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Sweet Pea Births

Chandler, Arizona

Sweet Pea Births

...celebrating every swee​t pea their birth

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REVIEW: ACOG Committee Opinion on Approaches to Limit Intervention During Labor and Birth

Posted on March 7, 2017 at 6:24 PM Comments comments (0)
Note: all words in this piece that are in “quotation marks” are excerpts or quotes from the ACOG Committee Opinion published February 2017.  HERE is that article.


 
The American College of Obstetrics and Gynecology just came to a very important conclusion in THIS Committee Opinion that was published in February 2017:
 
“Many common obstetric practices are of limited or uncertain benefit for low-risk women in spontaneous labor. In addition, some women may seek to reduce medical interventions during labor and delivery. Satisfaction with one’s birth experience also is related to personal expectations, support from caregivers, quality of the patient–caregiver relationship, and the patient’s involvement in decision making (57). Therefore, obstetrician–gynecologists and other obstetric care providers should be familiar with and consider using low-interventional approaches, when appropriate, for the intrapartum management of low-risk women in spontaneous labor.”
 
FINALLY.
 
Yes, it is a little frustrating that it has taken years for the doctors who manage pregnancy, labor and birth to acknowledge that less intervention is best for birth outcomes.  However, I am grateful that ACOG has caught up with Dr. Bradley and all the other proponents of dignity in birth that know “It’s not nice to fool Mother Nature.”
 
The part that interests me the most as a childbirth educator is how they treat the topic of pain relief and coping techniques in labor.  There is the acknowledgement that, “pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering. “
 
And then this statement:
“None of the nonpharmacologic techniques have been found to adversely affect the woman, the fetus, or the progress of labor, but few have been studied extensively enough to determine clear or relative effectiveness.”
 
So there is finally the recognition that nonparmacologic techniques do not adversely affect the woman, the fetus or the progress of labor. And to CYA, they have to state that there is no conclusive study to determine effectiveness.  Be that as it may, it doesn’t matter to me as a childbirth educator if a study can measure the effectiveness.  What I do know as an educator and a doula is that if the mother perceives a pain coping practice as effective, it is being effective for her in that moment.
 
The key to continuing that pain coping practice hinges on two questions: “Is the mother okay? Is the baby okay”” As long as both the mother and the baby continue to tolerate the intensity of labor, then the conclusion effectively says LEAVE THEM ALONE.
 
In the article there are two distinctions between pain coping practices:
 
The pain coping practices that have been studied and, “have all demonstrated statistically significant reductions in pain in many studies”
Water immersion consistently has been found to lower pain scores (8, 34).
Intradermal sterile water injections
Relaxation techniques
Acupuncture
Massage
 
“Other techniques may help women cope with labor more than directly affect pain scores”
Childbirth education
Transcutaneous electrical nerve stimulation [TENS]
Aromatherapy
Audioanalgesia
 
Here are some more areas of discussion in the committee opinion that bring obstetric care into the humane versus management for their convenience.  I have included the corresponding bullet points from the summary and also provided some lay-person translation as needed.
 
Latent Labor: Labor Management and the Timing of Admission
·       “For a woman who is at term in spontaneous labor with a fetus in vertex presentation, labor management may be individualized (depending on maternal and fetal condition and risks) to include techniques such as intermittent auscultation and nonpharmacologic methods of pain relief.”
 
IN OTHER WORDS: If your baby is head-down when you start labor, then your labor management can be individualized and include intermittent fetal monitoring (freedom to move as labor indicates) instead of continuous fetal monitoring (thus anchored to the bed) AND mother is free to try any method of pain relief of non-drug pain relief that she would like to try.
 
·       “Admission to labor and delivery may be delayed for women in the latent phase of labor when their status and their fetuses’ status are reassuring. The women can be offered frequent contact and support, as well as nonpharmacologic pain management measures.”

IN OTHER WORDS: If your labor has started and your bag of waters is intact, there is no rush to admit you to the labor and delivery ward.  If the mother is okay and the baby is okay, phone contact and support from your care provider is the order of the day, and the mother is free to continue with any non-drug pain coping practice that is working for her.
 
