her third trimester.  Jennifer shares her real life story, on the heels of a favorite character’s similar experience on the popular TV show “Downton Abbey.”  Today, we learn about Jennifer’s experience and on Thursday we learn more about resources and organizations working hard to make this potentially deadly disease less harmful to pregnant and postpartum women.  - Sharon Muza, Community Manager

Introduction: 

http://flic.kr/p/dJBJhW

The recent episode of “Downton Abbey” brought much needed attention to the maternal health issue of pre-eclampsia. Why is it we rely on fiction for permission to get real? Where is the line between evidence-based research and fictional representations of the lack of it? How do we encourage each other and the next generation of maternal health advocates to harness the undeniable power of media but not become part of a social construction of maternal mortality as not real? As a qualitative researcher, I believe that some of our best evidence stems from researching real experiences from real women. It is my pleasure to introduce a real woman who experienced the full range of eclampsia and its psychological aftermath: Jennifer Carney.

Note: Consultation with Science and Sensibility contributor, Christine Morton, PhD was conducted to insure accurate and current statistical data regarding pre-eclampsia and eclampsia. 

Walker: Jennifer, can you tell us your story?

JC: My second pregnancy was easier than my first. Up until it wasn’t. I conceived as soon as we started trying. We had no soft markers on the ultrasounds, no need for an amnio, and no borderline gestational diabetes. I was only 34 and with a successful full-term first pregnancy; I was considered “safe” from preeclampsia. The only risk factor I had was my weight, but even with that, statistically my risks were much lower than for a healthy first time mom. There was something about it that seemed too easy. I felt like the other shoe was going to drop – but I never imagined that it would fall with such force.

In my 32nd week, I began to feel ill – like I had the flu. I took a day off from work to rest and recover. I thought I was getting better, but that night I began feeling worse. I called in sick to work again – it was a Friday – and my husband and son went off to work and daycare. I was alone. I laid down and slept for about 4 hours. When I awoke, I felt much, much worse. The headache radiated out from behind my eyes. I was seeing spots. I was incapable of thinking clearly. The phone rang several times, but the receiver was not on the base. I couldn’t locate it before the answering machine picked up. By this point I was aware that something was very wrong, but I wasn’t able to do anything about it. I stayed on the couch, barely moving for as long as I could.

Signs and Symptoms of Pre-eclampsia

  •  High blood pressure. 140/90 or higher. A rise in the systolic (higher number) of 30 or more, or the diastolic (lower number) of 15 or more over your baseline might be cause for concern.
  • Protein in your urine. 300 milligrams in a 24 hour collection or 1+ on the dipstick.
  • Swelling in the hands, feet or face, especially around the eyes, if an indentation is left when applying thumb pressure, or if it has occurred rather suddenly.
  • Headaches that just won’t go away, even after taking medications for them.
  • Changes in vision, double vision, blurriness, flashing lights or auras.
  • Nausea late in pregnancy is not normal and could be cause for concern.
  • Upper abdominal pain (epigastric) or chest pain, some- times mistaken for indigestion, gall bladder pain or the flu.
  • Sudden weight gain of 2 pounds or more in one week.
  • Breathlessness. Breathing with difficulty, gasping or panting.

If you have one or more of these signs and symptoms, you should see your doctor or go to an emergency room immediately. 
Source: Preeclampsia Foundation

Sometime after 5:00, I realized that I was going to have to call someone else to pick up my son at daycare by the 6:00 closing time. I managed to get to my feet and stagger toward the kitchen. I reached out to steady myself on the counter and missed. I fell to my left, onto the hard tile floor in front of the stove. I knew this was bad, but all I could think was that I had to hold on and that someone would be coming. I told myself that I couldn’t let this happen. Shortly thereafter, I tried to scream and felt the beginning of what I later learned was a tonic-clonic or grand mal seizure.  

This was eclampsia – full blown seizures caused by extremely high blood pressure. Somehow, I held on. Somehow, I held on in this state for something like 3 full hours. I have no way of knowing how many seizures I had in that time. When my friend arrived after 8:00, she found me on the floor. I came to long enough to answer her question – “yes, I know where I am. I’m fine.” I tried to get up – and immediately started seizing again. She called 911 and within minutes the paramedics arrived. 

