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Uterine Rupture: Assessing the Risks
Posted on April 26, 2016 at 10:18 AM |
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Uterine rupture is a topic that came up when I was pregnant with
Otter that I was not ready to allow into my consciousness until she was
safely in our arms. After enough time
had passed and we have proven to ourselves that homebirth can be a safe option
when a person is healthy and low risk, I am ready to write about it.
I gave Stephanie Stanley, former facilitator of the East Valley
ICAN group, byline credit for this because I am using her research from a
uterine rupture presentation she did at a meeting for my post today. ICAN, the International Cesarean Awareness
Network, is a non-profit organization that strives to improve maternal-child
health by preventing unnecessary cesareans through education, providing support
for cesarean recovery, as well as educate about Vaginal Birth After Cesarean
(VBAC) and options for what is called a "gentle cesarean" where the event is honored as a birth even though it's via a surgery. ICAN’s goal is to see a healthy
reduction of the cesarean rate that is patient-driven. By providing education and support, they hope
that more women making evidence based, risk appropriate childbirth decisions
will lead to an overall reduction in the rate of cesareans performed.
Uterine rupture seems to be the leading reason why care providers are
hesitant to allow a mother to have a trial of labor (TOL) after a previous
cesarean. In Arizona, a licensed midwife or certified professional midwife can attend a homebirth
with a mom who is striving to have a VBAC only if the mother meets certain criteria. Arizonana for Birth Options is leading a grassroots efforts to change this so
that as per the ICAN vision, women living here can make evidence based and risk
appropriate decisions. They want all
options to be available: for a hospital birth if mom feels that is the best
option, or a homebirth if both mom and midwife agree that they are a good
candidate for VBAC.
Uterine rupture is defined as an anatomic separation of the
uterine muscle with or without symptoms.
What this means for baby is that the uterus ceases to function as a sealed protective container from the rest of the blood and organs surrounding the baby. The function of the placenta and umbilical
cord may also be compromised. Mom is
subject to blood loss and shock. A
decision also has to be made about repairing the uterus or performing a
hysterectomy.
Another term used when talking about uterine rupture is
“dehiscence”. A dehiscence is the
splitting or incomplete opening of the cesarean scar. It can happen without complication for mom or
baby and sometimes it is only discovered after the delivery. It is also called a “window” by some care
providers.
As it turns out, while uterine rupture is a consideration when you are preparing for a birth after a cesarean, it's not the only one your care provider should be having a conversation about. You can read THIS post to see where the risk for uterine rupture falls in comparison to other risks of pregnancy and labor. So what does the research say?
Here is the overarching conclusion: anyone can be at risk,
whether you have an unscarred or scarred uterus. At most, your risk rate is 2%. 2 percent!
Why then is it that this is such a big deal? I believe it lies with the potentially
devastating circumstance a family will find themselves in if the uterus does
rupture. While 98% of the population
may have a successful VBAC, the worst case scenario of a uterine rupture is
the loss of the baby and possibly a hysterectomy for mom which makes future
pregnancies impossible.
Another point to ponder is that the statistics listed below
are close to other statistics for labor emergencies, such as placenta accreta,
placental abruption, miscarriage; for a longer list click here.
Statistics for the risk of uterine rupture – see links at
the end of this post for references: VBAC: .5% - .7% VBA2C: 1.7% (vaginal
birth after 2 cesareans) VBAMC: 1.2% (vaginal
birth after multiple cesareans) Previous VBAC: .4% - .5%
(if you had a previous successful VBAC) VBAC + Augmented labor:
.9% (stats for first attempt) VBAC + Induced labor: 1%
(stats for first attempt)
Here is a link to the comparison of risk rates for VBAC,
CBAC (a cesarean birth after a trial of labor) and ERC (elective repeat
cesarean)
http://www.sciencedirect.com/science/article/pii/S0002937808004213
The risk factors when considering whether or not to do a
trial of labor after a cesarean are: The type of scar you have: the most favorable is a low
transverse scar. Classical T-shaped
scars, vertical scars or high uterine scars are said to have a higher risk of
rupture.
