Empowering Birth Blog

If Baby is "Late," Stay Busy!

A watched pot doesn't boil and there is no use sitting around and waiting for baby.  It is Sunday and we are off to church.  I sing in our church's gospel choir most Sundays but today the youth choir sings and I must admit will not mind having the freedom to sit during mass.  After church we are going to look at a new house that came on market, visit a park with the kids and head home to cook dinner.

Tomorrow I am taking my midwife to lunch for her birthday, along with two of her apprentices. I will probably begin the morning with another hike in the arboretum.  On Tuesday I might schedule an acupuncture or acupressure session and on Wednesday I have another prenatal with my midwife.

Interestingly enough, even the American College of Obstetricians and Gynecologists does not consider a pregnancy post-term until the 42 week mark has been hit.  Here is a good article on why waiting is good for baby.

Well I have a busy week ahead of me so I don't expect to blog again until I am in labor or have had the baby.   Be well!

Rebozo Time

I am off to my friend's this afternoon for a good rebozo, a technique for helping baby swing from a posterior to anterior position.  Also great for relaxing uterine ligaments!  I spent a delicious morning at the aboretum with the kids.  After feeding the koi, I left the kids with Mom and husband and vigorously hiked the azalea trail up to the top of the mountain.  I didn't meet a single soul along the way which allowed me to feel completely free to sing songs to baby.  My body felt loose and ready to open among the wet and soft spring earth and I had plenty of achy contractions.  Ah but life is good!

Premature Labor?

My friend just had a 72 hour labor.  WOW, 72 hours, now there is a number that could get a mom really discouraged.  It was preterm labor (35 and 1/2 weeks) and her midwife offered morphine to help her rest (which would mean staying at the hospital), I suggested home, rest, hot bath, and wine.  So this birth has gotten me thinking about two things.  One, when is a mom in labor, and two, what is a good way for mom to get rest/slow down contractions.  I don't think I am ambitious enough to tackle both in one blog post so let's start with helping mom rest/slowing down labor.

In Spiritual Midwifery, Ina May writes:

"If there is no bloody show and there is no or very little dilation of the cervix (less than 1 cm), give the mother a full glass of water followed by a glass of wine.  Alcohol is a depressant, and it suppresses the release of oxytocin from the pituitary gland.  It works well for stopping labor in the third trimester.  Alcohol should not be given in the first two trimesters to inhibit labor because of possible damage to the developing baby.  The woman should stay in bed and everything should be as nice and quiet around her as possible."1

Now my friend was 4 centimeters dilated, not one, but the midwife was offering morphine so my thought was, if wine works (and there is no history of alcoholism in the family), why not?  And the wine was indeed a tremendous help.  It slowed down my friend's contractions, helped her manage a long labor, and possibly helped keep the baby in her an extra two plus days, which got the baby a lot closer to 36 weeks.

So a few days after my friend's birth, I was listening to the tape on Prolonged Labor by Diane E. Barnes, CNM and Gertrude L. Welsh, CNM, NP from "Midwifery Today's Clinical Tape Package" and the CNMs were discussing ways to help mom sleep when she is faced with a potentially long labor or just really needs some rest.  Instead of morphine, they recommend 50mg of Vistaril and 1000 mg of Tylenol.  If the mom's contractions are more painful, they suggest giving a Tylenol #3 (with codeine) in addition to two regular Tylenol). Apparently the midwives have had success promoting the Tylenol/Vistaril combination to hospital doctors as an alternative to morphine.   Among other things, lack of rest, nourishment and hydration can also encourage pre-term contractions, so before tackling the problem of how to help mom rest/slow down those contractions, you should ask mom are you hydrated/how much rest have you had/what have you been eating, etc. etc.?

Which brings me to another thought.  One of the midwives on the tape noted that she didn't believe in Braxton-Hicks contractions before 36 weeks.  She felt that contractions before 36 weeks were due to an irritable uterus or a sign of potential preterm labor.  What an interesting way to think about uterine contractions.  If there is no such thing as Braxton-Hicks contractions before 36 weeks, then if you experienced contractions before 36 weeks, you might think to yourself, I need to hydrate/rest/nourish myself.  If Braxton-Hicks contractions can be experienced before 36 weeks, you might think to yourself, oh, there goes my uterus again.

