Beloved midwife and friend, Kris Harper, sent this to me from a local yahoo group that she is a part of in the Memphis area. I love the part about communication, especially requesting a nurse who is "enthusiastic about natural birth."
If you choose a hospital instead of a homebirth you can do it naturally in a hospital in Memphis if you do the following things:
*Have an ob/gyn who is excited and open to natural birth. Have a dialogue with them early in your pregnancy to make sure that they are on the same page with you.
*Have a good support person (partner, doula, etc.)
*Educate yourself about birth and prepare yourself body, mind and spirit (good resources: Birthing from Within, Ina May's Book of Childbirth,and Active Birth)
*Have a birth plan signed off by your doctor and in your chart as early as the 1st trimester and no later than 24 weeks. Also, have a copy of the birth plan with you when you go to the hospital.
*Do not go to the hospital as soon as your water breaks or at the first contraction. Women in Memphis have done well in having a low-intervention experience in a hospital if they wait until contractions are 5 minutes apart before hopping into the car and heading to the hospital.You have to listen to your body and trust that your intuition will kick inas to when to go.
*COMMUNICATE!!!! This is important throughout your pregnancy, but especially during labor and delivery. Many labor & delivery medical professionals do not have experience with, or have opportunities to see a lot of natural births in Memphis. Their job is to make you more comfortable, and keep you and the baby safe. They have been trained to stop pain with medical intervention. Women birthing naturally in a hospital setting have the opportunity to teach the professionals that birth is normal and that you will let them know when you need them. I suggest posting a sign on your hospital door that says: "Natural Birth in Progress - Please wash hands upon entry and do not offer any pain relief. Patient will request assistance if she needs it. Thank You!" When you get to the hospital mention that you would like a nurse who is enthusiastic about natural birth before you get into your room. When you meet your nurse be gracious and remind them of your birth plan. Let them know that you are grateful for their help and ask if they attend many natural births. If they have not seen many natural births then let them know that you are going to make sounds and move a lot during your birth. Tell them that the best way that they can support you is by giving you space and time alone with your partner while laboring. Let them know that if the pain is really intense during a contraction that they will be a help by making eye contact, calling you by name, and telling you that you can do it.
These suggestions are all based on my own experiences and how I have learned to navigate these strange waters in Memphis. It can be done but it takes alot of preparation and communication.
Monday, March 17, 2008
Maternal Mortality Rate in U.S. Highest in Decades
Kaiser Daily Women's Health Policy
Monday, August 27, 2007 Pregnancy & Childbirth
Maternal Mortality Rate in U.S. Highest in Decades, Experts Say
The maternal mortality rate in the U.S. is the highest it has been in decades, according to statistics released this week by CDC's National Center for Health Statistics, the AP/Washington Post reports. According to the figures, the U.S. maternal mortality rate was 13 deaths per 100,000 live births in 2004. The rate was 12 deaths per 100,000 live births in 2003 -- the first year the maternal death rate was more than 10 since 1977 (Stobbe, AP/Washington Post, 8/24). A total of 540 women were reported to have died of maternal causes in 2004, 45 more than were reported in 2003, according to the report (NCHS report, 8/21).
Reasons for Increase A rise in the number of caesarean sections -- which now account for 29% of all births -- could be a factor in the increased maternal mortality rate, some experts said. According to a review of maternal deaths in New York, excessive bleeding is one of the primary causes of pregnancy-related death, and women who have undergone several previous c-sections are at particularly high risk of death.Some studies have found that race and quality of care also factor into the maternal mortality rate. The maternal mortality rate among black women is at least three times higher than among white women. Black women also are more susceptible to hypertension and other complications, and they tend to receive inadequate prenatal care. Three studies have shown that at least 40% of maternal deaths could have been prevented with improved quality of care.The rise in obesity also might be a factor, some experts said. According to researchers, overweight women tend to have diabetes or experience other complications that could affect pregnancy outcomes. Overweight women also might have excessive tissue or larger infants, which could make a vaginal birth more difficult and lead to more c-sections. More women also are giving birth in their late 30s and 40s, when risks of pregnancy complications are higher, according to the AP/Post (AP/Washington Post, 8/24).In addition, the report says the increase in maternal deaths "largely reflects" more states' use of a separate item on the death certificate indicating pregnancy status of the woman. According to the report, the number of maternal deaths does not include all deaths of pregnant women, but only those deaths reported on the death certificate that were assigned to causes related to or aggravated by pregnancy or pregnancy management (NCHS report, 8/21). California, Idaho and Montana in 2003 changed death certificate questions, the AP/Post reports (AP/Washington Post, 8/24). The report is available online (.pdf).