Induction of labor using cervical ripening agents, i.e., Cytotec,
Cervidil: the prostaglandins that soften the cervix may also soften the scar
tissue. In addition, ripening agents can
cause uterine hyperstimulation, meaning contractions that are much more intense
and frequent than the uterus is designed to withstand in the course of an unmedicated
labor.
More than one cesarean: as you can see from the statistics
above, there is a slight increase of risk.
Among factors that are disputed in medical literature are: - Age of mother: if a mother is over 30 she may be considered
at higher risk for uterine rupture. - Obese women - Size of baby: more than 8 pounds, 14 ounces - Post-term baby: 40+ weeks gestation from last menses To compare, here are the stats and risk factors for an
unscarred uterus: “The normal, unscarred uterus is least
susceptible to rupture. Grand multiparity, neglected labor, malpresentation,
breech extraction, and uterine instrumentation are all predisposing factors for
uterine rupture. A 10-year Irish study by Gardeil et al showed that the overall
rate of unscarred uterine rupture during pregnancy was 1 per 30,764 deliveries
(0.0033%). No cases of uterine rupture occurred among 21,998 primigravidas, and
only 2 (0.0051%) occurred among 39,529 multigravidas with no uterine scar. A meta-analysis
of 8 large, modern (1975-2009) studies from industrialized countries revealed
174 uterine ruptures among 1,467,534 deliveries. This finding suggested that
the modern rate of unscarred uterine rupture during pregnancy is 0.012% (1 of
8,434). This rate of spontaneous uterine rupture has not changed appreciably
over the last 40 years, and most of these events occur at term and during
labor. An 8-fold increased incidence of uterine rupture of 0.11% (1 in 920) has
been noted in developing countries. This increased incidence of uterine rupture
has been attributed to a higher-than-average incidence of neglected and
obstructed labor due to inadequate access to medical care. When one assesses
the risk of uterine rupture, this baseline rate of pregnancy-related uterine
rupture is a benchmark that must be used as a point of reference.” If you choose to have a VBAC, or realistically for any woman
in labor since the statistics show she has a slight risk, here are the signs that may
help you recognize that a uterine rupture is occurring or may have occurred: - Excessive vaginal bleeding - Extreme pain between contractions – these may or may not
be felt through an epidural block, though due to severity of pain it’s possible
they may be felt - Contractions that slow down or become less intense - Abdominal pain or tenderness - Baby’s head moves back up the birth canal - Bulge in the abdomen, bulge under the pubic bone, or
pressure on the bladder where the baby’s head may be coming through the tear in
the uterus - Sharp onset of pain at the site of the previous scar - Uterus becomes soft - Shoulder pain - Heart decelerations in the baby - Maternal tachycardia (rapid heart rate) and hypotension
(low blood pressure)
If you have a true uterine rupture, then an emergency
cesarean will be required. A Chandler
doctor told the ICAN group that the care provider has 5 – 7 minutes to get the
baby out safely, although in reading for this post I saw some estimates as 10 –
37 minutes. According to a 2010 National Institutes of Health study,
there have been no maternal deaths in the US due to uterine rupture. Overall,
14 – 33% will need a hysterectomy. 6% of
uterine ruptures result in perinatal death, and for term babies this risk was
put at less than 3%. **
If you do have a uterine rupture, it will have an effect on
your future pregnancies. Each cesarean a
mother has increases the risk for future complications of cesarean
surgery. If you have a hysterectomy, you
will not be able to carry any more children.
In today’s medical climate, a uterine rupture will most likely result in
all future pregnancies being delivered via repeat cesarean.
There are a lot of points to ponder as a new mom or as a mom
considering a VBAC. Our Bradley® mantra
is: Healthy Mom, Healthy Baby. We teach
that as long as you make all your decisions with those two goals in mind, you
are likely to make the choices that have a positive outcome for both Mom and
Baby. What are your thoughts on VBAC and/or uterine rupture?
**NOTE: Stephanie’s presentation called out these statistics
as inflated as the Landon study (2004) included women who had pre-labor
stillbirths included in the statistics.