My son was born, not breathing, about an hour later. The doctors were able to revive him, thankfully. He went off to the NICU and I was sent to the ICU. Two days later, I regained consciousness. I was on a respirator and completely disoriented. I was later diagnosed with HELLP syndrome, eclampsia, pneumonia, acute respiratory distress syndrome (ARDS), and sepsis – any of which can be fatal on their own. My son was moved to another hospital with a larger NICU, and I spent 8 days in the hospital where he was born. I saw him briefly before they transferred him – but was unable to hold him until after I was discharged – more than a week after he was born. For the next 20 days, I was only able to see him and hold him during daily visits to the NICU. It would be 4 full weeks from his birth before we could take him home to meet his 4 ½  year old brother for the first time. This was definitely not what we had envisioned.

This experience changed my entire perspective on life. It was the first significant health crisis that I had ever faced and it shook my sense of security and safety. It took a long time to recover physically from the trauma and emotionally I was just a wreck. I was aware that Post-traumatic Stress Disorder (PTSD) was a possibility, but I think the picture I had in my mind of what PTSD was turned out to be very different from the ways in which I experienced it. I had envisioned a quick, big breakdown – but the reality was much subtler. At first, I experienced an aversion to seeing pregnant women. I wanted to warn them, but I also could barely look at them. It manifested in other ways, too – dreams about seizures, muscle spasms, intrusive thoughts. But it felt manageable and the antidepressants helped control the runaway anxiety that had hampered my first postpartum experience 4 years earlier.

Photo: J. Carney 

The mental health issues were helped by the antidepressants, but I wish that I had tried therapy much sooner. It’s doing wonders for me now – but I waited over 6 years to try it. Today, my preemie is in kindergarten and doing well. Aside from my son, getting involved with the March of Dimes and Preeclampsia Foundation has been by far the best part of the whole experience. I wouldn’t change that part, at all.

Walker: How is mental health neglected in the overall understanding of the topic, treatment, and recovery?

JC: This is a huge problem. I got great care while I was in the hospital. I saw social workers, chaplains, and a wide variety of people who inquired after my pain levels and my coping skills. The problem with this is that I was on massive pain killers the whole time. Percocet and morphine can mask emotional pain as well as physical pain. I’m sure I came off as reasonably well adjusted to the whole experience, despite the mental confusion left over from the seizures and the serious health issues that remained. And I was relatively okay. Even during the month-long NICU stay, I was doing all right. I was sleeping well, eating, taking care of myself – but I was also still on Percocet. It smoothed over the rough edges.

It wasn’t until the help dried up, the prescriptions ran out, and the reality of being at home by alone with an infant to care for that the walls started to come down again. Here I was at the scene of the initial trauma, cooking at the same stove that I had seized in front of for hours, responsible for a premature infant who needed drugs to remind him to breathe. This is when I needed the help. This is when I needed information on PTSD and postpartum depression (PPD). This is when I needed support. And as I began the long process of understanding what had happened and why, I found I needed even more support to help me wrap my head around it all.

As I noted while talking about myths, there is a pervasive culture of blame in the overall birth discussion regarding preeclampsia. It can be hard to find information that doesn’t make you feel that you somehow brought this condition on yourself. I looked at the risk factors and the arguments about lifestyle, obesity, and diet – and found a lot of things that sounded like they made sense. But they only made sense if I internalized them and blamed myself for the shortcomings. Maybe it was my fault. This, as you can imagine, does not help the feelings of depression and trauma. It took a LONG time for me to come to the conclusion that there was no way for me to have known that this would happen or to have prevented it. Statistically speaking, I had a very low chance of developing eclampsia even with the risks factored in. Statistically speaking, my son and I should not have survived, either. But we did – and now I want to make sure that I use that in a meaningful way. 

Walker: Did your childbirth education prepare you for your experience?

JC: Heck no. I only took classes with my husband before our first child. We weren’t planning to take the classes again with the second, but since he was born at 7 months, we probably would have missed most of them even if we had planned to. I distinctly remember the childbirth educator talking about her own response to sleeplessness, which was a sort of slap happy, giddy reaction. She mentioned PPD, but not in any real way that conveyed the depths or potential seriousness of the condition. We also received almost no information on pregnancy complications. To me, preeclampsia meant high blood pressure – and I had never had problems with that before. It was totally off my radar. Plus, Preeclampsia very rarely happens in a second pregnancy if it didn’t happen in the first. So, no one prepared me for it. Not my doctor, not my classes, not my books.

Walker: What recommendations do you have for childbirth educators and doulas regarding this issue?

JC: Really, I think it comes down to trusting that the moms you are helping can handle the information that they NEED to know. I was alone. If I had known that these symptoms could mean eclampsia or preeclampsia, I might have been able to save myself from the seizures – which would have also likely saved me from the ARDS and pneumonia. My ICU stay might have not happened. My son was going to be born early – but if I had gone to my doctor or called an ambulance myself, it might not have been so close a call. It’s not my fault that I didn’t know – but it could have been tragic.  

