Tuesday, Feb 24 2015
LONDON — Reversing a generation of guidance on childbirth, Britain’s national health service on Wednesday advised healthy women that it was safer to have their babies at home, or in a birth center, than in a hospital.
Women with uncomplicated pregnancies — about 45 percent of the total — were better off in the hands of midwives than hospital doctors during birth, according to new guidelines by the National Institute for Health and Care Excellence. For these low-risk mothers-to-be, giving birth in a traditional maternity ward increased the chances of surgical intervention and therefore infection, the regulator said.
Hospital births were more likely to end in cesarean sections or involve episiotomies, a government financed 2011 study carried out by researchers at Oxford University showed. Women were more likely to be given epidurals, which numb the pain of labor but also increase the risk of a protracted birth that required forceps and damaged the perineum.
The risk of death or serious complications for babies was the same in all three settings, with one exception: In the case of first-time mothers, home birth slightly increased that risk. Nine in 1,000 cases would experience serious complications, compared with five in 1,000 for babies born in a hospital.
The findings could affect how hundreds of thousands of British women think about one of the biggest questions facing them. Nine in 10 of the roughly 700,000 babies born every year in England and Wales were delivered in a hospital.
As recently as 2007, the guidelines had advised women to be “cautious” about home birth in the absence of conclusive risk assessments.
Mark Baker, clinical practice director for the health institute, said first-time mothers with low birth risks would now be advised that a midwife-led unit would be particularly suitable for them, while mothers who already have given birth would be told that a home birth would be equally safe for the baby and safer for the mother than a hospital. But women are still free to choose the option they are most comfortable with, Dr. Baker said. “This is all about women having a choice,” he said.
Not everyone was at ease with the new guidelines. “Things can go wrong very easily and we do feel this advice could be dangerous,” Lucy Jolin of the Birth Trauma Association told the BBC.
So far doctors have not expressed any outrage over the decision. “If we had done this 20 years ago there would have been a revolution,” Dr. Baker said. “The penny has dropped. We’ve won the argument.”
With the exception of the Netherlands, where home births have long been popular and relatively widespread, few developed countries have significant numbers of women opting for nonhospital deliveries. In the United States, where a culture of litigation adds a layer of complication, only 1.36 percent of births took place outside a hospital in 2012. Two-thirds of those nonhospital births took place at home and 29 percent at free-standing birthing centers, according to the National Center for Health Statistics.
“We believe that hospitals and birthing centers are the safest places for birth, safer than home,” said Dr. Jeffrey L. Ecker, the chairman of the committee on obstetrics practice for American College of Obstetricians and Gynecologists. Under Britain’s integrated health system, if there is a complication, “they have a process and protocol for appropriately and quickly getting you somewhere else,” said Dr. Ecker, who added that he did not believe the British-style guidelines would come to America anytime soon. If such a recommendation were made in the United States, doctors might worry about losing patients to midwives.
That concern is absent in Britain’s taxpayer-funded system. “There are no financial incentives in the U.K. for doctors to deliver in a particular setting because there is no personal gain,” said Dr. Baker of the health institute. Childbirth is “effectively an N.H.S. monopoly,” he said, referring to the National Health Service, Britain’s public health system.
Holly Powell Kennedy, the immediate past president of the American College of Nurse-Midwives, an organization in the United States, praised the guidelines, saying, “This is how the practice should be happening.” In a hospital, “you are less able to labor without interventions,” Dr. Kennedy said.
Reducing the number of hospital births would save the health service money, but British officials said budgets had not factored into the new guidelines. A traditional hospital birth costs the country’s health system about $2,500, with a home birth roughly $1,500 and a birth center about $2,200.
“Yes, it’s a very expensive way to deliver healthy babies to healthy women,” Dr. Baker said about hospital births. “Saving money is not a crime.”
Sitting on a chair for hours on end (as many of us do while at the computer) is not good for your posture, or health. So, during your pregnancy, try sitting on a chair with a fitness ball built in instead of your regular office chair, and see how helpful it is in keeping your spine straight and body centered.
When your body and baby are laboring, you want to keep your pelvis open and moving. Slow dancing with your partner is a great way to do this. Sitting on a birth ball (aka fitness ball) is also great. Whatever kind of birth you choose, with or without medication, you can literally rock your birth (and potentially shorten your labor) with the help of a birth ball.
During labor, birth balls are simple to use, and as long as your upper body is supported so you don’t fall off, safe. Simply sit on the ball and lean on whatever feels best to you: into the arms of your partner, your doula, the edge of the bed. The forward leaning position will help align and center your baby and is usually one of the most comfortable positions during strong contractions. Since the ball is waterproof, you can also sit on it while in the shower. Mamas I’ve worked with have sometimes stayed in their hospital room shower enjoying the warmth and relaxation of the water while laboring on the ball for hours at a time!