IN other words, women whose babies had passed away before labor and
still delivered via VBAC rather than choosing a repeat cesarean were counted in
the perinatal death statistics. Please
read Henci Goer’s analysis for more information
For the resource list, click here. Disclaimer: The material included on this site is for informational
purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®. |
VBAC Preparation: Ask the Midwife
Posted on April 29, 2015 at 7:16 PM |
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Our posts for Cesarean Awareness Month continue. With their permission, I am sharing notes today that I took at an
ICAN meeting presented by some Phoenix-area midwives in 2012. The main presenters and most of what you see below are the paraphrased words of Diane Ortega, CNM
and Belinda Hodder, CNM. They are midwives at Valley Women for Women, whose overall cesarean rate in 2014 was 7% in the midwife practice.* Also in
attendance and adding commentary to some of the answers was another CNM in the
area. While all three midwives believe
in and support the natural process, all of these women have had a cesarean
themselves. It seems to me that it lends them an
extra dose of vestment in their patient’s goals for a vaginal birth after
cesarean.
The format of this meeting was question and answer. Below is a paraphrase of the midwives’
answers to the questions posed by the women in attendance at the ICAN meeting
on October 24, 2012 in Tempe, AZ.
There is not a lot of opinion offered here.
It was a presentation of information so that a woman considering a vaginal birth after cesarean (VBAC) could consider
the information as she prepared for her next birth journey. This information is offered a starting
point for the previous cesarean birth woman to do her own research so that she could make the decision that
is right for her unique situation.
VBAC Planning and Preparation
Q: What are the best methods to prepare for a VBAC? A: There are several things you can do to prepare:
Q: What can I do to prepare my body for a VBAC?
A: There are a few things you can do
Q: Will the type of sutures I have determine whether or not I can have a VBAC?
A: Whether an obstetrician will do a
single-layer or a double-layer of sutures depending on how they are trained,
and sometimes it depends on what the uterus looks like. As long as you have a low, transverse scar,
or the status of your scar is “unknown” than you can have what is called a
“trail of labor”. If you have a vertical
scar, the standard is to have a repeat cesarean. Uterine Rupture
Q: Will my chance for a uterine rupture increase with the length of labor?
A: There is no evidence in the research that supports that. (At this point, ICAN leader Stephanie Stanley mentioned that a uterine rupture can happen at any time, with or without a previous cesarean – HERE is her research on that topic). Q: What are signs of uterine rupture? A: Pain that doesn’t go away after the contraction is over,
and a decrease in the baby’s movement an/or heart rate.
Q: How long does it take to heal from a uterine rupture? A: Like a cesarean; maybe there will be a little more bleeding.
Going Past 40 Weeks
Q: What is the concern about going postdate? A: ACOG guidelines are that babies should be born by 42 weeks gestation. While the literature does not show an increase of risk for uterine rupture, it does indicate that a baby does not tolerate a labor as well after 42 weeks. There are more issues with meconium, the umbilical cord and the placenta after the 42-week mark. You could find a care provider that is willing to let you go past 41 weeks as long as you are having ultra-sounds and non-stress tests done.
Q: What is the policy for induction if a
mother wants a trial of labor after multiple cesareans? A: That usually depends on the personal beliefs of your doctor(s). The use of prostaglandins or Cytotec is not indicated. In reality, there are no guidelines, only protocols to consider and to follow.
Q: How do I know if I am really “past” my estimated due date? A: The ultrasound at 9-10 weeks is considered to be the most accurate predictor of your estimated due date. If you know the history of your menstrual cycle (menses), or if you used an ovulation kit, you might have another data point for establishing your conception date, and thereby having another way to estimate your due date.
Q: What are strategies for inducing labor for a VBAC mom? A: Things that are done in office and then allow you to go home and labor there: a foley bulb (aka foley ball) or a stripping of the membranes. In the hospital and you stay at the hospital: foley ball, artificial rupture of membranes, and in some cases, you could use Pitocin.
About Labor
Q: What is the most common reason for a repeat cesarean after a trial of labor? A: A slow progress of labor with no real signposts that labor is going to progress. Keep in mind that if you come to the hospital early in labor, you start chipping away at your chances for a VBAC.