Know the signs and symptoms. Know that a woman with severe PE might be having cognitive issues – confusion, and vision problems. Don’t ask her to drive. Don’t downplay distress. And take complaints of headaches, upper quadrant pain, nausea, diarrhea, shoulder pain, visual disturbances, and a general feeling that something is “off” seriously. And if you have a client or patient that experiences something like this, please follow up and ask about mental health issues. Be careful not to ask questions that can be answered with the words: “I’m fine”. Dig deeper.

Closing Thoughts

How might we increase our understanding of this issue through Jennifer’s story? Is it possible to begin a dialogue here–one in which we agree to change paradigms of learning and knowing women’s experiences beyond an episode of a fictional television show?  Jennifer presents an exemplar synthesis of the fullest range of insight possible when empirical and phenomenological considerations are employed.. Her lived experience combined with and through her knowledge of the evidence creates an exemplar of how knowing and knowledge cannot be divided if the pursuit of knowledge is truly desired.

In the next installment, scheduled for February 7th,  Jennifer reflects on common myths about PE, and her work with the Unexpected Project and the Preeclampsia Foundation.   

Birth Trauma, Childbirth Education, Depression, Guest Posts, Maternal Mental Health, NICU, Postpartum Depression, Pre-eclampsia, Pre-term Birth, Pregnancy Complications, PTSD , , , , , , , , , , , , ,

Donor Milk and Milk Banks; A Gift That Saves Lives

August 7th, 2012 by avatar
This week, in recognition of World Breastfeeding Week,  I am attending a fundraiser in my community, Seattle, for the Northwest Mothers Milk Bank, (NWMMB) which includes a reception and screening of the documentary, Donor Milk.  I am excited to support this important mission and am looking forward to viewing the film and participating in the Q&A afterwards with the filmmakers, NWMMB team members, a donor mom and a physician who routinely prescribes donor breastmilk for patients.
Science & Sensibility’s Lisa Baker and Deena Blumenfeld discussed the newest American Academy of Pediatrics’ statement on Breastfeeding and the Use of Human Milk, Donor Milk for Preterm Infants and the formation of a donor milk bank in Calgary, Alberta, Canada in some posts earlier this year.
I wanted to learn more about Northwest Mothers Milk Bank right in my own backyard, so I contacted Scotti Weintraub, Executive Board Member for the organization to get some of my questions answered.
Sharon Muza: Whose idea was it to start the NWMMB?

Scotti Weintraub:  A group of local lactation professionals had been talking about the need for a milk bank for several years.  In spring 2008, enough people were talking about it that an open meeting was held for anyone interested in starting a milk bank.  From that initial meeting grew the beginnings of a board of directors and a committed group of volunteers.

Sharon Muza: Why Portland, OR and the Pacific Northwest?

Scotti Weintraub:  Right now the closest nonprofit milk banks are in Denver and San Jose.  Oregon and Washington have the highest breastfeeding rates in the country so it makes sense that we’d have a milk bank in the Northwest.   Our volunteer effort grew in Portland and we incorporated as a nonprofit in Oregon.

Photo courtesy of NWMMB

 Sharon Muza: How has the vision of a milk bank been received in your community?

Scotti Weintraub: Very positively!  People involved in lactation are extremely supportive of our mission and want to see a milk bank open.  When we talk to the public, we often get asked, “Shouldn’t Portland already have a milk bank?” They are right – it would make sense that Portland and the Northwest would already have a milk bank.

Potential donor moms have been also very interested and supportive. We have a great deal of education and outreach work to do in the broader medical community.  The research is strongly in support of the use of donor milk and it is evidence-based best-practice.  But there are some who have been slow to embrace the unknown and have questions.  Part of our work up to and from here is to educate medical professionals and increase the use of donor milk.

Sharon Muza: Have there been any concerns or less supportive comments or actions?

Scotti Weintraub: Overwhelmingly people have supported our efforts.  When we are questioned about the safety of donor milk or why it’s so important, we point to the clear research.  Similarly, the AAP, WHO and the Surgeon General have all advocated donor milk as the next best food for babies if their own mom’s milk isn’t available.

Photo courtesy of NWMMB

 Sharon Muza: Are you modeling your bank after one already in existence?

Scotti Weintraub: The Human Milk Banking Association of North America has been hugely helpful in our start-up process.  Member milk banks have graciously shared their insight, time and wisdom.  We are modeling as much as can on their success.

