Tuesday, October 05, 2010

Lamaze/ICEA Conference part 3

I woke up Sunday morning feeling so much better. I took Dio to breakfast with me and brought him back before the first breakout session. 

Mary Lou Moore, PhD, nurse, and faculty member at Wake Forest School of Medicine, spoke about The Perinatal Care System in the 21st Century: Induction, Cesarean Birth and Late Preterm Birth, sponsored by the March of Dimes. Her presentation covered recent research showing that elective deliveries (induction and cesarean) should not be performed before 39 weeks. In addition, it's advisable not to induce at that point unless the Bishop score is 8+ for primips and 6+ for multips.

These "early term" births at 37 & 38 weeks have increased rates of complications for baby and mother. (We're not talking about mothers who go into labor spontaneously at these weeks.) It's not just an issue of fetal lung maturity, but a wide range of other physiological changes the term baby undergoes before labor beings. We only understand a small number of these complex mechanisms. We know, for example, that a baby's brain grows rapidly between 34-40 weeks; the frontal lobes are especially vulnerable to elective deliveries as they are the last to fully develop.

She then outlined several hospitals around the country that have implemented these new guidelines for elective deliveries:
  • Starting in 2004, Magee Women's Hospital in Pittsburgh implemented a policy of no elective deliveries before 39 weeks. Between 2004-2007, their rate of elective induction (EI) went down 30% and the overall induction rate fell 33%. The cesarean rate for primips dropped 60% over those years from 34.5% to 13.8%.
  • The Perinatal Quality Collaborative of North Carolina (PQCNC, pronounced "picnic") decided to stop elective deliveries before 39 weeks in 38 hospitals across the state. This led to a 12% reduction in elective deliveries, a fall in newborn complications and NICU admissions. 
  • The Ohio Perinatal Quality Collaborative (OPQC) has had similar outcomes.
For more information and resources on reducing early term elective deliveries, visit The March of Dimes' toolkit on reducing elective deliveries before 39 weeks. What I found most remarkable about Dr. Moore's presentation was how rapidly changes have occurred in some places. The Joint Commission backs these new guidelines for elective deliveries as part of their Perinatal Care Core Measures, giving hospitals increased motivation to implement them.

Zari joined me for the final keynote speaker: Linda Smith, author of Impact of Birthing Practices on Breastfeeding. I missed about the first third of the presentation because Suzanne Arms pulled me aside and said, "I hear I need to meet you!" (How cool is that??!) We talked about what we're both working on and her future plans in trying to gather people from all walks of life and all parts of the world to envision a new global strategy for improving all things related to birth and breastfeeding.

Back to Linda Smith's presentation...I entered right before she showed an excerpt from a fantastic new breastfeeding DVD Skin to Skin in the First Hour After Birth: Practical Advice for Staff after Vaginal and Cesarean Birth. Here's an excerpt for you to watch:

I really hope I can obtain a copy of this DVD to review. It was produced for health care providers and teaches immediate, uninterrupted skin-to-skin for both vaginal and cesarean births. It also shows nine stages that newborns go through in the first hour after birth when they are placed skin-to-skin immediately after the birth. Really amazing stuff!

Linda emphasized that 30+ years of birth advocacy have done little to change childbearing practices. However, using the breastfeeding angle to change birth practices has been remarkably successful. In fact, the new Baby-Friendly curriculum includes a Mother-Friendly module as part of step 3: "Inform all pregnant women about the benefits and management of breastfeeding." I wasn't able to write down the details, since I was keeping Zari occupied, but you can email Linda if you'd like more information about this. She urged us to keep an eye out for the Surgeon General's breastfeeding statement that will be coming out in the next few months. There's a lot of support behind breastfeeding--witness Michelle Obama's many supportive statements about breastfeeding--especially because it is associated with lower obesity rates. In sum, if you want to change birthing practices, use the breastfeeding angle. There's a lot of money, government support,  momentum behind breastfeeding, so run with that to improve health care for both mothers and babies!


