The U.S. ranks 50th in maternal mortality globally
Improving maternal care in the U.S. will involve much more than increased spending. Better care can be provided at lower costs simply by recognizing that child birth is more than just a medical process that needs very expensive technical expertise. In many cases much lower cost alternatives can provide more care and more effective and humane care as has been shown by the example in the many industrialized countries that have universal health care systems.
Doctors Urge Patience, And Longer Labor, To Reduce C-Sections
Read the full NPR article here
Women with low-risk pregnancies should be allowed to spend more time in labor, to reduce the risk of having an unnecessary C-section, the nation's obstetricians say.
The new guidelines on reducing cesarean deliveries are aimed at first-time mothers, according to the American College of Obstetricians and the Society for Maternal-Fetal Medicine, which released the guidelines Wednesday online and in Obstetrics and Gynecology.
About one-third of all births in the U.S. are done by C-section, and most of those are in first-time mothers. There's been a 60 percent increase in these deliveries since the 1990s, but childbirth hasn't become markedly safer for babies or mothers.
That discrepancy has led many to conclude that the operation is being overused. A C-section is major surgery. The procedure can increase complications for the mother and raise the risk during future pregnancies.
Women giving birth for the first time should be allowed to push for at least three hours, the guidelines say. And if epidural anesthesia is used, they can push even longer. Techniques such as forceps are also recommended to help with vaginal delivery.
Early labor should also be given more time, the doctors say, with the start of active labor redefined to cervical dilation of 6 centimeters, rather than 4.
It seems that a key point of the new guidelines is that doctors and patients shouldn't rely too slavishly on fetal heart rate monitors when trying to figure out if the baby's in distress. Is that right?
The incidence of a child being injured in the womb is pretty low, probably about 1 percent in a normal pregnancy. In 100,000 women you're going to have 1,000 problems. If you miss one that's really bad, that's an injured baby, that's an upset family. It really impacts the doctors and the nurses, and, of course, it's costly to the hospital. We don't want to miss things. But if we're trading off hundreds of C-sections to prevent one injury, the question is what that trade-off should be. At some point that number is too high. The harm on the moms is too high, and on future pregnancies, too.
Is that different from what you learned in medical school?
My practice really changed when I came to San Francisco in 1999. I was initially horrified by how long the physicians and the midwives allowed women to labor. I came from an environment where we had benchmarks, and we followed them. Then we started looking at the second phase of labor, just when you're pushing. We found, lo and behold, that women who pushed longer than three hours, longer than four hours, even five hours, the babies didn't have worse outcomes than the babies delivered in the second hour. And they did better than babies delivered in the first hour.
How can it be that we're just now finding out what's a normal length of labor?
You know, before 1955 there was essentially no quantitative data on the length of labor. Then Emanuel Friedman said we should study this. He studied 500 women, and, of those, he said here are the 200 women who have idealized labors. We then managed 4 million a women a year for the next 50 years based on 200 women. It's not that the wrong approach was taken; it's that we started science and then didn't continue to do the science.
How is science done? A lot of it is driven by economic demand. There's no money in being patient in labor. I don't think they're going to come up with a special stopwatch. Because of that, nobody has really pushed to look at this again.
Epidurals Prolong Labor Longer Than Doctors Previously Thought (STUDY)
By Bahar Gholipour, Staff Writer
Published: 02/06/2014 06:40 AM EST on LiveScience
Using epidurals for pain relief during a baby's delivery may prolong labor more than previously thought, a new study finds.
In the study, the researchers looked at more than 42,000 women in California who delivered vaginally between 1976 and 2008, and compared the length of the second stage of labor, which is the time it takes for "pushing" the baby out after the cervix has fully opened, among women who had received epidurals and those who hadn't.
Although it was thought that epidurals lengthen labor by about one hour, the researchers found that women who had epidurals actually took two to three hours longer to get through the second stage of labor, compared with women who hadn't received this pain medication, according to the study, published today (Feb. 5) in the journal Obstetrics & Gynecology.
The findings could affect doctors' decisions to perform cesarean-section deliveries, the researchers said. Some C-sections are performed because labor is judged as taking too long. The new findings suggest that for women who receive an epidural, doctors may be able to wait a little longer before opting for the surgery.
"When epidural is used, it may be normal for labor to take two hours longer, and physicians don't necessarily have to intervene, as long as women are progressing and the baby is OK," said Dr. Yvonne Cheng, one of the researchers on the study and an obstetrician at University of California, San Francisco. [8 Odd Changes That Happen During Pregnancy]
Current definitions of "normal" labor account for one additional hour for women who have epidurals. This means that women who take longer than that may get a label of "prolonged second stage," and their doctors may choose to intervene by performing a C-section, or use either a vacuum device or forceps to help the baby out of the birth canal.
"Although the American College of Obstetricians and Gynecologists specifically says that the doctor doesn't have to intervene based on the passage of time alone, it is still kind of a gray zone," Cheng said.
Most definitions of what is normal during labor are based on norms established by Dr. Emmanuel Friedman in the 1950s, and may not properly fit the contemporary population, experts say. Today, women and babies are heavier on average, more women give birth at older ages and more women use epidurals.
"In the Friedman population, epidural was used in 8 percent of the population," Cheng said. "Today, it's closer to 60 percent."
In the new study, in women who were having a baby for the first time, the second stage of labor took 336 minutes with epidural, and 197 minutes without epidural — a difference of 2 hours and 19 minutes.
For women who had given birth before, the length of second stage was 255 minutes with epidural, and 81 minutes without epidural — a difference of 2 hours and 54 minutes, the study found.
