Back to the Home Birth Topic

So, recently in the May 2011 addition of the ACOG journal (American College of Obstetricians and Gynecologists) were two articles discussing the topic of planned home birth. I'd like to share some key points from their articles as things to consider with homebirth. However, it appears they have based their information off of only one study in the Netherlands and the rest of their research has to do with the physicians ethical practice of medicine and what they feel is in the best interest for patients.

They state that "planned home births were associated with a twofold increased risk of neonatal death." They further state that the cause of this may be largely in part due to distance from a hospital in the event of an emergency (many patients studied lived >20 minutes from hospitals). They also state that the majority of home deliveries there are not attended by Certified Midwives, but rather by lay midwives who lack experience and the skill to save a baby or mother if needed. They also stated percentages of complications were higher in first time pregnancies in women laboring at home versus those who had experienced other births.

The College does however, note the right of the patient to make an informed medical decision being fully aware of her risks to herself and to her baby. They also advise physicians not to participate in home birth, but to give care and advice during pregnancy despite where the patient decides to deliver and to be willing to provide emergency care in the hospital when needed if a patient participating in home birth necessitate emergency hospital care.

So here are my thoughts. I respect ACOG's present position and generally I try to follow their guidelines for care of my patients. However, I don't feel that they have enough research on other areas (like Sweden) where they have Certified Midwives providing home births in areas close to the hospital etc. I still believe there are places where home birth is safe and effective for LOW RISK women.

I've decided if any of you out there would like to try home birth, I may be willing to deliver you at home if you see me throughout pregnancy for your care, are extremely low risk and remain that way throughout pregnancy. You would also have to live within 15 minutes from the local hospitals that I have privileges at, be willing to sign arbitration and home birth consent forms and pay out of pocket for this service if your insurance does not cover home birth. Further, I will likely not exceed 2-3 home births/month as this may complicate things with my other patients, hospital deliveries, and office/clinic schedule. This is open as a trial period and I may stop if I feel it is putting you, your baby, or myself at too much risk.

I welcome all comments!

Breastfeeding

Sorry I'm such a slacker at blogging. I'd like to say I'll get better, but that might be lying.

I've been thinking about topics I may have missed, and I got to thinking about one of my favorite parts of motherhood....breastfeeding. This is one of those difficult postpartum tasks that many women unfortunately give up on due to struggles with latch, pumping, etc. I'd like to encourage my patients out there to not give up! As most of you know, breastfeeding has sooooo many benefits to the baby as well as for yourself. To start with, it provides your baby with the right amount fats, proteins, carbohydrates, and water for your baby's growth and hydration. Secondly, it provides your baby with antibodies you've made towards infections which supports your baby's immune system and prevents illness in your baby. It may also decrease the risk of SID (sudden infant death syndrome) in the first year of life. Third, it's FREE! What can motivate you more than saving money on formula? I don't know about you, but that was a huge motivator for me:)

Ok, now that we've covered some benefits for the baby, let's cover benefits for you. First off, as your baby breastfeeds as a newborn, the hormone oxytocin is released in your body and this release causes your uterus to cramp and go back to it's original size. This further decreases your bleeding and risk for postpartum hemorrhage- yeah! Second benefit to you is that breastfeeding decreases your risk for breast cancer and possibly other gynecologic cancers. It may also help you lose weight faster and get back to your pre-pregnancy weight.

So why do people stop breastfeeding? The major reason I see is difficulty with latch or breast infections. One way to help encourage breastfeeding is education. I encourage my patients to take breastfeeding classes prior to delivery to learn about positioning, latch, pumping and storing milk (if you have to go back to work or be away from your baby), and signs and symptoms of infection. Fortunately, breast infections are usually easy to treat with antibiotics or creams, and if you stick it out, the infection will cure and you continue breastfeeding. Please feel free to call if you think you have an infection or need help with this. There is also Le Leche League and lactation consultants available through the hospital to help you as well. Do not give up!

