preterm labor and prematurity
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: HHS offers $40M in grants to reduce preterm births!
February 10th, 2012“To help reduce the increasing number of preterm births in America and ensure more babies are born healthy, HHS Secretary Kathleen Sebelius announced more than $40 million in grants to test ways to reverse that trend, as well as a public campaign to reduce early elective deliveries.”
Thus begins the February 8, 2012 press release issued by the US Department of Health and Human Services announcing the $40Million grant program, The Strong Start Initiative. Strong Start is a joint collaboration between Centers for Medicare & Medicaid Services (CMS), the Health Resources and Services Administration (HRSA), the Administration on Children and Families (ACF), and outside groups devoted to the health of mothers and newborns. (i.e. The March of Dimes, the American College of Obstetricians and Gynecologists (ACOG), the National Partnership for Women and Families, the Society for Maternal and Fetal Medicine, American College of Nurse Midwives, Childbirth Connection, Leapfrog Group, and the National Priorities Partnership convened by the National Quality Forum and others.)
The mission of The Strong Start Initiative is two-fold:
- A test of a nationwide public-private partnership and awareness campaign to spread the adoption of best practices that can reduce the rate of early elective deliveries prior to 39 weeks for all populations; and
- An initiative to reduce the rate of preterm births for women who are at-risk for preterm birth and covered by Medicaid through testing enhanced prenatal care models.
According to the HHS press release,
“More than half a million infants are born prematurely in America each year, a trend that has skyrocketed by 36 percent over the last 20 years. Children born preterm require additional medical attention and often require early intervention services, special education and have conditions that may affect their productivity as adults.
The funds will be awarded to organizations and providers that serve women on Medicaid and will be used to test and implement treatments and protocols that will reduce preterm birth and improve outcomes amongst this population. This is great news for such organizations as Centering Healthcare, CommonSense Childbirth, The International Center for Traditional Childbearing and The Indian Health Services and others which serve large populations of women on Medicaid. These organizations, with their proven methods of prenatal care and lower incidences of complications and preterm births are poised to teach the rest of the health care industry how to provide care to women in a compassionate and culturally sensitive manner all the while improving outcomes.
In addition to preventable preterm births, the Strong Start initiative will also focus on reducing early elective deliveries, which can lead to a variety of health problems for mothers and infants. Up to 10 percent of all deliveries are scheduled as induced or surgical deliveries before 39 weeks that are not medically indicated. It has been well established that elective delivery before 39 weeks gestation is asssociated with increased complications to both mother and baby in the immediate intrapartum and for many years post partum. The Strong Start Initiative seeks to significantly reduce the incidence of elective preterm birth and its associated morbidities in mothers and infants.
Finally, The Strong Start Initiative is poised to save money for the health care system. It is estimated that medical care in the first year of life for preterm babies covered by the Medicaid program averages $20,000 compared to $2,100 for full-term infants. Medicaid pays for slightly less than half of the nation’s births each year. Even a 10 percent reduction in deliveries occurring prior to 39 weeks would generate over $75 million in annual Medicaid savings. Such savings could be poured back into the Medicaid program to further the health of its recipients and reduce the ever escalating costs of health care in the Medicaid population.
References
The US Department of Health and Human Services
The Center for Medicare and Medicaid Innovation
Mamas on Bedrest: Vaginal Progesterone Cuts Premature Births
December 23rd, 2011I’m tossing yet another tidbit of information for Mamas on Bedrest to share and discuss with their doctors.
In a study published online on December 14, 2011 in the American Journal of Obstetrics and Gynecology, a coalition of researchers from around the world (United States, Austria, Brazil, Denmark, India, South Africa, Turkey, and the United Kingdom) concluded that vaginal progesterone, administered in the mid-trimester of pregnancy to women with shortened cervix detected via ultrasound, can cut their risks of preterm labor by as much as half.
I found this information very interesting given the current brouhaha over Makena (the progesterone injections used for prevention of preterm labor) and how progesterone is often used early in pregnancy for women with repeated miscarriages (my situation!).