But each community is unique and each milk bank is unique in its structure, how it’s funded and how it operated within its community. The Northwest Mothers Milk Bank is an independent 501c3 organization whereas many milk banks are part of a larger hospital system or hospital foundation.

 Sharon Muza: How many human milk banks are there in the US right now?

Scotti Weintraub: Right now there are 11 operating milk banks in the US.  There are several that are considered “Developing” like NWMMB – meaning that we have met some criteria set out by HMBANA and are in the works.  A couple other milk banks are not yet considered “Developing” but are moving in that direction.  Here’s the list.

Sharon Muza:  What is the cost to families who need milk?

Scotti Weintraub: Milk banks charge processing fees to cover the costs of screening donors, processing, pasteurizing, and culturing the milk and shipping.  This fee is set by the individual milk bank based on their costs, so we don’t yet know what NWMMB will charge for processing fees.

Donor milk that is dispensed while a baby is in the hospital is charged through the hospital.  Some of our NW hospitals are providing donor milk to their patients and are absorbing the costs into their budgets.  Some insurance companies cover donor milk.  There is more work to be done encouraging insurance companies to cover the costs of donor milk.

Photo courtesy of NWMMB

Since we are not yet open, I will share the policy from Mothers’ Milk Bank Austin, TX

“When your baby is hospitalized, the milk processing fee and shipping are billed to the hospital, and subsequently your insurance company. If a baby is not hospitalized, the fee will be billed to you. Texas Medicaid currently covers the cost for donor milk for a limited period of time, when medically necessary. If your family has private insurance, we encourage you to file a claim. We are happy to work with the family, the baby’s healthcare provider and insurance company to obtain coverage. If necessary, we can establish a payment plan. All babies with a medical need for milk, whose moms cannot provide milk, are eligible to receive it for at least a limited time, regardless of ability to pay.”

 Sharon Muza: What is the cost to collect, test, process and distribute milk?

Scotti Weintraub:  Nonprofit milk banks do not recoup their processing costs with the processing fees they charge and must raise additional funds.  Costs vary a bit depending on volume, equipment, etc.

Sharon Muza: Who will the milk be available to?  How will priority be determined?

Scotti Weintraub: Donor milk is available by prescription only.  Priority is given to the sickest and most vulnerable infants depending upon availability.  So there is a triage system for dispensing milk, especially during times of low supply.

 Sharon Muza: Under what circumstances are babies most likely to need donor milk?

Scotti Weintraub:

  • preterm birth
  • failure to thrive
  • malabsorption syndromes
  • allergies
  • feeding/formula intolerance
  • immunologic deficiencies
  • pre- or post-operative nutrition
  • infectious diseases

 Sharon Muza: What if a family cannot afford the milk?

Scotti Weintraub: Families are not turned away due to inability to pay.

 Sharon Muza: How is the donor milk tested and treated to insure its safety?

Scotti Weintraub: Here’s how the milk is processed.  The milk is pasteurized and then cultured to ensure the absence of bacteria.  Frozen donor milk is thawed, nutritionally analyzed, cultured, pooled and poured into bottles, then pasteurized at 62.5 C in a shaking water bath or automatic pasteurizer. Pasteurized milk is quick-cooled, then frozen at -20’C. Microbiological cultures are obtained by an independent laboratory from individual donors’ deposits prior to pasteurization and pooling, and from each batch of milk after pasteurization. This is done to verify that no heat-resistant pathogens are present before pasteurization, and that there is zero growth of bacteria after the heating process.

Sharon Muza: What are the obstacles to establishing the Northwest Mothers Milk Bank?

Scotti Weintraub: Fundraising!  If someone gave us a check for $150,000 tomorrow we could be open in a matter of months.  We have raised over $300,000 but must raise the remaining $150,000 before we can open.  As soon as we have secured the necessary funds, we will work quickly to open.

 

Photo courtesy of NWMMB

Sharon Muza: How much milk do you anticipate moving through your milk bank yearly?

Scotti Weintraub: We anticipate processing at least 40,000 ounces (more than 312 gallons) a year.  We also know that we are shipping a large volume of milk out of the region right now.  For instance, in June we shipped over 5,700 ounces of donated milk from four of our Donor Drop Off Sites to other milk banks.  And that’s only the milk from less than half of our current drop-off sites (the others haven’t yet reported their volume).  We anticipate growing the number of drop-off sites and donors once we open.  So we expect to have a large volume right away.

Sharon Muza: How can childbirth educators help spread the word about donor milk in their classes, both for potential donors and those in need?  

Scotti Weintraub: Everyone who works with pregnant and new parents can play a role in spreading the word.  Childbirth educators can tell expectant families about the availability of donor milk should they need it (most have no idea what donor milk is or that they could access it) and let them know that donation is also possible, if they have an abundance.

