A Perspective on Risk

September 8th, 2011 § 0 comments § permalink

Michele at “Birth After Cesarean”, shares a good perspective on the risks with VBAC, compared to other risks we encounter in our everyday lives. It’s a great post!

When making a decision about your health care…

February 4th, 2011 § 0 comments § permalink

I found this little acronym on Rixa Freeze’s “Stand and Deliver” blog. I thought it was good, and might be helpful to some mothers and fathers. So often the “routine” procedures, tests, and ways pregnancy and birth are managed are viewed as absolutely essential—when actually, they aren’t always necessary. So for the thinking mothers and fathers who truly want to be involved in their care…here are some questions to help you determine (along with your care provider) what tests and procedures are truly of benefit, and those that are just “routine”.

(Disclaimer: Although she does have some excellent articles on various pregnancy and birth topics, I do not endorse everything on her site.)


Trying to make a decision? Get BRAINED!

Ask yourself, and your caregivers, these questions:
Benefits – How could the recommended course of action help me or my baby?
Risks – How could the recommended course of action harm me or my baby?
Alternatives – Are there any other courses of action I could consider?
Intuition – What are my gut feelings about this?
Nothing – What happens if I do nothing?
Evaluate – Can you give me some time to consider my choices? Then…
Decide – Now that I have the information I need, I’m ready to make a decision.

BRAINS
Benefits- How will this procedure benefit me and my baby?
Risks – What are the risks to me and my baby?
Alternatives – What are some other things we might try instead?
Instinct/Intuition – What is your gut telling you?
Now/Never/Nothing – What if we don’t do the procedure right now? What if we never do it? What if we do nothing?
Safety/Satisfaction – Will this procedure increase the safety and satisfaction of the birth for me and my baby?

(At the end of her post, she adds this addendum.) To give credit where it’s due: the BRAINED acronym comes from a handout that someone gave me from “Lucina Birth Services.” The BRAINS acronym was passed around on a doula list serve.

Postdates Pregnancies and the Biophysical Profile

December 24th, 2010 § 0 comments § permalink

A mother’s due date has come and gone.

A few days? “Not a problem.” Such is life, especially with first-time mothers who, on the average, carry their babies for 41 weeks and 1 day.

A week? “It may not be a big problem—due dates are only estimates, after all—as long as the baby is still kicking and active and growing, everything is probably fine.” We will make sure the mother is well-hydrated, and that she is continuing to eat plenty of nutritious foods to ensure the placenta and baby are well-supported and supplied. Also, we will have the mother monitor the baby’s activity a little more closely than before. Did this mother carry longer with any previous babies, or did her mother tend to carry late, too? Sometimes this sort of thing runs in the family.

Two weeks? Hmm…why is this baby not here? Concern starts to build…especially if “dates” are quite certain (based on ovulation chart or date of conception, which are more reliable than LMP or late/mid-pregnancy sonogram). We need to make sure all is still well with baby.

Midwives do not like inducing labor. We are advocates for the natural process, we are the “guardians of natural birth”, we only intervene when truly necessary for the mother and baby’s health and wellness. And then we are fine with intervening, but even then, interventions have risks.

Therein lies my dilemma. I have, during my recent studies, come across numerous articles, and several research studies that have demonstrated that ultrasound has not been proven safe for small bodies and brains, and showing actual harm it can do. So I believe it should be used only if truly necessary, or if the mother decides, after being fully informed, that she wants one done (although I wouldn’t really encourage it without a medical indication, if she wants one, it is her choice). The question then becomes, “What constitutes a truly necessary situation, or a truly good reason?”

Of course, we never used biophysical profiles in years gone by for post-dates mothers—the midwife or doctor would have the mother do kick-counts, and if the baby stayed active, continued growing, and the amniotic fluid felt normal in quantity, it was presumed/assumed that the baby was doing well. (In the absence of any concerning signs, presume that everything is fine, but be watchful.)