Monday, August 27, 2007 Pregnancy & Childbirth
Maternal Mortality Rate in U.S. Highest in Decades, Experts Say
The maternal mortality rate in the U.S. is the highest it has been in decades, according to statistics released this week by CDC's National Center for Health Statistics, the AP/Washington Post reports. According to the figures, the U.S. maternal mortality rate was 13 deaths per 100,000 live births in 2004. The rate was 12 deaths per 100,000 live births in 2003 -- the first year the maternal death rate was more than 10 since 1977 (Stobbe, AP/Washington Post, 8/24). A total of 540 women were reported to have died of maternal causes in 2004, 45 more than were reported in 2003, according to the report (NCHS report, 8/21).
Reasons for Increase A rise in the number of caesarean sections -- which now account for 29% of all births -- could be a factor in the increased maternal mortality rate, some experts said. According to a review of maternal deaths in New York, excessive bleeding is one of the primary causes of pregnancy-related death, and women who have undergone several previous c-sections are at particularly high risk of death.Some studies have found that race and quality of care also factor into the maternal mortality rate. The maternal mortality rate among black women is at least three times higher than among white women. Black women also are more susceptible to hypertension and other complications, and they tend to receive inadequate prenatal care. Three studies have shown that at least 40% of maternal deaths could have been prevented with improved quality of care.The rise in obesity also might be a factor, some experts said. According to researchers, overweight women tend to have diabetes or experience other complications that could affect pregnancy outcomes. Overweight women also might have excessive tissue or larger infants, which could make a vaginal birth more difficult and lead to more c-sections. More women also are giving birth in their late 30s and 40s, when risks of pregnancy complications are higher, according to the AP/Post (AP/Washington Post, 8/24).In addition, the report says the increase in maternal deaths "largely reflects" more states' use of a separate item on the death certificate indicating pregnancy status of the woman. According to the report, the number of maternal deaths does not include all deaths of pregnant women, but only those deaths reported on the death certificate that were assigned to causes related to or aggravated by pregnancy or pregnancy management (NCHS report, 8/21). California, Idaho and Montana in 2003 changed death certificate questions, the AP/Post reports (AP/Washington Post, 8/24). The report is available online (.pdf).
Wednesday, March 12, 2008
Doula Training?
Any interest out there in another doula training? Two years ago I coordinated the ALACE doula training. This is a training to become a birth doula. Because of the time I put in, I got my training for free, plus some other perks. If you want to get this training, but don't have the money (around $400), this is the way to do it -- be a coordinator! See www.alace.org for more info. FYI, ALACE also has an educator program which is a correspondence course.
We only have a handful of doulas working in the area right now (much improved from 2 years ago!). I'd love to see lots more. I'm particularly interested in contacting older women who have a lot of wisdom to offer and who have the flexibility to be on call for births. If you know women (of any age) interested in this important work, feel free to refer them to me. I can start a list to let them know if we have another training.
Tracey
We only have a handful of doulas working in the area right now (much improved from 2 years ago!). I'd love to see lots more. I'm particularly interested in contacting older women who have a lot of wisdom to offer and who have the flexibility to be on call for births. If you know women (of any age) interested in this important work, feel free to refer them to me. I can start a list to let them know if we have another training.
Tracey
Suggested Reading
If you're a birth nut like me, and like to read, especially about anthropology/sociology, I'd like to recommend Birth as an American Rite of Passage by Robbie Floyd-Davis. You may have seen her in The Business of Being Born (birth documentary, which is now available from Netflix). It's not an "easy read," or even one I'd recommend if you're currently pregnant, but a tremendously fascinating work. Enjoy.
Tracey
Tracey
Society's Understanding of the Term "Natural Birth"
To some, the term "natural birth" means a vaginal birth (i.e., not a cesarean). Some people think that any intervention at all nullifies the term "natural" (for example, suctioning the baby with a bulb syringe). Obviously, these are two extremes. How do you define natural birth? When you hear that term, what comes to mind? What came to mind before you had a baby?
Tracey
Tracey
Natural Solution to Postpartum Depression
My dear friend and former midwife, Thalia Hufton (CPM, Tyler, Texas) is a wonderful source of information. See her birth center in the links section. Here is a question I asked her, with her reply.
Q: A friend of mine is really struggling with depression. Her baby is 18 months old and still nurses a little (morning/night, occasionally during the day). She knows she doesn't have much milk. Her cycles have returned regularly. Is there anything natural she could take to help?
