Thursday, July 30, 2009
Friday, July 24, 2009
Is a Woman in Labor a "Person"? New Assaults on Pregnant Women's Civil Rights in a NJ Case
http://www.huffingtonpost.com/louise-marie-roth/is-a-woman-in-labor-a-per_b_242307.html
Louise Marie Roth
Posted: July 21, 2009 05:35 PM
Yet another ruling is providing legal support for the false belief that obstetricians are infallible and stripping pregnant women of basic civil rights that are then accorded to other individuals. In the case, New Jersey Division of Youth and Family Services v. V.M. and B.G., the New Jersey appellate court found that V.M. and B.G. had abused and neglected their child, based on the fact that the mother, V.M., refused to consent to a cesarean section and behaved erratically while in labor. The mother gave birth vaginally without incident, and the baby was "in good medical condition." Then she was never returned to her parents, and the judge in the case approved a plan to terminate their parental rights and give custody of the child to foster parents. What, beyond the obvious, is wrong with this picture?
First, from a legal perspective, individuals have a right to informed consent and bodily integrity. In obstetrics, informed consent is a blurry concept since many hospitals perform obstetric procedures on laboring women without informing them of the evidence concerning those procedures or their risks. Perhaps this legal case illustrates how paternalistic hospitals can be with respect to pregnant women -- assuming that the hospital staff know best and that informed consent is unnecessary. Never mind that hospitals tend to be run with organizational efficiency, rather than patient interests, in mind. In this specific case, one obstetrician who tried to convince the mother to consent to a c-section concluded that she was not psychotic and had the capacity for informed consent with regard to the c-section. It is clear within the law there is no informed consent without informed refusal, so this obstetrician's conclusion should have made V.M.'s refusal to consent to the c-section her decision alone. If this mother is not legally permitted to refuse major abdominal surgery, then she is clearly stripped of her civil rights to informed consent.
In fact, individuals are not legally required to consent to invasive procedures even to save other individuals, including fetuses that lack full legal status. But in this case the district and appellate courts subverted a pregnant woman's informed medical decision-making in the name of fetal rights, arguing that her refusal was a form of abuse and neglect of the child that had not yet been born. This is another dangerous precedent, along with other court-ordered cesarean cases, that will allow all pregnant women to lose their rights to bodily integrity and informed consent. It may be understandable, if not excusable, that the courts don't understand medicine or recognize that medical judgment is fallible, but it is hard to understand how they could so fundamentally misinterpret the law, in which performing surgery on an individual without that person's permission can constitute criminal "battery" under common law.
The court's opinion also suggests that lawmakers have no concept of what it is like to be in labor. Women in labor tend to find themselves on a different mental plane, where they have to focus inward and work with their bodies to give birth. As midwives know, some women become belligerent. Some seek privacy and seclusion. Most women in labor are likely to find the routine and usually unnecessary procedures of hospitals to be invasive and unwelcome. Yet the courts that decided this case didn't seem to be aware that women are unlikely to behave the same way when they are in labor as when they aren't. The decision cites hospital records that describe the mother, V.M., as "combative," "uncooperative," "erratic," "noncompliant," "irrational" and "inappropriate." Also, her husband indicated that the way she was acting was not her "normal manner and that she is not as 'tranquil.'" Why would anyone expect a woman in labor to be compliant, tranquil, or rational? What kinds of expectations does our society have for women undergoing a powerful physiological process, often with an absurd amount of poking, prodding and general interference? This mother was uncooperative with hospital staff, but clearly her uncooperativeness had nothing to do with the well-being of her baby. There is no reason to believe that she did not have the well-being her baby as her top priority, even though she was not a model patient. There is also no reason to believe that everything the hospital staff wanted to do was essential or even beneficial for the well-being of either mother or baby. In fact, typical obstetric care engages in many procedures that are unnecessary and often harmful, more out of habit and for the convenience of hospital staff than in the best interest of patients.
While the court opinion also focuses on the parents' psychiatric diagnoses (which are fallible medical judgments) and their history of care in determining their fitness as parents and abrogating their parental rights, their psychiatric state would never have been questioned if the mother had not refused invasive abdominal surgery -- which was entirely within her rights. The tragic consequence for this family was separation from their infant daughter from the moment of her otherwise uneventful vaginal birth. That kind of injustice can't have been good for the psyche.
Louise Marie Roth
Posted: July 21, 2009 05:35 PM
Yet another ruling is providing legal support for the false belief that obstetricians are infallible and stripping pregnant women of basic civil rights that are then accorded to other individuals. In the case, New Jersey Division of Youth and Family Services v. V.M. and B.G., the New Jersey appellate court found that V.M. and B.G. had abused and neglected their child, based on the fact that the mother, V.M., refused to consent to a cesarean section and behaved erratically while in labor. The mother gave birth vaginally without incident, and the baby was "in good medical condition." Then she was never returned to her parents, and the judge in the case approved a plan to terminate their parental rights and give custody of the child to foster parents. What, beyond the obvious, is wrong with this picture?
First, from a legal perspective, individuals have a right to informed consent and bodily integrity. In obstetrics, informed consent is a blurry concept since many hospitals perform obstetric procedures on laboring women without informing them of the evidence concerning those procedures or their risks. Perhaps this legal case illustrates how paternalistic hospitals can be with respect to pregnant women -- assuming that the hospital staff know best and that informed consent is unnecessary. Never mind that hospitals tend to be run with organizational efficiency, rather than patient interests, in mind. In this specific case, one obstetrician who tried to convince the mother to consent to a c-section concluded that she was not psychotic and had the capacity for informed consent with regard to the c-section. It is clear within the law there is no informed consent without informed refusal, so this obstetrician's conclusion should have made V.M.'s refusal to consent to the c-section her decision alone. If this mother is not legally permitted to refuse major abdominal surgery, then she is clearly stripped of her civil rights to informed consent.
In fact, individuals are not legally required to consent to invasive procedures even to save other individuals, including fetuses that lack full legal status. But in this case the district and appellate courts subverted a pregnant woman's informed medical decision-making in the name of fetal rights, arguing that her refusal was a form of abuse and neglect of the child that had not yet been born. This is another dangerous precedent, along with other court-ordered cesarean cases, that will allow all pregnant women to lose their rights to bodily integrity and informed consent. It may be understandable, if not excusable, that the courts don't understand medicine or recognize that medical judgment is fallible, but it is hard to understand how they could so fundamentally misinterpret the law, in which performing surgery on an individual without that person's permission can constitute criminal "battery" under common law.
The court's opinion also suggests that lawmakers have no concept of what it is like to be in labor. Women in labor tend to find themselves on a different mental plane, where they have to focus inward and work with their bodies to give birth. As midwives know, some women become belligerent. Some seek privacy and seclusion. Most women in labor are likely to find the routine and usually unnecessary procedures of hospitals to be invasive and unwelcome. Yet the courts that decided this case didn't seem to be aware that women are unlikely to behave the same way when they are in labor as when they aren't. The decision cites hospital records that describe the mother, V.M., as "combative," "uncooperative," "erratic," "noncompliant," "irrational" and "inappropriate." Also, her husband indicated that the way she was acting was not her "normal manner and that she is not as 'tranquil.'" Why would anyone expect a woman in labor to be compliant, tranquil, or rational? What kinds of expectations does our society have for women undergoing a powerful physiological process, often with an absurd amount of poking, prodding and general interference? This mother was uncooperative with hospital staff, but clearly her uncooperativeness had nothing to do with the well-being of her baby. There is no reason to believe that she did not have the well-being her baby as her top priority, even though she was not a model patient. There is also no reason to believe that everything the hospital staff wanted to do was essential or even beneficial for the well-being of either mother or baby. In fact, typical obstetric care engages in many procedures that are unnecessary and often harmful, more out of habit and for the convenience of hospital staff than in the best interest of patients.
While the court opinion also focuses on the parents' psychiatric diagnoses (which are fallible medical judgments) and their history of care in determining their fitness as parents and abrogating their parental rights, their psychiatric state would never have been questioned if the mother had not refused invasive abdominal surgery -- which was entirely within her rights. The tragic consequence for this family was separation from their infant daughter from the moment of her otherwise uneventful vaginal birth. That kind of injustice can't have been good for the psyche.
Monday, July 20, 2009
A day in the birth world
I had the honor of starting my day out with the faces of my girls smiling at me, then off to help support a needy momma in labor, as she struggled through a long, slow labor. I only was able to stay a few hours, but I hope I was able to be of help to her. As I type this, she is in full active labor, with a great doula by her side.
Later in the day,I had a phone conversation, a mom looking for a doula. She told me her story, about her Cesarean. How it left her hurt, betrayed, angry, and left her knowing there was better for her and her baby. This time, she has done her homework. But she's still angry, and knows the battle ahead for her to achieve the VBAC she desires.
I can't help but feel so sad for all the women out there, who want a great birth, especially those VBAC ladies, who are having their rights taken away from them. Where else in society, to we FORCE someone into surgery? Unlike an illness, or cancer, the person has the right refuse treatment, or seek other options. Sure the mother to be can refuse surgery, but at what cost? Many women choose homebirth for this reason. But too many women don't feel that its the best choice for them to birth at home, and are left with no other choice but to go through a major surgery, all because of rules and protocols not even backed by science.
If a woman has given truly informed consent, then the Dr should support her. Not tell her she will kill her baby, or sabotage the birth with words of doubt and fear.
I ended my day by attending a Tampa Bay Birth Network meeting. We had a speaker tonight, Dr. Charles Mahan, MD, Professor Emeritus at University of South Florida.
We discussed informed consent, the status of the Cesarean trend and that we are practically the worst in the country, how we rank poorly with the March of Dimes an "F" ranking in fact, and much of what is driving these rates.
He did empower us though, with information on how to best tackles the problem, at a grassroots level, and the steps currently being taken around the country, to make real changes.
As someone who is passionate about educating families, so they can give TRUE informed consent or true informed decline of consent, I was thrilled to see the sample of a document being worked up that a mom signs, while pregnant, while their is time to really weight out her choices, giving all the facts.