Another kind of ball you can use in labor is the peanut ball. As you’ve no doubt been told, lying on your back in labor is the worst place you want to be — both for your baby’s positioning, and your comfort. Lying on your side, however, is a great way to rest. Placing a peanut ball between your legs helps widen your pelvis and allows the baby more room to descend and rotate.
Birth balls are widely available (Target sells them in the sports section) and many hospitals already have them available for you to use when laboring there (White Plains Hospital and Greenwich Hospital, for example). Since it is best to keep your hips open and pelvis rotating in pregnancy anyway, you may want to have one available at home to sit on. Rock on, mamas.
(Click on the link ABOVE to view the article including video)
Keep that bun in the oven: Induced births falling in the U.S.
Today’s expectant moms and their doctors have decided it’s not nice to fool Mother Nature. Rather than inducing labor, they’re letting nature take its course, with the length of pregnancies in the U.S. on the upswing, according to a new study by the CDC.
The study released Wednesday tracks labor started through surgical or medical means during the years 2006 through 2012. The researchers found that induction rates at 38 weeks — once considered full-term gestation but now called an early-term gestation — declined for 36 states and the District of Columbia during this six-year period. Declines ranged from 5 percent to 48 percent.
Geography didn’t seem to matter. Thirty-one states and the District of Columbia posted declines of at least 10 percent. The researchers did find that trends in induction rates at each week from 35 weeks, considered late pre-term, to 38 weeks, varied by maternal age. At 38 weeks, though, induction rates declined for all maternal age groups under 40, dropping 13 percent to 19 percent for women in their 20s and 30s.
This is a sharp reversal of trends tracked from 1981 through 2006 in which the proportion of babies born at less than 39 weeks gestation increased nearly 60 percent, while births at 39 weeks or more declined more than 20 percent.
“We were surprised that the overall induction rate went down,” says lead researcher Michelle Osterman, a health statistician with the National Center for Health Statistics, which is part of the CDC.
And it is welcome news, too. “For years we were taught that the 37th or 38th week of pregnancy was full term, but we did not appreciate the neonatal outcomes,” says ob/gyn Dr. Nancy Cossler, vice chair for quality and patient safety at University MacDonald Women’s Hospital in Cleveland, Ohio.
“It was an ingrained part of our culture that 37 weeks is OK, but it’s not necessarily OK for the baby,” she says, citing issues such as hypothermia, feeding difficulties and respiratory distress among infants born early.
Historically, MacDonald Women’s Hospital had a rate of about 11 percent for labor induction for non-medical reasons among patients who were 37 to 38 weeks pregnant. Today, it’s nearly zero. In 2013, only one birth among the 37 to 38 week gestational age was done through induction. The patient had metastatic breast cancer, which is not among the usual listed criteria for medical induction, and needed to start chemotherapy and needed an early delivery, says Cossler.
Indeed, there is a big push nationally for longer-term births, such as the large-scale educational program called the 39-Week Initiative, supported by the March of Dimes and other groups. It seeks to end non-medically indicated deliveries prior to 39 weeks. Last year, the American Congress of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine even recommended the label “term” in pregnancy, be replaced with categories based on gestational age. Today, babies born at 39 weeks through 40 weeks and six days of pregnancy are considered “full term.” Babies born at 37 to 38 weeks are now considered “early term.”
“I think this study is very positive since several of us have now provided evidence that babies have better outcomes (with longer term births),” says Dr. Kimberly Noble, assistant professor of pediatrics at Columbia University.
In a study published in the journal Pediatrics of 128,000 New York City public school children, Noble and her colleagues found that compared to children born at 41 weeks, those born at 37 weeks had a 33 percent increased chance of having third-grade reading problems, and a 19 percent increased chance of having moderate math issues.
But doctors do worry that the pendulum could swing too far and patients may be afraid of induced deliveries.
Our study “can’t differentiate between induction done for medical reasons and induction done for convenience, and if your doctor says this baby needs to come out at 37 weeks because of a problem, you need to trust your doctor,” says Noble, citing issues such as maternal or fetal distress as a cause for earlier delivery. What patients and doctors shouldn’t do is schedule an earlier delivery because of a vacation or other issue. “We know that 39 weeks and beyond is good for the baby,” she says.
Nation’s Ob-Gyns Take Aim at Preventing Cesareans
February 19, 2014
Washington, DC — Allowing most women with low-risk pregnancies to spend more time in the first stage of labor may avoid unnecessary cesareans, according to The American College of Obstetricians and Gynecologists (The College) and the Society for Maternal-Fetal Medicine (SMFM). In a jointly-issued Obstetric Care Consensus guideline, the new recommendations are targeted at preventing women from having cesareans with their first birth and at decreasing the national cesarean rate.