A: If it's depression, not mood swings, I would suggest that she do either Sam-e or St. John's Wort--both safe for nursing baby but you can't use birth control pills when on St. John's Wort.
If it's truly hormonal--then red clover--also safe to take. And if two months on any of these herbs doesn't help she needs to see a medical doctor.
Thalia
Q: A friend of mine is really struggling with depression. Her baby is 18 months old and still nurses a little (morning/night, occasionally during the day). She knows she doesn't have much milk. Her cycles have returned regularly. Is there anything natural she could take to help?
A: If it's depression, not mood swings, I would suggest that she do either Sam-e or St. John's Wort--both safe for nursing baby but you can't use birth control pills when on St. John's Wort.
If it's truly hormonal--then red clover--also safe to take. And if two months on any of these herbs doesn't help she needs to see a medical doctor.
Thalia
Tuesday, March 11, 2008
Birth Story: Annabelle Grace
[Tracey's note: I love Caroline's birth story about her daughter Annabelle. Stop and start labor is normal, and Caroline had such amazing patience to let the natural process unfold.]
My labor with Annabelle began at around 35 weeks of pregnancy. For a solid 3 weeks I experienced mild contractions, dilating regularly (about 1 cm each week), and I had an uncomfortable pressure in my pelvis that could not be ignored. Since this was my 2nd pregnancy I knew that these signs did not mean I would have my baby within a couple of days. The only thing I knew for certain was that these were signs that my body was preparing itself for labor; and that every uncomfortable day was one day closer to when I could hold my baby for the 1st time.
By the time I approached my 38th week I had dilated to 4 cm and my mother-in-law joked that the baby would one day just fall out! During this week all those signs of progression disappeared and I had mixed emotions. On one hand, I was happy to not be feeling so uncomfortable! On the other hand, I felt that my body had stalled-out and thought that it would be another few weeks before my baby made her grand arrival. In order to not be so disappointed I told myself that my body needed to rest after working for the last 3 weeks. I also told myself that my body needed to conserve its energy for the big day.
About 5 days into this energy conservation mode I woke one morning with more energy than I'd had in a long time. I remember feeling as if I couldn't stop "doing" around the house. My husband was very curious about my new found energy; but I reassured him that this isn't the real deal because even though I started having contractions again, they were very mild and very sporadic. After all, the 3 weeks prior was a lot more uncomfortable than this! At about 5 that evening I was on the phone with my dad making plans for the evening. When I got off the phone my husband asked me, "So, what are the plans?" At that point my response was, "I don't know because while he was talking I had a contraction and it was so strong I didn't hear what he was saying." My husband was very firm in suggesting that I stay home and I agreed. Throughout the day my husband had been asking me how I was feeling, but now he wanted details; he was beginning to suggest that I was in labor for real. However, I kept telling him that it could still stop and we could still go for another few weeks. He didn't argue, but I knew that he didn't believe me. Three hours later, I was lying on the couch, timing my contractions, and my husband was coaching me through them.
Even though this was my 2nd pregnancy it was my 1st attempt at a natural delivery. I was shocked at how do-able this was. My contractions were strong, but with each break I found new energy and the confidence to move through the next one. I kept telling myself that if I made it through the last one I can make it through the next one. Around 11:30 things were getting difficult and we headed to the hospital. The entire drive to the hospital was so difficult that I was thinking, "I can't do this anymore and as soon as we get to the hospital I'm getting an epidural." When we arrived at the hospital I was fully prepared to tell the nurses to go ahead and get the epidural started. The nurse wanted to check me first and shockingly announced, "Oh my goodness! You've already dilated to a 9!" I was elated and would have done cartwheels down the hall if the nurses would have let me! I though to myself, "if I've made it this far I can make it for another centimeter." I could see the finish line and it was within reach. It gave me enough confidence to deny the epidural and push through to the end.
The last 4 contractions I had were the absolute hardest, I was exhausted, and inside I was begging my body to begin pushing. Although my husband was very encouraging throughout the entire process, this was when he was the most helpful. With each contraction getting stronger he would tell me things like, "you've got this one licked." His confidence in me spilled over and I could see that the end was near. All of a sudden my body began pushing and 20 minutes later I crossed the finish line and held my baby for the 1st time.
I used to think that having a natural childbirth meant learning how to tolerate & ignore pain. I was wrong. I'm not going to lie, there was a lot of pain & hard work involved; but the characteristic that I needed to tap into the most was patience. In order for me to have such a great delivery, I had to be patient through the last uncomfortable month of pregnancy. I realized that I would need this patience throughout my child's life; therefore, I might as well learn how to be patient with Annabelle even before she was born.