So this has been a day of birth related highs, it has left my inspired and fire up to make changes for our community, for the birth community my daughters will once be in. What will their options be?
Later in the day,I had a phone conversation, a mom looking for a doula. She told me her story, about her Cesarean. How it left her hurt, betrayed, angry, and left her knowing there was better for her and her baby. This time, she has done her homework. But she's still angry, and knows the battle ahead for her to achieve the VBAC she desires.
I can't help but feel so sad for all the women out there, who want a great birth, especially those VBAC ladies, who are having their rights taken away from them. Where else in society, to we FORCE someone into surgery? Unlike an illness, or cancer, the person has the right refuse treatment, or seek other options. Sure the mother to be can refuse surgery, but at what cost? Many women choose homebirth for this reason. But too many women don't feel that its the best choice for them to birth at home, and are left with no other choice but to go through a major surgery, all because of rules and protocols not even backed by science.
If a woman has given truly informed consent, then the Dr should support her. Not tell her she will kill her baby, or sabotage the birth with words of doubt and fear.
I ended my day by attending a Tampa Bay Birth Network meeting. We had a speaker tonight, Dr. Charles Mahan, MD, Professor Emeritus at University of South Florida.
We discussed informed consent, the status of the Cesarean trend and that we are practically the worst in the country, how we rank poorly with the March of Dimes an "F" ranking in fact, and much of what is driving these rates.
He did empower us though, with information on how to best tackles the problem, at a grassroots level, and the steps currently being taken around the country, to make real changes.
As someone who is passionate about educating families, so they can give TRUE informed consent or true informed decline of consent, I was thrilled to see the sample of a document being worked up that a mom signs, while pregnant, while their is time to really weight out her choices, giving all the facts.
So this has been a day of birth related highs, it has left my inspired and fire up to make changes for our community, for the birth community my daughters will once be in. What will their options be?
Wednesday, July 8, 2009
Having a Baby?
10 Questions to Ask
Have you decided how to have your baby? The choice is yours!their other babies through the birth canal.Ask, "How do you allow for differences in culture and beliefs?"Mother-friendly birth centers, hospitals, and home birth services are sensitive to the mother’s culture. They know that to ask the questions below to help you learn more.Ask, "Who can be with me during labor and birth?"Mother-friendly birth centers, hospiﾭtals, and home birth services will let a birthing mother decide whom she wants to have with her during the birth.
First, you should learn as much as you can about all your choices. There are many different ways of caring for a mother and her baby during labor and birth.
Birthing care that is better and healthier for mothers and babies is called "mother-friendly." Some birth places or settings are more mother-friendly than others.
A group of experts in birthing care came up with this list of 10 things to look for and ask about. Medical research supports all of these things. These are also the best ways to be mother-friendly.
When you are deciding where to have your baby, you’ll probably be choosing from different places such as:
• birth center,
• hospital, or
• home birth service.
Here’s what you should expect, and ask for, in your birth experience. Be sure to find out how the people you talk with handle these 10 issues about caring for you and your baby. You may want
This includes fathers, partners, children, other family members, or friends.
They will also let a birthing mother have with her a person who has special training in helping women cope with labor and birth. This person is called a doula or labor support person. She never leaves the birthing mother alone. She encourages her, comforts her, and helps her understand what’s happening to her.
2-They will have midwives as part of their staff so that a birthing mother can have a midwife with her if she wants to.
Ask, "What happens during a normal labor and birth in your setting?"
If they give mother-friendly care, they will tell you how they handle every part of the birthing process. For example, how often do they give the mother a drug to speed up the birth? Or do they let labor and birth usually happen on its own timing? They will also tell you how often they do certain procedures. For example, they will have a record of the percentage of C-sections (Cesarean births) they do every year. If the number is too high, you’ll want to consider having your baby in another place or with another doctor or midwife.
Here are numbers we recommend you ask about.
• They should not use oxytocin (a drug) to start labor for more than 1 in 10 women (10%).
• They should not do an episiotomy (ee-peezee-AH-tummy) on more than 1 in 5 women (20%). They should be trying to bring that number down. (An episiotomy is a cut in the opening to the vagina to make it larger for birth. It is not necessary most of the time.)
• They should not do C-sections on more than 1 in 10 women (10%) if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies.
A C-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through the opening. Mothers who have had a C-section can often have future babies normally. Look for a birth place in which 6 out of 10 women (60%) or more of the mothers who have had C-sections go on to have
mothers and families have differing beliefs, values, and customs.
For example, you may have a custom
that only women may be with you during labor and birth. Or perhaps your beliefs include a religious ritual to be done after birth. There are many other examples that may be very important to you. If the place and the people are mother-friendﾭ4ly, they will support you in doing what you want to do. Before labor starts tell your doctor or midwife special things you want.
Ask, "Can I walk and move around during labor? What position do you suggest for birth?"
In mother-friendly settings, you can walk around and move about as you choose during labor. You can choose the positions that are most comfortable and work best for you during labor and birth. (There may be a medical reason for you to be in a certain posiﾭtion.) Mother-friendly settings almost never put a woman flat on her 5back with her legs up in stirrups for the birth.
Ask, "How do you make sure everything goes smoothly when my nurse, doctor, midwife, or agency need to work with each other?"
Ask, "Can my doctor or midwife come with me if I have to be moved to another place during labor? Can you help me find people or agencies in my community who can help me before and after the baby is born?"
continued on next page
Device Lowers Birthing Danger in Low-Income World
This came accross the MFCI (Mother Friendly Childbirth Initiative) yahoo group today
Device Lowers Birthing Danger in Low-Income World
Run Date: 07/07/09
By Molly M. GintyWeNews correspondent
An estimated 125,000 women die each year of severe bleeding after childbirth. But a new device--first developed to treat wounded American soldiers in the Vietnam War--promises to lower those deaths, concentrated in low-income countries.
(WOMENSENEWS)--When a woman named Olanna gave birth to a healthy baby boy at her home in southwestern Nigeria last year, she and her family celebrated--until she began bleeding heavily after the delivery.
Rushed to the emergency room in the city of Ibadan, Olanna had no pulse and no blood pressure. Her relatives gathered at the hospital to mourn her death. Then doctors wrapped the 30-year-old mother in a new "anti-shock garment" that revived her and saved her life.
Like an estimated 125,000 women across the world each year, Olanna could have died of postpartum hemorrhaging.
But doctors intervened with a garment that they have given to 400 women in Nigeria and 100 women in India through a two-year-old program. This initiative is run by Pathfinder International, a Watertown, Mass., nonprofit that promotes global reproductive health and is the source of Olanna's story.
Mostly Preventable Deaths
The anti-shock device that saved Olanna fits tightly around the abdomen and legs. It stems the flow of blood from the body parts compressed under it, which alleviates postpartum hemorrhaging. It also reverses shock, during which the heart, lungs and brain are deprived of oxygen because blood accumulates in the lower abdomen and legs. The garment returns blood to the vital organs, counteracting shock and restoring the pulse and blood pressure.
Postpartum hemorrhaging, also known as PPH, is defined as the loss of more than 17 ounces of blood following vaginal delivery or more than 34 ounces after Cesarean delivery.
"The vast majority of deaths from PPH are completely preventable," said Dan Pellegrom, Pathfinder's chief executive officer. "And it is within our capacity to make maternal deaths as rare in developing countries as they are in the United States."
Postpartum hemorrhaging can occur when there is an infection, when a woman is fatigued after prolonged labor, when her uterus fails to contract after delivery, or when part of the placenta remains in the womb.
It is typically treated with blood transfusions and surgery; two remedies that, combined with six hours in the garment, saved Olanna's life.
While 1 in 100,000 pregnant women die of postpartum hemorrhaging in high-income countries, 1 in 1,000 do so in low-income nations, according to a 2003 British study.
Inadequate nutrition makes many women more vulnerable to anemia and heavy bleeding, and geographic isolation means that they are more apt to give birth without the help of a skilled attendant. Failure to recognize when bleeding is severe, delays in getting treatment and substandard care when clinics and hospitals are accessible also increase the likelihood of postpartum hemorrhaging.
Targeting Nigeria, India
Anti-shock garments were first developed to treat wounded American soldiers in the Vietnam War. Tightened with five Velcro closures, the Pathfinder garment is made of neoprene, the same substance used for wet suits.
Health advocates say the garment is particularly needed in the two countries that Pathfinder is targeting.
Women in India and Nigeria suffer more than one-third of all maternal deaths worldwide--with one quarter of those deaths stemming from postpartum hemorrhaging, reports the Geneva-based World Health Organization.
"In India, an estimated 50 percent of women give birth at home, while in remote parts of northern Nigeria up to 80 percent of women do," said Susan Collins, a senior program officer for Pathfinder. "When a hemorrhaging woman can get the anti-shock garment, wearing it for up to three days can buy her time while she is transported to a facility where doctors can treat her."
In November 2007, after Pathfinder affiliates had worked for four years to test the anti-shock garment on 2,000 women in Nigeria, Egypt and Mexico, the Chicago-based John D. and Catherine T. MacArthur Foundation offered a $10.7 million grant to help Pathfinder create a "Continuum of Care" project around the garment's use.
Run in collaboration with Dr. Suellen Miller of the University of California, San Francisco; Dr. Stacie Geller of the University of Illinois at Chicago; and Dr. Oladosu Ojengbede of the University of Ibadan in Nigeria, the project is funded through October 2010.
Other Methods Address Problem
In addition to using the anti-shock garment, the "continuum of care" model relies on two other means to address postpartum hemorrhaging. The first element is a blood collection drape that helps providers diagnose the severe bleeding more readily and measure the amount of fluid lost. The second element is "uterotonic" drugs, such as oxytocin and misoprostol, which can stem excess bleeding by causing the uterus to contract.
In eight states in Nigeria and eight states in India, Pathfinder researchers are not only employing these technologies, but lobbying for their widespread use. They are training medical providers to supervise a woman while she is in the garment and to remove it slowly to prevent excess blood loss.