We began teaching our clients how to challenge and count the kicks of their babies [fetal kick counts] (FKC) and report any decrease in movement. …Women so often feel incapable of trusting their knowledge of whether their unborn child is doing well. There are many “old wives tales” that tell a pregnant woman that if her baby is still active, delivery is way off or that the baby will stop kicking before she goes into labor. I have used FKC to empower women and give them something they can do to truly monitor their babies’ well-being. I love FKC as a teaching tool. If a baby is not moving, it needs to be assessed right away. Babies even move during contractions. Over the years, I have found that women really only use this means of monitoring if they are worried that the little one is moving less than usual. Drinking a cold glass of water usually remedies the problem and offers the reassurance these women need.

When I first began my practice in this rural community, I worked with a physician who insisted, “Mother Nature knows what she’s doing.” I watched one woman go four weeks past her very certain due date. I watched another go six weeks past the day we were certain she was due. I was a wreck. But my mentor was more than right. Mother Nature does know what she’s doing. Women’s bodies are meant to be pregnant and give birth. Babies have their own time to be born. Pushing women to deliver by 39 weeks is defensive medicine to the level of absurd. Not every baby is ready to be born in that timing.

— Kathryn Jensen excerpted from “Does Mother Nature Really Make Mistakes?” Midwifery Today Issue 72

Now with the advent of sonography, the collective decision made by the by-and-large medical community was that sonograms would do a better job of determining if the baby was doing well than careful palpation and observation/noting of fetal movements. Are they right?

The risk of fetal demise rises as the time past a mother’s due date increases, more so after 43 weeks (although it is rather rare for mothers to carry this late, it can and does occasionally happen). I’d rather be overly cautious than overconfident of the safety of ultrasound and later regret unnecessarily exposing women and their babies to an unproven technology. X-rays were once also thought safe for use during pregnancy on mothers and babies. Only later did we realize that they caused/contributed to childhood cancer. I believe there are good and valid reasons to recommend a sonogram—however, I’m also willing to entertain the thought that perhaps there are lower-tech ways of determining the baby’s well-being in the post-dates period without one.

At this point, I’m most comfortable with doing a BPP (biophysical profile) if a mother goes a couple weeks past her due date, but I’m definitely going to keep studying this issue, and if I find evidence that doing the BPP doesn’t improve outcomes, or no more than having the mother do kick-counts, listening to fetal heart tones for reactivity and palpating for fetal growth, movement, and fluid levels, then I will certainly present that information to my clients if they find themselves carrying post-dates.

Elizabeth Davis in her book Heart and Hands, A Midwife’s Guide To Pregnancy and Birth, has the following to say:

“Can the midwife’s assessments as cited earlier provide enough information to substitute for the biophysical profile? In my opinion, the answer is yes. Although fetal breathing movements [something that is accessed when a biophysical profile is done] cannot be assessed directly, these may be presumed to be adequate on the basis of normal muscle tone, as demonstrated by kick-counts. NST [non-stress test, a test done by monitoring the baby’s heart rate and pattern for a period of time] is readily accomplished with a standard fetascope. And to reiterate, even the subtlest changes in amniotic fluid volume are easily noted with continuity of care [having the same care provider palpate at each prenatal visit].”

And just to clarify, performing a NST with a fetoscope would be more accurately termed an Asucultated Acceleration Test (Varney’s Midwifery, 635).

For further reading:

Suspect Diagnoses Come With Biophysical Profiling
by Gloria LeMay
Postdates Pregnancies from a Midwifery Today E-Issue
A Timely Birth by Gail Hart

Heart and Hands by Elizabeth Davis, pages 86-88, “Postdatism”

Group B Streptococcus (GBS) Protocol

July 14th, 2010 § 0 comments § permalink

I finally have my first-edition GBS protocol (see below). I imagine it might change slightly, though, as I gather more experience, and more research is done on this bacteria.

[Added later: This is a simple, but great article written by an Arkansas midwife on GBS. It shows the relatively low risk babies are at from this bacteria, and puts the risk in better perspective. Take a look.]

Group Beta-Streptococci

Definition:
Group Beta-Streptococci is a bacteria found in up to 40% of women. It originates in the intestinal tract, but because of the close proximity between the rectum and the vagina, if a mother has intestinal/rectal colonization she will most likely have vaginal colonization. Genital colonization can cause symptoms, but rarely results in maternal illness. It can carry significant risks for the baby, however, if he or she becomes colonized and develops an infection from the bacteria. Overall neonatal infection rate is 1-4/1000.

