Membrane sweeping - reconsider…?

Cervical Manipulations Linked to Perinatal Sepsis: Consider GBS-specific chemoprophylaxis OB/GYN News, Oct 15, 2001 by Kathryn DeMott QUEBEC CITY — Obstetricians may want to hold off on performing cervical manipulation or membrane stripping to hasten labor in women with cervical/vaginal infection or colonization with pathogens, Dr. Carol Stamm reported at the annual meeting of the Infectious Diseases Society for Obstetrics and Gynecology. In a series of eight case reports, Dr. Stamm of the University of Colorado, Denver, described how cervical manipulation or membrane stripping preceded perinatal sepsis and even one instance of stillbirth caused by invasive group B streptococcus (GBS) as well as other pathogens. In each case, the salient features were the same: Each woman had a history of term gestation in a previously healthy pregnancy. All had elective or nonurgently indicated promotion of labor, digital cervical manipulation, and rapid labor with placental findings of histologically severe intrauterine infection or funisitis, half the time in the absence of classical clinical criteria of chorioamnionitis. One patient gave birth to a stillborn 15 hours after membrane stripping due to overwhelming fetal GBS sepsis. In four of the eight cases, the women had no risk factors such as known GBS infection or symptoms of chorioamnionitis; in the remaining four cases there were such red flags. It has always been assumed that such events are rare; however, their incidence can only really be established by large, prospective epidemiologic studies, Dr. Stamm noted in her poster presentation. Membrane stripping and cervical manipulation to release prostaglandins can be considerably vigorous. And this series of case reports builds on prior evidence that suggests that it is traumatic enough to cause vaginal microbes to spread into the lower uterus. On the basis of these case reports, obstetricians may want to reconsider doing elective cervical manipulation, at least on patients who have cervical vaginal infection or colonization with potential perinatal pathogens. They may also want to consider providing GBS-specific chemoprophylaxis before membrane stripping, she said.

Posted: October 4, 2008 Tell it like it is (0)

The rule of 10

 

I’ve been wondering about a few things recently.

  • The purple line and its relation to dilation - meaning that lots of VEs were done on women as they progressed through labour to see whether there was a correlation. 
  • Why we wait until 10cm to be convinced that a woman is dilated.
  • Where the 10cm rule came from.
A recent article I saw in Midwifery Today got me thinking more.

 

"There is a rule of labor that forbids a woman to push with contractions until her cervix is completely dilated to 10 cm. Women are warned that to push before this doorway is completely open and out of the way will result in a swollen and/or torn cervix."

I’m curious to hear more on this topic and when I’m done with my current paper, I’ll look into it some more.

I’m developing a style of practice that is being hands off and observational, which is often in conflict with the hospital system that I am learning in. I get that I am a student and that I have to learn before I can be. I also get that I am the midwife I will be in the future; it’s in the heart and soul, not in the textbooks, but I need the knowledge and skills to catch up to that passion. But wow it’s hard going to be trained in The System when I don’t agree with so much of what I have to do.

Posted: September 8, 2008 Tellings! (2)

VBAC EDD blah

EDD or EDB - expected due date, date of delivery, date of birth
VBAC - vaginal birth after c-section

It’s a common question - when is the baby due? And what happens if my pregnancy goes longer than the expected period?

Well, firstly let’s consider how a "due date" is calculated and what it means. Most are calculated using Naegele’s Rule which adds a year to the woman’s last period, subtracting three months and adding seven days to that date. It assumes that the cycle is 28 days, that 9 months = 281 days (ie about 30 days in the calendar months between those dates) and also that the gestation period is average at 40 weeks. Given that full term is anywhere between 37 and 42 weeks though, this is just the centre of the period where the baby may decide to make an entrance.

Or alternately:

Wood’s method:
nullips: LMP + 1 year - 2 months - 14 days, +/- days cycle varies from 28 days
multips: LMP + 1 year - 2 months - 18 days , +/- days cycle varies from 28 days
Nichols, Carol Wood, "Postdate Pregnancy, Part II: Clinical Implications," J. of Nurse-Midwifery, Vol. 30, No. 5, Sept/Oct., 1985, pp. 259-268.

Mittendorf’s Study
31 nullips, 83 multips found first pregnancies lasted on average 288 days and multips 283.
Nullips: LMP -3 months + 15 days (adjust for variation in cycle length)
Multips: LMP -3 months +10 days etc . . .
Mittendorf, R. et al., "The length of uncomplicated human gestation," OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932.

So if you had someone with a last period starting on 08/07 and a 28 day cycle, my obs wheel would tell me 14/04, Wood’s rule gives a date of 24/04 and Naegele’s rule gives a date of 15/04! So if you’re promised a VBAC if you go into labour before your due date, when you may never have had a vaginal birth before so you can be 10 days behind the mark before you can even think about being ready for labour. So yes, your ob or midwife is just humouring you.