"We're doing advocacy and education so government agencies and communities know about the need to improve all aspects of postpartum care," said Cathy Solter, Pathfinder's director of technical services.
Over the next several years, Pathfinder affiliates hope to prevent tens of thousands of deaths from postpartum hemorrhaging in India and Nigeria.
Widespread adoption of the continuum of care model could prevent 80 percent of the 125,000 deaths caused by this type of bleeding and 25 percent of maternal deaths from all causes, according to ongoing research at the University of California, San Francisco.
Molly M. Ginty is a freelance writer based in New York City.
Device Lowers Birthing Danger in Low-Income World
Run Date: 07/07/09
By Molly M. GintyWeNews correspondent
An estimated 125,000 women die each year of severe bleeding after childbirth. But a new device--first developed to treat wounded American soldiers in the Vietnam War--promises to lower those deaths, concentrated in low-income countries.
(WOMENSENEWS)--When a woman named Olanna gave birth to a healthy baby boy at her home in southwestern Nigeria last year, she and her family celebrated--until she began bleeding heavily after the delivery.
Rushed to the emergency room in the city of Ibadan, Olanna had no pulse and no blood pressure. Her relatives gathered at the hospital to mourn her death. Then doctors wrapped the 30-year-old mother in a new "anti-shock garment" that revived her and saved her life.
Like an estimated 125,000 women across the world each year, Olanna could have died of postpartum hemorrhaging.
But doctors intervened with a garment that they have given to 400 women in Nigeria and 100 women in India through a two-year-old program. This initiative is run by Pathfinder International, a Watertown, Mass., nonprofit that promotes global reproductive health and is the source of Olanna's story.
Mostly Preventable Deaths
The anti-shock device that saved Olanna fits tightly around the abdomen and legs. It stems the flow of blood from the body parts compressed under it, which alleviates postpartum hemorrhaging. It also reverses shock, during which the heart, lungs and brain are deprived of oxygen because blood accumulates in the lower abdomen and legs. The garment returns blood to the vital organs, counteracting shock and restoring the pulse and blood pressure.
Postpartum hemorrhaging, also known as PPH, is defined as the loss of more than 17 ounces of blood following vaginal delivery or more than 34 ounces after Cesarean delivery.
"The vast majority of deaths from PPH are completely preventable," said Dan Pellegrom, Pathfinder's chief executive officer. "And it is within our capacity to make maternal deaths as rare in developing countries as they are in the United States."
Postpartum hemorrhaging can occur when there is an infection, when a woman is fatigued after prolonged labor, when her uterus fails to contract after delivery, or when part of the placenta remains in the womb.
It is typically treated with blood transfusions and surgery; two remedies that, combined with six hours in the garment, saved Olanna's life.
While 1 in 100,000 pregnant women die of postpartum hemorrhaging in high-income countries, 1 in 1,000 do so in low-income nations, according to a 2003 British study.
Inadequate nutrition makes many women more vulnerable to anemia and heavy bleeding, and geographic isolation means that they are more apt to give birth without the help of a skilled attendant. Failure to recognize when bleeding is severe, delays in getting treatment and substandard care when clinics and hospitals are accessible also increase the likelihood of postpartum hemorrhaging.
Targeting Nigeria, India
Anti-shock garments were first developed to treat wounded American soldiers in the Vietnam War. Tightened with five Velcro closures, the Pathfinder garment is made of neoprene, the same substance used for wet suits.
Health advocates say the garment is particularly needed in the two countries that Pathfinder is targeting.
Women in India and Nigeria suffer more than one-third of all maternal deaths worldwide--with one quarter of those deaths stemming from postpartum hemorrhaging, reports the Geneva-based World Health Organization.
"In India, an estimated 50 percent of women give birth at home, while in remote parts of northern Nigeria up to 80 percent of women do," said Susan Collins, a senior program officer for Pathfinder. "When a hemorrhaging woman can get the anti-shock garment, wearing it for up to three days can buy her time while she is transported to a facility where doctors can treat her."
In November 2007, after Pathfinder affiliates had worked for four years to test the anti-shock garment on 2,000 women in Nigeria, Egypt and Mexico, the Chicago-based John D. and Catherine T. MacArthur Foundation offered a $10.7 million grant to help Pathfinder create a "Continuum of Care" project around the garment's use.
Run in collaboration with Dr. Suellen Miller of the University of California, San Francisco; Dr. Stacie Geller of the University of Illinois at Chicago; and Dr. Oladosu Ojengbede of the University of Ibadan in Nigeria, the project is funded through October 2010.
Other Methods Address Problem
In addition to using the anti-shock garment, the "continuum of care" model relies on two other means to address postpartum hemorrhaging. The first element is a blood collection drape that helps providers diagnose the severe bleeding more readily and measure the amount of fluid lost. The second element is "uterotonic" drugs, such as oxytocin and misoprostol, which can stem excess bleeding by causing the uterus to contract.
In eight states in Nigeria and eight states in India, Pathfinder researchers are not only employing these technologies, but lobbying for their widespread use. They are training medical providers to supervise a woman while she is in the garment and to remove it slowly to prevent excess blood loss.
"We're doing advocacy and education so government agencies and communities know about the need to improve all aspects of postpartum care," said Cathy Solter, Pathfinder's director of technical services.
Over the next several years, Pathfinder affiliates hope to prevent tens of thousands of deaths from postpartum hemorrhaging in India and Nigeria.
Widespread adoption of the continuum of care model could prevent 80 percent of the 125,000 deaths caused by this type of bleeding and 25 percent of maternal deaths from all causes, according to ongoing research at the University of California, San Francisco.
Molly M. Ginty is a freelance writer based in New York City.
Sunday, July 5, 2009
The Lie of the EDD: Why Your Due Date Isn't when You Think
As seen on the http://happyhealthyliving.wordpress.com/ blog
The Lie of the EDD: When your due date itsn't when you think!
September 24, 2008 by Misha Safranski
We have it ingrained in our heads throughout our entire adult lives-pregnancy is 40 weeks. The “due date” we are given at that first prenatal visit is based upon that 40 weeks, and we look forward to it with great anticipation. When we are still pregnant after that magical date, we call ourselves “overdue” and the days seem to drag on like years. The problem with this belief about the 40 week EDD is that it is not based in fact. It is one of many pregnancy and childbirth myths which has wormed its way into the standard of practice over the years-something that is still believed because “that’s the way it’s always been done”.
The folly of Naegele’s RuleThe 40 week due date is based upon Naegele’s Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele’s rule. Strictly speaking, a lunar (or synodic – from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we’ve been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks.
Variants in cycle length
Aside from the gross miscalculation of the lunar due date, there is another common problem associated with formulating a woman’s EDD: most methods of calculating gestational length are based upon a 28 day cycle. Not all women have a 28 day cycle; some are longer, some are shorter, and even those with a 28 day cycle do not always ovulate right on day 14. If a woman has a cycle which is significantly longer than 28 days and the baby is forced out too soon because her due date is calculated according to her LMP (last menstrual period), this can result in a premature baby with potential health problems at birth.
The inaccuracy of ultrasound
First trimester: 7 days
14 – 20 weeks: 10 days
21 – 30 weeks: 14 days
31 – 42 weeks: 21 days
Calculating an accurate EDD
Recent research offers a more accurate method of approximating gestational length. In 1990 Mittendorf et Al. undertook a study to calculate the average length of uncomplicated human pregnancy. They found that for first time mothers (nulliparas) pregnancy lasted an average of 288 days (41 weeks 1 day). For multiparas, mothers who had previously given birth, the average gestational length was 283 days or 40 weeks 3 days. To easily calculate this EDD formula, a nullipara would take the LMP, subtract 3 months, then add 15 days. Multiparas start with LMP, subtract 3 months and add 10 days. The best way to determine an accurate due date, no matter which method you use, is to chart your cycles so that you know what day you ovulate. There are online programs available for this purpose. Complete classes on tracking your cycle are also available through the Couple to Couple League.
ACOG and postdates
One of the most vital pieces of information to know when you are expecting is that ACOG itself (American College of Obstetricians and Gynecologists) does not recommend interfering with a normal pregnancy before 42 completed weeks. This is why knowing your true conception date and EDD is very important; if you come under pressure from a care provider to deliver at a certain point, you can be armed with ACOG’s official recommendations as well as your own exact due date. This can help you and your baby avoid much unnecessary trauma throughout the labor and delivery. Remember, babies can’t read calendars; they come on their own time and almost always without complication when left alone to be born when they are truly ready.
Sources:
Mittendorf, R. et al., “The length of uncomplicated human gestation,” OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932.
ACOG Practice Bulletin #55: Clinical Management of Post-term Pregnancy
The Lie of the EDD: When your due date itsn't when you think!
September 24, 2008 by Misha Safranski
We have it ingrained in our heads throughout our entire adult lives-pregnancy is 40 weeks. The “due date” we are given at that first prenatal visit is based upon that 40 weeks, and we look forward to it with great anticipation. When we are still pregnant after that magical date, we call ourselves “overdue” and the days seem to drag on like years. The problem with this belief about the 40 week EDD is that it is not based in fact. It is one of many pregnancy and childbirth myths which has wormed its way into the standard of practice over the years-something that is still believed because “that’s the way it’s always been done”.
The folly of Naegele’s RuleThe 40 week due date is based upon Naegele’s Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele’s rule. Strictly speaking, a lunar (or synodic – from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we’ve been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks.
Variants in cycle length
Aside from the gross miscalculation of the lunar due date, there is another common problem associated with formulating a woman’s EDD: most methods of calculating gestational length are based upon a 28 day cycle. Not all women have a 28 day cycle; some are longer, some are shorter, and even those with a 28 day cycle do not always ovulate right on day 14. If a woman has a cycle which is significantly longer than 28 days and the baby is forced out too soon because her due date is calculated according to her LMP (last menstrual period), this can result in a premature baby with potential health problems at birth.