You can also encourage medical facilities and providers to utilize donor milk for their patients.  Find out if donor milk is available in your area NICUs and family birth units.  Share information about research and best practices to encourage the use of donor milk.

Sharon Muza: Can nursing mothers with babies of any age donate milk? Do you try and match new mothers’ milk with new babies?

Scotti Weintraub: Each milk bank sets their own donor requirements based on the HMBANA guidelines.  Generally milk is accepted from babies less than one year old.  All milk donations are pooled – meaning that the milk from 3-5 donors is mixed together within one batch.  This ensures even distribution of the milk components.  Occasionally, specialized milk is available – for instance preterm milk or dairy-free milk.

NWMMB Education Vid from Bob Eggleston on Vimeo.

Sharon Muza: What are some of the benefits of donor milk for babies?

Scotti Weintraub: According to the AAP, these are the benefits:

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

Sharon Muza: Can older children with severe allergies have access to the milk?

Scotti Weintraub: Milk is sometimes available to older children or adults for a variety of conditions depending on availability.

Sharon Muza: Any final comments to share with our educators and other birth professionals and readers? 

Scotti Weintraub: Donor milk is lifesaving for our most vulnerable babies and it’s very cost effective.  Just for NEC,

“Research shows that necrotizing enterocolitis (NEC), which donor human milk can help prevent, will increase a baby’s length of hospital stay by two weeks at an additional cost of $128,000 to $238,000. In addition, reductions in other complications such as sepsis through the use of donor human milk instead of formula means that the baby goes home sooner with fewer medical issues – and stays healthier.”

The remaining investment needed to open the NWMMB is less than the cost of ONE case of NEC!

Childbirth Educators, do you talk about donor milk and milk banks in your childbirth and breastfeeding classes?  How would you bring up this subject?  Do you think it is important to talk about with expectant and new parents?

Do any of our readers work in a facility that has human milk available for the tiniest patients in the hospital?

Have any of our readers chosen to donate breastmilk or been on the receiving end with their child?  I would love to hear your experiences. – SM

 References

American Academy of Pediatrics. Policy Statement: Breastfeeding and the Use of Human Milk. Pediatrics 2012; 129: e827–e841.

Arnold LDW. The cost-effectiveness of using banked donor milk in the neonatal intensive care unit: prevention of necrotizing enterocolitisJ Hum Lact May;18, 2002, (2):172-7

Boyd, CA, Quigley MA, Brocklehurst P. Donor breast milk versus infant formula for preterm infants: systematic review and meta-analysis.  Archives of Disease in Childhood – Fetal and Neonatal Edition 2007;92:F169-F175

Kuschel CA, Harding JE. Multicomponent fortified human milk for promoting growth in preterm infants. Cochrane Database of Systematic Reviews 2004, Issue 1.

McGuire, W, Anthony MY. Donor human milk versus formula for preventing necrotising enterocolitis in preterm infants: systematic review Arch Dis Child Fetal Neonatl Ed. 2003 8 F11-F14.

Quigley MA, Henderson G, Anthony MY, McGuire W. Formula milk versus donor breast milk for feeding preterm or low birth weight infants (review). Cochrane Database of Systematic Reviews 2007; 1-41.

Silvestre D, Ruiz P, Martinez-Costa C, Plaza A, Lopez MC. Effect of pasteurization on the bactericidal capacity of human milk. J Hum Lact. 2008 Nov;24(4):371-6. Epub 2008 Sep 10.

Sisk PM, Lovelady CA, Dillard RG, Gruber KJ, O’Shea TM. Early human milk feeding is associated with a lower risk of necrotizing enterocolitis in very low birth weight infants. 2007. J Perinatol Jul;27(7):428-33

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

Tully DB, et al. Donor milk: what’s in it and what’s not.  J Hum Lact. 2001. 17: 152-155.

United States Breastfeeding Committee. Statement on the Safe Use of Donor Human Milk. Washington, DC: United States Breastfeeding Committee. 2008.