Caroline Nixon
My labor with Annabelle began at around 35 weeks of pregnancy. For a solid 3 weeks I experienced mild contractions, dilating regularly (about 1 cm each week), and I had an uncomfortable pressure in my pelvis that could not be ignored. Since this was my 2nd pregnancy I knew that these signs did not mean I would have my baby within a couple of days. The only thing I knew for certain was that these were signs that my body was preparing itself for labor; and that every uncomfortable day was one day closer to when I could hold my baby for the 1st time.
By the time I approached my 38th week I had dilated to 4 cm and my mother-in-law joked that the baby would one day just fall out! During this week all those signs of progression disappeared and I had mixed emotions. On one hand, I was happy to not be feeling so uncomfortable! On the other hand, I felt that my body had stalled-out and thought that it would be another few weeks before my baby made her grand arrival. In order to not be so disappointed I told myself that my body needed to rest after working for the last 3 weeks. I also told myself that my body needed to conserve its energy for the big day.
About 5 days into this energy conservation mode I woke one morning with more energy than I'd had in a long time. I remember feeling as if I couldn't stop "doing" around the house. My husband was very curious about my new found energy; but I reassured him that this isn't the real deal because even though I started having contractions again, they were very mild and very sporadic. After all, the 3 weeks prior was a lot more uncomfortable than this! At about 5 that evening I was on the phone with my dad making plans for the evening. When I got off the phone my husband asked me, "So, what are the plans?" At that point my response was, "I don't know because while he was talking I had a contraction and it was so strong I didn't hear what he was saying." My husband was very firm in suggesting that I stay home and I agreed. Throughout the day my husband had been asking me how I was feeling, but now he wanted details; he was beginning to suggest that I was in labor for real. However, I kept telling him that it could still stop and we could still go for another few weeks. He didn't argue, but I knew that he didn't believe me. Three hours later, I was lying on the couch, timing my contractions, and my husband was coaching me through them.
Even though this was my 2nd pregnancy it was my 1st attempt at a natural delivery. I was shocked at how do-able this was. My contractions were strong, but with each break I found new energy and the confidence to move through the next one. I kept telling myself that if I made it through the last one I can make it through the next one. Around 11:30 things were getting difficult and we headed to the hospital. The entire drive to the hospital was so difficult that I was thinking, "I can't do this anymore and as soon as we get to the hospital I'm getting an epidural." When we arrived at the hospital I was fully prepared to tell the nurses to go ahead and get the epidural started. The nurse wanted to check me first and shockingly announced, "Oh my goodness! You've already dilated to a 9!" I was elated and would have done cartwheels down the hall if the nurses would have let me! I though to myself, "if I've made it this far I can make it for another centimeter." I could see the finish line and it was within reach. It gave me enough confidence to deny the epidural and push through to the end.
The last 4 contractions I had were the absolute hardest, I was exhausted, and inside I was begging my body to begin pushing. Although my husband was very encouraging throughout the entire process, this was when he was the most helpful. With each contraction getting stronger he would tell me things like, "you've got this one licked." His confidence in me spilled over and I could see that the end was near. All of a sudden my body began pushing and 20 minutes later I crossed the finish line and held my baby for the 1st time.
I used to think that having a natural childbirth meant learning how to tolerate & ignore pain. I was wrong. I'm not going to lie, there was a lot of pain & hard work involved; but the characteristic that I needed to tap into the most was patience. In order for me to have such a great delivery, I had to be patient through the last uncomfortable month of pregnancy. I realized that I would need this patience throughout my child's life; therefore, I might as well learn how to be patient with Annabelle even before she was born.
Caroline Nixon
Fitting Birth Analogy
"Musical improvisation is a balance between the cerebral and intuitive. You must keep some guidelines in your mind, but if you think too much, it doesn't flow."
-- Discussion of Jazz on LPB
-- Discussion of Jazz on LPB
Sunday, March 9, 2008
Midwives Deliver Healthy Babies With Fewer Interventions
Midwives Deliver Healthy Babies With Fewer Interventions
By TAMAR LEWIN
New York Times
April 18, 1997
Women with low-risk pregnancies who choose midwives to deliver their babies have healthy births with fewer medical interventions than those who go either to obstetricians or family-practice doctors, according to a new study of obstetric care.
The University of Washington study, reported in the current issue of The American Journal of Public Health, found that certified nurse-midwives' patients had fewer Caesarean sections, received less anesthesia and had a lower rate of episiotomies and induced labor than the doctors' patients.