The inaccuracy of ultrasound
First trimester: 7 days
14 – 20 weeks: 10 days
21 – 30 weeks: 14 days
31 – 42 weeks: 21 days
Calculating an accurate EDD
Recent research offers a more accurate method of approximating gestational length. In 1990 Mittendorf et Al. undertook a study to calculate the average length of uncomplicated human pregnancy. They found that for first time mothers (nulliparas) pregnancy lasted an average of 288 days (41 weeks 1 day). For multiparas, mothers who had previously given birth, the average gestational length was 283 days or 40 weeks 3 days. To easily calculate this EDD formula, a nullipara would take the LMP, subtract 3 months, then add 15 days. Multiparas start with LMP, subtract 3 months and add 10 days. The best way to determine an accurate due date, no matter which method you use, is to chart your cycles so that you know what day you ovulate. There are online programs available for this purpose. Complete classes on tracking your cycle are also available through the Couple to Couple League.
ACOG and postdates
One of the most vital pieces of information to know when you are expecting is that ACOG itself (American College of Obstetricians and Gynecologists) does not recommend interfering with a normal pregnancy before 42 completed weeks. This is why knowing your true conception date and EDD is very important; if you come under pressure from a care provider to deliver at a certain point, you can be armed with ACOG’s official recommendations as well as your own exact due date. This can help you and your baby avoid much unnecessary trauma throughout the labor and delivery. Remember, babies can’t read calendars; they come on their own time and almost always without complication when left alone to be born when they are truly ready.
Sources:
Mittendorf, R. et al., “The length of uncomplicated human gestation,” OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932.
ACOG Practice Bulletin #55: Clinical Management of Post-term Pregnancy
Saturday, July 4, 2009
links for great stuff!!
Every mom should get mothering magazine!
http://www.mothering.com/discussions/index.php
http://www.modernmommygear.com/
Beautiful natural toys and products
http://www.novanatural.com/
http://www.babylegs.com/
Locally made slings
http://www.happybabywearing.com/home
Thursday, July 2, 2009
A few videos to check out
vidoes to watch
about the film Orgasmic Birth (don't let the name scare you away, its really a great film that shows how relaxing, intimate and beautiful childbirth can be)
http://www.orgasmicbirth.com/
Business of Being Born- http://www.thebusinessofbeingborn.com/trailer.php
a woman uses song to help her with labor during her homebirth
http://www.youtube.com/watch?v=z3WA9iHz5ww
one mom discusses natural vs epidrual birth
http://www.youtube.com/watch?v=tXVhaVATcbQ
about the film Orgasmic Birth (don't let the name scare you away, its really a great film that shows how relaxing, intimate and beautiful childbirth can be)
http://www.orgasmicbirth.com/
Business of Being Born- http://www.thebusinessofbeingborn.com/trailer.php
a woman uses song to help her with labor during her homebirth
http://www.youtube.com/watch?v=z3WA9iHz5ww
one mom discusses natural vs epidrual birth
http://www.youtube.com/watch?v=tXVhaVATcbQ
A Timely Birth from Midwifery Today
A Timely Birth
by Gail Hart
© 2004 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 72, Winter 2004.] Photo by Caroline Brown
The timing of birth has major consequences for a baby. Too early or too late can mean the difference between life and death. Or so we have come to believe; and it's undoubtedly true at the extreme ends of preterm and postterm birth dates. Although few babies are born at these extremes of the normal length of pregnancy, much of our prenatal care is based on bringing babies to birth "in a timely fashion"—neither too early nor too late. But our understanding of "timely" is clouded, and some of our methods are self-defeating. By intervening in the natural timing of birth, we sometimes exacerbate the problems or create entirely new ones.
Normal human pregnancy is approximately 280 days, with a variation of about three weeks. There may be reason for concern if labor has not begun weeks after the due date, since placental function begins to slow after some point in gestation. Placental insufficiency can lead to poor fetal growth and, eventually, damage to the baby's organ systems or even stillbirth. This is rare, but it is not necessarily connected to the calendar. The placenta can begin to fail at any point in pregnancy, and part of good prenatal care is monitoring growth and fluid levels so we can act before the baby's reserves are drained. We induce labor—even advise a cesarean without labor—if the baby is in trouble, regardless of due dates. It is obvious that a baby is "better off out than in" if the placenta can no longer nourish him/her or if the uterus has become a dangerous place.
Induction Risks
But induction of labor causes so many problems that it should be a rarity, performed only when the benefits can be proven to outweigh the risks. Induction multiplies the risk of cesarean section, forceps-assisted delivery, shoulder dystocia, hemorrhage, fetal distress and meconium aspiration. It is a major contributor to birth-related expenses and complications in the US. Yet it is so common that we almost think of it as normal. More than a third of American women were induced in 1999, and another third had labors augmented with Pitocin. (The FDA says that this is the lowest estimate and that the true incidence of induction is "widely under-reported.")
Even with early pregnancy tests and ultrasounds, induction of labor remains one of the largest causes of prematurity. Ultrasonic estimation of gestational age is still an inexact science; the range of error increases as pregnancy advances. Artifact and technician inexperience can multiply the inaccuracy. Many practitioners seem unaware of this error range or, alternatively, are unwilling to second guess a due date "confirmed" by ultrasound, even when the woman's history and clinical assessment indicate a later due date. Hence, the woman may be induced, even though the baby is clearly several weeks early. Some people discount the danger of early induction as long as the baby is within the last month of gestation. But even minor degrees of prematurity can cause harm. Babies born before full maturity can suffer from breathing difficulties or transient tachypnea, requiring separation in the hospital. They may be more prone to meconium aspiration. They are at risk for hypoglycemia and may have trouble maintaining body temperature. They are at increased risk for nursing difficulties and feeding disorders. They suffer from colic and digestive disturbances. These "minor problems" can affect the early bonding experience and make family adjustments more difficult. The incidence of child abuse is higher with "difficult" babies. As midwives we should aim for our families to experience the best emotional as well as physical health possible. A timely birth is a good step in this direction!
Preterm birth is rising in the United States. Some of this rise results from misjudged due dates and the fear of postdates pregnancy. Some reason that the risk of inducing an early baby is lower than the risk of allowing a pregnancy to continue past due, even when the due date is uncertain. This might be true if the perceived risk of postdates matched the actual risk. But it doesn't!
Postdates
Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43 weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as "double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data collected in 1958.(1)
The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)
There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks need to be compared to the risks of interventions. Induction, as already noted, is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.
Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56 /1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3) This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term.(4)
In some studies, postterm births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does not appear to be a result of underlying pathology associated with post-term pregnancy." They suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at-risk' may be a significant contributing factor." In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(5) When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.
Preventing Prematurity
Few medical treatments have been proven to truly prevent preterm birth. (Avoiding iatrogenic prematurity is most effective, of course!) Some of the most promising avenues are readily available to midwives, and we should share this research with our clients.
The following are some factors shown to be associated with preterm birth and some strategies for lowering the risks:
Overwork, job fatigue, stress—Women in high-stress jobs or who work long hours on their feet have nearly three times the risk of preterm rupture of membranes leading to preterm birth. In a study of 3000 primips, those who worked in "high fatigue jobs" had a risk of preterm premature rupture of membranes (pPROM) of 7% compared to 2% for those who didn't work outside the home.(6) Although many women must work until the end of pregnancy, changing to less fatiguing jobs, if possible, will lower their risk of preterm birth.
Poor nutrition in pregnancy, low weight gain—Low maternal weight gain is the single risk factor that crosses all racial and economic indicators. A woman with a low prepregnancy weight and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein and carbohydrates provides the best nutrition. According to the Cochrane Database, restricted carbohydrate diets may raise the risk of preterm birth without having any effect on the incidence of macrosomia.
Vitamin C supplements—Low levels of vitamin C have been implicated for several decades as contributors to prematurity and preterm rupture of membranes.(7) In a study of 2064 pregnant women, those who had total vitamin C intakes of ‹10th percentile of the average intake prior to conception had twice the risk of preterm birth due to preterm rupture of membranes (relative risk, 2.2).(8)
Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to preterm birth, as well as, frequently, induced labor. Researchers tested women for plasma vitamin C levels. Women who consumed less than 85 mg of vitamin C doubled their risk of developing preeclampsia (odds ration 2.1). Women who consumed the lowest amounts had almost four times the risk of those who consumed the highest.(9)
It is theorized that oxidative stress plays a role in preeclampsia, and we are learning that optimum levels of vitamin C protect against oxidative stress. We don't know yet the optimum level of vitamin C or the best recommendation for supplements, but it has been proposed that 300 mg to 500 mg is probably needed. Many American women consume less than 85 mg daily!
Bacterial Vaginosis
Bacterial Vaginosis (BV) has been associated with a two to three times increased rate of preterm labor and delivery, urinary tract infections (UTIs), premature rupture of the membranes (PROM) and endometritis.(10) Because about 50% of women show no symptoms, universal screening for BV was proposed over a decade ago. (Screening and treatment is a current World Health Organization recommendation.) Screening is simple and there are several effective prescription treatments. But BV has a tendency to recur and is sometimes resistant to chemical treatment.
However, women may be able to discourage BV with some simple home methods. Numerous studies have shown that when natural vaginal Lactobacilli levels drop, BV invades. Lactobacilli inhibit the growth of Mobiluncus, Gardnerella vaginalis, Bacteroides and anaerobic cocci even in a petri dish.(11) Colonizing (or recolonizing) with Lactobacilli is key to vaginal health. According to Skarin and Sylwan, "The paucity of vaginal Lactobacillus is pivotal in allowing overgrowth of many other organisms of the vagina."(12) Lactobacilli grow best in an acidic environment. A healthy vagina is acidic and naturally resists infection by "bad" bacteria—including strep.
