Saturday, June 26, 2010

Single-Layer C-Section Closure Ups Risk of Uterine Rupture


From Reuters Health Information








NEW YORK (Reuters Health) Jun 21, 2010

Compared with double-layer uterine closure, single-layer closure following caesarean section doubles the risk of uterine rupture during a subsequent trial of labor, Canadian investigators report in the July issue of Obstetrics and Gynecology.

The researchers therefore recommend that "single-layer closure be reserved for women undergoing tubal ligation or those who require very expedient closure of the uterus." There is no consensus on the best way to close the uterus after c-section, the authors note. Single-layer closure has gained popularity because it shortens operative time and needs fewer hemostatic sutures.

Dr. Emmanuel Bujold, from Universite Laval, Quebec, and colleagues conducted a case-control study among women who underwent a trial of labor following a prior single, low-transverse cesarean delivery. Patients were selected from deliveries at nine centers in the Montreal area between 1992 and 2002.

The analysis included 96 cases of uterine rupture matched to 288 controls by time period and hospital. Rates of single-layer closure were 36% and 20% in the two groups, respectively,
"In multivariable analysis, single-layer closure (odds ratio 2.69) and birth weight greater than 3,500 g (OR 2.03) were linked with increased rates of uterine rupture, whereas prior vaginal birth was a protective factor (OR 0.47)," the team reports. All ORs were statistically significant. On the other hand, suture material had nothing to do with outcomes.

Dr. Bujold and associates say it's possible that a single, continuous suture technique does not approximate the tissues precisely together, and they suggest that single-layer closure leaves a thinner or weaker scar more prone to rupture.

Obstet Gynecol 2010;116:43-50.

Tuesday, June 1, 2010

Natural Childbirth —You CAN Do it !

