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Posts tagged ‘complications’

“The American Propensity to Shun Human Milk is a Public Health Problem”

A Historical Perspective

Bulletin: Chicago School of Sanitary Instruction (June 3, 1911)

This is a part of my comment reply placed to an individual who had commented on The Feminist Breeder’s  post “When It Comes to Breastfeeding, We Can’t Handle the Truth”

“There were countless situations over the last 200 years which forced caregivers (whether the natural mother or another individual)to resort to artificial feeding of one kind or another. It is amazing what some of them came up with to try to feed those infants! Necessity was the mother of invention. And many were able to survive. It’s wonderful that they could. Many more, however, sadly died. Many many babies were sickly or died in those times.
You say: “The matter is that formula/breastmilk substitutes became so helpful that people continued for centuries to make it work.” I agree.
But my take on it is that the necessity of an available safe artificial alternative to breastfeeding for those mothers who could not breastfeed their babies took centuries to formulate…to make it nutritious enough and safe enough and to come up with a safe enough feeding container. It was just that.. an artificial substitute.
Gosh– I am NOT an expert on this aspect at all.
I just feel that the heart of this conversation is that artificial infant feeding has risks. Risks that mothers aren’t informed about because society has normalized artificial feeding. Breastfeeding is normal feeding.
No one should ever take away an individual’s choice..EVER…!!!!!
Mother’s simply need better information to make INFORMED choices.
I’m very sensitive and careful in my approach to moms… helping them with information they need to make the best choice for them. Then I will ALWAYS support that mother 100%.
Here’s an interesting historical perspective link for your review from the American Journal of Public Health | December 2003, Vol 93, No. 12
It covers history from about 1890 to early 1900’s.”

“Low Breastfeeding Rates and Public Health in the United States”

Here are some quotes and excerpts from this article published in the American Journal of Public Health (December 2003, Vol 93, No. 12 ) discussing Public Health THEN and NOW.

Quotes:

“Late-19th-century physicians . . . constantly
decried the ‘children with weak and diseased
constitutions belonging to that generally
wretched class called bottle-fed.’

“Today’s medical community recognizes what their
predecessors knew a century ago—that the
American propensity to shun human milk is
a public health problem and should
be exposed as such.”

Abstract: “The medical community has orchestrated breastfeeding campaigns in response to low breastfeeding rates twice in US history.
The first campaigns occurred in the early 20th century after reformers
linked diarrhea, which caused the majority of infant deaths, to the use of cows’ milk as an infant food.
Today, given studies showing that numerous diseases and conditions can be prevented or limited in severity by prolonged breastfeeding, a practice shunned by most American mothers, the medical community is again inaugurating efforts to endorse breastfeeding as a preventive health measure.
This article describes infant feeding practices and resulting public health campaigns in the early 20th and 21st centuries and finds lessons in the original campaigns for the promoters of breastfeeding today.”

I found this article to be very informative and very interesting.

WHAT HAVE WE LEARNED???


For Expectant Families… your “Due Date”…

Hi everyone! Happy New Year!

I have been very very busy over these past months and I’ve spent very little time on the computer….. many of you have had the same situation. Thanks to all of you who keep checking my blog anyway!

I’m here now to talk about one of my big concerns.

Your due date…

Every single year around the holidays, we have a surge of elective, social induction requests.  Here are some comments we occasionally may hear each year around this time on an L&D unit:

“Please, please induce me so I can have the baby and be home for Christmas…please!”

“I’m only 2 1/2 weeks from my due date anyway so I’m ready…”

“I can’t have this baby on Christmas day..I just can’t…you HAVE to help me!!”

“I’m so tired of being pregnant and I have so much to do…can’t you do SOMETHING and make me have this baby today??” (37weeks)

“I really really need another tax deduction this year… ” (heard quite often!)

“Please do something so this baby is born by the end of December…I’ll even have a C/S if you want.”

“Can you induce me while my family is all here?? Please??”

Young pregnant women~ Please don’t do something crazy for a special delivery date.

Please!

Please educate yourself about the risks of induction and the risks of late preterm births.

PATIENCE

“A little patience now adds up to long-term health benefits for your new baby.”

I have received this following information from the Mother-Friendly childbirth community.

I felt it was well worth sharing……..

This is an excerpt from a newsletter from the CIMS ~ Coalition for Improving Maternity Services.

Please read, check out their website link above and the other resources listed below the letter.

Thanks so much!

“For Expectant Families

What you need to know about your due date and late preterm birth

A little patience now adds up to long-term health benefits for your new baby.

You’re not alone if you’re secretly (or openly!) hoping that your baby will get here sooner rather than later.  But when it comes to your due date, it’s important to understand what it represents, what it does not represent, and the potentially serious consequences of agreeing to an induction or c-section before your baby is ready to be born.

Mayri Sagady Leslie, CNM, MSN, clinical faculty at Yale University School of Nursing, recently penned an insightful post for Lamaze International’s Science and Sensibility blog.  In “Beyond Due Dates: How Late is Too Late,” we’re reminded that, despite widespread belief that EDD stands for ‘due date’, it actually stands for ‘estimated date of delivery’!  Mayri writes, “No matter what you call that date on the calendar, it is nothing more than a formula derived from statistical averages which says that sometime within a range of 4-5 weeks your baby will probably be born.  Smack dab in the middle of that range is one of days on which the labor may start.  Yet when it comes to dates in our life, few take on more significance than this one.”

Appreciating this fact is something of considerable consequence when it comes to the immediate and long-term health of your baby.  There is mounting evidence that only the baby should have the right to choose her/his birthday.  Two recent reports add to this evidence.

