Friday, September 03, 2010

News roundup

Lots of interesting things have come my way lately. Today's news roundup touches on cesareans, home birth, epidurals, and kangaroo care.

Caesareans: Majority Done Before Labor
The New York Times reports on a new study that finds--big surprise--that the majority of cesareans are done before labor begins.
A new study suggests several reasons for the nation’s rising Caesarean section rate, including the increased use of drugs to induce labor, the tendency to give up on labor too soon and deliver babies surgically instead of waiting for nature to take its course, and the failure to allow women with previous Caesareans to try to give birth vaginally....

[Co-author] Dr. Zhang said one thing that surprised him about the study was that a third of first-time mothers were having Caesareans. Although it was known that the overall Caesarean rate was 32 percent, some of that was thought to be due to repeat Caesareans.

The main reason for a Caesarean was a prior Caesarean. But in women who have not had Caesareans before, one factor that may increase the risk is the use of drugs to induce labor. The practice has been increasing, and the study found that induced labor, compared with spontaneous labor, was twice as likely to result in a Caesarean.

In the study, 44 percent of the women who were trying vaginal delivery had their labor induced. When Caesareans were done after induction, half were performed before the woman’s cervix had dilated to six centimeters, “suggesting that clinical impatience may play a role,” the authors wrote. Full dilation is 10 centimeters, and a Caesarean before six centimeters may be too soon, the researchers said. 
Home Birth: Refuse a cesarean, lose your baby
My midwife lists have been buzzing about a family whose baby was removed by CPS after being born at home. The baby was breech, and the parents refused a cesarean and left the hospital AMA. The parents explain on their Facebook page Bring Ruth Home:
Ruth Abigail Light was born at home on July 21st at 7:38PM. She weighed 7 lbs. 10 oz. and was 20 inches long. During the birth, her shoulders were stuck momentarily (Shoulder Dystocia) but once they were free, she came right out. Ruth was doing well but a few hours later she seemed to be fussier than usual and we decided to take her in to get her checked out just to be sure. We took her to the ER in the middle of the night. Over the next few days, they told us that her arms had nerve damage from her shoulders getting stuck and a couple of days later, someone filed a complaint against us citing medical neglect for having her at home vs. the recommended C-section since she was breech. Since that time, Ruth has had every test possible run and so far, she seems to be doing very well. Her arms are recovering and she is a very content baby. 
CPS removed the baby to foster care. The parents' contact was limited to a few hours per week at first. Ruth is now in the custody of her grandmother. The parents recently received permission to increase their daily visitation hours from 4 to 8. They are currently waiting for their next custody hearing.

(Question--because I am too lazy right now to pull out my midwifery textbooks--can a breech baby really have a shoulder dystocia? SD is when the baby's shoulders become lodged behind the pubic bone. But if the head is facing the other direction, it wouldn't really be a shoulder dystocia...more a case of entrapped arms, right?)

Home Birth: Paramedic accused of denying transport to laboring woman
In the UK, a woman planning a home birth needed urgent transport to a hospital when the baby's heart rate dropped. The midwife phone an ambulance, but the paramedic allegedly refused to transport the woman and lied about why his ambulance team could not take her to the hospital. Another ambulance arrived 11 minutes later, bringing the woman in for a cesarean section. Both mother and baby are doing well. Read more about it at the Dorset Echo and the BBC news.

Do epidurals protect the pelvic floor?
According to The Globe and Mail, a study from Australia of first-time mothers planning a vaginal birth found that women with epidurals experienced pelvic floor damage. But is this really the case? Certified nurse-midwife Amy Romano explains what the study actually did and did not find. You'll learn about "levator microtrauma" (a term invented by the study's authors) and how it is not associated with pelvic floor damage.
They [the study's authors] excluded the 13% of vaginal births in which levator avulsion [tearing of the pelvic floor muscles] was diagnosed and evaluated the rest of the women for "microtrauma". We put "microtrauma" in quotes because no one has ever defined or determined the prevalence of this "condition". The researchers invented it themselves!...