"There are major differences in the way physicians and nurse-midwives approach low-risk patients," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine and principal investigator on the study.
"Nurse-midwives establish a relationship with their patients that leads to excellent outcomes with less use of medical resources. We physicians have something to learn from midwives about the approach to low-risk women."
The midwives' patients also use 12 percent fewer resources than the doctors' patients, the study found, while all three specialties achieved equally good outcomes.
While other studies over the years have reported similar findings about certain aspects of midwives' obstetric care, the University of Washington study is the first to examine differences among the three types of providers on a statewide basis.
The study is based on an analysis of the charts of 1,322 healthy low-risk patients from a random sample of all urban practitioners who deliver babies in hospitals in Washington state.
Women were excluded from the study if they had a major medical condition, a previous obstetrical complication, a serious risk factor in the current pregnancy, no obstetrical care in the first trimester or were under 18 or over 34 years old -- qualifications that excluded 53 percent of the cases screened.
One of the most striking findings in the study was the difference in the rate of Caesarean sections.
Although Caesarean sections are surgery, and must be performed by a doctor, if a midwife's patient ended up needing the procedure, the study attributed the surgery to the midwife, not to the obstetrician who performed the operation.
Still, the study found, the midwives' patients had a Caesarean section rate of 8.8 percent, compared with 13.6 percent for the obstetricians and 15.1 percent for family doctors.
"It is striking that the patients of midwives had a Caesarean section rate under 10 percent, and in some sense it gives us a target that we can consider obtainable," Rosenblatt said.
Nationally, the rate of Caesarean sections -- among low-risk and high-risk women combined -- more than doubled from 10.4 percent in 1975 to 22.7 percent in 1985. While organizations ranging from the American College of Obstetricians and Gynecologists to the Centers for Disease Control and Prevention have campaigned, with some success, for a reduction in the number of Caesarean sections, the national rate in 1995 was still 20.5 percent. Within the United States, the West has historically had the lowest rate, while the South has had the highest.
While midwives deliver the majority of babies in some European countries, including Britain, Rosenblatt said, they attend only about one in 20 births in the United States. He suggested that the training and orientation of those providing the obstetric care in this country might be a major factor in the high rate of Caesarean sections.
By TAMAR LEWIN
New York Times
April 18, 1997
Women with low-risk pregnancies who choose midwives to deliver their babies have healthy births with fewer medical interventions than those who go either to obstetricians or family-practice doctors, according to a new study of obstetric care.
The University of Washington study, reported in the current issue of The American Journal of Public Health, found that certified nurse-midwives' patients had fewer Caesarean sections, received less anesthesia and had a lower rate of episiotomies and induced labor than the doctors' patients.
"There are major differences in the way physicians and nurse-midwives approach low-risk patients," said Dr. Roger A. Rosenblatt, a University of Washington professor of family medicine and principal investigator on the study.
"Nurse-midwives establish a relationship with their patients that leads to excellent outcomes with less use of medical resources. We physicians have something to learn from midwives about the approach to low-risk women."
The midwives' patients also use 12 percent fewer resources than the doctors' patients, the study found, while all three specialties achieved equally good outcomes.
While other studies over the years have reported similar findings about certain aspects of midwives' obstetric care, the University of Washington study is the first to examine differences among the three types of providers on a statewide basis.
The study is based on an analysis of the charts of 1,322 healthy low-risk patients from a random sample of all urban practitioners who deliver babies in hospitals in Washington state.
Women were excluded from the study if they had a major medical condition, a previous obstetrical complication, a serious risk factor in the current pregnancy, no obstetrical care in the first trimester or were under 18 or over 34 years old -- qualifications that excluded 53 percent of the cases screened.
One of the most striking findings in the study was the difference in the rate of Caesarean sections.
Although Caesarean sections are surgery, and must be performed by a doctor, if a midwife's patient ended up needing the procedure, the study attributed the surgery to the midwife, not to the obstetrician who performed the operation.
Still, the study found, the midwives' patients had a Caesarean section rate of 8.8 percent, compared with 13.6 percent for the obstetricians and 15.1 percent for family doctors.
"It is striking that the patients of midwives had a Caesarean section rate under 10 percent, and in some sense it gives us a target that we can consider obtainable," Rosenblatt said.
Nationally, the rate of Caesarean sections -- among low-risk and high-risk women combined -- more than doubled from 10.4 percent in 1975 to 22.7 percent in 1985. While organizations ranging from the American College of Obstetricians and Gynecologists to the Centers for Disease Control and Prevention have campaigned, with some success, for a reduction in the number of Caesarean sections, the national rate in 1995 was still 20.5 percent. Within the United States, the West has historically had the lowest rate, while the South has had the highest.