“Evidence now shows that labor actually progresses slower than we thought in the past, so many women might just need a little more time to labor and deliver vaginally instead of moving to a cesarean delivery,” said Aaron B. Caughey, MD, a member of The College’s Committee on Obstetric Practice who helped develop the new recommendations. “Most women who have had a cesarean with their first baby end up having repeat cesarean deliveries for subsequent babies, and this is what we’re trying to avoid. By preventing the first cesarean delivery, we should be able to reduce the nation’s overall cesarean delivery rate.”
In 2011, one in three women in the US gave birth by cesarean delivery, a 60% increase since 1996. Today, approximately 60% of all cesarean births are primary cesareans. Although cesarean birth can be life-saving for the baby and/or the mother, the rapid increase in cesarean birth rates raises significant concern that cesarean delivery is overused without clear evidence of improved maternal or newborn outcomes.
Safe Prevention of the Primary Cesarean Delivery discusses ways to decrease cesarean deliveries, including:
- Allowing prolonged latent (early) phase labor.
- Considering cervical dilation of 6 cm (instead of 4 cm) as the start of active phase labor.
- Allowing more time for labor to progress in the active phase.
- Allowing women to push for at least two hours if they have delivered before, three hours if it’s their first delivery, and even longer in some situations, for example, with an epidural.
- Using techniques to assist with vaginal delivery, which is the preferred method when possible. This may include the use of forceps, for example.
- Encouraging patients to avoid excessive weight gain during pregnancy.
“Physicians do need to balance risks and benefits, and for some clinical conditions, cesarean is definitely the best mode of delivery,” said Vincenzo Berghella, MD, SMFM President, who helped develop the new recommendations. “But for most pregnancies that are low-risk, cesarean delivery may pose greater risk than vaginal delivery, especially risks related to future pregnancies.”
The College and SMFM encourage physicians, organizations, and governing bodies to conduct research that provides a better knowledge base to guide decisions about cesarean delivery and to encourage policy changes that safely lower the rate of primary cesarean delivery.
Safe Prevention of the Primary Cesarean Delivery is the first in a new Obstetric Care Consensus series from the College and SMFM; the series will provide high-quality, consistent, and concise clinical recommendations for practicing obstetricians and maternal-fetal medicine subspecialists.
Obstetric Care Consensus #1 “Safe Prevention of the Primary Cesarean Delivery” is published in the March issue of Obstetrics & Gynecology.
# # #
- Primary Cesarean Delivery Rates, by State: Results From the Revised Birth Certificate, 2006–2012.
- Committee Opinion #559 “Cesarean Delivery on Maternal Request” (April 2013)
- Committee Opinion #579 “Definition of Term Pregnancy” (November 2013)
- Practice Bulletin #115 “Vaginal Birth After Previous Cesarean Delivery” (Reaffirmed 2013)
- Patient FAQ: Cesarean Birth (C-section)
by Maria Pokluda, co-creator of Birth Boot Camp DOULA
1. The research says you should.
2. Your partner will be able to eat, grab a cup of coffee and go to the bathroom knowing that he is not leaving you alone.
3. A doula won’t leave at shift change….even if your labor progresses through more than one shift change.
4. Doulas know the “best” for all things pregnancy. Be it in the search for the perfect care provider or the perfect maternity bra…doulas know and will share their knowledge.
5. Doulas give good foot rubs during labor.
6. Doulas give good back rubs during labor.
7. Your doula works for YOU. Not the hospital and not your care provider.
8. When a couple has a doula, they have better breastfeeding success.
9. Labor hurts less when you have a doula.
10. Labor is often faster when you have a doula.
11. When you are approaching your due date, your doula will never ask you, “Have you had that baby yet???”
12. A doula has a rebozo and knows how to use it.
13. Your doula will tell you that you are beautiful even if you are wearing a hospital gown. She totally believes it too.
14. She will listen and relive all the details of your birth both in the moments right after delivery and in the weeks to follow. She will probably even still remember details years later.
15. Woman who have doulas reduce their odds of having a cesarean delivery.
16. Doulas are great for babies too! A doula reduces NICU admission and hospital stays for mom and baby.
17. Doulas know your birth experience matters.
18. Doulas help your partner support you.
19. Your doula can talk you through your options at every step of the way. They won’t ever make decisions for you but they will help you ask the questions so that you can make the best choices for your birth.
20. Doulas will support you no matter what happens!
*Curious about some of these statements about doulas? Many are backed by research. Check out Cochrane Review for more info.*
Maria Pokluda is a doula serving families in the Dallas/Ft. Worth area. She got involved in birth through her own experience of researching infertility and then pregnancy and birth. Maria is the co-creator and trainer of Birth Boot Camp DOULA.