Right now, all over the world, tens-of-thousands of women are giving birth. Laboring in their own homes, in community birthing facilities (birthing homes & birth centers), and in hospitals, the vast majority of mothers, outside the US, give birth without the use of drugs and with minimal medical technology. They walk around, eat & drink, and actively push their babies out: sitting up, squatting, on their hands & knees, even standing! They remain safe, giving birth to healthy babies.
    Caught in the hands of midwives and given immediately to their mothers, babies suckle at the breast and gaze at the faces of their parents, rarely being separated. Having assisted throughout the labor & birth experience, the mothers’ partners share in the joy and work of birthing, often surrounded by other supportive family members and friends.
    In the United States, however, birth has become a medical event, separating families from their homes and loved ones. The medical model of obstetric care involves many interventionary procedures and the routine use of technologies, even though they have been proven to cause more problems than they prevent.“Just-in-Case obstetrics has become the modern way of managing birth in U.S. hospitals. The legal ramifications of “not” using such methods, should a complication or problem occur, are too great to risk, in the minds of most OB/Gyn’s today. In the last 80 years, the natural, normal function of birth, in our culture, has been taken out of the home and out of the family’s life experience. More often than not, birth is seen by mainstream American society as an emergency (watch an episode of “Private Practice”, “Trauma” or “Deliver Me”).
    The pain and discomfort of labor and birth is considered unacceptable by most medical professionals, having been trained to relieve pain, whenever possible. Women are told not to be “martyrs”... that they should not have to “endure” labor without drugs, as if birth were an excruciatingly, painful event. Many women insist on pain relief, most often through the use of epidurals, “as soon as possible” upon entering the hospital, often before hard, active labor has even commenced. The use of epidural anesthesia is at a record high today.
    Women share their birth experiences with other women much like men tell war stories. Using phrases like, “It was the most terrible pain I’ve ever had.” or “It was the worst experience of my life.” or “I don’t ever want to do that again.”  When was the last time you heard a women talk about her birth as a “lovely” or “a wonderful, powerfully emotional experience”? It doesn’t happen much.
    With the pressures of their busy schedules, more and more women are opting for induction of labor with Pitocin® (a synthetic form of oxytocin, the natural chemical that causes uterine contractions, the let-down reflex of lactation, and orgasm) often before their due dates. Most do so due to the discomforts of term pregnancy, the desire to know when they will deliver, or so their doctor is sure to “be there,” rarely because the baby or mother is medically at any risk.
    The medical model of obstetrics deems that the routine use of technologies, drugs, and procedures, whether or not medically indicated, is necessary and prudent for all birthing women. All laboring women are considered “emergencies waiting to happen,” regardless of their risk factors or lack thereof. The American College of Obstetricians and Gynecologists’ (ACOG) current position is that home birth is unsafe, “Choosing to deliver a baby at home, is to place the process of giving birth over the goal of having a healthy baby.” Yet, they ignore the vast body of current research conducted across the globe to the contrary.
    The use of continuous fetal monitoring has been proven, in multiple studies, to be unnecessary; with outcomes for babies being no different than babies whose mothers are monitored intermittently (15 minutes out of every hour.) Outcomes for mothers are worse, however, with a higher rate of C-section and instrumental delivery, than those intermittently monitored. The monitor cords combined with the routine use of I.V. restricts movement and inhibits women from positioning themselves as they feel necessary, thus hampering their ability to cope with labor without pain relief... and thus, the domino-effect of cascading interventions begins. (see:  http://www.richmondmidwife.com/Documents/DOMINO%20Effect.pdf)
    There are some serious, potentially fatal, risks associated with the use of epidurals, as well as many less serious risks that affect mothers and their babies. Yet doctors encourage women to get an epidural, claiming that its “safe” for her and baby, even though studies show that the use of epidurals causes slowed labor, often requiring pitocin augmentation. The combined use of these drugs can cause undue stress on the baby. For this reason, mothers are required to stay in bed and be continuously monitored.
    To speed stalled or slow-to-progress labor, a woman’s water (amniotic sack) is often routinely ruptured, even though doing so increases the risk of infection to both mother and baby, particularly in the hospital setting, where antibiotic-resistant bacteria thrive and are shuttled from room to room by the staff.
    Epidural numbness makes active pushing by the mother difficult, often requiring the doctor to perform an episiotomy (cutting the opening of the vagina) and use forceps or a vacuum extractor to pull the baby’s head out. Or the baby’s head can become wedged in a deep, transverse position (turned crossways in the pelvis) so that pushing or pulling the baby out vaginally becomes almost impossible, thus a C-section is necessary. And, there is growing evidence that epidurals cause infants to have poor initial rooting and suck reflexes, reducing their instinctive response to breastfeeding immediately after birth.
    Breastfeeding, while proven to be the most superior food for the human infant through and beyond the second year, is still a taboo subject in our culture. Only a small percentage of U.S. mothers are fully nursing their babies by the age of six weeks, while the average age of weaning in the world population is between 3 and 4 years old! Our society does not value breasts for their primary purpose and function in the nurturing of infants; only as sexual body parts, not to be seen or talked about in public. Breastfeeding in public is often frowned upon; mothers have been asked to stop nursing, to leave, or have even been arrested for indecent exposure, just for feeding their babies! Nursing mothers resort to hiding out in bathrooms, sitting in corners with their backs turned, and draping themselves with blankets, all for the sake of sparing others from embarrassment or offense. In most municipalities, thankfully, this is changing and breastfeeding mothers may feed their babies wherever and whenever they choose.
    So, what should YOU do? How can YOU have a healthy, safe, memorable birth experience and successfully breastfeed your baby? Consider for a moment the generations of women in your ancestral history who birthed their babies as described in the opening paragraphs. Remember that your own body is designed to give birth without gadgets, procedures, and drugs. Trust your own instincts and your body’s ability to do the work of birthing and breastfeeding.
    Educate yourself by reading many, many books, magazines, and research papers regarding safe maternal/child health care. Minimize your risk factors by taking exceptionally good care of yourself: eat healthy, whole foods; take a walk everyday; get sufficient rest; and refrain from unhealthy habits (no smoking, caffeine, alcohol or drugs.) Invest in an independent childbirth education class; one that will spend the majority of time teaching you labor-coping techniques and birth physiology, rather than telling you about procedures and what to expect when you enter the doors of the hospital.
    Consider hiring a professional Birth Assistant, known as a “Doula” or “Monitrice” to provide the emotional and physical support you will need in the foreign environment of the hospital. Women supporting women through childbirth has been an ageless tradition common to nearly all the cultures of the earth throughout the centuries.
    It is unfortunate but true that, in just two generations of humanity, we have, in large measure, lost the knowledge, confidence, and respect for the normality of pregnancy, birth, and breastfeeding.  For these reasons, the addition of the modern-day Doula to the birth team can be and is a valuable asset, not to be considered a trend or fad.
    The professional Birth Assistant expresses confidence in a woman’s body to birth normally, respect for the process of “natural birth,” and recognition of the transcendent and life-altering aspects of childbearing. She helps pregnant couples actively choose their means of care, enabling them to reclaim the process of birth, improves the quality of their experience, gives them confidence, and empowers them. She maintains a respect for the integrity of the birthing family, believing that they must be the central focus of the birth team.
    Parents must be empowered to make their own best choices and enabled to follow through on those goals without intervention unless medically indicated.  The Doula’s role as a labor support person is augmented by her role as advocate for the birthing family (maintaining the integrity of their experience.) An experienced Doula’s value is measured, in large part, in that she provides her clients with information, education, and practical options and alternatives to a medicalized birth experience, so that they may give birth to their baby safely, with minimal or no medication or interventions; with great confidence, strength, satisfaction, and joy!
    Not only does a woman remember her birth experience, but she remembers the people who are with her and who help (or do not help) her.  She remembers how she was treated; good or bad; with or without respect and dignity; as important or as insignificant; as the one in control or as a victim. Empowering, affirming words and practical, helpful emotional and physical support during labor and delivery impress forever on a woman. By “mothering the mother” during birth, the Doula can influence how a new mother will mother her own child. Her birth experience helps frame how she sees herself, her womanhood, and is the rite of passage to her motherhood. One of the Doula’s most important jobs is to protect and nurture the woman’s memory of her birthing experience.  This, in and of itself, is of great worth.
    Another of the Doula’s roles is to facilitate the integration of new ideas, options, and coping skills for the couple. This includes grieving over what isn’t the “fantasy birth” and/or the “perfect baby." If the birth process requires medical intervention or the outcome is unexpected, the mother often struggles emotionally with this transition. The Doula knows that, when a birth experience deviates from normal, emotional support of the mother is of critical importance.
    The Doula individualizes the support she provides to meet each individual’s needs, always considering their feelings paramount to those of others and of herself.  Because the needs of a laboring woman change throughout her birth; the Doula’s goals are to respond to the current and pressing needs of the woman and her partner “at this time” — “for here and now."  This is a valuable asset for the couple so that they may find their own way through their birth experience.
    Expectant couples deserve loving, friendly, empowering care throughout their pregnancy & birth.  Thousands of women give birth every day, yet every birth is a uniquely personal experience.  The Doula serves her clients with genuine concern for their birth memories.
    Providing quality labor support to birthing women has been shown to significantly reduce the need for medication and other interventions, dramatically reduce cesarean and forceps deliveries, reduce maternal fever and infant sepsis evaluations (minimizing separation), increase maternal confidence, and ultimately provide for better outcomes for the mother, baby, and a successful breastfeeding relationship.
    For these reasons, the purpose and value of professional labor support, especially in our culture, should not be taken lightly. Dr. Marshall Klaus, MD, co-author of Mothering the Mother says, "If a Doula were a drug, it would be unethical not to use it."
    We give birth but a few times in our lives, and the impact of those moments stays with us, molds us, and affects our whole society. Thus, the resurgence of home births, the increased interest in natural birth, and the care offered by midwives. Midwives specialize in understanding normal aspects of the childbearing cycle. They serve and care for childbearing women: before, during, and after their pregnancies. The midwife attends childbirth, provides support during labor and delivery, and supervises the general health care of women and children directly after birth. She is trained to recognize deviations from the normal, recommend holistic means for bringing the situation back into the realm of normal, or refer to another practitioner when necessary. She believes it is important is to provide time for questions, teaching, and time to listen to the concerns and needs of the women they care for. Thus, the average midwifery prenatal appointment lasts an hour.

