November 23
Volume 7, Issue 24
Midwifery Today E-News
“VBAC Disinformation”
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Quote of the Week

"The first intervention in natural childbirth is the one that a healthy woman does herself when she walks out the front door of her own home in labour."

Michael Rosenthal, OB/GYN


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The Art of Midwifery

I discuss at length with my patients how to prevent a malpresentation. It's much easier to prevent this problem than to treat it. The number one way to prevent malpresentation is for the mom to stay as active as possible: Walk every day. When going up stairs, take two steps at a time. If the back hurts, do pelvic rocks. Get familiar with your baby, feel your belly. Do you mostly feel "small parts" (knees, elbows, feet)? That's not good—baby could be posterior. Do exercises to change that situation. Do you feel mostly a smooth longitudinal back? Great! Avoid like the plague sitting in a recliner. Lying on your back in the recliner helps encourage the posterior position. My Mennonite women say, "During pregnancy, wash your kitchen floor on your hands and knees every time and you will have an easier birth." It's true. That position puts the baby's back toward your front. And while washing your floor, scooting on your knees from one spot to the next, wiggle your hips to encourage proper positioning of the head. My best advice is to not be a slug in these coming weeks, and your baby will be in the best possible position.

Joyce, Midwifery Today Forums


ALL BIRTH PRACTITIONERS: The techniques you've perfected over months and years of practice are valuable lessons for others to learn! Share them with E-News readers by sending them to mtensubmit@midwiferytoday.com.


Research to Remember

Trauma at birth such as postpartum separation of the newborn from its mother may affect the offspring's immune system to the extent that it is more susceptible to viral infections later in life. This susceptibility ultimately could trigger multiple sclerosis, thought to be an autoimmune condition. Researchers at Texas A & M University have found intense newborn trauma to affect immune, endocrine, and behavioral responses to viral infection. The researchers used reaction to Theiler's virus to investigate the role of stress in autoimmune diseases. Mice who had been separated from their mothers after birth and later injected with the virus revealed altered behavioral signs of infection and greater difficulty clearing the infection than did mice that had not been separated from their mothers at birth. Researchers concluded that early life is a critical period of development of the immune system, and that serious stressors can alter immune system function for a lifetime.

http://rev.tamu.edu/stories/04/062104-6.html


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VBAC Disinformation

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 (NEJM) 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 5/1000, the same as other studies have shown, 7/1000 with oxytocin induction, but a whopping 25/1000 with prostaglandin (PGE2) induction. The risk in women planning cesareans was 2/1000, 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 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."

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 important, 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.

I recalled that NEJM had published several articles and editorials on obstetrics over the past few years that followed this same pattern—distorted interpretation of data, prejudiced editorial using loaded language, or both [Ed note: to read more, see the entire article in Midwifery Today Issue 63]:

1992:
"Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial": This study was widely hailed as proving that induction at 41 weeks was preferable to expectant management. The study itself only claimed, contrary to many previous studies of induction, that cesarean rates were lower (20% vs 25%).

Flaws: One-third of the expectant management group was actually induced, and one-third of the induction group actually began labor spontaneously, which would flatten out the differences between groups. A follow-up analysis in a different journal revealed that one-fifth of women in the expectant management group with spontaneous labor onset had cesareans versus a third of women who were induced. Among nulliparous women, 25% of women with spontaneous labors had cesareans compared with 40% of induced women. The question of why so many healthy women with term pregnancies and a singleton, cephalic baby in either group ended up with c-sections wasn't of course, addressed.

1996:
"Comparison of a trial of labor with an elective second cesarean section": "Major complications were nearly twice as likely among women undergoing a trial of labor."

Flaws: The only VBAC study to conclude that repeat cesarean had the advantage, it did so by coding wound infections and hemorrhage requiring transfusion as "minor complications." These would normally be considered major complications, and coding them as such would have wiped out the difference. Even so, the major complication rate was a bit less than 1% in the elective cesarean group, a bit more than 1% in the VBAC group, hardly grounds for recommending elective cesarean.

2001:
"Misprostol [Cytotec] and pregnancy": This review admits Cytotec's adverse effects and equivalent cesarean rates compared with PGE2 or oxytocin but goes on to conclude that "there is ...strong and consistent evidence to support the use of misoprostol...for induction of labor." The accompanying editorial signed by two official representatives of the American College of Obstetricians and Gynecologists, chastises Searle, the drug's manufacturer, and the FDA for opposing Cytotec's use. "The real victims," it states, "are pregnant women who receive treatment in hospitals that will not allow the use of misoprostol. Alternative medications are expensive [true] and relatively ineffective [a statement contradicted in the review itself]." It asks the FDA to "recognize the beneficial roles misoprostol can have," and closes with "Women in the United States should not be deprived of access to misoprostol."