In fact, pH alone—the acid/alkaline level measured by nitrazine or litmus paper—is a marker for prematurity risk. Retrospective and prospective studies show that high vaginal pH (a low acid, or alkaline, state) is predictive of preterm labor and preterm rupture of membranes. Viehweg, et al. state: "Measurements of the vaginal pH value are able to verify an alkalinization of the vagina caused by atypical vaginal flora.…In contrast to normal pregnancies there is a relation between a pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm labor."(13) In the Multicenter Bacterial Vaginosis (BV) Trial—a prospective study—21,554 women were screened for vaginal pH and outcome. Women with a vaginal pH of 5.0 or greater had a significantly increased risk of preterm birth and/or low birth weight.(14)
Several alkaline organisms other than Gardnerella (BV) are implicated in PROM. Women with high levels of these alkaline-producing bacteria had over 300% increase in rate of PROM. In an article on pPROM, Ernest, et al. note: "Numerous infectious organisms that change the normal vaginal milieu have been associated with preterm PROM. Because these organisms alter vaginal pH, the use of pH was evaluated as a potential marker for women at increased risk for preterm PROM.…Those with a mean vaginal pH above 4.5 had a threefold increased risk of preterm PROM as compared with those with a mean pH of 4.5 or lower."(15)
Testing pH level is simple, fast, inexpensive and non-intrusive. Women can do it themselves by touching a strip of nitrazine paper to their vaginal walls. Nitrazine or litmus paper is available in most drug stores. The urine test strips used by most midwives also assess pH.
Cultivating Good Bacteria
How can a woman GET an acidic vagina? The old time vinegar douche is an acidic wash and effective treatment for BV and yeast. Vinegar's mild cleansing action is stronger against undesirable bacteria than against Lactobacilli, and it has a short residual effect, which helps encourage rapid regrowth of Lactobacilli. (In pregnancy, a woman should seek her caregiver's advice and use only a low-pressure, low-level douche.)
An infusion of two tablespoons of hydrogen peroxide kills BV and helps Lactobacilli colonize. But recent research shows that Lactobacilli themselves are the source of most of the acid produced in a healthy vagina! They create their own optimum growth pH. "Lactobacilli bacteria, not epithelial cells, are the primary source of lactic acid in the vagina," according to an article in Human Reproduction (16)
So... a woman can get an acidic vagina by GROWING the Lactobacilli. How? By planting them—just like any good gardener!
Researchers are working on a two-pronged approach to using Lactobacilli as a natural antibiotic. Some are trying to analyze, isolate and replicate the effective ingredient, while others are working on methods to establish optimum vaginal growth. Pharmaceutical companies want to create a Lactobacilli super pill, but I think we women should do our own home gardening!
Yogurt—Vaginal Application
Many methods have been advised for colonizing the vagina directly. Wearing a tampon soaked in yogurt is an old folk remedy used for yeast infections (it works!). The yogurt can be used like a cream or gently squeezed in with a bulb syringe.
Many strains of Lactobacilli exist. You can purchase acidophilus compounds and special "probiotics" at some pharmacies and most health food stores. But good yogurt contains live cultures, is readily available, inexpensive and proven to be effective. In the Tasdemir study, pregnant women with bacterial vaginosis were treated with commercial yogurt. The yogurt was administered daily with a 10-ml syringe for seven days and then was repeated after a one-week interval. All the women showed clinical improvement on the third day of treatment. A month after the second treatment, 90% of the women had no signs or symptoms of bacterial vaginosis. The researchers concluded: "Commercially available yogurt may restore the microenvironment and pH of the vagina," cure BV and "prevent prematurity."(17)
In another study, from Japan, women with BV were treated with intravaginal application of 5 ml of commercial yogurt. In the initial cultures, 29 strains of bacteria were detected. The women were evaluated and recultured three days later. There was significant decrease in discharge and vaginal redness, and the vaginal pH was lowered significantly (acidified). All 14 strains of Gram-negative bacteria disappeared! The researchers concluded that "the Lactobacillus therapy was effective in both clinical and bacteriological responses."(18) In other words, improvement occurred in both the SYMPTOMS and the cultures.
Yogurt—Oral Introduction
But yogurt doesn't need to be planted directly into the vagina, in order to grow there. Several studies have shown that simply EATING it will result in increased vaginal Lactobacilli! The Lactobacilli colonize the intestinal tract and migrate to the vagina and urinary tract system. (Urinary tract infections are also risk factors for preterm labor and newborn infections.) Researchers say: "The instillation of Lactobacillus GR-1 and B-54 or RC-14 strains into the vagina has been shown to reduce the risk of urinary tract infections and improve the maintenance of a normal flora. Ingestion of these strains into the gut has also been shown to modify the vaginal flora to a more healthy state. In addition, these strains inhibit the growth of intestinal, as well as urogenital, pathogens, colonize the gut and protect against infections."(19)
In one study, ten women with a history of BV, yeast and urinary infections, drank a Lactobacilli solution in milk twice daily. The Lactobacilli were molecularly typed for identity. One week later, the researchers were able to culture the tagged Lactobacilli from the vaginas of every participant. (And six of the cases of BV were resolved within the week). This is one of several studies that have proved that the oral route can seed the vagina.(20)
Of course, the quality of the yogurt is crucial. If it doesn't contain live cultures, it's useless! Make sure it's really yogurt and not simply a form of milk pudding!
These once-alternative ideas have become mainstream. The American Journal of Obstetrics and Gynecology published an article in March 2003 stating, "Certain Lactobacilli strains can safely colonize the vagina after oral and vaginal administration, displace and kill pathogens including Gardnerella vaginalis and Escherichia coli and modulate the immune response to interfere with the inflammatory cascade that leads to Pre-term Birth."(21)
In sum, cultivating a healthy vaginal "floriculture" can reduce the incidence of preterm birth and lower the rate of bladder infection and UTIs.(22) A healthy colony of Lactobacilli guards the mother and baby against yeast and E. coli infections.(23) It also may offer protection against Group B Strep. Adding live-culture yogurt to the diet—or treating with "probiotics"—is an effective natural method to treat subclinical vaginal infections. It can also treat intestinal infections, which may trigger preterm birth. I agree with the conclusion of these researchers: "The lack of systemic side effects makes it a drug of choice in the treatment of pregnant women."
No magic pill exists to assure a timely birth—a baby born at its healthiest point in gestation, neither too soon nor too late. Born ready to breathe, eager to nurse, primed to learn and love. Good health, good nutrition, good living habits and the avoidance of stress go far to ensure the baby will thrive until his birth date. As we learn more about normal pregnancy, we gain new tools to help both mother and baby achieve optimum health. This new research may help tip the balance in favor of better health—and a timely birth.
Gail Hart graduated from a midwifery training program as a Certified Professional Midwife in 1977. She was certified by the Oregon Midwives Council and licensed in 1995. She is now "semi-retired" and no longer maintains her license, but still has a small practice. Gail is strongly interested in ways to holistically incorporate evidence-based medical knowledge with traditional midwifery understanding.
References:
McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573–82.
Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3 Pt.1): 296–99.
Weinstein, D., et al. 1996 Sep–Oct. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293–97.
Hannah, M.E., et al. 1992 Jun 11. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92. PMID: 1584259
Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79. PMID: 10224605.
Newman, B., et al. 2001 Feb. Occupational fatigue and preterm rupture of membranes. Am J Obstet Gynecol 184(3): 438–46. PMID: 11228500
Woods, J.R., Jr., et al. 2001 Jul. Vitamins C and E: Missing links in preventing preterm premature rupture of membranes? Am J Obstet Gynecol 185(1): 5–10. PMID: 11483896.
Siega-Riz, A.M., et al. 2003 Aug. Vitamin C intake and the risk of preterm delivery. Am J Obstet Gynecol 189(2): 519–25. PMID: 14520228
Zhang, C., et al. 2002 Jul. Vitamin C and the risk of preeclampsia. Epidemiology 13(4):409–16. PMID: 12094095.
McCoy, M.C., et al. 1995 Jun. Bacterial vaginosis in pregnancy: an approach for the 1990s. Obstet Gynecol Surv 50(6): 482–88.McGregor, J.A., and J.I. French. 2000 May. Bacterial vaginosis in pregnancy. Obstet Gynecol Surv 5(5 Suppl 1): S1–19.
Skarin, A., and J. Sylwan. 1986 Dec. Vaginal Lactobacilli inhibiting growth of Gardnerella vaginalis, Mobiluncus and other bacterial species cultured from vaginal content of women with bacterial vaginosis. Acta Pathol Microbiol Immunol Scand [B]. 94(6): 399–403.
Ibid.
Viehweg, B., et al. 1997. [Usefulness of vaginal pH measurements in the identification of potential preterm births]. Zentralbl Gynakol 119 Suppl 1: 33–37. PMID: 9245123. German.
Hauth, J.C., et al. 2003 Mar. Early pregnancy threshold vaginal pH and Gram stain scores predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol 188(3): 831–35. PMID: 12634666.
Ernest, J.M., et al. 1989 Nov. Vaginal pH: a marker of preterm premature rupture of the membranes. Obstet Gynecol 74(5): 734–38. PMID: 2812649.
Boskey, E.R., et al. 2001 Sep. Origins of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source. Hum Reprod, 16(9): 1809–13.
Tasdemir, M., et al. 1996. Alternative treatment for bacterial vaginosis in pregnant patients; restoration of vaginal acidity and flora. Arch AIDS Res 10(4): 239–41. PMID: 12347751.
Chimura, T., et al. 1995 Mar. [Ecological treatment of bacterial vaginosis]. Jpn J Antibiot 48(3): 432–36. PMID: 7752457. Japanese.
Reid, G., and J. Burton. 2002 Mar. Use of Lactobacillus to prevent infection by pathogenic bacteria. Microbes Infect 4(3): 319–24. PMID: 11909742.
Reid, G., et al. 2001 Feb. Oral probiotics can resolve urogenital infections. FEMS Immunol Med Microbiol 30(1): 49–52. PMID: 11172991.