Term Premature Rupture of Membranes
·       Obstetrician–gynecologists and other obstetric care providers should inform pregnant women with term premature rupture of membrane (PROM [also known as prelabor rupture of membranes]) who are considering a period of expectant care of the potential risks associated with expectant management and the limitations of available data. For informed women, if concordant with their individual preferences and if there are no other maternal or fetal reasons to expedite delivery, the choice of expectant management for a period of time may be appropriately offered and supported. For women who are group B streptococci (GBS) positive, however, administration of antibiotics for GBS prophylaxis should not be delayed while awaiting labor. In such cases, many patients and obstetrician–gynecologists or other obstetric care providers may prefer immediate induction.
 
IN OTHER WORDS:
If your bag of water breaks and you are not GBS-positive, you as the patient can decline immediate induction and this committee opinion instructs the care provider to support the patient in that choice.  If you are informed, you also know this includes declining vaginal exams that have the potential to introduce infection and that water immersion is an available pain coping practice (see Henci Goer’s Thinking Woman’s Guide to a Better Birth”).
 
What bothers me a little is that if a woman is not informed, it sounds like they are going to railroad her into the immediate induction route.  Yuck.
 
As for women who are GBS-positive, the recommendation is to admit the patient and start the administration of antibiotics.  The committee says that the preference is for immediate induction, but it doesn’t say one way or the other that it is the best practice.  You can go back to those two important questions, “Is mom okay? Is baby okay?” If you get YES answers to both of those questions, you may think about getting the antibiotics and then postponing anything else that is offered until there is a medical indication “to do something”.
 
Continuous Support During Labor
·       “Evidence suggests that, in addition to regular nursing care, continuous one-to-one emotional support is associated with improved outcomes for women in labor.”
 
IN OTHER WORDS:  LET THE DOULAS IN THE ROOM!!!
 
Routine Amniotomy
·       “For women with normally progressing labor and no evidence of fetal compromise, routine amniotomy need not be undertaken unless required to facilitate monitoring.”
 
IN OTHER WORDS: Amniotomy is the artificial breaking of the bag of waters.  You can read the info sheet on this procedure HERE. What this committee opinion states clearly is that THERE IS NO REASON to break the bag of waters if labor is progressing and there is no evidence of fetal compromise.  Not to “help things along”.  Not to “speed labor”.  Not “to see what happens”. NONE. DO NOT break the bag of waters.
 
The only reason stated for breaking the bag of waters is in the case of the need of an internal fetal monitor. This monitor is screwed into the baby’s fontanel, so in order to facilitate access to said fontanel, the bag of waters needs to be out of the way.
 
Intermittent Auscultation
·       “To facilitate the option of intermittent auscultation, obstetrician–gynecologists and other obstetric care providers and facilities should consider adopting protocols and training staff to use a hand-held Doppler device for low-risk women who desire such monitoring during labor.”
 
IN OTHER WORDS: Get with the program and learn how to do labor evaluation with a hand-held Doppler device.  P.S.: Midwives have been doing this for years.
 
There are many risks associated with continuous fetal monitoring – for more information I recommend you read THIS Cochrane review that shows how a decrease in fetal monitoring increases positive birth outcomes.  There are many cases of false positives with continuous fetal monitoring.  These false positives result in a more aggressive management of labor that often leads to an increase in unnecessary cesarean birth outcomes.  While there is a time and a place and much gratitude for cesarean births that are needed, it is devastating for a mother to read her operative report and realize that her cesarean birth could have been avoided with a different approach to her care.
 
Techniques for Coping With Labor Pain
·       “When women are observed or admitted for pain or fatigue in latent labor, techniques such as education and support, oral hydration, positions of comfort, and nonpharmacologic pain management techniques such as massage or water immersion may be beneficial.”
 
IN OTHER WORDS: Don’t push the epidural if the patient wants to try some other things first.
 
·       “Use of the coping scale in conjunction with different nonpharmacologic and pharmacologic pain management techniques can help obstetrician–gynecologists and other obstetric care providers tailor interventions to best meet the needs of each woman.”
 
IN OTHER WORDS: Treat your patients as individuals!! What works for one does not work for all.  And pain is not the only marker for labor management.  As stated in the committee opinion, “pharmacologic methods mitigate pain, but they may not relieve anxiety or suffering.“  If the mother can handle the pain and is doing something that does reduces anxiety or suffering, that is ok.  It may be hard to watch, however, doing nothing is fine as long as the mother and the baby are doing well.
 
 
Hydration and Oral Intake in Labor
“Women in spontaneously progressing labor may not require routine continuous infusion of intravenous fluids. Although safe, intravenous hydration limits freedom of movement and may not be necessary.”
 