Early-onset GBS disease (within the first week of life) is the leading cause of neonatal mortality and morbidity including sepsis, meningitis, and pneumonia. The newborn may become infected in utero, or during passage through the birth canal. Vertical transmission from mother to baby primarily occurs after the onset of labor or after the membranes rupture.

Predisposing factors to colonization:
Age >20
Low parity
Colonization with Candida
Multiple sexual partners in the previous 12 months (although not all studies have found this a factor)
External genital erythema and scaling
Use of tampons
Purulent vaginal discharge
Vaginal pH >5

Increased risk for active neonatal infection in the following circumstances:

Preterm birth (<37 weeks), although less than 30% of all infected babies are preterm
Rupture of membranes (>18 hours)
Heavy maternal or neonatal colonization with GBS
Maternal fever over 100.4 F
Previous birth of a baby with active GBS infection
Internal fetal monitoring for over 12 hours
Maternal GBS urinary tract infection
Multiple birth (only one study found an increased risk independent of the prematurity factor)
Low maternal titers for anti-GBS capsular IgG antibodies

A baby can be colonized and infection in any of the following ways:
GBS ascends into the intrauterine space from the vagina in an asymptomatic mother
The fetus aspirates infected amniotic fluid (can lead to stillbirth, pneumonia, or sepsis)
The baby passes through a colonized genital tract during birth (usually leading to colonization of newborn skin/mucous membranes; most of these babies do not get sick)
On rare occasions, babies become ill with GBS without any evidence of colonization in their mothers.
Group B Strep, Continued

Plan:
An informed consent form giving a thorough description of the disease, the testing, the risks, and options for treatment will be given to each client. The client will read and decide what course of action to take. I will offer routine testing at 36 weeks, but will respect the client’s right to decline. The client may choose to:
Decline testing, and watch the baby closely after birth for signs/symptoms of GBS disease (see below)
Consent to testing and do nothing if GBS-
Consent to testing, and if GBS+ discuss treatment options (see below)

For clients testing GBS+ I shall inform the client of the risks, and the standard for care, which includes IV antibiotics during labor or upon rupture of membranes, if that occurs first. I will offer the following treatment options:
Do nothing prophylactically, carefully watch the baby for s/s of infection, and immediately transport to hospital for antibiotic treatment if signs of GBS disease develop.
Use natural treatments to suppress the bacteria and boost the mother’s and baby’s immune system from 36/37 weeks until the baby is born. I may recommend:
Naturally fermented foods (natural yogurt, keifer, miso, kombucha) to support naturally-occurring flora
Acidophilus 2x daily (lactobacillus- 2 billion per capsule)
Echinacea 2x daily (350 mg)
Garlic 2x daily (580 mg)
Insert a clove of peeled, unnicked garlic vaginally every other night (remove in the morning)
Vitamin C (2000 mg daily)
Vitamin E 2x daily (500 mg)
Grapefruit seed extract (33%) 10 drops 2-3x daily, along with HMF Probiotics 1-2 capsules 2x daily until birth
Tea tree oil suppositories- Soak cotton ball or small cotton tampon with 50/50 blend of tea tree oil/olive oil, every 4 to 6 waking hours for ten days (to be done near term)
Use Hibiclens vaginal washes during labor/upon rupture of membranes (if ROM occurs first).
If a client desires to have IV antibiotics during labor, I will refer her to a doctor or other health care provider able to provide antibiotics.

I will monitor the well-being of my client and her baby during labor and delivery and proceed with desired course of treatment for GBS.

I will fully inform the client of the s/s of GBS disease in the newborn, and shall instruct the client to call immediately if the baby develops s/s of GBS disease.
If baby develops signs of sepsis, I will transport immediately for testing and treatment as needed. Signs of sepsis include:
Temperature lability
Tachypnea (apneic periods)
Labored breathing
Poor color
Lethargy
Poor suck

References:
Holistic Midwifery Volume 1 by Anne Frye, pg. 573
Heart and Hands 3rd Edition by Elizabeth Davis, pg 30, 133-134 [4th edition, 40]
Varney’s Midwifery 4rd Edition by Helen Varney, pg 868-870
Understanding Diagnostic Tests in the Childbearing Year 7th Edition by
Anne Frye, pg. 743-756