Reid, G., and A. Bocking. 2003 Oct. The potential for probiotics to prevent bacterial vaginosis and preterm labor. Am J Obstet Gynecol 189(4): 1202–28. See also Elmer, G.W., et al. 1996 Mar 20. Biotherapeutic agents. A neglected modality for the treatment and prevention of selected intestinal and vaginal infections. JAMA 275(11): 870–76.
Reid, G., and J. Burton. op cite.
Andreeva, P., and A. Dimitrov. 2002. [The probiotic Lactobacillus acidophilus—an alternative treatment of bacterial vaginosis]. Akush Ginekol (Sofia) 41(6): 29–31. Bulgarian.
by Gail Hart
© 2004 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in Midwifery Today Issue 72, Winter 2004.] Photo by Caroline Brown
The timing of birth has major consequences for a baby. Too early or too late can mean the difference between life and death. Or so we have come to believe; and it's undoubtedly true at the extreme ends of preterm and postterm birth dates. Although few babies are born at these extremes of the normal length of pregnancy, much of our prenatal care is based on bringing babies to birth "in a timely fashion"—neither too early nor too late. But our understanding of "timely" is clouded, and some of our methods are self-defeating. By intervening in the natural timing of birth, we sometimes exacerbate the problems or create entirely new ones.
Normal human pregnancy is approximately 280 days, with a variation of about three weeks. There may be reason for concern if labor has not begun weeks after the due date, since placental function begins to slow after some point in gestation. Placental insufficiency can lead to poor fetal growth and, eventually, damage to the baby's organ systems or even stillbirth. This is rare, but it is not necessarily connected to the calendar. The placenta can begin to fail at any point in pregnancy, and part of good prenatal care is monitoring growth and fluid levels so we can act before the baby's reserves are drained. We induce labor—even advise a cesarean without labor—if the baby is in trouble, regardless of due dates. It is obvious that a baby is "better off out than in" if the placenta can no longer nourish him/her or if the uterus has become a dangerous place.
Induction Risks
But induction of labor causes so many problems that it should be a rarity, performed only when the benefits can be proven to outweigh the risks. Induction multiplies the risk of cesarean section, forceps-assisted delivery, shoulder dystocia, hemorrhage, fetal distress and meconium aspiration. It is a major contributor to birth-related expenses and complications in the US. Yet it is so common that we almost think of it as normal. More than a third of American women were induced in 1999, and another third had labors augmented with Pitocin. (The FDA says that this is the lowest estimate and that the true incidence of induction is "widely under-reported.")
Even with early pregnancy tests and ultrasounds, induction of labor remains one of the largest causes of prematurity. Ultrasonic estimation of gestational age is still an inexact science; the range of error increases as pregnancy advances. Artifact and technician inexperience can multiply the inaccuracy. Many practitioners seem unaware of this error range or, alternatively, are unwilling to second guess a due date "confirmed" by ultrasound, even when the woman's history and clinical assessment indicate a later due date. Hence, the woman may be induced, even though the baby is clearly several weeks early. Some people discount the danger of early induction as long as the baby is within the last month of gestation. But even minor degrees of prematurity can cause harm. Babies born before full maturity can suffer from breathing difficulties or transient tachypnea, requiring separation in the hospital. They may be more prone to meconium aspiration. They are at risk for hypoglycemia and may have trouble maintaining body temperature. They are at increased risk for nursing difficulties and feeding disorders. They suffer from colic and digestive disturbances. These "minor problems" can affect the early bonding experience and make family adjustments more difficult. The incidence of child abuse is higher with "difficult" babies. As midwives we should aim for our families to experience the best emotional as well as physical health possible. A timely birth is a good step in this direction!
Preterm birth is rising in the United States. Some of this rise results from misjudged due dates and the fear of postdates pregnancy. Some reason that the risk of inducing an early baby is lower than the risk of allowing a pregnancy to continue past due, even when the due date is uncertain. This might be true if the perceived risk of postdates matched the actual risk. But it doesn't!
Postdates
Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43 weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as "double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data collected in 1958.(1)
The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)
There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks need to be compared to the risks of interventions. Induction, as already noted, is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.
Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800 postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering "on time" (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56 /1000 in the postterm and 0.75/1000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3) This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term.(4)
In some studies, postterm births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does not appear to be a result of underlying pathology associated with post-term pregnancy." They suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at-risk' may be a significant contributing factor." In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(5) When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.
Preventing Prematurity
Few medical treatments have been proven to truly prevent preterm birth. (Avoiding iatrogenic prematurity is most effective, of course!) Some of the most promising avenues are readily available to midwives, and we should share this research with our clients.
The following are some factors shown to be associated with preterm birth and some strategies for lowering the risks:
Overwork, job fatigue, stress—Women in high-stress jobs or who work long hours on their feet have nearly three times the risk of preterm rupture of membranes leading to preterm birth. In a study of 3000 primips, those who worked in "high fatigue jobs" had a risk of preterm premature rupture of membranes (pPROM) of 7% compared to 2% for those who didn't work outside the home.(6) Although many women must work until the end of pregnancy, changing to less fatiguing jobs, if possible, will lower their risk of preterm birth.
Poor nutrition in pregnancy, low weight gain—Low maternal weight gain is the single risk factor that crosses all racial and economic indicators. A woman with a low prepregnancy weight and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein and carbohydrates provides the best nutrition. According to the Cochrane Database, restricted carbohydrate diets may raise the risk of preterm birth without having any effect on the incidence of macrosomia.
Vitamin C supplements—Low levels of vitamin C have been implicated for several decades as contributors to prematurity and preterm rupture of membranes.(7) In a study of 2064 pregnant women, those who had total vitamin C intakes of ‹10th percentile of the average intake prior to conception had twice the risk of preterm birth due to preterm rupture of membranes (relative risk, 2.2).(8)
Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to preterm birth, as well as, frequently, induced labor. Researchers tested women for plasma vitamin C levels. Women who consumed less than 85 mg of vitamin C doubled their risk of developing preeclampsia (odds ration 2.1). Women who consumed the lowest amounts had almost four times the risk of those who consumed the highest.(9)
It is theorized that oxidative stress plays a role in preeclampsia, and we are learning that optimum levels of vitamin C protect against oxidative stress. We don't know yet the optimum level of vitamin C or the best recommendation for supplements, but it has been proposed that 300 mg to 500 mg is probably needed. Many American women consume less than 85 mg daily!
Bacterial Vaginosis
Bacterial Vaginosis (BV) has been associated with a two to three times increased rate of preterm labor and delivery, urinary tract infections (UTIs), premature rupture of the membranes (PROM) and endometritis.(10) Because about 50% of women show no symptoms, universal screening for BV was proposed over a decade ago. (Screening and treatment is a current World Health Organization recommendation.) Screening is simple and there are several effective prescription treatments. But BV has a tendency to recur and is sometimes resistant to chemical treatment.
However, women may be able to discourage BV with some simple home methods. Numerous studies have shown that when natural vaginal Lactobacilli levels drop, BV invades. Lactobacilli inhibit the growth of Mobiluncus, Gardnerella vaginalis, Bacteroides and anaerobic cocci even in a petri dish.(11) Colonizing (or recolonizing) with Lactobacilli is key to vaginal health. According to Skarin and Sylwan, "The paucity of vaginal Lactobacillus is pivotal in allowing overgrowth of many other organisms of the vagina."(12) Lactobacilli grow best in an acidic environment. A healthy vagina is acidic and naturally resists infection by "bad" bacteria—including strep.
In fact, pH alone—the acid/alkaline level measured by nitrazine or litmus paper—is a marker for prematurity risk. Retrospective and prospective studies show that high vaginal pH (a low acid, or alkaline, state) is predictive of preterm labor and preterm rupture of membranes. Viehweg, et al. state: "Measurements of the vaginal pH value are able to verify an alkalinization of the vagina caused by atypical vaginal flora.…In contrast to normal pregnancies there is a relation between a pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm labor."(13) In the Multicenter Bacterial Vaginosis (BV) Trial—a prospective study—21,554 women were screened for vaginal pH and outcome. Women with a vaginal pH of 5.0 or greater had a significantly increased risk of preterm birth and/or low birth weight.(14)
Several alkaline organisms other than Gardnerella (BV) are implicated in PROM. Women with high levels of these alkaline-producing bacteria had over 300% increase in rate of PROM. In an article on pPROM, Ernest, et al. note: "Numerous infectious organisms that change the normal vaginal milieu have been associated with preterm PROM. Because these organisms alter vaginal pH, the use of pH was evaluated as a potential marker for women at increased risk for preterm PROM.…Those with a mean vaginal pH above 4.5 had a threefold increased risk of preterm PROM as compared with those with a mean pH of 4.5 or lower."(15)
Testing pH level is simple, fast, inexpensive and non-intrusive. Women can do it themselves by touching a strip of nitrazine paper to their vaginal walls. Nitrazine or litmus paper is available in most drug stores. The urine test strips used by most midwives also assess pH.
Cultivating Good Bacteria
How can a woman GET an acidic vagina? The old time vinegar douche is an acidic wash and effective treatment for BV and yeast. Vinegar's mild cleansing action is stronger against undesirable bacteria than against Lactobacilli, and it has a short residual effect, which helps encourage rapid regrowth of Lactobacilli. (In pregnancy, a woman should seek her caregiver's advice and use only a low-pressure, low-level douche.)
An infusion of two tablespoons of hydrogen peroxide kills BV and helps Lactobacilli colonize. But recent research shows that Lactobacilli themselves are the source of most of the acid produced in a healthy vagina! They create their own optimum growth pH. "Lactobacilli bacteria, not epithelial cells, are the primary source of lactic acid in the vagina," according to an article in Human Reproduction (16)
So... a woman can get an acidic vagina by GROWING the Lactobacilli. How? By planting them—just like any good gardener!
Researchers are working on a two-pronged approach to using Lactobacilli as a natural antibiotic. Some are trying to analyze, isolate and replicate the effective ingredient, while others are working on methods to establish optimum vaginal growth. Pharmaceutical companies want to create a Lactobacilli super pill, but I think we women should do our own home gardening!