 

 

Babies, Breastfeeding, Childbirth Education, Newborns, NICU, Pre-term Birth, Research , , , , , , , , , , , , ,

Elective Induction at Term Reduces Perinatal Mortality Without Increasing Operative Delivery? Looking Behind the Curtain

May 29th, 2012 by avatar

A recent study of elective induction at term purports to show that it would reduce perinatal mortality without affecting spontaneous birth rates, although it would increase admission to a special neonatal care unit if done before 41 weeks. The study, conducted in Scotland, analyzed outcomes of 1,271,549 women carrying a singleton, head-down baby of 37 to 40 weeks gestation who gave birth between 1981 and 2007. (Forty-one weeks was considered postterm.) Women with prior cesarean, breech baby, or placenta previa were excluded. Elective induction was defined as induction with no medical indications (hypertensive or kidney disorders, thromboembolic disease, diabetes, liver disorders, pre-existing medical disorder, antenatal investigation of abnormality, suspected fetal abnormality, fetal compromise, or previous stillbirth or neonatal death), and 176,136 women met these criteria. Perinatal mortality was defined as stillbirth or death within the first month, excluding deaths associated with congenital anomalies. Outcomes were adjusted for maternal age, parity (no prior births vs. one or more prior births), time period, and birth weight.

Investigators reported outcomes by week in two ways: women electively induced compared with women not electively induced who delivered after that week and women electively induced compared with women not electively induced who delivered in or after that week. I will report outcomes according to the second method because it is less biased.

Perinatal mortality rates declined from 2.4 per 1000 at 37 weeks to 1.6 per 1000 at 41 weeks in the “not electively induced” population and varied from 0.9 to 0.6 per 1000 in the electively induced population, showing no trend, which meant that the excess

Drewesque, via Flickr, Creative Commons Attribution

perinatal mortality rate fell from 2.3 per 1000 more deaths at 37 weeks in the “not electively induced” population to 0.9 more at 41 weeks. That would seem to clinch the argument for elective term induction were it not for one fatal flaw: investigators did not compare similar populations. They isolated a low-risk—I may even say ultra-low-risk—group of women and compared them with everyone else, including women with the high-risk conditions listed above! Finding lower perinatal mortality rates should not be surprising. It would have been extraordinary if they had not.

Even with that advantage, more babies were admitted to special or intensive care nurseries after elective induction at every week through 40 weeks, which contradicts the current belief that elective delivery at 39 weeks poses no excess risk. Excesses declined from 94 more babies per 1000 with elective induction at 37 weeks to 10 more babies per 1000 at 40 weeks. (At 41 weeks, 3 more babies per 1000 were admitted to special or intensive care in the “not electively induced” population.)

What about finding similar spontaneous vaginal birth rates? Spontaneous birth rates were, indeed, similar between groups, but more women delivered via cesarean surgery in the electively induced group. Depending on the week, 0.3 to 1.5 more women per 100 electively induced had cesareans. Spontaneous birth rates were similar because the cesarean excess was offset by an excess of instrumental vaginal deliveries at each week in the “no elective induction” group. An excess of instrumental deliveries is concerning primarily because of the increased likelihood of anal sphincter injury; however, an excess in cesarean deliveries is far more serious, carrying as it does increased likelihood of severe maternal and perinatal morbidity and mortality in both current and future pregnancies.

Rob, Joyce, Alex & Nova's photostream, via Flickr, Creative Commons Attribution

Rob, Joyce, Alex & Nova's photostream, via Flickr, Creative Commons Attribution

Furthermore, the investigators chose not to report cesarean rates according to parity. Women with a prior vaginal birth or births will be little affected by induction, but first-time mothers are a different story. Studies (see references below) comparing term elective induction with spontaneous onset report that elective induction roughly doubles the chance of cesarean with excesses ranging from 3 to 31 more women per 100 having labor end in cesarean. Three studies (Hannah et al. 1996, Kassab et al, 2011; Pavicic et al. 2009.) specifically evaluating elective induction at 41 weeks compared with expectant management for at least one more week in low-risk first-time mothers report a remarkably similar excess: 8 to 9 more cesareans per 100 women induced electively. In first-time mothers, then, the excess cesarean surgery rate was almost certainly much greater than the excess rate in the Scottish population overall.

So there you have it. Does elective induction at term save babies? We don’t know because the investigators compared apples to oranges. It certainly increases likelihood of admittance to special or intensive neonatal care through 40 weeks, an excess all the more ominous because comparison women were not all low risk. It’s also a safe bet that it substantially increases cesarean surgery rates in first-time mothers going by what other studies have found. And, again, the excess would likely have been greater even in the population overall had investigators compared low-risk women to low-risk women. Lesson learned: if you don’t look at what’s behind the curtain, you may get very misleading ideas of what is really going on.

Boulvain, M., Marcoux, S., Bureau, M., Fortier, M., & Fraser, W. (2001). Risks of induction of labour in uncomplicated term pregnancies Paediatr Perinat Epidemiol, 15(2), 131-138.