The CDC’s National Center for Health Statistics recently reported a 20% increase in the nation’s late preterm (34 to 36 weeks ) birth rate from 1990 to 2006.  The report also cites alarming increases in the number of late preterm births among births for which labor was induced as well as among births that were delivered by c-section.  The report cautions, “…it is becoming increasingly recognized that infants born late preterm are less healthy than infants born later in pregnancy.  Late preterm babies are more likely than term babies to suffer complications at birth such as respiratory distress; to require intensive and prolonged hospitalization; to incur higher medical costs; to die within the first year of life; and to suffer brain injury that can result in long-term neurodevelopment problems.”

March of Dimes 2009For the March of Dimes, prematurity is an extremely important public health issue.  The March of Dimes launched a multimillion dollar, multiyear campaign in 2003 to prevent premature birth and raise awareness of its serious consequences.  Last month, the March of Dimes released its annual Premature Birth Report Card.  Sadly, for the second consecutive year, the U.S. earned only a ‘D’ grade, “demonstrating that more than half a million of our nation’s newborns didn’t get the healthy start they deserved.”

We know you’re anxious to meet your baby.  It’s perfectly understandable too if you’re just plain tired of being pregnant.  We just want to remind you that a little patience now adds up to long-term health benefits for your new baby.

Learn more:

  • Beyond Due Dates: How Late is Too Late” by Mayri Sagady Leslie on Lamaze International’s Science & Sensibility blog.
  • Born a Bit Too Early: Recent Trends in Late Preterm Births” a NCHS Data Brief from the CDC.
  • U.S. Gets A “D” For Preterm Birth Rate” press release from the March of Dimes.”
  • Initial Low Milk Supply: A Breastfeeding Story – Case Study

    034     The History:

     One typical busy morning coming on shift, one of the couplets I received report on was a 3 day post-op C/S mom and baby who were scheduled for discharge this same morning.  She had been a long 3 or 4 day failed attempt to induce a vaginal delivery for fetal macrosomia (big baby) at 40 5/7 weeks before the C/S.  Lots of IV’s, lots of Pitocin… all before the birth.

    Her baby weighed 10 lbs 4 oz at birth. We got in report that his glucose sticks had all been over 60 initially so they were stopped early on. His exams were normal.  His total bilirubin this AM was 11.3 at over 72 hours of age. He was “breastfeeding only”  (*sigh*from the nurse giving me report).  She then expressed a concern that  he was down 10% from birth weight weighing 9 lbs 4.5 oz today.  When I asked her about the feedings, she said he’s been nursing beautifully all the time but nobody’s had time to stay in the room and watch him feed. I asked about the output and she reported he’s been voiding, the last stool was a couple shifts ago.  Then the nurse added “We told her you were here today, Melissa, she has a lot of questions for you. ”

    I was able to juggle some things around, have staff cover some of my other responsibilities temporarily to make this a priority. Since I am a general staff nurse, there are often more pressing situations. Fortunately, today I was able to manage the time to see her right away.

    I went in and introduced myself to Meg*, Brad* and their son Mikey* (*names changed). They had indeed been waiting for me.  Breakfast was underway and Mikey was asleep in his crib. I asked her a few general questions in a relaxed manner about breastfeeding first to try to establish some background: Mikey’s energy level, drinking pattern, feeding frequency, and diaper checks.  It is important to gather information and observe the feeding  in the process of  a full evaluation to determine adequacy of feedings.  The information I got was concerning.  He spends a lot of time at the breast, falls asleep quickly, not very energetic with every feed, not much change in her breasts at this point and no stool since yesterday. I did not tell her I was concerned at this point, nor did I mention the weight yet. I asked if I could check him now and if  it would be alright if I observed the next feeding.. We determined that should be with in the next hour. I talked about feeding cues and asked her to get me if  Mikey seemed ready to eat before I came back.  His vital signs were normal, jaundice not too significant for his age, diaper contained a small amt concentrated urine, and Mikey went immediately back to sleep.  I felt he was OK at the moment and needed to go do a few other  things with other patients.
     
    At this point I am feeling pulled in different directions because Meg’s situation could easily take hours of my already busy morning. I am upset that this has possibly been going on the last 3 days and hasn’t been evaluated properly, now it’s day of discharge! How do you do the proper evaluation, give the needed gentle support, make possible feeding plan arrangements in fragments of time? This is what I am trying to change…in my opinion, we the hospital, helped contribute to this situation of possible inadequate feeding and supply… we need to help her! I talk to the charge nurse and it’s cleared to keep my coverage the rest of the morning.. good thing L&D was quiet!
     
    Mikey’s doctor comes in and thankfully it is a partner who is very pro breastfeeding and open minded to try options a mom may choose. I gave her report on his physical status, VS, weight, earlier glucoses, and the Bilirubin. I summed up my plan to evaluate feeding quality but suspected he has been ineffective at the breast & milk supply/production may be delayed. I added that I was going to check his glucose if he had low energy level, and encourage pumping or expression for the mom and get that milk into the baby as well as encouraging her to stay for a few feedings to work with me. The MD was happy with these ideas but requested he be supplemented (complemented) with formula at all feedings now until his weight came up. She supports the theory (as I do) that the birth weight can be somewhat inflated with all the pre-birth IV fluids mom rec’d and some of what he lost may be fluid.  The MD said that if things were better by afternoon, he could go home. She went out to examine him at mom’s bedside.
     
    I went in for my feeding observation a little while later. Meg now knows his total weight loss and feels very upset. I give her a lot of support and agree with the doctor that some of that could be fluid. I then find out..Meg is an RN here at my hospital on another floor! It had not come up in conversation! So now I know she is even more worried because we nurses always think the worst! I do my best to think simple and encourage her to do the same… it is very early and we can turn this around quickly with a strong approach.
     