Yogurt—Vaginal Application
Many methods have been advised for colonizing the vagina directly. Wearing a tampon soaked in yogurt is an old folk remedy used for yeast infections (it works!). The yogurt can be used like a cream or gently squeezed in with a bulb syringe.
Many strains of Lactobacilli exist. You can purchase acidophilus compounds and special "probiotics" at some pharmacies and most health food stores. But good yogurt contains live cultures, is readily available, inexpensive and proven to be effective. In the Tasdemir study, pregnant women with bacterial vaginosis were treated with commercial yogurt. The yogurt was administered daily with a 10-ml syringe for seven days and then was repeated after a one-week interval. All the women showed clinical improvement on the third day of treatment. A month after the second treatment, 90% of the women had no signs or symptoms of bacterial vaginosis. The researchers concluded: "Commercially available yogurt may restore the microenvironment and pH of the vagina," cure BV and "prevent prematurity."(17)
In another study, from Japan, women with BV were treated with intravaginal application of 5 ml of commercial yogurt. In the initial cultures, 29 strains of bacteria were detected. The women were evaluated and recultured three days later. There was significant decrease in discharge and vaginal redness, and the vaginal pH was lowered significantly (acidified). All 14 strains of Gram-negative bacteria disappeared! The researchers concluded that "the Lactobacillus therapy was effective in both clinical and bacteriological responses."(18) In other words, improvement occurred in both the SYMPTOMS and the cultures.
Yogurt—Oral Introduction
But yogurt doesn't need to be planted directly into the vagina, in order to grow there. Several studies have shown that simply EATING it will result in increased vaginal Lactobacilli! The Lactobacilli colonize the intestinal tract and migrate to the vagina and urinary tract system. (Urinary tract infections are also risk factors for preterm labor and newborn infections.) Researchers say: "The instillation of Lactobacillus GR-1 and B-54 or RC-14 strains into the vagina has been shown to reduce the risk of urinary tract infections and improve the maintenance of a normal flora. Ingestion of these strains into the gut has also been shown to modify the vaginal flora to a more healthy state. In addition, these strains inhibit the growth of intestinal, as well as urogenital, pathogens, colonize the gut and protect against infections."(19)
In one study, ten women with a history of BV, yeast and urinary infections, drank a Lactobacilli solution in milk twice daily. The Lactobacilli were molecularly typed for identity. One week later, the researchers were able to culture the tagged Lactobacilli from the vaginas of every participant. (And six of the cases of BV were resolved within the week). This is one of several studies that have proved that the oral route can seed the vagina.(20)
Of course, the quality of the yogurt is crucial. If it doesn't contain live cultures, it's useless! Make sure it's really yogurt and not simply a form of milk pudding!
These once-alternative ideas have become mainstream. The American Journal of Obstetrics and Gynecology published an article in March 2003 stating, "Certain Lactobacilli strains can safely colonize the vagina after oral and vaginal administration, displace and kill pathogens including Gardnerella vaginalis and Escherichia coli and modulate the immune response to interfere with the inflammatory cascade that leads to Pre-term Birth."(21)
In sum, cultivating a healthy vaginal "floriculture" can reduce the incidence of preterm birth and lower the rate of bladder infection and UTIs.(22) A healthy colony of Lactobacilli guards the mother and baby against yeast and E. coli infections.(23) It also may offer protection against Group B Strep. Adding live-culture yogurt to the diet—or treating with "probiotics"—is an effective natural method to treat subclinical vaginal infections. It can also treat intestinal infections, which may trigger preterm birth. I agree with the conclusion of these researchers: "The lack of systemic side effects makes it a drug of choice in the treatment of pregnant women."
No magic pill exists to assure a timely birth—a baby born at its healthiest point in gestation, neither too soon nor too late. Born ready to breathe, eager to nurse, primed to learn and love. Good health, good nutrition, good living habits and the avoidance of stress go far to ensure the baby will thrive until his birth date. As we learn more about normal pregnancy, we gain new tools to help both mother and baby achieve optimum health. This new research may help tip the balance in favor of better health—and a timely birth.
Gail Hart graduated from a midwifery training program as a Certified Professional Midwife in 1977. She was certified by the Oregon Midwives Council and licensed in 1995. She is now "semi-retired" and no longer maintains her license, but still has a small practice. Gail is strongly interested in ways to holistically incorporate evidence-based medical knowledge with traditional midwifery understanding.
References:
McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573–82.
Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3 Pt.1): 296–99.
Weinstein, D., et al. 1996 Sep–Oct. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293–97.
Hannah, M.E., et al. 1992 Jun 11. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92. PMID: 1584259
Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79. PMID: 10224605.
Newman, B., et al. 2001 Feb. Occupational fatigue and preterm rupture of membranes. Am J Obstet Gynecol 184(3): 438–46. PMID: 11228500
Woods, J.R., Jr., et al. 2001 Jul. Vitamins C and E: Missing links in preventing preterm premature rupture of membranes? Am J Obstet Gynecol 185(1): 5–10. PMID: 11483896.
Siega-Riz, A.M., et al. 2003 Aug. Vitamin C intake and the risk of preterm delivery. Am J Obstet Gynecol 189(2): 519–25. PMID: 14520228
Zhang, C., et al. 2002 Jul. Vitamin C and the risk of preeclampsia. Epidemiology 13(4):409–16. PMID: 12094095.
McCoy, M.C., et al. 1995 Jun. Bacterial vaginosis in pregnancy: an approach for the 1990s. Obstet Gynecol Surv 50(6): 482–88.McGregor, J.A., and J.I. French. 2000 May. Bacterial vaginosis in pregnancy. Obstet Gynecol Surv 5(5 Suppl 1): S1–19.
Skarin, A., and J. Sylwan. 1986 Dec. Vaginal Lactobacilli inhibiting growth of Gardnerella vaginalis, Mobiluncus and other bacterial species cultured from vaginal content of women with bacterial vaginosis. Acta Pathol Microbiol Immunol Scand [B]. 94(6): 399–403.
Ibid.
Viehweg, B., et al. 1997. [Usefulness of vaginal pH measurements in the identification of potential preterm births]. Zentralbl Gynakol 119 Suppl 1: 33–37. PMID: 9245123. German.
Hauth, J.C., et al. 2003 Mar. Early pregnancy threshold vaginal pH and Gram stain scores predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol 188(3): 831–35. PMID: 12634666.
Ernest, J.M., et al. 1989 Nov. Vaginal pH: a marker of preterm premature rupture of the membranes. Obstet Gynecol 74(5): 734–38. PMID: 2812649.
Boskey, E.R., et al. 2001 Sep. Origins of vaginal acidity: high D/L lactate ratio is consistent with bacteria being the primary source. Hum Reprod, 16(9): 1809–13.
Tasdemir, M., et al. 1996. Alternative treatment for bacterial vaginosis in pregnant patients; restoration of vaginal acidity and flora. Arch AIDS Res 10(4): 239–41. PMID: 12347751.
Chimura, T., et al. 1995 Mar. [Ecological treatment of bacterial vaginosis]. Jpn J Antibiot 48(3): 432–36. PMID: 7752457. Japanese.
Reid, G., and J. Burton. 2002 Mar. Use of Lactobacillus to prevent infection by pathogenic bacteria. Microbes Infect 4(3): 319–24. PMID: 11909742.
Reid, G., et al. 2001 Feb. Oral probiotics can resolve urogenital infections. FEMS Immunol Med Microbiol 30(1): 49–52. PMID: 11172991.
Reid, G., and A. Bocking. 2003 Oct. The potential for probiotics to prevent bacterial vaginosis and preterm labor. Am J Obstet Gynecol 189(4): 1202–28. See also Elmer, G.W., et al. 1996 Mar 20. Biotherapeutic agents. A neglected modality for the treatment and prevention of selected intestinal and vaginal infections. JAMA 275(11): 870–76.
Reid, G., and J. Burton. op cite.
Andreeva, P., and A. Dimitrov. 2002. [The probiotic Lactobacillus acidophilus—an alternative treatment of bacterial vaginosis]. Akush Ginekol (Sofia) 41(6): 29–31. Bulgarian.
Back to the babies
I can't believe this year is half over already. Our new baby is almost 6 months already, and she's amazing. I've decided to start attending births again. Only 1 a month for now. Its so wonderful to have a supportive family and group of people in my, and my girl's lives to help with this special work. I feel blessed to be able to do this work as a means to help support my family, and fufill my passions.
For details and information about having me as your doula, please email me at DoulaHallie@yahoo.com or call 727-743-6671
For details and information about having me as your doula, please email me at DoulaHallie@yahoo.com or call 727-743-6671
what to do if your hospital has bannged VBACs
Your Right to Refuse: What to Do if Your Hospital Has "Banned" VBAC
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Tuesday, April 14, 2009 at 10:24pm Edit Note Delete
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Your Right to Refuse: What to Do if Your Hospital Has "Banned" VBAC Q & AThe International Cesarean Awareness Network has tracked over 300 hospitals across the U.S. that have instituted policies seeking to ban vaginal birth after cesarean (VBAC), misleading women to believe they must undergo cesarean surgery whether there is a medical need for it or not. Clinical research shows the risks of VBAC are small and that repeat cesarean surgery carries its own risks. In spite of this, many hospitals have attempted to ban VBAC in order to limit their exposure to liability. As a result, many women around the U.S. have been told they must choose unnecessary surgery or forgo hospital care altogether. Below is a guide for women in this situation. Women who are seeking to avoid other medical interventions will also find this information useful.
Q: Does my doctor or hospital have the right to force me to undergo surgery?
A: No. You have the legal right to refuse any medical treatment, including cesarean surgery. VBAC "bans" exist only because they have not been challenged by patients. The doctrine of informed refusal is upheld by common law, case law, Constitutional law, federal law, state law, state mandated medical ethics and the ethical guidelines of the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG). Any facility or care provider claiming that you must undergo a cesarean you wish to refuse is violating the governing principles of their respective institutions and professions, as well as the rule of law.