While midwives deliver the majority of babies in some European countries, including Britain, Rosenblatt said, they attend only about one in 20 births in the United States. He suggested that the training and orientation of those providing the obstetric care in this country might be a major factor in the high rate of Caesarean sections.
Saturday, March 8, 2008
What Can I Do to Avoid an Episiotomy?
This information comes from the American Academy of Husband-Coached Childbirth (Bradley)
Twelve things mothers do to help avoid an episiotomy:
An episiotomy is a medical procedure that may be needed occasionally but is not part of the natural process. It has become traditionally part of the birth process.
1. Good nutrition – A well nourished mother has healthier skin that is more likely to stretch with the process of labor.
2. Squatting – Squatting on a daily basis with the feet flat on the floor is the only exercise we have that helps to give elasticity to the perineum, the skin that stretches during birth. Women who squat have a perineum that is thinner and more elastic. Those who do not squat are more likely to tear because the perineum is thicker and less likely to stretch easily.
3. Air – For the health of the perineum light and air are important. Perhaps one of the worst things a mother can do is wear tight fitting clothes like panty hose. Around the house wear a long flowing skirt with no underwear or at least breathable cotton underwear.
4. Kegel – Daily Kegel practice throughout pregnancy helps the baby to put its chin on its chest in labor, and encourages the smallest part of the baby's head to come first. The smaller part coming first helps the perineum to stretch normally.
5. No soap – soap can be drying and takes away the natural oils causing irritation to the skin, especially the perineum. A warm bath works well without soap.
6. Lotion and Massage – Putting lotion on the perineum can be soothing. Be sure you are using a lotion that you are not allergic to. Perineal massage is not necessary, especially the exaggerated perineal massages you see on the internet. There does not seem to be any difference in the episiotomy rate. Gentle massage as you apply the lotion is fine.
7. Talk to your doctor or midwife in advance-Chances are you have a doctor or midwife who is supportive of natural childbirth and probably has lots of patients. Do not assume that they can remember what everyone wants. Talk to them ahead of time so they know what you want. Make sure they are in agreement so there are no surprises.
8. Be patient – some babies pop right out in second stage, some take their sweet time. Push to the point of comfort.
9. Keep your elbows up and out and knees back - during second-stage contractions, to help prevent tearing. Putting your knees apart (widening) as far as possible over-stretches the perineum and makes it more likely that a tear will occur. If the doctor or midwife does need to do a small midline episiotomy it is not as likely to extend if knees are back and toward
your shoulders and your elbows are up and out because this shortens the birth canal and relaxes the surrounding tissues. It also reduces the amount of pain women feel while pushing.
10. Push with self-control – When the urge to push starts. Take a minute and think about how hard your body is telling you to push. Push to the point of comfort. That might be with all your might, especially in the beginning, or you may feel like a gentle push as the perineum is stretching. Tune into your body and follow those clues.
11. Remind the doctor or midwife about your wishes. -You may have talked to your doctor or midwife weeks ago about avoiding an episiotomy, but how do know they remember? Bring extra copies of your birth plan to the birth to remind them about your wishes. Tell them again when you see them for the first time at the birth. They are human you know.
12. Some babies come out fast on their own, others ease out, - if the mother uses self-control. If possible, ease the baby out. Some women, especially first time mothers feel the baby come down into the vagina and over-react by screaming 'get it out'. They push with all their might forcing the baby to fly out and often tear in the process. Stay calm and let the baby do its thing.
©2007 AAHCC
Twelve things mothers do to help avoid an episiotomy:
An episiotomy is a medical procedure that may be needed occasionally but is not part of the natural process. It has become traditionally part of the birth process.
1. Good nutrition – A well nourished mother has healthier skin that is more likely to stretch with the process of labor.
2. Squatting – Squatting on a daily basis with the feet flat on the floor is the only exercise we have that helps to give elasticity to the perineum, the skin that stretches during birth. Women who squat have a perineum that is thinner and more elastic. Those who do not squat are more likely to tear because the perineum is thicker and less likely to stretch easily.
3. Air – For the health of the perineum light and air are important. Perhaps one of the worst things a mother can do is wear tight fitting clothes like panty hose. Around the house wear a long flowing skirt with no underwear or at least breathable cotton underwear.
4. Kegel – Daily Kegel practice throughout pregnancy helps the baby to put its chin on its chest in labor, and encourages the smallest part of the baby's head to come first. The smaller part coming first helps the perineum to stretch normally.