The researchers cautioned that labor norms should not be established based on their study alone, and that more research is required to re-establish what should be considered normal labor in the contemporary population.
It is not fully understood exactly why epidurals prolong labor, but experts speculate that the drug relaxes the pelvic muscles and the woman has less urge to push.
http://www.huffingtonpost.com/2014/02/06/epidurals-prolong-labor_n_4738949.html
Get educated, know your options, and push for your baby
Seven women share their personal childbirth experiences, including the highs and lows, and underscore the importance of childbirth education to having the safest, healthiest birth possible.
A Breastfeeding Topic Every Mom Should Know About
This is a recent post by highly regarded Dr. Jack Newman on an VERY important topic you should know about (before the birth of your baby).
"This is post about test weights (weighing a baby before and after a feeding to see how much he got). I disagree with this approach which, at first glance, seems scientific and accurate. But it’s not. In the first place, see my previous post about percent weight loss and scales. Okay, test weights are done on the same scale, often scales made for testing weights, so they are likely to be accurate. But there is more to be concerned about.
Consider this: A baby who is exclusively breastfeeding and gaining weight well at 5 months is not getting any more milk than a 1 month old who is exclusively breastfed and gaining weight well even though the 5 month old weighs at least twice as much as the one month old. So how much is a baby supposed to get from the breast even if the weights are accurate? We don’t know. Breastmilk is magic and defies the logic of the “bean counters”.
In any case, the amount that is calculated that the baby “needs” is based on what a formula feeding baby would “need”. But even calculating on the basis of what formula fed babies need does not make sense because even formula fed babies do not always drink the same amount.
On top of that most mothers will agree that they have more milk in the morning than in the evening. So if the milk intake is measured in the morning, the result may be falsely reassuring. If measured in the late afternoon or evening, the result may be falsely concerning.
It is well known that the amount of fat in breastmilk is variable so that 30 ml (one ounce) of high fat milk may be a lot more satisfying than 30 ml lower fat milk and just as adequate for the baby’s growth as considerably more formula. And I don't me "hind milk". Studies also show that breastmilk fat content varies throughout the day.
It is also well known that anxiety can decrease the milk ejection reflex and thus, how much milk the baby will get. Being “put to the test” of test weighings can be very anxiety producing and affect the intake of milk by the baby.
So the best way to know if a baby is drinking or not drink from the breast is to watch the baby on the breast and watch for the pause in the chin. The links for the videos follow in the comments."
To Succeed At Breast-Feeding, Most New Moms Need Help
To significantly increase your likelihood of success in SF:
- Request a lactation consultant before you leave the hospital
- Set up a 2 hour consult with a postpartum doula/ lactation consultant for the day you arrive home. Lactation and newborn care support is worth every penny!
- Check out the most progressive pediatrician in the city and consider applying for care at Getzwell Pediatrics now! They have lactation consultants on staff.
ACOG president suggests that physicians haven’t caught up with ACOG’s current practice!!!!
Based on a recent study, the president of ACOG agrees that physicians aren't staying current with evidenced based science. No kidding!!!!!!!
Just another reason doulas are so important! It actually takes effort and dedication to stay abreast of the latest birth related research. Make sure there's someone on your birth team that has done extension research.
If your OB/midwife isn't comfortable with practices like delayed cord camping and true skin to skin please switch providers or hospitals. Your birth location and team are crucial choices. Know your options!
Why "skin to skin" and "rooming in" are important
The science and benefits of skin to skin and rooming in are important and backed by actual studies/science.
Research shows that you are likely to get just as much sleep with your baby in your room as you would if your baby were in the nursery. Research also tells us that babies who go to the hospital nursery at night cry more and are more likely to have trouble breastfeeding than babies who room-in with their mothers.
Watch a quick 3 minute video here.
Benefits for Babies Held Skin to Skin After Birth:
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They have more stable temperatures
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They cry less
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They have more stable blood sugar
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They breastfeed sooner, longer, and more easily
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They have lower levels of stress hormones
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They are exposed to the normal bacteria on the mother’s skin, which may protect them from becoming sick due to harmful germs
Friedman’s Curve and Failure to Progress: A Leading Cause of Unplanned C-sections
“Failure to progress” is the number one reason for unplanned C-sections in the U.S.
In 2013, researchers published a report of 38,484 first-time C-sections that occurred among a national sample of women. The overall C-section rate among first-time mothers was 30.8%. More than 1 in 3 (35%) of these Cesareans were due to a diagnosis of “failure to progress,” or slow progress in labor. This means that 10%, or 1 in 10, of all first-time mothers in the U.S. had a Cesarean for failure to progress during the years 2002-2008 (Boyle, Reddy et al. 2013).
To stop the flood of over-diagnoses of “failure to progress,” the following recommendations were made:
- Inductions should only be labeled “failed” after at least 24 hours of Pitocin (plus water broken, if possible)—this clock should not start until after cervical ripening is completed, if needed
- Women should be given an adequate time for both labor and pushing—and an “adequate” time is much longer than what has traditionally been allowed in the past
To read more on this topic from Rebecca Dekker, PhD, RN, APRN click here.
What's the big deal about birth?
"Birth is one of the last places in America where a modern woman is expected to lie back, shut her mouth, and take what's done to her. In many ways, our medical and legal systems support the total disempowerment of women in a major life event they'll always remember, and that can have lasting health consequences. And this is all happening in a system that delivers dismal outcomes for moms and babies, and costs more than anywhere else on the planet. The big deal is that when women take back the life event that defines their biology, we will see safer and healthier births, happier moms and babies and a new value on women themselves -- by women themselves."
Read more of Cristen Pascucci's (improvingbirth.org founder) interview here.