The researchers reviewed data from 5 highly respected studies and evaluated the efficacy and safety of using vaginal progesterone for the prevention of preterm labor in the presence of cervical shortening with rates of neonatal morbidity and mortality. Here are their findings:
- Vaginal progesterone reduced the rate of birth at less than 33 weeks’ gestation by 42% . It also reduced the risk for birth at less than 35 weeks’ gestation by 31% and less than 28 weeks’ gestation by 50% *.
- Vaginal progesterone also improved the following outcomes: respiratory distress syndrome, a composite measure of neonatal morbidity and mortality, birth weight less than 1500 g, admission to neonatal intensive care unit and need for mechanical ventilation.
Given these outcomes, one would think that physicians and researchers across the board would be recommending that women receive progesterone if they presented with shortened cevix. But such was not the case. Two commentators felt that the data was not conclusive enough. Sarah Bradley, MD, clinical assistant professor of obstetrics and gynecology from the University of Wisconsin–Madison felt that the data was “murky”. Her position stemmed from the fact that different studies used different definitions for shortened cervix. She also noted that many women had received a cervical cerclage (surgical stitch placed to keep the cervix closed) in addition to the progesterone and felt that it couldn’t be definitively stated that the progesterone was in fact the true reason that preterm labor was averted.
Aaron B. Caughey, MD, PhD, director of women’s health and chair of obstetrics and gynecology, Oregon Health Sciences University, Portland, had a similar comment on the definition of shortened cervix. He also felt that the meta-analysis really didn’t add any new information to what is already “standard of care”.
As a result, researchers recommend that women be advised of both treatments. While it is commonly recognized that either a cerclage or progesterone alone is often enough to prevent preterm birth, many women may elect to have both treatments and that is okay. Researchers also recommend that further research be undertaken to specify “shortened cervix” and to give specific measurements at which treatments are beneficial. They also recommend research to assess the effects of race, ethnicity, socioeconomic status, and maternal age on cervical shortening and preterm labor.
While I’m all in favor of evidenced based research, sometimes I think we analyze things to death. We know that adequate progesterone levels are essential to maintaining a healthy pregnancy. We see progesterone used in early pregnancy, especially in cases where women have undergone fertility treatments and/or have luteal phase defects resulting in repeated miscarriage. We know that progesterone injections (Makena and compounded variations) are effective in prolonging pregnancy in the instances of preterm birth later in pregnancy but before 37 weeks gestation. So I am not surprised that using vaginal progesterone is effective in helping prolong pregnancy and prevent preterm birth in cases of shortened cervix.
But I am surprised that commentators are pulling up short in making the recommendation that vaginal progesterone be used in the mid-trimester. Is it really necessary to determine that progesterone alone will prevent preterm birth in the presence of a cerclage? Is it really so awful if a woman has a cerclage and uses vaginal progesterone if she has a shortened cervix? And while it will be nice to know how efficacious progesterone is in various races, ethnicities, socioeconomic levels and in women of advanced maternal age, must we wait to have all this data before making recommendations? Can’t we do the work concurrently? It has been shown that use of progesterone produces more good than harm, so why not use it as currently stated and make the specific recommendations as the study data becomes available?
Many will judge my opinion and I am fine with that. But I was a woman who had repeat miscarriages until we figured out that my progesterone levels were not adequate to support pregnancy to term (beyond 1st trimester actually!). I know women who benefited from having progesterone injections in the second and third trimesters to prolong their pregnancies. I think that I can safely say, It didn’t matter if we were white or black, rich or poor, “old” or young, if it helped us to maintain our pregnancies and have healthy babies, we were all for it! If it helps specific subgroups, even better.
But on behalf of high risk pregnant women everywhere, please don’t wait to use a treatment that has been shown to be safe and efficacious in preventing preterm birth just so that you can get “exact” data. If you know that progesterone is efficacious in preventing preterm birth in a woman who has a cervix of 20mm and has a cerclage, why not try it in a woman whose cervix is 15mm or even 10mm? If she is at such risk, why not try? As a physician and scientist, you may think that it’s a waste. But for the mama desperately hoping and praying for her baby, it’s hanging on to all hope by a thread. Please don’t cut us off.
*This post is a summary and commentary of the MedScape report and the published article in The American Journal of Obstetrics and Gynecology online journal. Statistical information was attenuated for ease of reading. To read the full study results, please read the complete texts provided here.
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