IN OTHER WORDS: Routine use of IV fluids is out!! Yeah!! The whole tone of this committee opinion is to treat patients as individuals, so if there is no medical indication and the patient declines routine IV, then leave her to labor without IV fluids.
 
HERE  is the summary of research presented at the Anesthesiology® 2015 Annual Meeting.  It states that, “most healthy women can skip the fasting and, in fact, would benefit from eating a light meal during labor…improvements in anesthesia care have made pain control during labor safer, reducing risks related to eating”.
 
 
Maternal Position During Labor
·       “Frequent position changes during labor to enhance maternal comfort and promote optimal fetal positioning can be supported as long as adopted positions allow appropriate maternal and fetal monitoring and treatments and are not contraindicated by maternal medical or obstetric complications.”
 
IN OTHER WORDS: As long as labor is progressing and mom and baby are well, let a mom labor in whatever position she deems useful.  When it’s time to monitor the baby, any position that allows for monitoring to happen is still acceptable. The easiest for the nurse and the most uncomfortable position for the mother/baby is to have the mother lie on her back (supine).  According to this committee opinion, other positions are now within range of acceptable.  Positions such as side lying, hands and knees, or tailor sitting are all examples of other positions that allow for fetal rotation and engagement in the pelvis while keeping the mother still enough to undergo fetal monitoring.
 
Second Stage of Labor: Pushing Technique
·       “When not coached to breathe in a specific way, women push with an open glottis. In consideration of the limited data regarding outcomes of spontaneous versus Valsalva pushing, each woman should be encouraged to use the technique that she prefers and is most effective for her.”
 
IN OTHER WORDS: Don’t tell a woman how to push.  If she follows her instincts, the baby will come out.  Valsalva pushing is when a woman is directed to do forceful pushing during a contraction for a certain count with no regard to what her body is doing physiologically.  Physiological pushing allows for a woman to work with her contractions: as she feels the peak, she will push as long as is comfortable. End of story.
 
Immediate Versus Delayed Pushing for Nulliparous Women With Epidural Analgesia
·       “In the absence of an indication for expeditious delivery, women (particularly those who are nulliparous with epidural analgesia) may be offered a period of rest of 1–2 hours (unless the woman has an urge to bear down sooner) at the onset of the second stage of labor.”
 
IN OTHER WORDS: “Nulliparous” means a woman that has not given birth before.  Unless there is a medical reason for the baby to be born as soon as possible, women, including those who have epidural analgesia, are to be allowed a time period between the time they are completely dilated (10 cm) and pushing.  If the woman is monitored and both she and baby are shown to be well, up to two hours can be allowed for the baby to descend into a position that creates the urge to push, thus making the pushing phase more effective.
 
Sometimes the cervix is open and the baby is still high in the pelvis, thus there is no urge to push.  When the pushing phase begins before there is an urge to push, this effectively “starts the clock” by which a care provider or hospital policy may deem it necessary to intervene with a vaginal operative birth (vacuum or forceps delivery) or a cesarean birth. 
 
 
I hope this little review offers you the confidence as a consumer to advocate for what you know is right for you and your baby.  Our inner wisdom about birth is present and powerful if we can allow it a voice in our labor space.

Disclaimer: 
The material included in this blog 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 and video contain information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained in this video and on our blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
 
Birthing From Within and Bradley Method® natural childbirth classes offered in Arizona: convenient to Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale


Q&A with SPB: Water

Posted on March 8, 2016 at 9:22 PM Comments comments (0)






 


Water is essential for good health. Pure water (nothing mixed in) is best for re-hydration of the body. Bottled or filtered water may be necessary, depending on your water source at your home or workplace. In the mother, water acts as a solvent and catalyst for biological reactions.  In the baby, water accounts for 75% of your baby's total body weight at birth.
 
Lack of water leads to dehydration, which can lead to over a 20% reduction of energy output (can you see why this could be a problem in pregnancy and/or labor?). Dehydration may also contribute to the headaches some women experience as a discomfort of pregnancy. Some of the complications a water deficiency can lead to are declined circulation (low blood flow which then affects what is *not* getting to the placenta), hypovolemia (low blood volume), and oligohydramnios (low amniotic fluid volume), which can trigger premature labor.
 
Note: water without adequate salt intake leads to an imbalance, making it hard for your body to absorb and retain fluids.
 