Me bitter much about a recent experience? Yes, yes I am.
 

Posted: May 22, 2008 Tellings (1)

Incubators

Remind me to dig up research that "supports"  the need for and success of incubators, in terms of helping babies who will have a good outcome to survive - because I’m genuinely curious as to whether the investment of money and hours and equipment is worth it for the families, or the babies.

From a Peak Oil point of view, I do wonder what will happen to premature babies when the oil runs out. Will we continue to invest so heavily in premature infants, and at whose expense? And yes, my asking this question does point to me being a hospital-trained midwife. I’d welcome some views on this as well :) .

Incubators seen to change babies’ heartbeats
Could the electromagnetic fields of incubator motors affect babies’ health? Katharine Sanderson

The incubators used to nurture premature babies give off electromagnetic fields that change the babies’ heart rhythms, researchers in Italy have found. Carlo Bellieni at the General Hospital of the University of Study in Siena and colleagues monitored the heart rates of 43 newborn babies being cared for in incubators.

They measured the babies’ heart rate variability (HRV) — a measure of the time lapse between heart beats — when the incubators were switched on and when they were switched off. Human hearts don’t beat at the same rate all the time, but rather quicken and slow when breathing in and out and with changes in hormones. This variation is healthy, and it can be used as a marker of how well the nervous system works. In adults, a low HRV is thought to point to a risk of heart disease. Bellieni and his colleagues found that when the incubators were switched on, the babies were exposed to 8.9 milligauss of electromagnetic frequency (normal background levels are around 1 milligauss) and their heart rate became less variable: the HRV dropped to half that of baseline levels. “This is not good at all,” says Bellieni. The results are reported in the Fetal and Neonatal Edition of Archives of Disease in Childhood 1. Bellieni doesn’t want to alarm parents: “We cannot save [most premature] newborns without incubators,” he says.

“Incubators are necessary to these babies, and no actual correlation with health problems has been shown.” But he hopes to prompt improvements in incubators to make them as safe as possible. Bad vibrations To check that it was the electromagnetic frequency rather than the noise or vibration of the motor to blame, Bellieni did separate experiments with 16 of these newborns in which he replicated the noise and vibrations without the EMF-producing electric motor. There was no change in the HRV of the babies in these experiments. The researchers are not sure why this is happening.

The World Health Organization notes that EMFs of higher than 1 gauss can stimulate nerves and muscles, as well as changes in the central nervous system. But for less intense exposure things are much less clear. Several epidemiological studies have suggested that childhood leukaemia is more frequent in households exposed to magnetic fields higher than 3 milligauss than in those with lower levels of exposure, says Sander Greenland, an epidemiologist at the University of California, Los Angeles. But the reason for this is unknown, and it might not have anything to do with EMF. Despite the controversy though, Greenland says that sustained exposure of newborns to levels of about 10 milligauss could be cause for concern.

Room for improvement
The abrupt changes in HRV as the incubators are turned on or off is worrisome, says Cynthia Bearer, a paediatrician at Case Western Reserve University in Cleveland, Ohio. About 10% of babies are born premature, she says, and most need to spend at least some time in an incubator. Changes in the nervous system such as those implied from HRV variations have been suggested, but not proven, to be involved in sudden infant deaths, for instance. "We know that premature infants are at risk for Sudden Infant Death Syndrome. Could this exposure be why?" says Bearer. Incubators can be improved, Bellieni says.

His previous work has shown that babies’ exposure to EMF in incubators can be significantly reduced if a ferromagnetic material is used to shield babies from the motor. These improvements would be trivial to make, and are well worth following up says Alan Preece, a medical physicist from Bristol University, UK. The study highlights a problem that needs more probing, he says. “We do not understand any of the mechanisms of low-frequency, low-power magnetic fields that seem in different studies to throw up effects," he says, on anything from gene expression to the development of leukaemia.

a.. References 1.. Bellieni, C. V. et al. Arch. Dis. Child. Fetal. Neonatal Edn doi:10.1136/adc.2007.132738 (2008).

Posted: May 16, 2008 Tell it like it is (0)

Games we must play to get the birth experience we want

Please go and read about this and see what you think.

Add to this - if you want a physiological third stage in a hospital setting, the words "lotus birth" will guarantee that no one severs the cord. Even if you have no intention of keeping the placenta until the cord falls off on its own, it will keep people from cutting cord, which is one of the only ways to insist on letting the baby get its full compliment of blood.

Posted: April 21, 2008 Tell it like it is (0)