Q: Why do I have to be continually monitored? A: Our hands are tied by hospital policy – any VBAC patient has
to have continuous electronic fetal monitoring.
We work in a community that is frightened of litigation.
On the upside, if everyone looking in from the outside can “see” that mom and
baby are doing fine, this can buy you more time.
There are options in monitoring. There
are waterproof monitors that can be used in water during labor, and there are
also some hospitals that use wireless monitors.
HERE is a great visual on all
the different positions you can labor in even if you are continuously
monitored.
In reality, the amount of monitoring is specific to the hospital. You have to decide how you feel about going
Against Medical Advice (AMA) if you feel strongly about not having a continuous
monitor.
Q: What are your thoughts on an epidural?
A: You want to try to get into labor on your own at the beginning since
epidurals tend to slow your labor down.
When we say “get into labor” we mean dilation to at least a 6 with a
good, established pattern of contractions.
Pain is one of the indicators that can tell you something is going wrong
right away. If a mom has an epidural,
bradycardia (slow heart rate) in the baby is the only indicator we have that
things are not staying low risk. The use
of Pitocin to augment a slowed labor can also increase your chance of uterine
rupture.
Q: How long can I go with ruptured
membranes (broken bag of waters)?
A: If you are GBS negative, you could wait up to 24 hours before coming
in. If you are GBS positive, then we
evaluate that on a case-by-case basis. (Krystyna’s note: the presence of GBS at the time of labor raises the
concern for mom/and or baby to develop an infection during labor since the bag
of waters in no longer intact and able to provide a barrier against infection.)
Q: What are ways to prevent tearing during the pushing phase?
A: Eat well – a good diet packed with fruits and vegetables. There is no evidence that shows that perineal
massage will prevent tearing. You could
avoid tearing by tuning into the natural “safety mechanism” known as the “Ring
of Fire”. By tuning into your body, you
will slowly ease the baby out. This is
another reason to consider going the natural route: you don’t feel the ring of fire
when you have an epidural. In closing, here are their "Words of Wisdom": CARE PROVIDER
WHAT IF…
If your VBAC doesn’t work out, be easy on yourself.
(Krystyna’s note:HERE is a family-centered cesarean on film.
What is a little startling about this is that one of the references is
dated 2008! At least we are doing our
part to bring awareness to this option.)
BELIEVE IN YOURSELF
*Rate for one baby, head down, for patients who wanted to have a vaginal birth was 7% in 2014. This marks the third year they have collected data and the rate has remained 8 % or below whilst their overall number of patients rises each year. What did you do to prepare for your VBAC/CBAC journey? What did you learn that you are willing to share? Please leave us a comment - it will be moderated and posted. *I think* that the amount of traffic you so generously generate has led to a lot of spam posting. In an effort to keep the spam to a minimum, I am taking the time to moderate comments now.
Link List Visual reference of labor positions during EFM http://www.icanofatlanta.com/?page_id=159 The Family-Centered Cesarean http://blog.ican-online.org/2012/04/14/the-family-centered-cesarean/ Video: The Family-Centered Cesarean http://www.youtube.com/watch?v=m5RIcaK98Yg
The material included on this site is for informational purposes only.