    My Evaluation:
    • Good independent maternal positioning, holding and offering of the breast
    • Nipples erectile, breast tissue soft, pliable, small amts colostrum expressed–> mom reports her breasts were “swollen first 2 days”
    • Latch fairly adequate but not optimal-> improved greatly with football position and instruction on asymmetrical latch approach (I’d like to say here that I have a” if it’s not broke don’t fix it” attitude. I don’t correct a latch for a mom who has no pain and good milk transfer, we talk about it in case it may come up for though)
    • Mikey very sleepy at breast, difficult to maintain latch, no milk transfer observed–>breast massage during feed tried without improvement
    • Due to continued low energy level (suspected caloric deprived state causing sleepy ineffective feeding behaviors) a bedside glucose was checked. Result was 49.
    • Diaper dry–> the previous concentrated void was only his 2nd in last 24 hrs No stool last 20 hrs and that one was dark.
    The mother’s feeding plan:
    Many options and teaching points discussed with Meg including the need to boost caloric intake –>starting right now, methods to get her milk or formula into the baby avoiding bottles, a vigorous pumping plan to augment breast stimulation, alternate breast massage, how to observe for swallowing and milk transfer at the breast etc.. I also discussed with her how in my experience, sometimes it is like magic once the baby regains up to birth weight… they just take off!
    She chose:
    • Cup feed formula now while she pumped –>Mikey would not cup feed so we used a syringe, 18 cc, repeat glucose 62
    • Pumping round the clock, double pumping –> Meg rented a hospital grade pump for home use
    • Keep close eye on feeding cues, put Mikey to breast in football w/ latch process discussed earlier
    • Closely watch signs for milk transfer, correct feeding activity while at breast, sucking rythym 1 or 2 sucks /swallow ( Brad was very involved in this process of learning the observation techniques)
    • Use breast massage/ compression while baby @ breast through feed to increase milk transfer
    • Goal of min 8 effective feeds in 24 hr..wanted to try for 10 –>agreed to feed expressed milk or formula 1/2 to 1 oz after each feed first 24 hrs until re-weighed next day
    • Have as 1st 24 hr goal:  to see 3 -4 increasingly wet/clearer diapers and at least 2-3 good sized stools
    • Return to MD for F/U bili and wgt check next day
    • Call IBCLC for eval in next few days if weight not adequate and not independently breastfeeding/output  within safe parameters for age

    The follow up reports:

    • DAY 1 (In hospital) Mikey fed 3 more times in the hospital at 2 hour intervals.  Each time he had about 15 to 20 cc of formula by syringe. Each feed was improved but not adequate quality of milk transfer. Meg pumped 4 times before discharge not getting much first 3 times but 4th time she got almost 10 cc! Mikey had 1 conc wet diaper and a med sized dark stool. We re-weighed Mikey prior to discharge and he was 9 lbs 5.5 oz.  Meg left the hospital late that afternoon while I had been called to a STAT C/S. She was determined to go home after all the time she had been there! I called her later and she was on target with her plan.
    • DAY 2 (first 24 hrs home) Seen at Peds office. (reported to me from MD)  Bilirubin 10.6, weight–> 9 lbs 7.5 oz! Baby more energetic, better quality feeds reported. Meg still power pumping, now getting 1 -2 oz per pumping and giving to baby with syringe and only used formula occassionally if no breastmilk.  Had 3 wet and 2 stools since discharge, stools lighter in color. MD arranged F/U weight visit for 2 days, will arrange IBCLC if no strong improvement before 2 more days
    • AGE 6 1/2 days Seen at Peds office. (reported to me from MD) Weight–> 9 lbs 11 oz !!! Meg having fairly same routine but not always pumping if she feels Mikey had good milk transfer. She reported increased  breast fullness, 6 wetter, lighter urines and 4 mostly yellow stools in each of the previous 24 hr periods.
    • AGE 2 weeks  I don’t have MD office reports but Meg called me to tell me Mikey was 1o lbs 7 oz at his 2 week check up and nursing a lot better EVERY feeding!! She was still attached to her pump, gradually decreasing the sessions, just felt safer to keep going with that. If she gets milk she was still giving it to him. This was her security blanket and she was happy doing it. She was very proud of herself and crying happy tears! 🙂

    Meg’s case was a beautiful example of HOW a situation can turn around quickly.  An individual mother’s determination coupled with a productive plan can produce these results. All situations are different.

    Every mother and baby deserve our best!

    I’m Proud of my Hospital….~ this week ~

    ~I’ve reason to be a little proud of the care given this week.008

    I hope this is a continuing trend of attention to detail, utilizing evidence-based practices and compassion, listening to our patients and providing them with options and the best possible care…. I’ll give you a few details about each as you read on… In summary, this week we have had the following situations:

    • A 25 week-er walk-in with a precipitous delivery stabilized & tranported quickly
    • Twins! Vertex/vertex –turned breech– turned vertex~ delivered vaginally
    • A Heroin/Cocaine  addict identified, baby able to be treated appropriately so comfortable transition
    • Safe Haven newborn about 1 day old.. placed up for adoption
    •  Homebirth Transfer handled with great respect overall and most importantly, the mother is happy with her experience.

    Whew! We have a lot of busy weeks but they don’t always have this intensity or variety! I feel proud because there may have been a few things done differently due to recent conversations I’ve had…Plugs I’ve made… and I keeping putting in little plugs to try to gently increase awareness & educate. I am an Instructor in Neonatal Resuscitation and Lactation.. sometimes the troops listen when I talk about other topics…. I’m no expert but I try to be current, correct and compassionate in care. (My 4 c’s)

    Okay… the details for the first 3… stay tuned for the others…..