Cammu, H., Martens, G., Ruyssinck, G., & Amy, J. J. (2002). Outcome after elective labor induction in nulliparous women: A matched cohort study. Am J Obstet Gynecol, 186(2), 240-244.

Dublin, S., Lydon-Rochelle, M., Kaplan, R. C., Watts, D. H., & Critchlow, C. W. (2000). Maternal and neonatal outcomes after induction of labor without an identified indication. Am J Obstet Gynecol, 183(4), 986-994.

Ehrenthal, D. B., Jiang, X., & Strobino, D. M. (2010). Labor induction and the risk of a cesarean delivery among nulliparous women at term. Obstet Gynecol, 116(1), 35-42.

Glantz, J. C. (2005). Elective induction vs. Spontaneous labor associations and outcomes. J Reprod Med, 50(4), 235-240.

Le Ray, C., Carayol, M., Breart, G., & Goffinet, F. (2007). Elective induction of labor: Failure to follow guidelines and risk of cesarean delivery. Acta Obstet Gynecol Scand, 86(6), 657-665.

Luthy, D. A., Malmgren, J. A., & Zingheim, R. W. (2004). Cesarean delivery after elective induction in nulliparous women: The physician effect. Am J Obstet Gynecol, 191(5), 1511-1515.

Macer, J. A., Macer, C. L., & Chan, L. S. (1992). Elective induction versus spontaneous labor: A retrospective study of complications and outcome. Am J Obstet Gynecol, 166(6 Pt 1), 1690-1696; discussion 1696-1697.

Maslow, A. S., & Sweeny, A. L. (2000). Elective induction of labor as a risk factor for cesarean delivery among low-risk women at term. Obstet Gynecol, 95(6 Pt 1), 917-922.

Prysak, M., & Castronova, F. C. (1998). Elective induction versus spontaneous labor: A case-control analysis of safety and efficacy. Obstet Gynecol, 92(1), 47-52.

Seyb, S. T., Berka, R. J., Socol, M. L., & Dooley, S. L. (1999). Risk of cesarean delivery with elective induction of labor at term in nulliparous women. Obstet Gynecol, 94(4), 600-607.

Vahratian, A., Zhang, J., Troendle, J. F., Sciscione, A. C., & Hoffman, M. K. (2005). Labor progression and risk of cesarean delivery in electively induced nulliparas. Obstet Gynecol, 105(4), 698-704.

van Gemund, N., Hardeman, A., Scherjon, S. A., & Kanhai, H. H. (2003). Intervention rates after elective induction of labor compared to labor with a spontaneous onset. A matched cohort study. Gynecol Obstet Invest, 56(3), 133-138.

Vardo, J. H., Thornburg, L. L., & Glantz, J. C. (2011). Maternal and neonatal morbidity among nulliparous women undergoing elective induction of labor. J Reprod Med, 56(1-2), 25-30.

Vrouenraets, F. P., Roumen, F. J., Dehing, C. J., van den Akker, E. S., Aarts, M. J., & Scheve, E. J. (2005). Bishop score and risk of cesarean delivery after induction of labor in nulliparous women. Obstet Gynecol, 105(4), 690-697.

Yeast, J. D., Jones, A., & Poskin, M. (1999). Induction of labor and the relationship to cesarean delivery: A review of 7001 consecutive inductions Am J Obstet Gynecol, 180(3 Pt 1), 628-633.

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Book Review: Fragile Beginnings

April 16th, 2012 by avatar

By regular contributor, Darline Turner-Lee, BS, MHS, PA-C

Book Review: Fragile Beginnings

Fragile Beginnings by Adam Wolfberg, M.D., is a deeply personal account of the events surrounding the birth of his daughter Larissa at 26 weeks and the emerging technologies that are being developed to save such fragile infants. Dr. Wolfberg examines the question, should such fragile infants be saved and what are the ethical issues associated with the research and development of treatments and the care of these tiny infants.

Interestingly, the book reads more like a novel. It reminded me of the books by Robin Cook, you know, Coma, Brain, Fever, etc…Had this book been called “Baby” I would have had to wonder if Dr. Wolfberg really was the author! I say this because while this book is factually accurate, it is quite easy to read and I personally found it engaging. I found myself wondering what happened to Larissa, so I kept reading.

The strength of the book comes from the great wealth of information presented. Dr. Wolfberg provides in-depth information on neuroplasticity, intraventricular hemorrhage in premature neonates, the research and development of treatments for premature infants with these disorders, discusses the ethics surrounding treating these conditions such as whether or not it is prudent to develop treatments for children who may have what many consider “sub-standard” lives.