Q: What can I do to protect myself from being forced into surgery?
A: There are multiple steps you can take to protect yourself:•Know your rights. Visit BirthPolicy.org to learn more about the illegal and unethical status VBAC "bans."•File a grievance with the Chief Compliance Officer at the hospital where you plan to give birth. Hospitals that attempt to ban VBAC are in violation of the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), which require all federally funded hospitals (approximately 80%) to honor the rights of patients to be informed of the risks, benefits, and alternatives of all procedures, to refuse any proposed treatment, including cesarean surgery, and to participate in all treatment decisions. To hold your hospital accountable under these regulations, you must first file a complaint with the hospital’s Chief Compliance Officer, who is required to issue a ruling within 60 days. If the CCO rules against you, then you have the right, first, to appeal to the your state CMS office and then to Office of the Inspector General’s Office at the Department of Health and Human Services. If HHS rules against you, then your appeal goes to the Department of Justice, which is authorized to bring litigation against the hospital on your behalf. You can read the CoP regulations by going to the Code of Federal Regulation’s main page. Enter "42CFR482.13" into the search engine, which will bring up all of the CoP regulations on patient rights and filing grievances. To find contact information for your state CMS office, go to MedLaw.•Replace your birth plan with a customized form documenting your refusal to consent. By law, you are not required to sign the hospital’s consent form. You can either customize the hospital’s form or write down your refusal to consent to treatment on any piece of paper and sign it. Put a line through any listed procedure you want to decline and then add the list of routine procedures, including cesarean surgery, you want to refuse, initial each change or addition and make sure you have all the required signatures. Doing so will legally document your refusal to consent and alert staff that you understand and are prepared to protect your rights. In addition, such a document will require staff to obtain direct, verbal consent from you each time they want to do a procedure you’ve already declined in writing. If possible, pre-register at the hospital no sooner than thirty days before your due date and take the forms home with you to review, add to, and sign. Be sure to keep personal copies of any forms you sign ansk your partner or doula to record any changes that were made during the course of your labor.
Q: What if the hospital refuses to admit me unless I consent to a cesarean?
A: The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment decisions until after the baby and placenta are delivered. The act was originally designed to prevent hospitals from "dumping" patients who couldn’t pay but has since been widely used to hold hospitals accountable for violating other patient rights, including the right to refuse treatment. If your hospital threatens to perform a cesarean despite your refusal, notify them that they are in violation of your rights under EMTALA and that you plan to file a complaint. To find out where to report an EMTALA violation, go to MedLaw.
Q: What happens if my care provider ignores my refusal to consent and performs a cesarean anyway?
A: Many women have been threatened by their care providers that they would be put under general anesthesia and sectioned if they sought care in the hospital, even if they were close to delivering the baby naturally. While these threats are intimidating, they are not supported in either legal or ethical guidelines. If your care provider performs surgery in spite of your refusal, you are within your legal right to file criminal assault and battery charges and, if you or your baby suffer an injury, you may also sue for negligence.
Q: What if I challenge my care provider and he or she decides to drop me from care?
A: Professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.
Q: What if my care provider or hospital seeks a court order to perform a cesarean?
A: While there is always the possibility that the local court could grant an order forcing you to undergo a cesarean, these cases have become very rare in the aftermath of several court rulings declaring that such orders violate the rights of pregnant women. As a result of these rulings, both the AMA and ACOG have revised their ethical guidelines to state that court-ordered cesareans are rarely, if ever, justified, and are most definitely not justified in instances where the proposed treatment poses any risks to the mother.
Q: I want to give birth in a hospital, but I am afraid that this is too much stress on my pregnancy and my family.
A: Unfortunately, the options for women whose hospitals have attempted to ban VBAC are limited. Your choices are to fight and assert your legal rights, submit to surgery, or opt for homebirth, either unassisted or attended by a midwife. Educate yourself about the benefits and risks of each option, and make the decision that is best for you and your baby. Call your local ICAN chapter for more information on your options and on the resources available to facilitate your decision.
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Tuesday, April 14, 2009 at 10:24pm Edit Note Delete
http://ican-online.org/vbac/your-right-refuse-what-do-if-your-hospital-has-banned-vbac-q
Your Right to Refuse: What to Do if Your Hospital Has "Banned" VBAC Q & AThe International Cesarean Awareness Network has tracked over 300 hospitals across the U.S. that have instituted policies seeking to ban vaginal birth after cesarean (VBAC), misleading women to believe they must undergo cesarean surgery whether there is a medical need for it or not. Clinical research shows the risks of VBAC are small and that repeat cesarean surgery carries its own risks. In spite of this, many hospitals have attempted to ban VBAC in order to limit their exposure to liability. As a result, many women around the U.S. have been told they must choose unnecessary surgery or forgo hospital care altogether. Below is a guide for women in this situation. Women who are seeking to avoid other medical interventions will also find this information useful.
Q: Does my doctor or hospital have the right to force me to undergo surgery?
A: No. You have the legal right to refuse any medical treatment, including cesarean surgery. VBAC "bans" exist only because they have not been challenged by patients. The doctrine of informed refusal is upheld by common law, case law, Constitutional law, federal law, state law, state mandated medical ethics and the ethical guidelines of the American Medical Association (AMA) and the American College of Obstetricians and Gynecologists (ACOG). Any facility or care provider claiming that you must undergo a cesarean you wish to refuse is violating the governing principles of their respective institutions and professions, as well as the rule of law.
Q: What can I do to protect myself from being forced into surgery?
A: There are multiple steps you can take to protect yourself:•Know your rights. Visit BirthPolicy.org to learn more about the illegal and unethical status VBAC "bans."•File a grievance with the Chief Compliance Officer at the hospital where you plan to give birth. Hospitals that attempt to ban VBAC are in violation of the Center for Medicare and Medicaid Services (CMS) Conditions of Participation (CoP), which require all federally funded hospitals (approximately 80%) to honor the rights of patients to be informed of the risks, benefits, and alternatives of all procedures, to refuse any proposed treatment, including cesarean surgery, and to participate in all treatment decisions. To hold your hospital accountable under these regulations, you must first file a complaint with the hospital’s Chief Compliance Officer, who is required to issue a ruling within 60 days. If the CCO rules against you, then you have the right, first, to appeal to the your state CMS office and then to Office of the Inspector General’s Office at the Department of Health and Human Services. If HHS rules against you, then your appeal goes to the Department of Justice, which is authorized to bring litigation against the hospital on your behalf. You can read the CoP regulations by going to the Code of Federal Regulation’s main page. Enter "42CFR482.13" into the search engine, which will bring up all of the CoP regulations on patient rights and filing grievances. To find contact information for your state CMS office, go to MedLaw.•Replace your birth plan with a customized form documenting your refusal to consent. By law, you are not required to sign the hospital’s consent form. You can either customize the hospital’s form or write down your refusal to consent to treatment on any piece of paper and sign it. Put a line through any listed procedure you want to decline and then add the list of routine procedures, including cesarean surgery, you want to refuse, initial each change or addition and make sure you have all the required signatures. Doing so will legally document your refusal to consent and alert staff that you understand and are prepared to protect your rights. In addition, such a document will require staff to obtain direct, verbal consent from you each time they want to do a procedure you’ve already declined in writing. If possible, pre-register at the hospital no sooner than thirty days before your due date and take the forms home with you to review, add to, and sign. Be sure to keep personal copies of any forms you sign ansk your partner or doula to record any changes that were made during the course of your labor.
Q: What if the hospital refuses to admit me unless I consent to a cesarean?
A: The federal Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals to admit women in active labor and to abide by their treatment decisions until after the baby and placenta are delivered. The act was originally designed to prevent hospitals from "dumping" patients who couldn’t pay but has since been widely used to hold hospitals accountable for violating other patient rights, including the right to refuse treatment. If your hospital threatens to perform a cesarean despite your refusal, notify them that they are in violation of your rights under EMTALA and that you plan to file a complaint. To find out where to report an EMTALA violation, go to MedLaw.
Q: What happens if my care provider ignores my refusal to consent and performs a cesarean anyway?
A: Many women have been threatened by their care providers that they would be put under general anesthesia and sectioned if they sought care in the hospital, even if they were close to delivering the baby naturally. While these threats are intimidating, they are not supported in either legal or ethical guidelines. If your care provider performs surgery in spite of your refusal, you are within your legal right to file criminal assault and battery charges and, if you or your baby suffer an injury, you may also sue for negligence.
Q: What if I challenge my care provider and he or she decides to drop me from care?
A: Professional ethical guidelines state that a physician may only drop you from his care after giving you 30 days notice. This means that if you are within 30 days of your likely delivery date, your care provider cannot terminate your care. In addition, if you are pregnant and are outside of that 30 day time frame, your provider must give you a referral and ensure you are transferred to a specific provider. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure.
Q: What if my care provider or hospital seeks a court order to perform a cesarean?
A: While there is always the possibility that the local court could grant an order forcing you to undergo a cesarean, these cases have become very rare in the aftermath of several court rulings declaring that such orders violate the rights of pregnant women. As a result of these rulings, both the AMA and ACOG have revised their ethical guidelines to state that court-ordered cesareans are rarely, if ever, justified, and are most definitely not justified in instances where the proposed treatment poses any risks to the mother.
Q: I want to give birth in a hospital, but I am afraid that this is too much stress on my pregnancy and my family.
A: Unfortunately, the options for women whose hospitals have attempted to ban VBAC are limited. Your choices are to fight and assert your legal rights, submit to surgery, or opt for homebirth, either unassisted or attended by a midwife. Educate yourself about the benefits and risks of each option, and make the decision that is best for you and your baby. Call your local ICAN chapter for more information on your options and on the resources available to facilitate your decision.
The Birth Survery
http://www.thebirthsurvey.com/
If you have given birth in the last 3 years, please fill out this survey about your caregiver and experience and help bring transparency to maternity care in our country!
If you have given birth in the last 3 years, please fill out this survey about your caregiver and experience and help bring transparency to maternity care in our country!
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