    ~25 Week gestation walk-in~

    She came in with mild cramps and pressure. She didn’t report any fluid leakage but did C/O pink vaginal mucus. We had her in an exam room pronto. She had a gentle speculum exam which revealed hour glassing membranes thru an approximate 4-5 cm cervix..visually.  Hour-glassing means that the intact amniotic sac has protruded thru the partially dilated cervix and expanded like a bubble  in the vagina. She went right into trendelenburg. The transfer teams were called. It was soon clear she would deliver here and the baby would need to be stabilized and transferred. The NICU team contacted us back they would be flying up to retrieve. The nurses caring for her were tremendously supportive.  All procedures explained, options offered and decisions honored.  They got her records faxed over from her OB’s office so we had a little history.

    Like a well oiled machine (from all of our drills), all the emergency equipment was readied, pediatrician in attendance, roles clarified. Once he was born almost without warning, precipitously, all at once, about 30 minutes later. He was quickly assessed, wrapped in plastic, ventilated, then intubated. We had a peripheral IV in place in case he needed meds or fluid volume. He had a chest xray and a blood culture/blood count sent.  He was kept warm, ventilated and appropriately oxygenated and had stable glucoses. He weighed in at about 700 gms (about 1 1/2 lbs). The team arrived when he was about 30 minutes old. They checked all labs, xrays and his IV line. They gave him Surfactant and pretty quickly and carefully,  loaded him in the transport incubator then got him out to his mommy for a visit before he was transferred. They answered all her questions before they left and we helped her deal with it all. The doctors discharged her shortly after that so she could get down to her baby.  At last report, he was doing just as expected for 25 wks, no other complications often seen at that gestation, for ELBW (Extremely Low BirthWeight) had come up. He was actually improving each day! So happy for everyone!

    ~Twins!~

    She came in to the hospital already in very active labor at 37.5 weeks gestation. Her twins were both head down (vertex/vertex). She labored quickly, uneventfully and delivered Twin A at about 1 pm. With the ultrasound machine in the room, they scanned over her still pregnant belly to see where Twin B was and if he was still in position. Turns out that once Twin A had vacated the womb, baby B had a lot of room and he had moved into a transverse/breech position. That means he was more bottom first than head first anymore. Most Ob’s now don’t attempt a breech delivery even with the second twin.  They are quick to do a C/S…. This day, however, …. the Ob in charge called over an associate to ask his opinion. They brought the mom into the OR and prepared to do a C/S  if they were unable to get the baby in proper position. The point is they were at least going to TRY!  With the U/S scanner and 2 assistants, they did an external version and worked Twin B  back into a head down vertex position without complication. He delivered vaginally about 1 hour and 45 minutes after his brother! The staff kept the first twin in the room the whole time so they could all be together. I spoke to the Ob later and congratulated him on a great job.. he said to me that he remembered what we had talked about awhile ago (when I had written the post about a C/S for the 2nd twin), and had researched it himself. I was happy that any little plug I had made had sparked interest in researching the topic and possibly even influencing a decision towards better care! I am happy to report that both babies went home with mommy on day 2!

    ~A Heroin/Cocaine addict~
    We are attempting to put together some consistant protocols for drug screening so that we don’t miss the opportunities to protect a newborn in need…. Some may not understand how important it is to sometimes screen the healthy and innocent to weed out those with problems…. They don’t always present in an obvious way. From my perspective, those individuals who are hiding something are very difficult to identify from outward appearance only. We identified a heroin/cocaine addict recently who was a very beautiful, well groomed, well nourished, affluent (seemed wealthy) woman who stated she was just visiting in our area, and had no prenatal care info or records with her…. she was in rip-roaring very active labor at 36 1/2 weeks with heavy vaginal bleeding and fetal distress. We thought we were headed to the OR but the baby had other ideas. We had little time to get more information before the baby was born. There was a small abruption but luckily, the baby was vigorous and did not seem to have suffered blood loss. The admitting nurse had collected a urine sample with a catheter insertion and sent it for drug screen. It came back positive for Opiates, Cocaine and THC. The baby’s urine also tested postive for Opiates, Cocaine and THC. Because we knew, we were able to start the NAS (Neonatal Abstinence Scoring) for signs of drug withdrawal and identify the signs quickly. If the baby is unable to be comforted by swaddling or holding or if we had 3 scores of 8 or higher, there are protocols set up for medicating the baby. The baby did require medication within 24 hrs. Once medicated, she was such a happy sweet little girl. The nurses named her “Molly” and we all loved her. She stayed with us all week until the pediatrician released her andChildren’s Services placed her in a foster home experienced with this kind of care. Unfortunately, some of the big drug problems have hit my area. Our local paper just did a big series of stories on local Heroin addiction problems. Apparently it is cheap and accessible.

    I am going to publish this part tonite and tell the other two stories soon…

    No Prenatal Care? …..What are YOU Hiding??

    No Prenatal Care is usually a symptom of something--hiding some type of underlying problem. Sometimes it's very ugly. The most common encounters we have involve illicit drug use during pregnancy. We need to develop a comprehensive Maternal and Neonatal Drug Screening protocol to protect the newborn.

    Read more

    OB Docs and Nurses Scoff at Homebirth

    My community hospital’s views have never been in favor of any type of home-birth… whether it’s with a skilled professional  practitioner or a skilled lay midwife. There could have been some free unassisted births going on but we were not aware….  As I grew-up in this profession, I learned first from my experienced counterparts…then I began to educate myself and learned a lot from mothers and babies.  The doctors and nurses I worked with were all stagnant in their knowledge in my early years. They were satisfied with how things were.  I was young, I had an open-minded philosophy and an eager quest for knowledge.