It is not intended nor implied to be a substitute for professional medical
advice. The reader should always consult her or his healthcare provider to
determine the appropriateness of the information for their own situation. Krystyna and Bruss Bowman and Bowman House,
LLC accept no liability for the content of this site, or for the consequences
of any actions taken on the basis of the information provided. This blog contains
information about our classes available in Chandler, AZ and Payson, AZ and is
not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or
the American Academy of Husband-Coached Childbirth®. |
Warning Labels: Drugs Used for Augmentation
Posted on June 21, 2013 at 11:07 AM |
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To be clear – we are not anti-care provider or anti-drug. We are grateful for modern medicine that saves lives in circumstances when Mother Nature needs help. It exists for a reason, and we are thankful for the opportunity to meet all the Healthy Moms and Healthy Babies when we hold a class reunion. We are passionate about helping families have their Best Possible Birth. By that we mean the path that leads each individual family to a Healthy Mom, Healthy Baby outcome. We want families to have a toolbox full of tips and techniques that help them manage the ebb and flow of labor. We want them to be comfortable with the path of a normal, low-risk labor. We want them to have true informed consent by having an open line of communication with their care providers. To that end, I am sharing the information below in the interest of furthering our goal that all our students have true informed consent: knowing all the benefits and risks of a drug or procedure. It is very rare for anyone to read the drug information insert that comes in all drug packages. To save you time and squinting, we are already researched Epidural Drugs and Induction Drugs. To conclude the “Warning Label” Series, here are the drugs used for Augmentation and to counteract the strong contractions they have the potential to stimulate. PITOCIN: Pregnancy Category X http://www.drugs.com/pro/pitocin.html Contraindications: “Antepartum [before delivery] use of Pitocin is contraindicated in any of the following circumstances: Where there is significant cephalopelvic disproportion; In unfavorable fetal positions or presentations, such as transverse lies, which are undeliverable without conversion prior to delivery; In obstetrical emergencies where the benefit-to-risk ratio for either the fetus or the mother favors surgical intervention; In fetal distress where delivery is not imminent; Where adequate uterine activity fails to achieve satisfactory progress; Where the uterus is already hyperactive or hypertonic; In cases where vaginal delivery is contraindicated, such as invasive cervical carcinoma, active herpes genitalis, total placenta previa, vasa previa, and cord presentation or prolapse of the cord; In patients with hypersensitivity to the drug.” Precautions “When properly administered, oxytocin should stimulate uterine contractions comparable to those seen in normal labor. Overstimulation of the uterus by improper administration can be hazardous to both mother and fetus. Even with proper administration and adequate supervision, hypertonic contractions can occur in patients whose uteri are hypersensitive to oxytocin. This fact must be considered by the physician in exercising his judgment regarding patient selection.” “Except in unusual circumstances, oxytocin should not be administered in the following conditions: fetal distress, hydramnios, partial placenta previa, prematurity, borderline cephalopelvic disproportion, and any condition in which there is a predisposition for uterine rupture, such as previous major surgery on the cervix or uterus including cesarean section, overdistention of the uterus, grand multiparity, or past history of uterine sepsis or of traumatic delivery. Because of the variability of the combinations of factors which may be present in the conditions listed above, the definition of "unusual circumstances" must be left to the judgment of the physician. The decision can be made only by carefully weighing the potential benefits which oxytocin can provide in a given case against rare but definite potential for the drug to produce hypertonicity or tetanic spasm. Maternal deaths due to hypertensive episodes, subarachnoid hemorrhage, rupture of the uterus, and fetal deaths due to various causes have been reported associated with the use of parenteral oxytocic drugs for induction of labor or for augmentation in the first and second stages of labor.” “Oxytocin has been shown to have an intrinsic antidiuretic effect, acting to increase water reabsorption from the glomerular filtrate. Consideration should, therefore, be given to the possibility of water intoxication, particularly when oxytocin is administered continuously by infusion and the patient is receiving fluids by mouth. When oxytocin is used for induction or reinforcement of already existent labor, patients should be carefully selected. Pelvic adequacy must be considered and maternal and fetal conditions evaluated before use of the drug.” Adverse Reactions “The following adverse reactions have been reported in the mother:
