Labor and Delivery
Mamas on Bedrest: Should I have tried vaginal birth?
February 15th, 2012My daughter’s birth was traumatic. Born via an “emergent” cesarean section, she was in respiratory distress when she was delivered and I began to bleed profusely.
We had planned to deliver my daughter via cesarean section at 39 weeks. My history of uterine fibroids and subsequent myomectomy made it risky for me to deliver vaginally according to my obstetrician and the fertility specialist who had performed my surgery. The cuts to my uterus put me at risk for uterine rupture.
But I always wondered if it may have been better to deliver her vaginally. I went into labor at 36 weeks and 6 days after weeks of “rumbling” (now known to be contractions) early in the morning. Throughout the morning I’d have a contraction, stop what I was doing, let it pass and then proceed. By mid afternoon, the contractions became regular and prolonged. I went to see my OB and when I had a 2 minute contraction that dilated my cervix 2 cm, I was admitted from her office.
When my daughter was born later that evening, she was only 5 lbs 3 oz and 18 inches long. I’ve always wondered if I shouldn’t have pushed her out. She was a tiny little thing and it’s hard to believe that a vaginal delivery could have been more traumatic than the scrambling that occurred after she was born due to my “profuse bleeding”. (They didn’t officially call it hemorrhaging, but I know my OB had a tough time closing me up because every time she tried to stitch, my uterus bled even more.) I’ve also wondered if the push through the vaginal canal may have in some way squeezed fluid out of her lungs and saved her the 10 day NICU stay for respiratory distress.
Seems like my musings may have in fact been correct. At the 32nd Annual Meeting of the Society for Maternal Fetal Medicine, researchers from Johns Hopkins University found that cesarean delivery provides no benefit for premature infants who are small for gestational age. According to a report in MedScape OB/GYN News,
Clinicians have commonly recommended cesarean delivery for infants who were premature and showed intrauterine growth restriction because it was considered more protective of higher-risk neonates than vaginal delivery.
However, a new study of neonates who were small for gestational age showed that cesarean delivery did not have fewer complications, and in fact had an increased risk for respiratory distress.
“I suspected there might be some benefits to each type of delivery, but it was a surprise to see no benefits…for [cesarean delivery], while there was a benefit for vaginal delivery in terms of less respiratory distress,” lead author Erika F. Werner, MD, MS, from the Department of Gynecology and Obstetrics at Johns Hopkins University in Baltimore, Maryland, told Medscape Medical News.
Dr. Werner and her colleagues also found other surprising outcomes as a result of cesarean delivery of premature, small for gestational age infants,
- Cesarean delivery did not result in a reduction in the complications that have been perceived as risks with vaginal delivery
- There is no reduction in neonatal death in infants born vaginally (as has been believed).
- The odds of developing respiratory distress syndrome were 30% higher with cesarean than with vaginal delivery. The rate remained higher after controlling for factors such as the mother’s age, ethnicity, education, prepregnancy weight, diabetes, hypertension, and gestational age at delivery.
- Infants delivered by cesarean had increased odds of having a 5-minute Apgar score below 7. No difference was seen after adjustment for confounding factors.
- Cesarean delivery is associated with increased likelihood of future cesarean deliveries.
This is really important information. So often when a mama is having complications, the immediate medical response is immediate cesarean delivery to “protect” the health of mama and baby. Well, according to these findings by Dr. Werner and her colleagues, this is not at all the case. According to this report, the study was well constructed and had a hearty sample size such that the results are valid and able to be extended to the broader population.
So would this new information have applied to my daughter’s delivery? Technically speaking, my daughter was not small for gestational age, she was just small. Had she gone to term my OB reassures me she would have been closer to 7 lbs. She has no developmental delays or problems, yet does have asthma. Is this in fact due to her delivery? Both my husband and I have asthma histories and my husband’s history is quite severe. So what’s to say her asthma isn’t genetic? And who’s to say that my uterus wouldn’t have ruptured from the previous surgical cuts andscarring? Hindsight is in fact 20/20. But I will always wonder, “What if I had delivered her vaginally…?” Maybe I could have delivered my son vaginally as well!
For you Mamas on Bedrest who may be wondering if you should have a cesarean section, we can only suggest that you have a frank discussion with your doctor about these research findings and if medically reasonable, consider a trial of labor.