    In the later 70’s, just when we began to have mothers speak out and request a more natural childbirth, I had a few friends who enlisted the aid of some lay midwife in the region and arranged for homebirths. They all had a really nice birth experience without a single complication. Perhaps that was why I was open to the idea even though I was not personally involved. Besides some of the truly prepared couples who came in and had incredibly beautiful births….. that had been my first exposure as an alternative option to the knock’em out–pull’em out births I had been working with on the job. I knew my friends were very low-risk and had done their homework. 

       However, the hospital’s exposure to a homebirth in those days was only if the homebirth went awry for some reason or another and they came in our doors seeking help…  here’s what the docs and nurses would say to one another :

    • “Can you believe she planned to deliver at home???”
    • “How could she take take a chance like that with her baby?”
    • “The reason people started coming to hospitals to give birth was because mothers and babies were dieing at home….she must be crazy or totally insane!!”

       We’ve had planned homebirths come in for various reasons, as I am sure other facilities did…. (keep in mind that in my area, the usual birth attendant was a lay midwife). The situations bringing the mother to the hospital were often scary and upsetting for her. The most common were:

    • Fetal heart rate decels with or without meconium stained fluid 
    • Lack of progress with pushing mostly after many hours..
    • Higher than normal bloody show or bleeding–possibly abrupting
    • Breech, brow or face presentation
    • Retained placenta

    Often the OB’s didn’t handle themselves well.. certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation…..regardless of why they came in.  And he often actually yelled at the mother, in the middle of her scary situation.

    “Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

    Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient. 

    The two significant situations I remember which would fall in to statistical data for morbidity were:

    1.  An abruption which resulted in a crash C/S upon admission and a neonatal resuscitation with good response….(final apgars 3@one min then 7@ five min) positive overall outcome, no long term sequelae.
    2. A birth where the father (a chiropractor) was the birth attendant for his wife, a multip, encountered a shoulder dystocia and the baby ended up with a displaced fractured left humerus. That baby was in a crib with traction to realign the bone. The child went on to be an honor student at a local university after homeschool.

    I feel that instead of the midwife or mother receiving hostility (or even the mother being wisked away to the OR without a trial of something if the baby was deemed stable..)~ the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.

    Despite all the negativity from the staff, we never had a seriously bad outcome from attempted homebirths arriving on our doorstep.  We still have attitude problems, probably always will~ just as we do with breastfeeding.  I wish they could  look at it from my perspective. Those who choose homebirth today have better information to hopefully make an educated informed decision about their birth options and choose wisely. I really like Ricki Lake’s “The Business of being Born” among other’s. I hope those choosing homebirth are truly investigating all these options, deciding what is best for them and not making any decisions out of “anger at the system” or any sort of revolutionary zeal.  

      There is so much out there for medical professionals to be aware of other than what goes on in their tiny little realm, their little part of the world. My co-workers and doctors need to be better informed.  

    Any one bad outcome (which most certainly happens in the hospital)  does not mean that every homebirth is a bad idea.

    Cesarean Delivery of the Second Twin… Why? 

    029I was talking to one of my on-line Twitter friends @onefinebreeder about twin delivery. I was telling her about how things used to be.. how vertex-nonvertex twin gestation’s were always delivered vaginally ….. and she commented on how it was sad that some of the old OB skills have been totally lost to surgery… So Very True!

    I got to thinking about the first combination Twin delivery I had witnessed back in the very early 80’s. This was actually one of our own (hospital employee) nurses .  She was a multip…. around 37-38 weeks and healthy…no complications during pregnancy. Twin A delivered spontaneously, vaginally with a generous episiotomy as they often performed at that time… The baby , a girl, was about 6 pounds, vigorous and had no problems. We were all marveling at the first baby, checked fetal hearts on the second twin and started waiting for him to get in position.  Still before consistent ultrasound, we were not worried. However, we had a newer doctor who was attending this birth. He began to get concerned after 5- 10 min when contractions slowed and he was worried that if this baby was breech, he would have difficulty with the “after-coming” head. Up to this point, all I had learned was this can be a real concern if the smaller feet or buttocks present through a cervix which is not fully dilated. Much research was done later on but at the time, I did not know about it. He began to ask us to call the OR for a C/S. This was unheard of in my limited experience at the time…. my 70’s world. I thought.. how can they do a C/S now when one baby was already born??? I tried to be an advocate… (my early days… )”We have Piper forceps…”  I said meekly… “Have you tried to grab a large part and help bring the baby down… ?” This was my limited knowledge… all I knew to suggest. I kept wishing one of the other doctors was on duty that day.. or maybe we could call them???

    In front of the mother, he said to me “I’m not going to have a bad outcome here!” By now it was 20 minutes or so. There was no cord prolapse, no drop in fetal hearts, no evidence of immediate trouble… the baby was seeming to work itself into breech position…. To the mother he said “Your baby is in serious danger and the best thing to save him is to take you for a Cesarean now!” “I’ll sew your episiotomy together while we are in the OR.”

    I was in shock. She signed, scared to death of course. So we prepped her for the OR. She went up for a C/S of her second twin and repair of her generous episiotomy. Her second baby was delivered frank breech…  a beautiful boy about the same size and was also vigorous and healthy. I remember I felt as though she was almost assaulted. I remember feeling that this was a true rare event if it every happened before. There was no immediate access to information like today.

    Luckily mom and babies did fairly well in the postpartum period even though healing from both the episiotomy and the C/S was difficult for her.

    "How can I get out if I'm not head 1st ??"

    " Psst-- How can I get out if I'm not head 1st ??"

    I wanted to see how much research I could find on this topic. I had gone to the green journal (OB & GYN) website but then it locked me out. (You can only look at abstracts anyway unless you want to purchase the article. You are on your own for that.) I had some luck with the abstracts at PubMed so I have put a few here.

    I decided to take a look across time…….