Be careful about your source of water – how much chlorine is in your municipal water? You can request a report from your town or city if they don’t send you an annual quality report.
 
Be careful of some bottled water. Read the labels. Some of them have additives such as magnesium sulfate (MgSO4), which is a laxative, muscle relaxant, and is used to stop labors. This common name for this additive is Epsom Salts.
 
Your water needs depend on your weight, your climate, and your energy output.

  • Formula: weight/2 = how many ounces of water you need
  • If you want to find out how many glasses of water that is, divide it by 8 ounces in a cup
  • Climate: is it humid or dry where you live? How much water are you perspiring?
  • Energy: again, perspiration also how much is being used by your body in the activities in which you participate?

Did you know that the color of your urine could be a hydration test?  If your urine is clear, pale or straw-colored, *and* you feel well overall, there is a good probability that you are adequately hydrated. If your urine is dark yellow or even orange, it's time to start drinking up some good, clean water. Strive for even more fluids if you have an active lifestyle, if it’s hot outside or both.
 
Note on oligohydramnios: if you are being told that your fluid levels are low, it might be a real thing.  Know that your amniotic fluid is not a closed system – your body is constantly making more and replenishing amniotic fluid.  I’ve read anywhere from 1 hour to every 3-4 hours for that process.  So, if you drink more water, you could potentially increase the amount of fluid in the uterus. However, if you have been drinking a lot of water and your fluid levels are still low, then definitely have an honest conversation with your care provider about your options.
 
Links to explore:
Importance of Water written by my Bradley colleague Lisa Pearson, AAHCC


Fluid Levels in Pregnancy via mamabirth.com



Disclaimer: 
The material included in this blog and video is for informational purposes only. It is not intended nor implied to be a substitute for professional medical advice. The viewer 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 and video contain information about our classes available in Chandler, AZ and Payson, AZ and is not the official website of The Bradley Method®. The views contained in this video and on our blog do not necessarily reflect those of The Bradley Method® or the American Academy of Husband-Coached Childbirth®.
 

Bradley Method® natural childbirth classes offered in Arizona: convenient to Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson
 
 

 

 


Info Sheet: Vaginal Exams

Posted on March 4, 2016 at 2:01 PM Comments comments (0)
Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson
Pelvic or Vaginal Exam during Pregnancy (3rd Trimester)

According to Mayo Clinic, “as your due date approaches, your prenatal visits might  include pelvic exams. These exams help your health care provider check the baby's position and detect cervical changes.”


*History

Pelvic examination during pregnancy is used to detect a number of clinical conditions such as anatomical abnormalities and sexually transmitted infections, to evaluate the size of a woman’s pelvis (pelvimetry) and to assess the uterine cervix so as to be able to detect signs of cervical incompetence (associated with recurrent mid-trimester miscarriages) or to predict preterm labour (see Section 11.3).

In an RCT that assessed the relationship between antenatal pelvic examinations and preterm rupture of the membranes (PROM), 175 women were assigned to no examinations and 174 women were assigned to routine digital pelvic examinations commencing at 37 weeks and continuing until delivery.233 In the group of women who had no pelvic examination, ten women developed PROM (6%) compared with 32 women (18%) from the group of women who were examined weekly. This three-fold increase in the occurrence of PROM among women who had pelvic examinations was significant. 

Based on the above study the NCBI concluded, “Routine antenatal pelvic examination does not accurately assess gestational age, nor does it accurately predict preterm birth or cephalopelvic disproportion. It is not recommended.” 

Another study completed by the NCBI concluded, “In patients with a US-documented viable pregnancy, the pelvic examination did not contribute to the patient's immediate obstetric treatment. Occult cervical pathogens may be present in these patients.” 

Sources:

*PROS

Vaginal Exams can possibly measure:


  • Cervical Dilation
  •  Cervical Ripeness
  • Cervical Effacement
  •  Station of baby (position in relation to pelvis -5 to +5)
  • Position of the baby (anterior vs. posterior)
  • Position of the cervix
  • May find cervical anomalies, like early dilation and effacement, so that appropriate changes can be made to the woman's care, including bedrest, hospitalization, tocolytics, etc.
  • May stimulate the cervix so that a medical induction does not become "necessary"



*CONS

  • Increased risks of infection, even when done carefully and with sterile gloves
  • Increased risk of rupturing the membranes
  • May stimulate the cervix prematurely
  • Information collected does not accurately predict when labor will begin and may excite or disappoint women unnecessarily 

Sources:

*Links to explore

Pelvic Exams Near Term: Benefit or Risk? Talking to Mothers About Informed Consent and Refusal

Premature rupture of membranes at term. Retrospective study of 88 cases

Chorioamnionitis in the delivery room

Bacterial vaginosis and intraamniotic infection

Premature rupture of the membranes and ascending infection

Did you have vaginal exams in your third trimester before your labor started? Thoughts?
Please leave us a comment - it will be moderated and posted. 
 