In any case, my friend said no to the morphine, returned home after laboring in the hospital for a while, took a few hot baths, rested, had a glass or two of wine, and these things seemed to slow her labor down, keep baby inside for a few more days, and gave her the energy she needed to birth her baby when the time came.  I should add that my Midwifery Tape on Prolonged Labor did not recommend wine due to fetal alcohol syndrome, but if Ina May recommends it, alcoholism doesn't run in the family, and you are in your third trimester, I can't help but think it seems like a good idea.  A mom I know who is German mentioned that a glass of wine or beer is a common recommendation for moms in early labor.  What do you think?  Oh, and if you have Spiritual Midwifery, there is a great birth story on page 70 of a mom who uses wine to stop pre-term labor.

Post to be continued....

1 Ina May Gaskin, Spiritual Midwifery, Fourth Edition (Summertown, TN:Book Publishing Company, 2002) 425.

Thoughts on Group B Strep

Pregnancy is a time when you should relax, take care of yourself, and avoid stress.  It saddens me that so many of the procedures used in routine obstetrical care increase stress without adding benefit.  I've been thinking about Group B Strep recently because a pregnant mom I know will soon be required to undergo testing for this common bacteria.  In the UK, pregnant women are not routinely screened for GBS, primarily because colonization is extremely variable and there is a tendency for recolonization after treatment.1 Here is a great link that provides more information on Group B Strep: http://www.homebirth.org.uk/gbs.htm.  If you don't have any risk factors present, you might want to consider whether or not testing for Group B Strep is the best decision for you.  The CDC's protocols are "expected to reduce, but not eliminate, the incidence of neonatal infection."2  In other words, GBS testing does not guarantee an infection-free newborn and the risks of routine GBS testing and treatment of all GBS positive moms remain unknown (a few follow below).  Interestingly enough, routine screening has not resulted in any decrease in late-onset neonatal GBS disease.3

Risk Factors (moms/babies who fall into the below categories have a higher risk of developing GBS disease):4

• Preterm babies (especially before 35 weeks, but also before 37 weeks. One recent UK study of risk factors found that 6 babies out of more than 62,000 born in the study period died of GBS infection; of these, 5 were born before 36 weeks (see ref 3).
• Mother having a fever during labour
• Prolonged rupture of membranes - over 18 hours
• GBS found in the mother's urine, not just the vagina
• Mother having had a previous child with GBS disease
• Rupture of membranes before 37 weeks

From Anne Frye, a few reasons to avoid the GBS test if no risk factors are present5:

• Some babies will become ill with GBS without any evidence of colonization from their moms.
• There are risks of fatal or severe side effects due to drug reactions.
• In many cases mom will transfer antibodies to fetus which will protect fetus from GBS infection (see http://www.ncbi.nlm.nih.gov/pubmed/768760?dopt=Abstract or http://www.jci.org/cgi/content/full/98/10/2308 for example). Instead of routine testing, why not a GBS vaccine?
• Antibiotic treatment may cause bacteria to develop mutations that will make them resistant to antimicrobial treatments.

A few completely random thoughts... 10-30% of all women have already been colonized by GBS bacteria and studies have shown that many colonized women pass on the antibodies that protect against GBS infection to their infants.  If almost a third of the female population is colonized by GBS, women probably had to come up with a mechanism of protecting their young (thus the transfer of antibodies) or natural selection would have weeded out moms colonized by GBS, right?  So what will happen if we continue to routinely test for Group B strep and administer antibiotics to all GBS positive moms, regardless of risk factors (a relatively new practice)?  Will our immune systems be compromised?  Will bacterial mutations render the antibodies that protect our infants from GBS ineffective?  Hospitals have loads of bacteria and procedures such as more then 12 hours of continual monitoring and more then six vaginal exams have already shown to increase the risk of active infection.6  Will babies be at an even increased risk of infection, having lost some of the natural immunity passed from their moms? Oh how I miss my student days when I would have an idea and carry out a research project to further explore my questions.  I am looking forward to being back in school (I will start taking online classes shortly) and diving into research again.

For Further Reading:

http://www.midwiferytoday.com/enews/enews0243.asp

http://www.womens-health.co.uk/gbs.asp

And I LOVE this paragraph from Henci Goer on infection rates for GBS Strep:

By the way, we do not know what GBS infection rates would be if clinicians kept their fingers out of the vaginas and and monitoring devices out of the uteruses of GBS positive women with ruptured membranes because we have no studies of which I am aware where vaginal exams and internal monitoring were avoided. The GBS organism comes from the rectum and is usually limited to the lower part of the vagina in colonized women where it is harmless to babies. It is possible that avoiding giving the bacteria a free ride on the examiner's finger or through internal EFM or contraction monitoring would be equally effective without the downside of antibiotic treatment. We'll never know because IV antibiotics do work, which leads to the question: If doctors had had antibiotics in Semmelweis' time, would they be washing their hands today?