    This first one is from 1981. . Quoted abstract from the PubMed site:

    Cesarean Section for Delivery of the Second Twin

    Evrard,JohnR.; Gold, Edwin M.
    Obstetrics & Gynecology. 57(5):581-583, May 1981.

    Four cases of combined vaginal-abdominal delivery of twins are presented, and an additional 5 cases from the recent literature are discussed. Malposition, malpresentation, and contracted cervix were the main indications for cesarean section for the birth of twin B. In the 9 cases presented, there were 2 perinatal deaths.

    Interesting that this research was done during the same time frame as my experience above. I’d like to know more about those poor outcomes 😦

    The next interesting article I found was researched over a 10 yr period, somewhat close to here in a larger facility, published 1997. THIS study examines the delivery of the second twin by utilizing external version vs breech extraction . 😉 The results are showing in favor of breech delivery vs version (those meeting exclusionary criteria ).. Versions were associated with higher a incidence of Cesarean and fetal distress. Neonatal outcomes no different and are stated below:

    Method of delivery of the nonvertex second twin: a community hospital experience.

     Smith SJ, Zebrowitz J, Latta RA.   J Matern Fetal Med. 1997 May-Jun;6(3):146-50

    Abington Memorial Hospital, Pennsylvania, USA.

    The purpose of this study is to examine the incidence of cesarean section and fetal distress complicating the delivery of the second twin in vertex-nonvertex twin gestations in which the second twin underwent either breech extraction or external version. The intrapartum courses of 510 twin gestations delivered at a community hospital over a 10-year period were retrospectively analyzed. All vertex-nonvertex twin gestations were identified in which the second twin underwent attempted breech extraction or external version. Exclusion criteria included birthweight < or = 1,500 g, fetal anomaly, intrauterine demise, and monoamniotic twins. Of the 76 twin sets that met inclusion criteria, 33 underwent external version and 43 underwent primary breech extraction. The two groups had similar demographic characteristics. External version compared to breech extraction was associated with a significantly greater incidence of cesarean section (8/33 vs. 1/43, P = .008) and fetal distress (8/33 vs. 1/43, P = .008). There was no difference between groups in neonatal outcome for the second twin as measured by length of stay, 5-minute Apgar < 7, intensive care unit admissions, hyaline membrane disease, intraventricular hemorrhage, and traumatic birth injury. In conclusion, the increased incidence of cesarean section and fetal distress in patients undergoing attempted external version suggests that breech extraction may be the preferable route of delivery for the nonvertex second twin weighing more than 1,500 g

    The next study was published a little later in 2001 and covered a 20 year span of time… during the 80’s and 90’s at a larger center in Nova Scotia, Canada. They noted an increase in their combination vaginal/cesarean twin births and documented some statistical data, looked at reasons for an operative second twin birth. I wish to read this study further some day to see if there is mention pertaining to mother/baby outcomes other than statistics outlined (even though that wasn’t their objective) in this abstract:

    Combined Vaginal-Cesarean Delivery of Twin Pregnancies

    Obstetrics & Gynecology . 98(6):1032-1037, December 2001.

    Department of Obstetrics and Gynaecology, Dalhousie University, Halifax, Nova Scotia, Canada.

    OBJECTIVE: To estimate the incidence and factors associated with combined vaginal-cesarean delivery in twin pregnancies. METHODS: We studied all twin births weighing 500 g or more during a 20-year period (1980-1999) at a tertiary care center. Major anomalies, monoamniotic and conjoined twins, and antepartum fetal deaths were excluded.

    RESULTS: During this 20-year period, 105,987 women delivered, of whom 1565 (1.5%) had twins. Of these, 1151 twin sets fulfilled the study criteria. The mode of delivery was vaginal in 653 (56.8%), cesarean in 448 (38.9%), and vaginal-cesarean in 50 (4.3%). During the 20 years there was a statistically significant increase in combined vaginal-cesarean and elective cesarean deliveries, with a decrease in vaginal deliveries. Parity, gestational age, and birth weight discordance (>25%) were not associated with combined delivery. Compared with vaginal delivery, the nonvertex second twin was associated with a twofold higher risk of cesarean delivery (relative risk [RR] 2.3; 95% confidence interval [CI] 1.3, 3.8; P =.002); and an interdelivery interval of over 60 minutes with an eightfold higher risk (RR 8.2; CI 4.6,14.6; P <.001). Vaginal-cesarean delivery had a 22-fold higher use of general anesthesia compared with vaginal delivery (RR 21.8; CI 5.4, 88.5; P <.001). CONCLUSION: There has been a significant increase in combined vaginal-cesarean and elective cesarean deliveries among twin gestations, with a decrease in vaginal births. Vaginal-cesarean delivery is associated with nonvertex second twin and a prolonged interdelivery interval.

    Now we come to 2008!  There is a study here from Texas. This study looked a twins born by C/S after labor and twins who had cesarean birth of the second twin. they campared outcomes to see if the twin of a combined delivery had more problems. The most important pieces of information I gather from this abstract of results…. (again, having NOT read the entire study):

    “Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.”  Hmmm 

    Cesarean Delivery for the Second Twin

    Alexander, James M.; Leveno, Kenneth J.; ….et al:for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units Network (MFMU)   Obstetrics & Gynecology . 112(4):748-752, October 2008.