“The possibility of increased blood loss and afibrinogenemia should be kept in mind when administering the drug.” “Severe water intoxication with convulsions and coma has occurred, associated with a slow oxytocin infusion over a 24-hour period. Maternal death due to oxytocin-induced water intoxication has been reported.” “The following adverse reactions have been reported in the fetus or neonate: Due to induced uterine motility:
Related drug SYNTOCINON® - most of the information is identical http://www.drugs.com/pro/syntocinon.html ERGOTRATE (ERGONOVINE) – Pregnancy: Should not be administered prior to delivery or delivery of the placenta http://www.drugs.com/mmx/ergotrate.html Pregnancy— “Use of ergonovine is contraindicated during pregnancy…Tetanic contractions may result in decreased uterine blood flow and fetal distress.” Labor and delivery— “High doses of ergonovine administered prior to delivery may cause uterine tetany and problems in the infant (hypoxia, intracranial hemorrhage) {03}. Ergonovine should not be administered prior to delivery of the placenta…Administration prior to delivery of the placenta may cause captivation of the placenta…or missed diagnosis of a second infant, due to excessive uterine contraction.” Breast-feeding “Problems in humans have not been documented. However, ergot alkaloids are excreted in breast milk…Although inhibition of lactation has not been reported for ergonovine, other ergot alkaloids inhibit lactation. Also, studies have shown that ergonovine interferes with the secretion of prolactin (to a lesser degree than bromocriptine) in the immediate postpartum period…This could result in delayed or diminished lactation with prolonged use.” “Ergot alkaloids have the potential to cause chronic ergot poisoning in the infant if used in higher-than-recommended doses or if used for a longer period of time than is generally recommended.” Pediatrics "Elimination of ergonovine may be prolonged in newborns...Neonates inadvertently administered ergonovine in overdose amounts have developed respiratory depression, cyanosis, seizures, decreased urine output, and severe peripheral vasoconstriction." METHERGINE: Category C http://dailymed.nlm.nih.gov/dailymed/lookup.cfm?setid=94c9b1cf-ae12-45f3-8fcb-708a922cbc10 INDICATIONS AND USAGE “For routine management after delivery of the placenta; postpartum atony and hemorrhage; subinvolution. Under full obstetric supervision, it may be given in the second stage of labor following delivery of the anterior shoulder.” CONTRAINDICATIONS "Hypertension; toxemia; pregnancy; and hypersensitivity." TOCOLYTICS MAGNESIUM SULFATE: Pregnancy Category A http://www.drugs.com/pregnancy/magnesium-sulfate.html “Studies in pregnant women have not shown evidence of fetal risk if magnesium sulfate is administered during any trimesters of pregnancy. However, because studies cannot completely rule out the possibility of harm, magnesium sulfate injection is only recommended for use during pregnancy when benefit outweighs risk.” “Newborns may show signs of magnesium toxicity (i.e. respiratory and/or neuromuscular depression) if the mother has received intravenous magnesium sulfate prior to delivery (especially if for a period of longer than 24 hours). Equipment for assisted ventilation as well as intravenous calcium should be immediately available for the first 24 to 48 hours after delivery. One study has reported that maternal magnesium sulfate treatment is associated with reduced brain blood flow perfusion in preterm infants. However, intravenous magnesium sulfate did not lead to lower neonate Apgar scores in a study of women treated for preeclampsia even though the newborns cord level indicated hypermagnesemia.” TERBUTALINE (BRETHINE): Pregnancy Category B http://www.drugs.com/sfx/brethine-side-effects.html “Terbutaline has been shown to cross the placenta, and the fetus may experience the general adverse effects reported in the mother. Pulmonary edema has been associated with the intravenous use of terbutaline in pregnant women. Myocardial necrosis in one infant was thought to be associated with terbutaline given at a rate of 0.5 mg/hr for 12 weeks by subcutaneous infusion. In one retrospective review of 8,709 patients receiving continuous low-dose subcutaneous infusion of terbutaline to arrest preterm labor, only 47 (0.54%) had one or more cardiopulmonary problems. Pulmonary edema was reported in 28 patients (0.32%), 17 of whom had been treated concurrently with large amounts of IV fluids or one to three tocolytic agents and four of whom had been diagnosed with pregnancy-induced hypertension and/or multiple gestation. Other cardiovascular effects occurred in 19 patients (0.22%), including electrocardiogram changes, irregular heart rate, chest pain, or shortness of breath. However, 7 of these patients had a history of cardiac problems. Use of terbutaline in pregnant women for the relief of bronchospasm may interfere with uterine contractility. For the treatment of asthma, administration by metered dose inhaler results in lower plasma concentrations and consequently