    Midwifery is quite possibly the oldest profession on the planet, as women have been helping women to give birth since the dawn of humankind. The term midwife,  derived from the Anglo Saxon word, “mit wif”, meaning "with woman," was first recorded in 1300. Written accounts dating to the 2nd century confirm the role of midwives in the birthing process. Modern midwives provide care to women during normal pregnancies and deliveries and collaborate with and or refer to obstetricians or other physicians if health complications develop or the pregnancy becomes high-risk.

    As trained health care professionals with expertise in supporting women to maintain a healthy pregnancy birth, midwives offer individualized care, counseling, education, and support to women and their newborns throughout the childbearing cycle. Midwives provide continuous support to women with low-risk, uncomplicated pregnancies during pregnancy and labor. Communication between midwife and her client is emphasized, and midwives focus on working with the woman to reduce the risk for complications during childbirth. Midwives also focus on the needs of the family, and encourage partner and family participation in the birth. They pay special attention to the family traditions, cultural values, and the personal preferences of the women in their care.
    Safety of highest priority in midwifery and studies show that outcomes are as safe or safer than similar birth attended by physicians and in hospitals. As part of their commitment to nonintervention, midwives do not advocate the use of pain medication, invasive procedures, and routine time management during the normal birthing process. They encourage women to actively participate in their birthing process.

The continuous presence of a midwife during labor can reduce:
  • the length of labor,
  • the need for pain medication,
  • the likelihood of forceps or other operative devices,
  • the possibility of cesarean delivery.
The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:
  • Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
  • Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
  • Minimizing technological interventions
  • Identifying and referring women who require obstetrical attention
The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.    Copyright © 1996-2004, Midwifery Task Force

    Midwifery is based on a strong belief in partnership with childbearing women and respect for birth as a normal life event. Midwives strive to empower parents with knowledge and support their right to create the birth experience which is best for them. Midwives respect intimacy, privacy, and family integrity, and draw on their own patience and understanding to provide care during pregnancy and birth. Midwives trust birth. Midwives believe in normal birth.
    You are “made” to be able to give birth and to Do It very well! Seek out the very best and supportive people to assist you in your goal to give birth safely, to a healthy baby, in the manner that best suits your needs. You can make a difference in your own life and in the lives of those closest to you — your children and their children. Trust “Mother Nature” she has more experience than anyone on this earth! Essentially that means: Trust yourself!

Natural Childbirth —You CAN Do it !