    Department of Obstetrics and Gynecology, University of Texas Southwestern Medical Center at Dallas, 5323 Harry Hines Boulevard, Dallas, TX 75235-9032, USA. james.alexander@utsouthwestern.edu

    OBJECTIVE: To examine maternal and infant outcomes after a vaginal delivery of twin A and a cesarean delivery of twin B, and to identify whether the second twin experienced increased short-term morbidity as part of a combined route of delivery. METHODS: Between January 1, 1999, and December 31, 2000, a prospective cohort study of all cesarean deliveries was conducted at 13 university centers. This secondary analysis was limited to women with twin gestations who experienced labor and underwent cesarean delivery. We compared outcomes of the second twin in women who had vaginal delivery of the first twin and a cesarean delivery of the second twin to those who had cesarean delivery of both twins. RESULTS: One thousand twenty-eight twin pregnancies experienced labor and underwent cesarean delivery; 179 (17%) had a combined vaginal/cesarean delivery. Gestational age at delivery was 34.6 weeks in both groups (P=.97). The rupture of membranes to delivery interval was longer in the combined group (3.2 compared with 2.3 hours, P<.001). Endometritis and culture-proven sepsis in the second twin were more common in the combined group, respectively (n=24, odds ratio 1.6, 95% confidence interval, 1.0-2.7; n=15, odds ratio 1.8, 95% confidence interval, 1.0-3.4). These differences were not significant after logistic regression analysis. There were no statistically significant differences in an arterial cord pH of less than 7.0, Apgar score less than or equal to 3 at 5 minutes, seizures, grade III or IV intraventricular hemorrhage, hypoxic ischemic encephalopathy, or neonatal death. CONCLUSION: Combined twin delivery may be associated with endometritis and neonatal sepsis when compared with a twin delivery where both are delivered by cesarean in twin pregnancies experiencing labor. More serious neonatal sequelae, including hypoxic ischemic encephalopathy and death, were not affected by the route of delivery of the second twin.

    I gather from these studies that a combined delivery route leads to more problems.. however…there are probably more problems than breech presentation alone to lead the provider to make that choice. I believe that many newer providers of obstetrics in a hospital setting are more apt to do a scheduled C/S for any vertex-nonvertex twins they encounter. That is what is done in my facility today. The same for all breech presentation singleton gestation.

    Where is that old-fashioned nurse when you need her?? How ’bout the old fashoined doc??? 😉

    I am very interested in anyone’s story or experience either in healthcare or your personal birth. Please let me know if you know anything about this!

    Thanks for reading!

    Our HOSPITAL’S First Planned VBAC

    I say our hospital’s first planned VBAC (Vaginal Birth After Cesarean)….. however a prelude is necessary because the actual first VBAC I can remember…. totally freaked everyone out. Here are the stories:

    Sometime in the mid 70’s -circa 1976, a mom came in to L/D for a labor check. She was near term with some regular contractions, a little bit of bloody show. The nurse calmly wrote her name down in the notebook…. [Yes– a notebook, that’s the only way we kept track of labor checks back in those days. No medical record, no registration, just a name in a book and the day they were here and checked]… She was getting ready to gather more information when the mom said she had a history of a prior C/S.
    Suddenly all the nurses were scrambling—“Quick, call the doctor!” “Quick, shave her belly,” “Get the Fetal Hearts” “Call the OR and tell them we have a STAT C/S”…We were all busy quickly getting her ready for the OR.
    This little baby, however, definitely had other ideas. The mom told them she had to go to the bathroom…
    Someone said: “Not now honey, we’re going to get you to the operating room to have your baby.”
    The Mom: “But—I have to go….. AUGHHHH” (loudly grunting)
    One of the seasoned nurses threw the sheets back and low and behold, that little baby was crowning!! “Doctor W– No time for the OR– This baby is coming!”
    She did deliver vaginally, quickly, and everyone was in a state of shock!
    I was thinking– I didn’t think that was possible–they told me once a cesarean always a cesarean—they told me the uterus would rupture–that the mother would hemorrhage. She and her baby were just fine. I realized once again that I had a lot to learn!

    Fast forward now to 1984.

    I was sent a nicely written post on the VBAC Pendulum by Dr Shelley Binkley which discusses the rise and fall of VBAC’s in the US and makes for very interesting reading. There’s been tremendous controversy surrounding this topic.

    VBAC’s were widely discussed in the literature at early to mid 80’s and many women were interested…the doctors???– not quite so sold on the idea.  However, in the late 70’s early 80’s, we had one very progressive young doctor (Dr.B)  in the main OB practice.  He was responsible for many of the advances we had in a more natural approach to childbirth.  He was willing and eager to give this a try. 

    I am not sure what he may have discussed in the office with his patients or how he may have selected his first patient who could try for a VBAC.  Knowing him, he may have brought it up to mom’s instead of the mom bringing it up to him. Anyway– sometime in the summer of 1984 we heard we would be having our first VBAC! She was due in December with her second child. Her first baby had been delivered at our hospital by Dr. B via C/S because of some fetal distress.  He knew her history and had full access to her records to know exactly what type or uterine incision she had.  She was young, healthy and continued her pregnancy to term without any complications. She was very excited. 

    The hospital staff was a nervous wreck.

    Where oh where were we going to labor her so that should ANY complication arise, we could do the fastest C/S possible??? We didn’t do C/S’s on our unit. The OR was down a floor and in another wing!!! Such a dilemma.  They finally decided to use the tiny windowless isolation room of the Recovery Room right outside the OR.  They decided to bring all the equipment from L/D down to that room to see how it all fit. We had a regular bed,overbed table, the fetal monitor, some other IV equipment/meds/ supplies etc.. a chair for dad, stool and sm desk for nurse…all crammed in the room. (OK- we scrapped the desk..that was rediculous) We were literally practicing like when they do separation surgery for conjoined twins!!  Quite the production. 