5. No soap – soap can be drying and takes away the natural oils causing irritation to the skin, especially the perineum. A warm bath works well without soap.
6. Lotion and Massage – Putting lotion on the perineum can be soothing. Be sure you are using a lotion that you are not allergic to. Perineal massage is not necessary, especially the exaggerated perineal massages you see on the internet. There does not seem to be any difference in the episiotomy rate. Gentle massage as you apply the lotion is fine.
7. Talk to your doctor or midwife in advance-Chances are you have a doctor or midwife who is supportive of natural childbirth and probably has lots of patients. Do not assume that they can remember what everyone wants. Talk to them ahead of time so they know what you want. Make sure they are in agreement so there are no surprises.
8. Be patient – some babies pop right out in second stage, some take their sweet time. Push to the point of comfort.
9. Keep your elbows up and out and knees back - during second-stage contractions, to help prevent tearing. Putting your knees apart (widening) as far as possible over-stretches the perineum and makes it more likely that a tear will occur. If the doctor or midwife does need to do a small midline episiotomy it is not as likely to extend if knees are back and toward
your shoulders and your elbows are up and out because this shortens the birth canal and relaxes the surrounding tissues. It also reduces the amount of pain women feel while pushing.
10. Push with self-control – When the urge to push starts. Take a minute and think about how hard your body is telling you to push. Push to the point of comfort. That might be with all your might, especially in the beginning, or you may feel like a gentle push as the perineum is stretching. Tune into your body and follow those clues.
11. Remind the doctor or midwife about your wishes. -You may have talked to your doctor or midwife weeks ago about avoiding an episiotomy, but how do know they remember? Bring extra copies of your birth plan to the birth to remind them about your wishes. Tell them again when you see them for the first time at the birth. They are human you know.
12. Some babies come out fast on their own, others ease out, - if the mother uses self-control. If possible, ease the baby out. Some women, especially first time mothers feel the baby come down into the vagina and over-react by screaming 'get it out'. They push with all their might forcing the baby to fly out and often tear in the process. Stay calm and let the baby do its thing.
©2007 AAHCC
Repeat Cesareans Increasingly Risky
Essentially, the first study says repeat VBAC's get safer, while repeat cesareans get riskier.
Study from Case Western that just came out in Obstetrics & Gynecology(2008;111:285- 291).
The study's OBJECTIVE: To estimate the success rates and risks of anattempted vaginal birth after cesarean delivery (VBAC) according to thenumber of prior successful VBACs.
METHODS: From a prospective multicenter registry collected at 19 clinicalcenters from 1999 to 2002, we selected women with one or more prior lowtransverse cesarean deliveries who attempted a VBAC in the currentpregnancy. Outcomes were compared according to the number of prior VBACattempts subsequent to the last cesarean delivery.
RESULTS: Among 13,532 women meeting eligibility criteria, VBAC successincreased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%,and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively(P<.001). The rate of uterine rupture decreased after the first successfulVBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%,0.52%(P=.03) . The risk of uterine dehiscence and other peripartumcomplicationsalso declined statistically after the first successful VBAC. No increase inneonatal morbidities was seen with increasing VBAC number thereafter.
CONCLUSION: Women with prior successful VBAC attempts are at low risk formaternal and neonatal complications during subsequent VBAC attempts. Anincreasing number of prior VBACs is associated with a greater probability ofVBAC success, as well as a lower risk of uterine rupture and perinatalcomplications in the current pregnancy.
Contrast that study with another from Obstetrics & Gynecology(2006;107:1226- 1232) which found that there is maternal morbidity associatedwith multiple repeat cesareans.
OBJECTIVE: To estimate the magnitude of increased maternal morbidityassociated with increasing number of cesarean deliveries.
METHODS: Prospective observational cohort of 30,132 women who had cesareandelivery without labor in 19 academic centers over 4 years (1999–2002).
RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks ofplacenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, theneed for postoperative ventilation, intensive care unit admission,hysterectomy, and blood transfusion requiring 4 or more units, and theduration of operative time and hospital stay *significantly increased *withincreasing number of cesarean deliveries. Placenta accreta was present in 15(0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) womenundergoing their first, second, third, fourth, fifth, and sixth or morecesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%)first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%)fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 womenwith previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67%for first, second, third, fourth, and fifth or more repeat cesareandeliveries, respectively.
CONCLUSION: Because serious maternal morbidity increases progressively withincreasing number of cesarean deliveries, the number of intended pregnanciesshould be considered during counseling regarding elective repeat cesareanoperation versus a trial of labor and when debating the merits of electiveprimary cesarean delivery.
