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Post-Cesarean Bacteria Transfer Could Change Health for Life, Study Shows – The New York Times

A new study shows that a mother’s beneficial microbes can be transferred, at least partially, from her vagina to her baby after a C-section.”  (The New York Times)

My colleagues here in Westchester County have been practicing this for the last few years.  Nice to see that The New York Times has picked up the story, which, like the story about the NHS in the UK recommending midwifery care to low-risk pregnant women instead of OB/hospital care — will hopefully mean that that swabbing the vagina pre-surgery and transferring the microbes to the baby directly following will become standard practice.

Source: Post-Cesarean Bacteria Transfer Could Change Health for Life, Study Shows – The New York Times

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British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies

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.”

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What You Don’t Know About Episiotomies Can Hurt You (The New York Times, 1/27/2013)

When Cyndi Sellers’s son was born at a hospital in southern Oregon, the obstetrician on call rushed in with wet hair wearing a tie-dye T-shirt, as if she had just been swimming. After only a few minutes in the room, the doctor then cut an episiotomy so long that Cyndi’s mother — who was watching the birth — later described it as “horrifying.”

The doctor delivered the baby, stitched up Cyndi, and hurried out again. In the brief time the obstetrician was in the labor room, she managed to do so much damage that, almost three years later, Cyndi tells me when we talk on the phone, things “still don’t feel right down there.”

An episiotomy is a surgical cut from the vagina to the anus, on the area of a woman’s body known as the perineum. Once routine, it continues to be a “common obstetrical procedure,” according to the authors of the 23rd edition of Williams Obstetrics, the 1,385-page manual that serves as a textbook for obstetricians.

The reason for the episiotomy’s popularity in the 1950s, ’60s and ’70s, when my brothers and I were born, was that doctors believed that a clean downward cut on the laboring woman’s perineum was safer for the baby and better for the mother than letting a woman’s perineum tear during pushing. A straight cut was easier to stitch than a jagged tear, and doctors argued that a woman would feel less postpartum pain and have fewer future problems with pelvic-floor complications (like urinary incontinence).

More than half a dozen scientific studies done since the 1990s suggest that those doctors were wrong. Episiotomies are actually associated with more postoperative pain, a much greater likelihood of tears in the anus (ouch), and other complications. One study showed that women who had episiotomies were as much as six times more likely to report fecal or flatus incontinence than women who delivered with an intact perineum.

“The biggest problem with any type of episiotomy is the lack of control of the cut once it’s done,” explained Louana George, a registered nurse and certified professional midwife who delivered babies for 25 years. “It’s not unusual for a cut to extend unintentionally into the rectum, necessitating extensive suturing to repair the damage.”

Another midwife demonstrated the problem to me by taking a piece of paper in two hands and pulling it apart. The paper started to give but did not tear. Then she put a cut in the top of the paper and pulled again. This time the paper ripped cleanly in half. “That’s what happens to a woman’s perineum when you do an episiotomy,” the midwife explained, sending shivers up my spine.

“You have a greater chance of having a much more severe tear,” she went on. “Then there’s the problem that you’re cutting through muscle — when you tear it usually only goes through tissue — so it can cause significant damage that needs to be repaired and leave a woman with pain, numbness and lifelong problems with sex.”

Some cuts are necessary. If a woman has an unusually tight perineum (because of her anatomy or because tight scar tissue has grown over a previous episiotomy) and the tissue just isn’t stretching, an episiotomy may be indicated. If a baby close to being born is showing signs of distress and needs to be born quickly, an episiotomy can facilitate birth. Sometimes the practitioner can see that a very large head may cause a rectal or urethral tear, and a cut may help avoid that potential damage.

But these instances are few and far between. “If they have an indication, it is rare indeed,” Paul Qualtere-Burcher, an obstetrician who has participated in over 4,000 births and who teaches at the Albany Medical Center, wrote in an e-mail. Dr. Qualtere-Burcher can’t remember the last time he cut an episiotomy. “They clearly increase lacerations into the rectum, they hurt more and take longer to heal,” he explains.

Most American doctors still believe episiotomies help prevent injury in the case of stuck shoulders. But a new study examining 94,842 births over a 10-year period suggests that assumption is also wrong. “Despite historical recommendations for an episiotomy to prevent brachial plexus injury when a shoulder dystocia is encountered,” the authors conclude, “the trend we observed does not suggest benefit from this practice.”

Though it is no longer the “standard of care,” many obstetricians continue to perform episiotomies, arguably for the wrong reasons and often without asking consent.

“Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed,” one obstetrician, who recently finished her residency, told me. This doctor has a colleague, an obstetrician in private practice, who “loves epis” and cuts them during almost every vaginal birth.

The American College of Obstetricians and Gynecologists recommends that doctors rely on their “clinical judgment” when it comes to episiotomies. Pregnant women who would prefer to assess that judgement ahead of time (and to find a practitioner who won’t come at their privates with a pair of blunt-tipped scissors) should talk episiotomies before they’re in the delivery room.

Or they can follow my mom’s lead when she was giving birth to me in 1969. Alone in the delivery room, on her back with her feet in cold metal stirrups, she saw the doctor coming closer to her vagina with a scalpel.

“No!” she managed to cry before another contraction consumed her concentration. “I told you I didn’t want that! NO EPISIOTOMY!”

“O.K., lady,” the doctor said, laughing, putting down his knife.

Were you given an episiotomy during labor? Did your doctor ask consent? Do you think the cut was a necessary part of the birth?

Jennifer Margulis, Ph.D., is a senior fellow at the Schuster Institute of Investigative Journalism at Brandeis University and the author of the forthcoming “The Business of Baby: What Doctors Don’t Tell You, What Corporations Try to Sell You, and How to Put Your Baby Before Their Bottom Line.”