Note: This post was written based on information in the MedScape News, OB/GYN and Women’s Health, Society for Maternal-Fetal Medicine 32nd Annual Meeting. Nancy A. Melville was the author of the report.
Mamas on Bedrest: Mama’s “Dream Team”
January 12th, 2012As the debate over who is the better provide of peripartum care wages on, I often wonder, has anyone ever stopped to consider what mamas want? What are mamas’ ideas of the “perfect birth scenario?” What would constitute a birth “Dream Team?” I have often contemplated what would have been my dream scenario (not that anyone ever asked me!!)? If I had to do it all over again and could have things organized around what would have served and soothed me, this would have been my “Dream Team”.
AntePartum Doula. For both of my pregnancies, especially my first, I would have loved to have had someone come to my home, perhaps once or twice a week and check on me. One of the main reasons that I was so reluctant to go on bed rest and pushed back against it was because during my first pregnancy, I was completely on my own (my husband travels for work) and for my second, I was on my own with a 3 year old. How nice it would have been to have folks stopping by, helping out around the house and making sure that I had any and all supplies that I needed. Had I been on full bed rest, helping me to be comfortable, helping me to exercise my muscles and providing massage would have also been greatly appreciated.
Birth Doula. I sort of had this my second go round (We flew in my sister and she was a HUGE source of support and relief!!), but the first time, things went south very quickly and both my husband and I could have used some support in the delivery OR. While I was bleeding profusely (don’t know if they classified it as hemorrhaged, but it wasn’t pretty) immediately post partum, to have had someone that I knew and trusted to help me calm down (they had whisked my daughter away and I was a raving maniac!!), someone who could have told me what was going on, someone to convey that I was in great pain and got me the relief that I needed immediately and not 6 hours later would have been great. I think that incessant emesis and screaming should have been a clue, but it didn’t get me any relief, so I am thinking verbal requests might have worked better.
Midwife AND Obstetrician. I think that both should be present! In the case of my daughter, things went south pretty quickly, so the obstetrician would have definitely been in command. But for my second birth, I think it would have been nice to have a trial of labor with a midwife, with an OB standing (very close) by. I had a scheduled c-section at 39 weeks, my cervix was totally closed and I had no hint of labor. While my son was and is totally fine, I think he and I both were strong enough to have “gone the distance” for a VBAC. But I guess hindsight is 20/20. I wonder if I had had a skilled midwife present could I have at least tried labor? Hmmm.
Lactation Consultant. The hospital in which I delivered my daughter (my first delivery) did well with this one and I really liked this lady! The neonatologist was all gunho on giving my daughter formula because she was unable to latch initially and she could not breathe and suck (her O2 saturation would drop into the mid to low 80’s). I refused. I wanted her to have breastmilk, but mine wasn’t in yet. The neonatologist was insisting on formula so that they could measue exactly how much my baby was getting. A very wonderful Lactation consultant arrived and asked, “Why hasn’t this mama been given a breast pump and offered donor breastmilk?” Everyone in the NICU kind of looked at her like, “Curses, foiled again!” but by the end of the day, I had a breast pump and was pumping out small amounts of colostrum and my daughter had a bottle of donor breast milk which was all we needed until my milk came in. This lovely woman also showed me the best ways to help my daughter to latch on so that she didn’t desaturate as much (just into the low 90’s) and her monitors didn’t all sceech and holler when I held her.
Social Support/Discharge Planning. Now I know that some of you reading this will say, “But most hospitals have social workers.” This is true. But neither time I delivered in either hospital (my children were born in two different hospitals) did a social worker come in and see if there was any support that I needed at home, did I have any questions or if I had any concerns. No one gave me any instructions on wound care for my c-section incisions and no one gave me, “If this happens, come back immediately” instructions or anything on the signs and symptoms of post partum depression. Interestingly, a social worker did come into my room when I had my son to offer me Medicare and WIC (foodstamps) papers. (Obviously she hadn’t read my chart and seen that I had private insurance or a well employed husband, but had merely seen “my face” and had made some pretty biases-okay, racist- assumptions. But I’ll leave that discussion for another post!)
