|December 11, 2002|
Volume 4, Issue 38
|Midwifery Today E-News|
“Obstetric Interventions, Part III”
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THIS WEEK'S ISSUE
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Quote of the Week
"Prevention is a worthy and good cause. The problem is that her cousin, intervention, likes to follow only a few paces behind."
- Mayri Sagady
The Art of Midwifery: Pubis Symphysis Pain
I have known women to be treated for pubis symphysis pain by application and wearing of a wide, firm elastic belt secured with Velcro around their hips, pulled firmly. While it does not cure, it certainly, according to the women, supports the symphysis pubis and enables more comfortable ambulation.
Share your midwifery arts with E-News readers! Send your favorite tricks to email@example.com.
News Flashes: Teen Pregnancy
A study examined ethnic differences in childhood and adolescent sexual abuse and the effect on teenage pregnancy rates. Almost 36% of women (n = 190) reported sex abuse before 18 years of age, and more than 26% were pregnant before reaching 18. Compared with nonabused peers, twice as many women who were coerced into sex or raped had a teen pregnancy. Minority-group teens were more likely than Anglos to have a teen pregnancy and to have been coerced into having sex rather than raped prior to pregnancy.
- Journal of Adolescent Health, 21(1), 1997
Obstetric Interventions: Induction
Induction of labor is so common that many people are unaware of the risks. Even a "simple" uncomplicated induction can start an avalanche of interventions. Beginning with a cervical stretching and sweep to ripen the cervix, then to IV Pitocin, electronic fetal monitoring, amniotomy, then perhaps an intrauterine pressure catheter, amnioinfusion for unusual fetal heart tones, an epidural for the pain of Pitocin-induced contractions, malrotation, or poor descent because of the epidural, then maybe a vacuum extraction or cesarean for "failure to progress." The mother ends up with life-long injury to her uterus. Her baby may be stressed and separated from the family. A normal birth may turn into a nightmare. And that's if all goes "well."
Induction is a minefield, a setup for complications. An induced labor forces the baby out before the body is ready, before the complex hormone interaction has primed the cervix, and often before the baby has reached his or her full intrauterine maturity. We now have drugs that can produce contractions and soften the cervix, but this is only a small part of the complicated process of labor. We can make a woman have contractions, but we don't always succeed in forcing her body to release the baby and give birth. If we start a labor with chemicals, we may very well have to finish the labor with the surgeon's scalpel.
Some studies show that induction raises the risk of cesarean by 800%. Electronic fetal monitoring must be used in all chemical induction methods because of the risk of hypertonic contractions and fetal distress. EFM alone increases the risk of cesarean and vacuum extraction or forceps delivery. Amniotomy increases the risk again. Cesarean for fetal distress is even more common, whether the distress is real or a result of an EFM artifact, because nonreassuring fetal heart tones are frequently observed. Meconium staining, meconium aspiration syndrome, and even shoulder dystocia are directly associated with inductions. The rise in the rate of induction closely mirrors the rise in cesarean delivery, as does the rising incidence of postcesarean rupture. A woman with prior cesarean is unlikely to experience a uterine rupture — odds are usually less than 1% — but if she is induced, her risk may rise to 2 to 4%.
- excerpted from
I first realized that the assault on normal childbirth wasn't merely a series of sporadic events when I read the VBAC study and accompanying editorial that appeared in the New England Journal of Medicine in July 2001. I was struck by the disparity between what the study said and the accompanying editorial.
The study analyzed data on 20,500 Washington State women with previous cesareans. Researchers found that the risk of uterine rupture during a spontaneous VBAC labor was 5/1,000, the same as other studies have shown, 7/1,000 with oxytocin induction, but a whopping 25/1,000 with prostaglandin (PGE2) induction. The risk in women planning cesareans was 2/1,000, not far off the odds with spontaneous labor. An unbiased person would conclude that PGE2 inductions should be avoided and that primary cesarean introduced the risk of uterine rupture regardless of subsequent birth route.
The editorial, however, written by a NEJM editor, hammered home the dangers of uterine rupture during VBAC and how doctors and their professional organizations were "coerced or cajoled" into supporting VBAC programs. It concluded, "After a thorough discussion of the risks and benefits of attempting a vaginal delivery after cesarean section, a patient might ask, 'But doctor, what is the safest thing for my baby?' Given the findings of Lydon-Rochelle et al., my unequivocal answer is elective repeated [sic] cesarean section." This message appeared all over the popular press.
The editorial seemed odd to me because the NEJM is perhaps the most prestigious and highly respected of the research journals. Surely a physician who had achieved the rank of editor had to know that the study said nothing of the kind. For one thing, the differences in rupture rates were modest, provided you didn't use PGE2. For another, uterine rupture isn't the crucial issue -- it's what happens to the baby as a result. The study didn't report this, but calculation using its data showed that with spontaneous labor, the odds of losing the baby were a very low 3/10,000. But more importantly, you can't determine the merits of VBAC versus elective cesarean by just looking at uterine rupture rates because there are complications that occur more frequently with cesarean. My own compilation of 30 studies comprising 56,300 VBACs and 30,000 elective cesareans found a 2/10,000 perinatal mortality rate in the elective cesarean group -- no different from the study's VBAC PMR. How could someone who must be a senior scientist make such elementary errors of data interpretation and evaluation?
- exerpted from
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INTERNATIONAL ALLIANCE OF MIDWIVES
Forum Talk: Breech Birth
It is an unfortunate fact of life that it is becoming harder and harder, almost impossible, to find a caregiver willing to do a vaginal breech birth. While we could debate the issue of safety of vaginal breech births till the cows come home, what I want to look at is how to optimize these women's chances of a successful VBAC for their next birth. I recall reading somewhere that women who dilated past 4 cm before a c-section were more likely to have a successful VBAC the next time. So would it not make sense for those with breech babies planning a c-section to go into spontaneous labour?