In the case of “levator microtrauma,” there is absolutely no data whatsoever linking the author’s definition of microtrauma to pelvic organ prolapse or other important pelvic floor problems such as incontinence or sexual dysfunction. The aforementioned corporate-sponsored researcher showed in an earlier study that macrotrauma (aka levator avulsion) is an appropriate surrogate for pelvic organ prolapse, but remember that epidurals were not associated with macrotrauma in this study. Forceps deliveries were – and what’s the major modifiable risk factor for forceps delivery?  Epidurals!

But let’s say that microtraumabest strategy for preventing pelvic floor problems?  Maybe doing away with coached pushing, fundal pressure, episiotomy, and supine positioning might be the better strategy. Maybe postpartum exercises can help reverse changes associated with pregnancy and vaginal birth so they don’t turn into symptomatic pelvic floor problems.
Kangaroo care saves a premature baby's life
An Australian woman gave birth to 27-week-old twins. The first, a girl, was born healthy. But the doctor was unable to revive the second twin, a boy. The mother recounts what happened next:
The doctor asked me had we chosen a name for our son,' said Mrs Ogg. 'I said, "Jamie", and he turned around with my son already wrapped up and said, "We've lost Jamie, he didn't make it, sorry". 'It was the worse feeling I've ever felt. I unwrapped Jamie from his blanket. He was very limp.

'I took my gown off and arranged him on my chest with his head over my arm and just held him. He wasn't moving at all and we just started talking to him. 'We told him what his name was and that he had a sister. We told him the things we wanted to do with him throughout his life.

'Jamie occasionally gasped for air, which doctors said was a reflex action. But then I felt him move as if he were startled, then he started gasping more and more regularly. 'I gave Jamie some breast milk on my finger, he took it and started regular breathing.'
The skin-to-skin contact, known as kangaroo care, saved her baby's life. She recently appeared on national television with her healthy 5-month-old son to emphasize the importance of skin-to-skin contact, especially for premature infants. You can read one verision of the story here
, but it was edited after its initial release to omit less flattering details about the physician's conduct. A more complete version of the story is found here.

Dr. Nils Bergman responded to this news story (you can download it here as a Word document), noting how skin-to-skin contact "restores the basic biology for survival." 
My own research and "hypothesis" on this is based on the fact that to almost all newborn mammals, separation from mother is life-threatening. This activates a very powerful defence response, which is to shut down and immobilise ( freeze and dissociation by vagal nerve activation)....

Our resuscitation technology can force some regulatory oxygen and breathing and blood pressure and temperature ... but it is working against the "autonomic nervous system tide". There is great variability in sensitivity and resilience in all human beings, and some are sensitive and succumb despite our technology.

What "kangaroo care" does is restore the basic biology for survival. It is "skin-to-skin contact" which is the key, because the deep sensory fibres from the skin go to the "emotional processing unit" of the brain (amygdala), and tells the brain "you are safe". This de-activates the dissociation (un-safe mode), and restores the regulation (safe mode) - which is the real function of the vagal nerve.


  1. Regarding the story of Jamie Ogg's reviving as a result of kangaroo care: the Daily Mail story was edited after it was initially posted, removing unflattering details about the doctor's conduct. I commented about it here. A more thorough account can be found here

    Great meta-post, Rixa! I hadn't read that study on sections before labour: thanks for posting it!

  2. Did you see this article about a test that researchers believe can predict the need for a cesarean?

  3. so curious about the shoulder dystocia/breech question... i had the same thought when i read that. my heart goes out to those parents! and that poor baby who is losing prime bonding time with mama.... :(

  4. About the shoulder dystocia -- I don't think you can have that with a breech delivery because the shoulders wouldn't get stuck underneath the pubic bone.


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