What provided interest were the background stories about Kelly, Dr. Wolfberg’s wife, as well as back stories about the various health care providers. All of the doctors and health care professionals mentioned were three dimensional. They were introduced and their integral role in Larissa’s care was described via their personal histories, trials and tribulations. We learned Jason Martin became a doctor in an effort to try to find a cure for his brother who had a spinal cord injury. We got to know Dr. Steven Ringer, the head of the Brigham and Women’s Hospital NICU and about his passion for saving babies.

Although I enjoyed reading the book, I kept asking, what is the point the author is trying to make and who is his intended audience? Is the intended audience other doctors or health care professionals? Is it a tribute to Brigham and Women’s Hospital NICU? Is it a piece outlining how far medicine has come in the care of fragile infants?

The book is called Fragile Beginnings and initially I thought that the book would focus more on Larissa and the Wolfberg family as they struggled to cope with Larissa’s prematurity. Yet, Larissa wasn’t really the star. The main focus was on the medical advances that have been made in neonatology, the doctors making those advances and the ethics behind the advances.

As such, this is not a book that I would recommend to new parents who recently gave birth to a premature infant. In my opinion, those parents need information on how to cope with this unexpected situation and resources to help raise and develop their child. This book does not at all address such issues. Towards the end of the book, we see Larissa developing and progressing, but we really have no idea how her parents found the physical therapists, occupational therapists and other ancillary health care personnel that helped care for Larissa.

We get a glimpse into the fact that the family lives in a town that provides a lot of social services. If I were a parent of a preemie, I would want to know how I go about finding out what services are available in my town and getting my child connected. This isn’t addressed.

I think parent readers would also prefer more details about what Dr. Wolfberg and his wife were going through on an emotional level. How about a chapter describing how they explained what happened to Larissa to her sister and their responses? How about a chapter describing how his wife Kelly coped with delaying her own career to care for such a fragile child? This is truly a difficult situation for many moms and while Dr. Wolfberg once mentioned Kelly’s irritation that he was able to continue this career while hers was stalled, a mom reading this chapter may be wondering how Kelly may have dealt with any resentment or feelings of guilt for having resentment at all.

As a parent of a fragile infant, I would want to know how Larissa’s medical issues specifically affected her development. Was she significantly delayed? When did she walk, talk and learn how to feed herself? If I was a mother of a severely premature infant, I would want to know how and when Kelly potty trained Larissa. If I were a new parent of a premature child, born around the same time as Larissa, I would want the “uncut” version of everything that I am about to encounter; how to find specialists, best ways to soothe the child, how and when to recognize when you can teach your child a new skill, etc.

We see Larissa as an infant in the NICU, then she goes home, and then we see her at about a year and then again at ages 5 and 9.

What happened in the interim? At what age did she start school? Did she begin in any sort of special education classes? Is she behind cognitively? Did she learn to speak on time? There are too many gaps to get a real impression of what it’s like raising a fragile infant. We as readers are left with too many inferences to make.

One other point of concern is that Larissa seemed to get the “creme de la creme” treatment. Describing Larissa being rushed to the NICU, Dr. Wolfberg talks about how the staff overrode the elevator asking other hospital guests to vacate while they whisked her away “for they were taking care of one of their own”. It made me wonder, is this the standard treatment that all premature infants receive? Larissa was the daughter of one of the OB/GYN residents. It doesn’t get much closer than that! (Except if she was the child of a neonatology resident!)

Would my child have received the same treatment if she had been born at Brigham and Women’s Hospital? Would a child whose parents were on Medicaid? Would a Medicaid child have the same access to care and services that Larissa had? Larissa’s family lives in Newton, MA, an affluent suburb of Boston known for its excellent schools and social services. I know this because I grew up there. But could a family that didn’t come from a town with the abundant social resources hope for the same outcome for their child? Would they have been informed about the program at the University of Birmingham? Would the family have been eligible or have had the means to attend? I would have preferred to have learned more about the particular services that Larissa had access to, what they contributed to her development and as a parent I would have liked more information on how to access those services in my hometown.

Overall, the book is well written and informative. However, I’ll recommend it like this; if you want to read a well written book about prematurity and advances in neonatology and brain injury, this is a really good book. If you want a book that reads like an episode of Grey’s Anatomy, you will probably like this book. If you are a parent of a premature infant, you may want to read this book to gain some understanding of why your child’s neonatologist is making the recommendations and decisions s/he is making.

But if you are a parent of a premature infant trying to cope with they myriad of emotions, while at the same time wondering what types of care your child will need, where to find services and providers, how to find out what is available in your area and how to access those services, this is not the book for you as it doesn’t answer any of those questions.

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