Study from Case Western that just came out in Obstetrics & Gynecology(2008;111:285- 291).
The study's OBJECTIVE: To estimate the success rates and risks of anattempted vaginal birth after cesarean delivery (VBAC) according to thenumber of prior successful VBACs.
METHODS: From a prospective multicenter registry collected at 19 clinicalcenters from 1999 to 2002, we selected women with one or more prior lowtransverse cesarean deliveries who attempted a VBAC in the currentpregnancy. Outcomes were compared according to the number of prior VBACattempts subsequent to the last cesarean delivery.
RESULTS: Among 13,532 women meeting eligibility criteria, VBAC successincreased with increasing number of prior VBACs: 63.3%, 87.6%, 90.9%, 90.6%,and 91.6% for those with 0, 1, 2, 3, and 4 or more prior VBACs, respectively(P<.001). The rate of uterine rupture decreased after the first successfulVBAC and did not increase thereafter: 0.87%, 0.45%, 0.38%, 0.54%,0.52%(P=.03) . The risk of uterine dehiscence and other peripartumcomplicationsalso declined statistically after the first successful VBAC. No increase inneonatal morbidities was seen with increasing VBAC number thereafter.
CONCLUSION: Women with prior successful VBAC attempts are at low risk formaternal and neonatal complications during subsequent VBAC attempts. Anincreasing number of prior VBACs is associated with a greater probability ofVBAC success, as well as a lower risk of uterine rupture and perinatalcomplications in the current pregnancy.
Contrast that study with another from Obstetrics & Gynecology(2006;107:1226- 1232) which found that there is maternal morbidity associatedwith multiple repeat cesareans.
OBJECTIVE: To estimate the magnitude of increased maternal morbidityassociated with increasing number of cesarean deliveries.
METHODS: Prospective observational cohort of 30,132 women who had cesareandelivery without labor in 19 academic centers over 4 years (1999–2002).
RESULTS: There were 6,201 first (primary), 15,808 second, 6,324 third, 1,452fourth, 258 fifth, and 89 sixth or more cesarean deliveries. The risks ofplacenta accreta, cystotomy, bowel injury, ureteral injury, and ileus, theneed for postoperative ventilation, intensive care unit admission,hysterectomy, and blood transfusion requiring 4 or more units, and theduration of operative time and hospital stay *significantly increased *withincreasing number of cesarean deliveries. Placenta accreta was present in 15(0.24%), 49 (0.31%), 36 (0.57%), 31 (2.13%), 6 (2.33%), and 6 (6.74%) womenundergoing their first, second, third, fourth, fifth, and sixth or morecesarean deliveries, respectively. Hysterectomy was required in 40 (0.65%)first, 67 (0.42%) second, 57 (0.90%) third, 35 (2.41%) fourth, 9 (3.49%)fifth, and 8 (8.99%) sixth or more cesarean deliveries. In the 723 womenwith previa, the risk for placenta accreta was 3%, 11%, 40%, 61%, and 67%for first, second, third, fourth, and fifth or more repeat cesareandeliveries, respectively.
CONCLUSION: Because serious maternal morbidity increases progressively withincreasing number of cesarean deliveries, the number of intended pregnanciesshould be considered during counseling regarding elective repeat cesareanoperation versus a trial of labor and when debating the merits of electiveprimary cesarean delivery.
Friday, March 7, 2008
CNMs in Louisiana
From http://www.acnm.org/
Drs. Labadie & Labadie
Marrero
North Oaks OB/GYN
Hammond
This practice of older OBs has employed CNMs for 13 years. They have four midwives who deliver in hospitals. They serve mostly medicare patients.
L. S. U. M. C.
Baton Rouge
Westside Rural Health Clinic
Plaquemine
Abbeville General Hosp Rural Hlth Clnc
Abbbeville
LSUHSC
Monroe
OBG-1
Lake Charles
Donald R. Parker MD
Lake Charles
Bayne Jones Army Community Hospital
Fort Polk
Drs. Labadie & Labadie
Marrero
North Oaks OB/GYN
Hammond
This practice of older OBs has employed CNMs for 13 years. They have four midwives who deliver in hospitals. They serve mostly medicare patients.
L. S. U. M. C.
Baton Rouge
Westside Rural Health Clinic
Plaquemine
Abbeville General Hosp Rural Hlth Clnc
Abbbeville
LSUHSC
Monroe
OBG-1
Lake Charles
Donald R. Parker MD
Lake Charles
Bayne Jones Army Community Hospital
Fort Polk
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