fewer adverse effects for the mother and fetus. Hepatitis has been reported in at least two patients receiving terbutaline to control premature labor.” “Terbutaline has been assigned to pregnancy category B by the FDA. Animal studies have failed to reveal evidence of teratogenicity. Terbutaline is only recommended for use during pregnancy when benefit outweighs risk.” INDOMETHACIN (NSAID): Pregnancy Category C http://www.drugs.com/pregnancy/indomethacin.html “Animal studies have failed to reveal evidence of teratogenicity or fetal harm except at doses which result in significant maternal toxicity. There are no controlled data in early human pregnancy. Indomethacin has been used in the management of premature labor. However, fetal hemodynamic changes, premature closure of the ductus arteriosus resulting in neonatal primary pulmonary hypertension, and neonatal oliguric renal failure, oligohydramnios, hemorrhage, and intestinal perforation have been reported as a result of this tocolytic therapy. Indomethacin is only recommended for use during pregnancy when benefit outweighs risk.” “Indomethacin crosses the placenta. In one study, 26 pregnant patients were administered indomethacin 50 mg orally one time approximately six hours prior to scheduled cordocentesis, at a gestational age of 23.6 to 36.6 weeks. At the time of the procedure, maternal serum indomethacin concentrations ranged from 42 to 690 ng/mL (mean 218 ng/mL) while fetal concentrations ranged from 87 to 496 ng/mL (mean 219 ng/mL). The mean maternal to fetal serum concentration ratio was 0.97. There was no correlation between gestational age and maternal/fetal ratio. Amniotic fluid concentrations averaged 21 ng/mL. Indomethacin has been used successfully in the treatment of premature labor as well as polyhydramnios. In several studies, indomethacin was as effective and better tolerated than beta-agonists for premature labor. However, while earlier reports and studies suggested indomethacin was safe for the fetus or neonate, especially when use was confined to pregnancies of 34 weeks gestation or less, more recent data suggest a substantial increase in the risk of serious fetal or neonatal side effects. Eronen (1993) studied the effects of indomethacin or nylidrin on the fetal and neonatal ductus arteriosus and tricuspid valve function. A total of 84 pregnancies (94 fetuses) with premature labor between 22.9 and 34.0 weeks gestation were evaluated. Ductal constriction occurred in 46/49 (86%) of fetuses (gestational age 24.0 to 34.0 weeks) treated with indomethacin. The gestational age of the fetuses without ductal constriction ranged from 24.3 to 28.6 weeks. Eleven fetuses with ductal constriction also had tricuspid regurgitation. Data from this study suggest increasing reactivity of the ductus with increasing gestational age; although, ductal constriction occurred in one fetus at 22.9 weeks gestation. In addition to hemodynamic changes, other serious sequelae of maternal indomethacin use have been documented. One study compared 57 infants delivered at or before 30 weeks gestation whose mothers received indomethacin for the treatment of premature labor with 57 infants whose mothers had not received indomethacin. The total dose of indomethacin ranged from 50 to 6000 mg (median 425 mg) and the duration of therapy ranged from 1 to 79 days (median 3 days). Necrotizing enterocolitis occurred in 29% of infants exposed to indomethacin compared with an 8% incidence in the control group (p=0.005). Intracranial hemorrhage occurred in 28% of infants in the indomethacin group compared with only 9% in the control group (p=0.02). Maternal use of indomethacin has resulted in reduced fetal urine output and subsequent oligohydramnios, neonatal renal failure, fetal pleural effusion, and ileal perforation. In addition, at least two cases of neonatal lower limb ischemia have been reported following prolonged intrauterine exposure to indomethacin. Fetal echocardiograms after 24 hours of maternal indomethacin therapy and then weekly, thereafter, if long-term therapy is necessary, have been recommended. In addition, assessment of amniotic fluid volume is also recommended.” RITODRINE (YUPOTAR): Pregnancy Category B http://www.drugs.com/pregnancy/ritodrine.html “There are no controlled data in human pregnancy. Neonatal hypoglycemia, tachycardia, and ileus have been reported. Rarely, ketoacidosis resulting in fetal death has been reported. Ritodrine is only recommended for use during pregnancy when benefit outweighs risk.” Disclaimer: The material included on this site is for informational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The reader should always consult her or his healthcare provider to determine the appropriateness of the information for their own situation. Krystyna and Bruss Bowman and Bowman House, LLC accept no liability for the content of this site, or for the consequences of any actions taken on the basis of the information provided. This blog contains information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained on this blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®. |
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