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®.

Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson

VBAC Preparation: Ask the Midwife

Posted on April 29, 2015 at 7:16 PM Comments comments (0)
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:
  • Use midwives so you can have the one-to-one model of care.
  • Stay at home until you are in established labor.
  • Be supported
  • Set yourself a mini-goal: what are my absolutes even if the VBAC doesn’t go as planned?
  • Take a good childbirth education course
  • Pain is associated with death, dying and injury.  You have to redirect that fear to the understanding that this pain, labor pain, is going to lead to life.  


Q: What can I do to prepare my body for a VBAC?
A: There are a few things you can do
  • Be physically fit – strengthen your body.
  • Eat well – eat foods that promote skin integrity and scar integrity (i.e., foods high in Vitamin C have collagen that is essential for building strong, stretchy tissues)
  • Be mobile – do everything you can to stay active to get baby in a good position for labor.

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
  • Take care in choosing your provider – do you trust them?  Do they follow evidence-based care?  Do their cesarean numbers bear that out?
  • By picking your care provider carefully, you can ensure that you hire a person that truly supports your desire to VBAC and will give you the time to labor as long as mom and baby are doing well. 
  • Choose a care provider with whom you can have an open dialogue.
  • If your instincts are telling you that you are with the wrong provider, then change.
  • Not only do you need to find out how your care provider feels about VBAC, you need to find out how their back-up doctor or other care providers in the practice feel about VBAC.  You do not want to do everything possible to prepare an then show up at your birthplace and realize that you won’t be able to have the birth you have prepared for.

WHAT IF…
If your VBAC doesn’t work out, be easy on yourself. 
  • Ease that path by writing a cesarean birth plan – what do you want to do differently this time
  • As long as things are not critical, you can opt for a “natural cesarean”, where some of the principles of natural birth can be honored.
(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
  • If you feel inside that you can do it, then give it a go!
  • Have faith 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


Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson  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®.



Info Sheet: Amniotomy

Posted on February 6, 2015 at 9:23 AM Comments comments (0)
Amniotomy, Artificial Rupture of the Membranes, AROM - Info sheet for Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, Payson
*Definition
Amniotomy, also known as Artificial Rupture of the Membranes (AROM) is the surgical rupture of fetal membranes to induce or expedite labor.

Source: 
American Heritage Medical Dictionary

 
*History
Amniotomy is used to start or speed up contractions and, as a result, shorten the length of labour.
 
Artificial rupture of the amniotic membranes during labour, sometimes called amniotomy or ’breaking of the waters’ was introduced in the mid-eighteenth century, first being described in 1756 by an English obstetrician, Thomas Denman (Calder 1999). Whilst he emphasized reliance on the natural process of labour, he acknowledged that rupture of the membranes might be necessary in order to induce or accelerate labour (Dunn 1992). Since then, the popularity of amniotomy as a procedure has varied over time (Busowski1995), more recently becoming common practice in many maternity units throughout the UK and Ireland (Downe 2001; Enkin 2000a ; O’Driscoll 1993) and in parts of the developing world (Camey 1996; Chanrachakul 2001; Rana 2003). The primary aim of amniotomy is to speed up contractions and, therefore, shorten the length of labour.
 
The first recorded use of amniotomy in the United States was in 1810; it was used to induce premature labor. Amniotomy and other mechanical methods remained the methods of labor induction most commonly employed until the 20th century. Amniotomy, or artificial rupture of the amniotic membranes, causes local synthesis and release of prostaglandins, leading to labor within 6 hours in nearly 90% of term patients. Turnbull and Anderson found that amniotomy without additional drug therapy successfully induced labor in approximately 75% of cases within 24 hours.
 