    Ready or not, here she comes…….arriving in labor almost a week late at 40 5/7 weeks.  She was in very early labor much to the relief of everyone involved. OF COURSE I was on duty! OF COURSE I was elected to be her nurse! I was after all, the most prepared (say all my co-workers).  So while other’s got the room ready downstairs, I admitted her. There were no special consents at the time.  My orders were continuous fetal monitoring,  start an IV right away, AND insert a Foley catheter so we would keep the bladder drained, avoid any excess pressure on the uterine scar and keep her from needing to get up.  I also had to do a big shave prep in case of an emergent C/S. We took her down to that tiny closet of a room when it was ready, around noon. She was still in early labor.  The plan was to do a double set-up in the OR for delivery. That meant a whole set-up for a vaginal birth and a whole set-up open for a C/S complete with the entire OR team. They would call them in when she was in active labor. She had progressed to 7 or 8 cm with her first baby before needing a section so the thought was she’d go fast this time. 

    Early labor continued into the late afternoon. All the managers involved kept stopping in repeatedly with all the same questions:….. “Is everything alright??”….. “Any problems??” …..”Any sharp pain in the lower abdomen?”….. “Any blood in the urine?”…….. “How about any excess vaginal bleeding?” ……..They were making me crazy.  We didn’t do any Pitocin augmentation. This poor mom was just in bed the whole time, in the closet with the single bright light, moving around when I suggested changing positions. Finally she headed into active labor and then did progress quickly to transition.  The membranes ruptured spontaneosly and the fluid was clear. The baby was great on the monitor!  The mom was a trooper, never complained, always smiling in between contractions, agreeable to whatever we said.  They asked me to stay and I stayed…. long past my shift.  

    They called in the OR teams. I wasn’t nervous anymore. Get me alone with my patient– away from the nervous Nellies and we can connect and work together through labor. It helped that I had seen that unplanned VBAC so many years before and that I had tremendous trust in and respect for Dr. B.. He was there past his shift also. I had already helped her through so many contractions. She didn’t have the slightest symptom of problems. I had her pretty relaxed, she went thru transition and headed into the second stage in good shape.  At this point, they wanted to move her to the OR for pushing. I think back and feel so bad for her… She was however, still excited and still very agreeable.  She pushed on the hard delivery table in the OR in front of the assembled teams. Talk about performance anxiety.  She sure had a lot of coaches!!

    She delivered and 8lb 14oz boy named Michael later that evening!!! He was 20 1/2 inches long, his apgars were 8 and 8, just needing some blow-by oxygen in the OR.

    There were no complications. This mom came back and had a few more VBAC’s ending up with 5 children overall. I don’t remeber how many VBAC’s we labored in that rediculous closet of a room before we would keep them in L&D. 

    I admire this mom for her strength and courage. I thank her for all she taught me…taught us..

    Michael will be 25 years old this December!

    If you like this story or have any interest in how any specific childbirth element was first seen or has evolved, Please comment or contact me! Thanks

    Medical Science vs Natural Childbirth 

    I sat here to write the story of our first planned VBAC and realized as I scanned my other posts that I had to tell just a little more history to help explain the attitudes of the times.

    During the mid 70’s early 80’s… our country was changing in many ways. In the medical world, Obstetrical medicine was becoming more specialized with the development of many subspecialties including  “Perinatology” and “Neonatology”.  Perinatology by definition is the study of the unborn fetus and recently born infant during the first several weeks of life. It was the changing concern of obstetricians from a sole focus on the mother’s health to one which is balanced between the mother’s health and the unborn or newborn. ACOG started to offer a specialty certification exam for perinatology  in 1974, and in 1977, the Society of Perinatal Obstetricians (now called the Society for Maternal-Fetal Medicine) was formed.  The term used to describe a Perinatologist today is a Maternal-Fetal Medicine Specialist.  This specialty is the management of high-risk pregnancies and the assessment and treatment of the fetus. Neonatology (established 1975 by the AAP) is the study of a highly specialized care of the newly born infant especially the ill or premature newborn infant usually hospital based in NICU’s.

    Young women were becoming more and more interested in a natural approach to childbirth. People all over the country were driving maternity services to offer the availability of birth options for these moms. The ICEA [International Childbirth Education Association] came to our town in the late 70’s and a local chapter was born. “Freedom of choice based on knowledge of alternatives” in childbirth was a motto on their pamphlet information. There were some individuals in the community going for the new certification of childbirth educators. They were educating some new mom’s about birth options…… that we, the staff hadn’t learned about let alone developed as an option for our patients. Many on the staff scorned this movement. It seemed to me that these changes were all happening at the same time. We were learning about advances in observing and monitoring the well-being of both the laboring mother and her unborn fetus, preventing complications etc…. arising from the research studies done from the emerging sub-specialties. We had one fetal monitor and purchased another. As soon as the specialists found that continuous fetal monitoring was advantageous to picking up potential problems in advance, to possibly avoid or prepare for complications, there was a natural childbirth revolt against the constant recumbent positioning that EFM (electronic fetal monitoring) seemed to require. There were more examples as with IV fluids or access and other routine procedures. The nurses didn’t understand. They were just trying to do what science and our doctors were telling them…[though not always willingly as some were afraid of the newer technology.] To them, this group pushing a natural childbirth movement was the same population that had just wanted to be given drugs, put to sleep and “wake me when it’s over” crowd.  

    I realize that although these advances in science and the movement of young people seeking natural childbirth options seemed to happen so close to the same time in my world, it probably didn’t happen this way for all of the country. Here, I really think it probably greatly contributed to the attitudes of nurses and doctors I worked with at the time. Those professionals who just couldn’t relinquish control. They were learning more about the science of birth, of monitoring and couldn’t quite allow or see how the “natural” component could fit in. Those individuals often were guilty of the abuse of professional power, the use of misinformation and the blindness and arrogance to maintain control of the birth process… taking it away from the mother.  Those professionals who should have known better.  They did not know of the rights of childbearing Women, or of general patient rights for that matter. Unfortunately– there are some who still have these control issues.

    That’s another story….