Lastly, there are a few conditions when a woman should not breastfeed. If you have HIV, herpes lesions on your breast, or tuberculosis you should not breastfeed. However, most other illnesses including respiratory viruses, flu, stomach viruses, and other bacterial infections (including mastitis) are still safe to breastfeed. Many medications are also safe with breastfeeding, but check with your provider or pediatrician if you are unsure what medications are safe.

One last note- make sure you are eating plenty of healthy calories with breastfeeding. You must consume approximately 500-800 calories more per day to make milk and you must drink plenty of water- at least 8-10 glasses per day, if not more. If you begin exercising, you may also need to increase your calories beyond the 800 calories to continue to make milk. If you think your milk supply is drying up, it may be that you are not consuming or drinking enough fluids. It actually takes more calories to make milk than it does to grow a baby in pregnancy- so don't skip meals trying to lose weight. The pregnancy weight will gradually come off with time.

Good Luck!

What is the GBS test?

GBS or group B strep is a pathogen that approximately 1/3 of all women carry. It is not a sexually transmitted infection and it doesn't make women or their partners sick. However, newborns born to women with positive GBS vaginal/rectal cultures are prone to sepis (wide spread infection) or illness because of their immature immune systems. Only about 5% of babies born to a GBS+ woman would actually become sick, but the illness can be so rapid and the newborn could potentially die, therefore, we perform universal testing and treatment for all women. Testing occurs usually between 35-37 weeks gestation unless preterm labor or premature rupture of the amniotic sac occurs. In the latter case we would test and treat immediately. Otherwise, we routinely swab (with a q tip type swab) in the vagina and slightly into the rectum during the last month of pregnancy. We do the rectal swab because the majority of strep actually lives in the intestinal tract and that area is still a risk factor for transmission to the baby. If the culture is positive we give intravenous antibiotics at the onset of labor and continue to give them intermittantly every 4 hours until delivery to prevent infection in the newborn.
Some patients may be positive with one pregnancy and negative with another. The reason is because strep can colonize (grow) and once it has grown to a certain level it is picked up on culture and said to be capable of causing infection in the baby. Once we treat you, it may stay at low enough levels that it is not a problem in future pregnancies. However, we will often treat anyway (especially if you'd prefer) if you have been positive with other pregnancies and negative with the current one just in case the bacteria grows in the time from doing the test to the time of labor even though current guidelines do not say this is necessary. We also repeat the test if it is negative and you don't deliver within 4 weeks to see if it turns positive in that time.
For those of you going natural and concerned about the IV with being strep positive, we recommend treating it with antibiotics and then we can hep cap your IV between doses so you can still feel free to get up and move or walk. You can even soak in the bath once you are treated (and preferably if your water bag is intact).

What's the Difference Between Doctors and Midwives?

This is a question I get asked a lot by patients or potential patients seeking an obstetric provider. The answer consists of many things and some different philosophies in general. Of course, there are some midwives who practice differently, and some obstetricians who practice differently, so you can't put everyone into the same nutshell, but here are the main differences. Doctors have been to medical school and have done a residency in their specialty area which includes surgery and management of high risk medical conditions. Certified Nurse Midwives (CNM's) have received Bachelor's degrees in nursing and have most have gone to graduate schools for Master's degrees in nurse midwifery. We do clinical hours and deliveries over about 2 yrs of school which consists of clinic time managing pregnancy, primary care, and gynecologic care. We also deliver babies and assist c/sections in many hospitals. Some do deliveries in birth centers and a small portion about 4% in this country do home births. Direct Entry Midwives are midwives who have had some training usually about 1 yr and perform most deliveries at home or in birth centers. There are also lay midwives who learn the trade from experience and time with other lay midwives. They perform home births.