Sources: 
 
PROS
  • Amniotomy was associated with a reduction in labour duration of between 60 and 120 minutes in various trials
  • There was a statistically significant association of amniotomy with a decrease in the use of oxytocin: OR = 0.79; 95% CI = 0.67-0.92 in several randomized trials
  • AROM does not involve any type of medication to mom or baby and is considered by some to be the most “natural” means of induction in a hospital setting.
 
CONS
  • In several randomized trials there was a marked trend toward an increase in the risk of Cesarean delivery: OR = 1.26; 95% Confidence Interval (CI)=0.96-1. 66.
  • Trial reviewers suggest that amniotomy should be reserved for women with abnormal labour progress.
  • In 15 studies containing 5583 women there was no clear statistically significant difference between women in the amniotomy and control groups in length of the first stage of labour
  • Evidence does not support routinely breaking the waters for women in normally progressing spontaneous labour or where labours have become prolonged.
  • [Once membranes are broken} most obstetricians want the baby birthed as soon as 6 hours post-onset to reduce the risk of infection from the introduction of bacteria into the vagina due to repeated vaginal exams. Some obstetricians will wait as long as 24 hours but that is less common. In contrast, midwives, who do not routinely perform cervical checks unless specifically indicated or requested, thus limiting the chance of infection, will often allow up to 36-48 hours as long as no indications of an active infection are present.
  • A large study of 3000 women’s opinions of the intervention was conducted by the National Childbirth Trust (1989). Two thirds of the women in this study reported an increase in rate, strength and pain of contractions following membrane rupture; they found these contractions more difficult to cope with, needed more analgesia and felt that the physiology of labour was disturbed.
  • When there is concern that labour is slowing down, benign measures to intensify contractions such as positional changes and movement may prevent the need for more invasive interventions (Simkin 2010). The Cochrane review of maternal positions and mobility during first stage labour supports the positive impact mobility has in shortening labour (Lawrence et al. 2009).
  • Smyth et al. 2007 studies showed that amniotomy is not an effective method of shortening spontaneous labour and increases the risk of caesarean section and more fetal heart abnormalities
 
Sources:


 
*Link List
 For further exploration on your part


What do you think? Is this an option you would consider, or that you chose for during your birth?
 

Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, PaysonDisclaimer: 
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®.

 

Rupture of Membranes

Posted on October 16, 2012 at 5:06 PM Comments comments (0)
Today’s post is going to be short and sweet.  We had a great question come up in class on Friday night.  Since we are not medical professionals, I am going to remind you that my Bradley™ teacher hat requires me to say that you are in charge of doing your own research and drawing your own conclusions.
 
The set up:  We were reviewing information from the previous class on vaginal exams, and reminding students that *anything* going upstream once the membranes have ruptured has the potential to introduce infection.  We were also reviewing what the pros and cons were to having an amniotomy (artificial rupture of membranes) performed.
 
The question: How long is too long to have your membranes ruptured? 
 
The answer:  Our answer was to remind our students that once the membranes rupture, care providers do not want patients putting anything in the vagina and discourage augmenting labor with intercourse (what!?). 
 
In addition, we have the privilege of having a pediatrician in attendance in our classes (she is going to be the assistant coach for one of our students), and I was happy to have her input.  She said that there are several studies that cite 48 hours as the time when the risk of infection rises.
 
So I set out to find these studies and I did not find them.  I did find that the medical term for one of the infections is chorioamnionitis, and this has been tied to risk associated with the number of vaginal exams in labor:
 
"Chorioamnionitis is an inflammation of the fetal membranes (amnion and chorion) due to a bacterial infection. It typically results from bacteria ascending into the uterus from the vagina and is most often associated with prolonged labor.  The risk of developing chorioamnionitis increases with each vaginal examination that is performed in the final month of pregnancy, including during labor."
 From Wikipedia

Here is a link that explains the risk of infection and the signs to look for that might indicate that the mother is developing an infection:
 
 
Here some additional links that you might also like to review:


 
 
In conclusion, we want all of our students and readers to remember that it is up to them to educate themselves – what are the benefits and risks to any of the procedures or protocols of pregnancy, labor and birth?  It is up to you to read up on the variations and complications of labor.  Once you are informed, then you can decide what course of action you may want to take in regards to your own situation and use that as a starting point for discussion with your care provider.

 
Disclaimer: 
Bradley Method® natural childbirth classes offered in Arizona: Chandler, Tempe, Ahwatukee, Gilbert, Mesa, Scottsdale, PaysonThe 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®.