Post Partum (Home Doula). I really needed this, especially after my second delivery! While my sister attended my birth, she had to leave the very next day. (I wasn’t even out of the hospital!) I was in the hospital most of the week following my c-section. When I went home, my parents were there, but they had already been there a week and only stayed two more. So at 3 weeks post partum, still sore and achey, I got up, got my 2 little ones ready and drove my parents to the airport. (Husband had already set off on another business trip!) I have to admit, my response timing was off and I really couldn’t adequately feel my feet to drive but I did it. And at 3 weeks post partum, I was on my own with 2 little people. At that time, I didn’t know about doulas and no one suggested one to me. A few friends stopped by, but for the most part, I was on my own. A doula would have been a Godsend! Post partum follow up is the norm in many countries. I truly believe that it needs to be standard of care in the United States!
So this would have been my dream team. This is actually the reality in many countries. Women in many countries receive this type of perinatal care as routine, and it’s covered by (often universal) insurance. Sadly, this level of care isn’t available to everyone in the US, only via private pay, so often women who need it most are least able to afford the assistance. Thankfully many doulas are able to fulfill the intrapartum, post partum and lactation duties, so you really get 3 rolled up into one. But we have a long way to go!
Few practices utilize both Obstetricians and midwives in the US. To me, this is where we really fall short of providing optimum care. The saying, “It takes a village to raise a child” is approriate because while takes a village to raise the child, it really takes a TEAM to bring the child into the world. It is high time that we all realize that no one provider-Obstetrician or Midwife-is better than the other. They have different skill sets, different strengths and mamas need both available to her as she brings her child (ren) into this world. It is high time that this bickering back and forth STOP and we get about the business of caring for the needs-medical, social and otherwise- of mamas and their babies.
Mamas, what is your ideal “Dream Team”? Do you have it? How can we help you get it? Share your comments below and be sure to subscribe to our RSS feed at the top right corner of this webpage.
Mamas on Bedrest: Priorities for Maternal and Child Health Identified
December 21st, 2011
Click to take the postpartum depression survey conducted by Case Western Reserve University http://filer.case.edu/~axp335/postpartdep.htm Thank you very much for your consideration.
.
.
On the heels of the 20/20 special segment, “Giving Life: A Risky Proposition” World Health Organization (WHO) has released Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health. This comprehensive document outlines the necessary steps and guidelines nations (developing low and mid income nations in particular) must adopt in order to further reduce maternal, infant and child mortality and to have a chance of reaching Millennium Development Goals .
Maternal, Infant and Child mortality is a global issue. According to the report,
Annually, 358,000 women die worldwide during pregnancy and childbirth. Approximately 7.6 million children die before the age of 5 years, and those in low-income countries are about 18 times more likely to die during that time than children in high-income countries. Under-5 mortality rates are highest in sub-Saharan Africa and Southern Asia.
Maternal, newborn, and under-5 mortality rates have declined in accordance with Millennium Development Goals 4 (reduce the under-5 mortality rate by two thirds between 1990 and 2015) and 5 (reduce the maternal mortality ratio by three quarters between 1990 and 2015). However, the improvements are not occurring quickly enough to reach the 2015 targets.
WHO and its partners The AGA Khan University (in Pakistan) and The Partnership for Maternal, Newborn and Child Health performed a survey of more than 50,000 review papers to determine what steps are necessary to critically impact maternal, newborn and child health. Their goal was to identify key interventions that low and middle income countries can implement that are cost effective, will maximize resources and maximize the health and mortality of women, infants and children and thus help these countries reach worldwide millennium health and development goals. Their research has revealed some 56 key evidence-based interventions that when implemented, will have a significant impact on maternal, newborn and child health.
Rather than try and list all the interventions here, I refer you to their report, Essential Interventions, Commodities and Guidelines for Reproductive, Maternal, Newborn and Child Health.
For each intervention, the authors indicated whether they recommend the intervention be delivered,
- Through the community or in the home-These health care workers are often community volunteers and/or influential outreach workers who have knowledge of the local community and are trusted by the community.
- Via healthcare professionals, outreach workers, or community health workers-Health care providers at this level are skilled professionals as well as outreach workers.
- In hospitals-Either local hospitals or regional referral hospitals that can provide higher levels of intervention and care.
The interventions were classified broadly as adolescents/prepregnancy, pregnancy, childbirth, postnatal (mother), postnatal (newborn), infancy and childhood, and cross-cutting community strategies.
Researchers believe that the recommendations in this report will help low and middle income countries’ health care workers best utilize their resources in an effort to reduce Maternal, Newborn and Child deaths. These guidelines will also help countries develop policies and regulations that will not only benefit women and children’s health, but also take into consideration the health care and policy environments of the countries so that all citizens will benefit.