The general philosophy of midwives is that pregnancy and childbirth is a natural and normal process that requires care of the woman, but that less intervention usually leads to better outcomes-such as a lower c/section rate. We also focus on educating our patients about things to watch for and do during pregnancy to encourage a healthy mom and baby and vaginal birth. We offer more time during prenatal visits to educate our patients and to really take time to know them and care for them. Most of us, myself included want our patients to feel that their desires are being addressed and that we are giving our patients educated options to choose from to meet their desires for childbirth. I personally don't think there is just one way that is the best way. I think natural births are wonderful, but there are some women that do not desire this and just because you choose a midwife doesn't mean you can't use medication or an epidural if desired. We/I just want you to be comfortable and safe and feel like you had a great experience. We never put your safety on the back burner either. We do intervene when necessary and consult or manage your care with an obstetrician if things are varying from a normal safe path. That being said, most midwives have lower c/section rates, bigger babies, and less preterm delivery. Part of the latter is likely because of the education time we try to take with our patients.

Last but not least, midwives usually spend more time with you during your labor offering labor support or emotional support and advocating with the nurses and other care providers on your behalf to help you get the birth experience you want. So, if you are

considering a midwife, come on in, you won't be disappointed!

HPV AND CERVICAL CANCER

HPV or human papillomavirus has 100+ strains, a few of which are considered "high risk" meaning they can cause cervical cancer. HPV is sexually transmitted, and because it is a virus, it is not curable. However, like flu virus, there is a vaccine to protect young women (and men now) against the dangerous strains of HPV. Not all HPV infections will turn into cervical cancer. In many cases, your body will take care of the virus and you will not require treatment for abnormal pap tests or cancer. However, your body may not treat all of the strains, and some of them may mutate and cause changes in the cervical cells which may lead to cancer down the road. Most abnormal cervical tests take 5+ years before they would be considered as full blown cancer requiring hysterectomy, etc. However, there are some cases that move faster and therefore, it is important to follow up with regular screenings, colposcopy, or other treatment as recommended by your provider. Further, there are other types of cancer that are not caused by HPV and that is why all women must be screened, not just women with muliple partners.
Gardisil and Cervarix are vaccines that are available to prevent cervical cancer. The vaccines are recommended for women aged 14-27. It must be given in three separate doses and most insurance does cover this vaccine, so if you fall in this age group, check with your insurance and your provider and get vaccinated! Gardisil also prevents certain types of HPV that cause genital warts as well, so if this vaccine is right for you, you may be "killing two birds with one stone!"
So....don't skip out on those yearly exams or vaccines!

Preeclampsia or (Toxemia, the old fashioned term)

I just realized I've never posted on preeclampsia which is one of the number reasons why it is important to get prenatal care. The cause of preeclampsia is unknown, yet its damaging effects are well known. Preeclampsia is diagnosed by an elevation of blood pressure and protein in urine. Thus the reason for regular urine samples and blood pressure checks during your prenatal visits. There is no cure for preeclampsia besides delivery, and so the goal of treatment is to hopefully get you to term 37+ weeks gestation and then deliver. However, if it becomes severe and begins to involve other organs such as your liver, then delivery prior to term becomes mandatory. Signs and symptoms of preeclampsia are elevated blood pressure, protein in the urine, abnormal labs typically low platelets, and elevated liver tests, spots in vision and/or blurry vision, headaches unrelieved with medication, and swelling of extremities and face. It is important to note however, that swelling by itself is not diagnositic of preeclampsia as many patients believe. You must have the elevation of blood pressure and protein in urine to truly have preeclampsia. If you believe you may be having these symptoms it is important to see your provider as soon as possible or go to labor and delivery for evaluation. The worst case scenario if this is left untreated is seizures in the mother (eclampsia), stroke, or even death. In the fetus, there is risk of growth restriction, morbidity and mortality associated with preterm delivery, and death as well from vasospasm and constriction of blood flow to the placenta and therefore to the baby. So, moral of the story, be sure to keep your regular prenatal appointments, and pay attention to symptoms that could be worrisome. Hopefully, the majority of you out there will not experience this!

Glimpse of my Lake Powell vacation

For those of you who want to see the good times had at lake powell last week-here you go! And yes I know it doesn't have to do with midwifery, but since I don't have a separate personal blog, I figured my friends would like to see that I do dare to go on vacation even if it's only about every 3 years!