Flaws: According to the FDA, Cytotec can cause, among other things, uterine tetany with marked impairment of blood flow to the fetus, uterine rupture, sometimes requiring hysterectomy; amniotic fluid embolism; severe genital bleeding; shock; fetal bradycardia; and fetal and maternal death. Uterine hyperstimulation may increase the incidence of meconium passage and cesarean delivery. As regards superior effectiveness, a meta-analysis of randomized controlled trials of PGE2 versus misoprostol shows that Cytotec produces virtually identical cesarean rates.

— Henci Goer, excerpted from "The Assault on Normal Birth: The OB Disinformation Campaign," Midwifery Today Issue 63


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Web Site Update

Read this article on our Web site:

This story about a South American midwife is now online in Spanish. Antonina Sánchez Méndez was born in 1952 in Guatemala. As with most women of her culture, her days are filled with physical labor. She has seven children and 11 grandchildren and is deeply connected to her community. She was 33 years old when she began her career as a midwife. Let your Spanish-speaking friends know about this article! If you're studying Spanish, read it alongside the English version which appears in print in Midwifery Today Issue 71.


We need your help! We have extensively updated our Web pages on many countries around the world. These pages include biographies (and sometimes a snapshot!) of our Country Contact, as well as links to information about birth, midwifery and parenting. For example, take a look at these country pages: Russia, Italy, Ukraine, Belgium and Israel.

However, we need more links for some countries: perhaps you know of some! Start on the international gateway page to begin your perusal, then click on a flag or country name.


Forum Talk

For someone whose baby rotates to transverse and then vertex and then breech, etc., with no fetal or pelvic anomalies (past 35 weeks), would you suggest a belly binder of some sort? Just wondering what would be the course of care to promote a longitudinal lie (preferably vertex).

Nicole


Go to our forums to share your thoughts and experience.


Question of the Week

Q: I have a client who has kidney failure and produces sistine kidney stones. Her creatinine levels are descending and are currently at 1.9. She has catheters from her kidneys to urethra which have been replaced during pregnancy to accommodate the uterus. Obviously her nephrologist and GYN have told her she should have a cesarean because the catheters won't withstand the "pressure" of labor. Does anyone have advice about/experience with this situation?

— Luna Maya Birth Center, Chiapas, Mexico


SEND YOUR RESPONSE to mtensubmit@midwiferytoday.com with "Question of the Week" in the subject line. Please indicate the topic of discussion *and the E-News issue number* in the message.


Question of the Week Responses

Q: I am looking for information for a client regarding septate uterus. She is now 21 weeks pregnant and can find resources only for prevention rather than stats about outcomes or what can be done to attempt to ensure a safe outcome and carry the baby to full term.

— Shari Gorman

A: Williams Obstetrics textbook: "Partially septate uteri may be expected to have relatively normal deliveries. Septate uterus has a complete longitudinal septum and may give rise to a host of possible difficulties, including prematurity, pathologic lie, uterine dysfunction, and even uterine rupture."

Pregnant women diagnosed with a septate uterus should do what every low-risk pregnant woman should do: eat a healthy diet, exercise moderately and anticipate a normal delivery.

— Judy Slome Cohain

A: I have worked with only three women with septate uterus. None of these women had difficulty carrying babies to term (no miscarriages). However, I shared a total of five births with one mom who was a G3 P2 the first time I cared for her. Her first two babies were vertex, her third (my first with her) presented breech, was a surprise and born at home with no complications. Her next baby was also breech, but with her history we found out about the septum with an ultrasound to double check this baby's presentation. Another full-term homebirth. The next baby was vertex, then breech; the last was vertex. The interesting part was that if the baby implanted on the right side, assuming ovulation from the right ovary, the baby would be breech throughout the pregnancy. If the baby implanted on the left, it would turn to vertex. The septum was not midline but rather pushed over into the right quadrant, and we theorized that babies implanted on the right side just did not have any room to rotate to vertex later in pregnancy. There was always a marked bulge on the right side with the breech babies and they were on average about 1-1/2 pounds lighter.

— Patricia Edmonds, midwife

A: I have a friend who was told repeatedly that she would not carry to term and that she would most likely require a section. She went on to deliver twice, full-term babies with not one problem. Just because a medical book says a septate uterus is a complication doesn't mean you have to believe it or treat it that way until it proves otherwise. She is not the only woman I have heard of to have been a success.