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Question of the Week: Itching in Pregnancy
Q: I am nearly 9 months pregnant (1st babe). Terrible itching plagues me. I have tried acupuncture, Chinese herbs and oatmeal baths. The medical suggestion is to take Benedryl, which I haven't done because it seems focused on allergic-type responses, which I don't think is the problem. The itching started at 32 weeks and worsens at night. It is worse on my palms, feet, ankles, back, breasts, and especially at joints. The rest of my body also itches (except my head and face) but is not as bad. It is a deep itch and is only temporarily relieved by scratching. I wake up itching several times a night. Any answers?
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Question of the Week Responses: Group B Streptococcus
Q: How are midwives treating group B streptococcus-positive women wanting a homebirth? I am having trouble establishing a protocol that I feel comfortable with.
A: I have used the Natural Pregnancy Book (Aviva Jill Romm) protocol several times. I usually reculture a GBS-positive woman from 35-36 weeks, again in labor, or culture the baby after birth to see if GBS can be detected. These protocols have not been studied. Goldenseal is known as an herb to combat GBS. This protocol is not endorsed by CDC.
- Vanita Lott, CNM
A: We have tried using olive leaf orally to treat the infections, and there has been discussion among some of the midwives in our state about using prophylactic antibiotic IVs, but it is out of the legal scope of practice for licensed midwives. A few midwives have talked about using nurse practitioners or CPMs to administer the IVs. Some believe that prophylactic antibiotics do not work.
We emphasize education about GBS and ask our clients to make their own decision once they understand the possibility of GBS respiratory distress in the newborn.
I apprentice with 3 different midwives, and they all have a different take: one treats herbally, one educates and one prefers to risk out of care.
- Lisa-Ann Colton
A: Recent research indicates that a vaginal flush during labor with antiseptic soap (chlorhexidine) helps prevent neonatal illness. (J Matern Fetal Med 2002 Feb;11(2):84-8)
Some healers recommend using 3 tsp colloidal silver per day. Other healthcare practitioners are concerned about silver toxicity and don't recommend it.
A naturopathic physician told me that treating GBS infections with large oral doses of probiotics is all that is needed to eliminate GBS as a vaginal pathogen.
I have begun using the following protocol of naturopathic treatment for GBS-positive women. As yet, not enough have taken this treatment to see if it indeed eliminates GBS. But a few women have had success in being clear of the bacterium in the weeks after a positive test at 36 weeks.
Twice a day, with breakfast and dinner:
1) acidophilus: 4 billion cells per dose
We then culture weekly to see if the bacteria are decreasing. The reading taken closest to delivery is supposedly the most reliable. If this regimen is successful at eliminating GBS, I would suggest staying on it until birth to give the best possible likelihood that it will not be present in your vagina at the time of birth.
A: My midwife treated me with 1,000 mg vitamin C daily and colloidal silver that was soaked in a tampon and inserted vaginally at night for four weeks before my EDD.
A: Have B strep-positive women insert a tampon soaked in diluted tea tree oil. After three days, they will no longer test positive! An alternative that takes longer is the vaginal use of acidophilus capsules for six weeks.
A: During my second pregnancy (my first homebirth) the doctor said if I was B strep positive I would have to have a hospital birth. This is completely false! IM treatment for group B strep with penicillin G benzathine is just as effective as intrapartum treatment. The recommended dose is 1.2 million units once a week for four weeks before delivery. The recommended treatment schedule is 1.2 million units in weeks 35, 36, 37 and 38. Study results have determined that penicillin levels are high enough to inhibit the growth of B strep for four weeks after the last injection.
The following articles should help you educate yourself and your clients:
- Erika Obert
A: Here in British Columbia, Canada, where midwifery is integrated into the public healthcare system, GBS+ women in my practise are offered:
1) Herbal treatment as soon as possible (when the positive culture comes back) to help reduce colonisation, with full informed choice that this is not evidence-based and no research is available. It consists of 2 acidophilus tablets inserted vaginally at bedtime and 3 orally per day. E-mail me for a douche formulation (email@example.com).
2) Women choosing antibiotic prophylaxis are given the first dose in hospital in case of anaphylaxis. My opinion about this vacillates because a) death from anaphylaxis is the main risk of the prophylaxis to the mother but b) it is so rare (1 in 100,000); I'd rather give informed choice about where the first dose is given. Subsequent doses are administered at home. Obvious practical difficulty exists for an anticipated quick labour. Some women in my practice choose against prophylaxis only because of having to go to hospital in labour for the treatment. It is important to know that once antibiotics are given they must be continually given until birth due to the risk of antibiotic resistance developing.
3) In B.C., we carry epinephrine, Benadryl, and are trained in treating anaphylaxis.
- Barbara Barta, RN
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Midwifery Today magazine Question of the Quarter
Theme for Issue No. 65: Tear Prevention
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Theme for Issue No. 66: Birth Environment
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The study on echinacea use in pregnancy disturbs me [Issue 4:37]. First and most important, the study was by far too small to show the significance in the rate of birth defects between those who used echinacea and those who didn't; plus, the women taking echinacea took varying amounts. You can't realistically compare effects of a medicine or herb unless all participants are taking the same dosage. This would be a poor study to use to support the safety of echinacea re: birth defects. However, the last of the article does concern me greatly ("There were 13 spontaneous abortions in the echinacea group compared with 7 in the control group"). Even though the groups are small, I think a doubling of the miscarriage rate seems significant. On the basis of this study, I would personally advise women to avoid echinacea in pregnancy until it's studied further for safety.
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