In the end, the decision to test or not is yours. As a mom I know recently noted so wisely, in the end most of us (normal birth junkies and the medical community alike) are just trying to control birth but the harsh reality is that we can't.  Neither GBS testing, nor cesarean for reasons of breech presentation, nor the best fetal monitoring will guarantee a healthy baby. What you can do is be informed, take care of yourself during your pregnancy, prepare your body/mind for birth, and trust birth.

 

1 Diane M. Fraser and Margaret A. Cooper, Myles Textbook for Midwives (London: Churchill Livingstone, 2003)380.

2 Anne Frye, Understanding Diagnostic Tests in the Childbearing Year (Portland,Oregon: Labrys Press, 1997)574.

3 http://www.sciencedirect.com/science?_ob=ArticleURL&_udi=B7MFD-4N6NHR8-1&_user=10&_rdoc=1&_

fmt=&_orig=search&_sort=d&view=c&_acct=C000050221&_version=1&_urlVersion=0&_userid=10&md5=2b

937fbf1f44d856b0e875001a08c0b9 (Accessed Jan 3, 2008)

4http://www.homebirth.org.uk/gbs.htm

5 Anne Frye, Understanding Diagnostic Tests in the Childbearing Year (Portland,Oregon: Labrys Press, 1997)569-578.

6 Anne Frye, Understanding Diagnostic Tests in the Childbearing Year (Portland,Oregon: Labrys Press, 1997)573.

Better Ways to Push

Quoting from my Myles Midwifery textbook (hmm, do doctors not learn this stuff?), pg. 3261:

Prolonged pushing with held breath such as the Valsalva manoeuvre, which is undesirable for healthy woman, may be dangerous for a woman with heart disease.  It raises the intrathoracic pressure, pushes the blood out of the thorax and impedes venous return, with the result that cardiac output falls.

So WHY do I see this kind of pushing at most of the hospital births that I attend?

And while we are on the subject of pushing, even before I started doing a lot of research on the subject, my intuition suggested that severe tears must be affected by position and epidurals in particular.  In a recent article*, anal tears were more common in moms delivering in the lithotomy position and squatting.   The study's author, Dr. Karin Gottvall from the Karolinska Institute, Stockholm, Sweden, explored the role of maternal position in the second stage of labor as a risk factor for anal sphincter tears. Nearly 13,000 women were included in the study. "The lithotomy position was also associated with postmaturity, induction of labor, use of epidural anesthesia (italics mine), prolonged second stage of labor, episiotomy, low Apgar score at 1 minute, and infant birthweight over 4000 g, the report indicates."2

I can understand the propensity to tear in the squatting position.  Squatting is a great position to labor in but it takes full advantage of gravity which can speed things along. When baby is crowning, speeding things along is NOT a good way to avoid tears.  It is also harder to rest between pushes when squatting and can therefore be difficult to take things slowly. 

*If this link doesn't work for you, google Dr. Karin Gottvall and birthing position and this should take you to the link.

1Diane M. Fraser and Margaret A. Cooper, Eds. Myles Textbook for Midwives (London: Churchill Livingstone, 2003) 326.

2Mother's Birthing Position Affects Risk of Anal Sphincter Tears, Reuters Health Information, 2007, http://www.medscape.com/viewarticle/563937?src=rss, accessed October, 23, 2007.

Take a deep breath and relax

Maternal anxiety can lead to fetal distress.  Today, while making a yummy veggie lasagna with local farm veggies, I listened to my Midwifery today tapes on fetal monitoring.  Marion Toepke McLean, CNM (Certified Nurse Midwife), speaking on Fetal Monitoring at the June 1995 Midwifery Today Conference in Eugene Oregon discussed the effect of maternal anxiety on fetal heart tones.  As the mother's anxiety increases, adrenalin is released, constricting blood vessels.  This constriction increases blood pressure and therefore blood flow to the placenta decreases and the supply of nutrients and oxygen to baby is reduced (the blood is moving too forcefully for proper exchange).  The result  can be a decrease in fetal heart rate and fetal distress.  Moms, please choose a birth place where you will be able to relax and a caregiver who will do his/her best to provide a calm, nurturing, safe, comfortable environment for birth. 

Pregnant? Take it easy!