— Heather

A: Unfortunately, not much can be done right now during pregnancy to solve your septate uterine issue. Good nutrition, relaxation and visualization are good. You may need careful monitoring from here on in. Pay attention to your uterus and contact your birth attendant if you experience any contractions. That is all you can do for now. Even a cerclage won't help because this is not a cervical issue. After your baby is born you may want to contact a good surgeon and have the septum removed. That way future pregnancies will be easier.

— Kathy Metzler, RN

A: For women with a septate uterus it is very, very important to have a vaginal birth rather than a cesarean if the woman is planning more than one child. According to Lieberman (2001) the uterine rupture rate in women with septate uterus in pregnancy after the cesarean was 8%, compared to the average rupture rate after cesarean which is 2/1000. (Lieberman. Risk factors for uterine rupture after cesarean. Clin Ob Gyn 2001; 44(3): 609–21.)

— Judy Slome Cohain


Regarding Group B Strep [Issue 7:22]:

Q: I am a mom of six and would like to find out how most midwives deal with Group B Strep (GBS)-positive mothers. Are there herbal remedies or are they destined to a hospital birth and IV antibiotics?

— Anon.

A: I do not agree with assessing risk factors to determine if a mom should be tested for GBS. I am a strong proponent of testing everyone, as risk factors do not accurately divulge everyone who is GBS-positive, therefore leaving numerous babies at risk of GBS infection from an untested mother. Some mothers are GBS-positive in a previous pregnancy and negative in subsequent pregnancies and vice versa.

One writer said that in homebirths, she doesn't test mothers and only does vaginal exams (VE) when necessary [Issue 7:22]. I agree that VE should be restricted in *any* delivery. However, it wasn't mentioned what she does when a mother's membranes are ruptured. The longer a bag of water is ruptured, the longer the baby is exposed to GBS. Studies show that giving a mother at least two doses of IV antibiotics spaced apart according to the safety of administration (i.e., PCN should be 4 hours apart and Clindamycin should be 8 hours apart for doses) prior to delivery (and this is as close to delivery as possible) enormously decreases the chance of passing on the GBS infection to the infant.

Have you ever seen an infant ill with a GBS infection? It can quickly bring them to demise. GBS is no small matter. It kills infants, whether full-term or preterm. Screening is necessary, along with proper treatment for prevention of infection in infants. This may entail a hospital birth if that is the only option in your community, but I would have to guess that a mother would be willing to give up the homebirth setting (even though it is so much more welcoming and calming) in exchange for greatly decreasing the chance of infection in her unborn child.

— Tanya Jennison, RN

A: I am a mother of two, and I was diagnosed with GBS in both pregnancies. I delivered my first son in a out-of-hospital birthing center with an IV and everything. It was a great birth and a healthy baby—no complications. Thirteen and a half months later, I gave birth at home to my second son without an IV. My midwife's backup doctor thought it would be safe for me to take oral antibiotics during the last two weeks or so before the birth. My second delivery was much better than the first, I had an equally healthy baby and a faster recovery time.

My personal advice and opinion is to study the risks and benefits of GBS and antibiotic treatment, then make your decision based on what you feel is right. Of course, talk to your midwife to make sure you understand the risks and what they could mean to you personally.

— Maria Moles

A: Unfortunately, too many women focus on their experience of birthing and forget that the most important aspect of the pregnancy is a safe and healthy outcome for mother and baby. While GBS doesn't affect the woman, it can (and does) have rapid and devastating effects on the infant. Recently our maternity unit in Australia had two sad cases of babies dying/developing meningitis as a result of no IV AB cover in labour. If women are really serious about the safety of their babies, they would consider the child's health over their own right to not have antibiotics. I am a big advocate for women's rights in pregnancy and labour, but comfort and wants should *never* outweigh health and safety.

— Meg


Editor's Note: Responses to any Question of the Week may be sent to E-News at any time. Write to mtensubmit@midwiferytoday.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.


Feedback

Regarding hair loss after birth:

During pregnancy there is

  • prolongation of the hair-growing phase (anagen), giving the impression that hair is growing faster
  • diminution of the number of hairs at rest and of the "hair falling" phase.

Around the second and fourth postpartum months this process reverses, leading to rapid hair loss. The hair's growth cycle returns to normal between six and twelve months postpartum.

Monique Pare, midwife
Quebec


Editor's Note: Only letters sent to the E-News official e-mail address, mtensubmit@midwiferytoday.com, will be considered for inclusion. Letters sent to ANY OTHER e-mail addresses will not be considered.


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