My first pregnancy I had spotting, my second pregnancy I had hemorrhaging.  The cause of bleeding was never discovered but during both first trimesters I was working very hard and with the second pregnancy, I had a very stressful first-trimester.  This pregnancy I am taking it easy, getting lots of good rest, and I am sure all will go well.  You CANNOT overestimate the importance of good diet, adequate rest, and low/no stress when you are pregnant.  I am not sure if it was at a conference or on one of my tapes purchased from Midwifery Today but I've heard Anne Frye say, if mom is well-nourished you can handle almost anything.  So moms, if you are pregnant, please please take excellent care of yourself.  Let me tell you, it isn't easy to get me to slow down, but after the scare I had during my second pregnancy, you can bet I am taking it easy.  If you are having a stressful day, don't add to your stress by worrying about the effects of stress on baby, take a fetal love break!  Tell baby throughout the day, mom is having a rough day but everything is going to be ok and I love you and when you get the chance, relax and take care of you!

The Labor Progress Handbook

There are some great resources out there on the web and I just discovered that one of my favorite labor books is available in its entirety on the web!  I LOVE The Labor Progress Handbook by Penny Simkin and Ruth Ancheta.  If you are a doula, buy a copy and stick it in your birth bag.  If you are a pregnant mama or a partner of a pregnant mama, you should read this too!  If you are birthing in a hospital and your provider seems to think your labor is slowing down and would like to try pitocin, pull out this handy little book, turn to the chapter "Prolonged Second Stage of Labor," for example, and say innocently, "Do you think one of the ideas in here could help?"

Pregnancy does not last 40 weeks

Well I suppose I might as well go ahead and put it out there...  I am pregnant!  Last night I pulled out the calendar to calculate my due date.  If you don't know when you conceived, an easy way to do this is to add 280 days to your last menstrual period (LMP) and then add a day for each day your cycle is over 28 days.  Your estimated due date is NOT 40 weeks from your LMP unless you have a perfect ovulate on day fourteen 28 day cycle (I do not, do you?).  How you calculate your due date does not change the fact that it is merely an estimation.  And did you know that this whole estimated due date thing was started by a German (man of course) in the early 1800s?  That is right, we have Franz Karl Naegele to thank for coming up with the standard method of calculating due dates.  So we all have the same cycles as early 19th century German women, right?  NOT!  Research shows that gestation varies by ethnic group, imagine that.  So when am I due? Around May 12th by my calculations.  But will I get nervous if baby is late?  ABSOLUTELY NOT.  Baby comes out when baby wants to come out and not before UNLESS the environment for baby is better outside the womb then in or if mom is not doing well.

Enjoy No Wine Before it's time, It's Time!

For those of us who believe that truly listening to our bodies can be more reliable then listening to our doctors, here is a study that supports what many of us have always suspected (smile).
And yes, I admit, I do have a glass of wine or beer occasionally during pregnancy, when my body feels up to it.  Wine is not of course recommended if there is any history of alcohol abuse in your family.

This blurb is from www.ORGYN.com's  weekly news update (accessed August 16, 2007).  I highly recommend subscribing to the email updates provided by this on-line magazine.  They are FREE and full of information.

Low-moderate alcohol exposure 'may not harm fetus'
Source: BJOG: British Journal of Obstetrics and Gynaecology 2007; 114: 243-52

Reviewing the evidence on the impact of maternal alcohol consumption on pregnancy outcomes.

A systematic review published this month has found "no convincing evidence" that low-moderate prenatal alcohol exposure harms the fetus.

However, the study authors, from the University of Oxford, UK, admit that methodological weaknesses in many studies preclude the conclusion that drinking alcohol during pregnancy is safe.

J. Henderson and fellow investigators reviewed the literature for studies comparing low-moderate alcohol consumption (less than 12 g/day) with abstention among pregnant women.

A total of 46 studies, involving 713,826 women, were included in the review.

Henderson et al reveal that there was "no consistently significant" effect of alcohol consumption on any of the pregnancy outcomes considered. These included stillbirth, miscarriage, impaired intrauterine growth, low birthweight, preterm birth, and birth defects (including fetal alcohol syndrome).

Indeed, low levels of alcohol seemed to have a mildly protective effect on several outcomes, such as stillbirth and growth retardation.

Nevertheless the authors urge caution in interpreting their findings and note that many studies were of suboptimal quality.

"More studies concentrating specifically on low-moderate levels of alcohol consumption would be of benefit and would allow for more detailed analysis of this area," Henderson et al conclude.

Posted: 27 February 2007

© 2007 Current Medicine Group Ltd, a part of Springer Science+Business Media