  1. That video looks great! I hope you do get to see the whole DVD. I'm curious about what circumstances they define as times when separation is necessary for the baby. Both of my babies have been taken to warmers for things like suctioning/oxygen, which could have been done on my chest if the hospitals were set up for it. (Though whether the suctioning was necessary at all is debatable)

  2. As a doula in Pittsburgh, I am really shocked to hear those numbers from Magee. It seems like me. and my colleagues are constantly helping clients to negotiate their ways out of inductions at 39 weeks for less-than valid reasons. Low fluid and fetal macrosomia are the most common. Then when the mothers are unable to progress past 5-6cm the are given a cesarean.

    On the ground here, I strongly question anyone who sets Magee up as a model. They are filled with practices that ignore evidence and interfere with the morherbaby.

  3. I was looking for a home birth midwife in Indiana. I was surprised to see a picture from Dio's birth on the website! I assume they asked your permission to use the pic. If not, here's the link:


    Just thought it was interesting since the place is in Indiana. I assume you know them?

  4. Never mind! I see Penny was your midwife for Dio? Not so weird anymore : )

  5. As always- Thank you, Rixa, for keeping me informed!

  6. I was also surprised to see Magee (Pittsburgh) listed in a positive light. I don't doubt that they have instituted this change (with good results), but I found them to be less than committed to evidence based practices. When I toured, I was informed that continuous fetal monitoring was the norm, but I could request that it not be used, and that I should remind the nurses to practice kangaroo care because some will "forget."

  7. A few questions:

    What is it with these docs? Why are they so keen to induce at 39 weeks? Or even at term? I get the issues that come after 41 weeks (though, as someone who has carried quite long with both of my pregnancies, I wish they were a little less trigger happy), but why are they so hot to trot before the due date has even come and gone?

    ...for less-than valid reasons. Low fluid and fetal macrosomia are the most common.

    What's the deal with low fluid? Is that not legit? I was induced at 41w2d with my first for low fluid and a non-reactive NST. (I'd also noted a pretty big drop-off in fetal movement, though he'd actually picked up again on the day I had the bad NST.) So is low fluid not a legitimate sign of pending problems? Or is the problem using it in isolation instead of in conjunction with other symptoms or recommending induction for fluid that is borderline and stuff like that?

  8. "Low fluid", being "overdue," often the day you hit 40 weeks, and having "big baby" are all reasons given for induction that are, for the most part, not medically indicated. (Now there is some debate once a woman is truly post-dates as to the real incidence of increased stillbirth rates, and at which point should induction be recommended or offered--41 weeks? 42 weeks? etc...) But a lot of women are induced for these three reasons that sound like medical indications, but are not supported by evidence. I don't know why some physicians push induction so strongly at 39 or 40 weeks. But gauging from many conversations I had or listened to at the Lamaze conference, it is a rampant practice and frustrates childbirth educators to no end.

    Back to low fluid: if there are no other risk factors present, low fluid isn't associated with adverse outcomes. Read more here:
    Fluid levels also vary depending on maternal hydration--they're not fixed in stone.

    ACOG is very clear that elective induction/cesarean for a suspected big baby in a non-diabetic mother is not recommended.

    More later, but it's time to eat dinner...

  9. Re: comments about Magee hospital, we're only talking about the effort to eliminate elective deliveries before 39 weeks. Not about any other evidence-based or non-evidence based practice. Not about elective induction or cesarean starting at 39 weeks.

  10. A couple of thoughts: I understand what the other commenters have stated, but even that -- it just goes to show how SO LITTLE a change in the system can result in SUCH A POSITIVE outcome! From Anonymous' comments above, it appears that Magee has a long way to go. But, still! "Do not despise the day of small beginnings", eh?

    Though I had chosen the OB for my 5th on the recommendation of a midwife, as he was friendly to natural birth practices, he was quite adamant that he induce me the day I hit 39 weeks. I refused, and gave birth to a 8 lb 13 oz baby (tied for my smallest) at 40/2 with no complications, save some minor hemorrhage that was stopped by IV pitocin (I had had no pitocin, nor any other meds for the birth).

    The reasons for his concern were: 1) it was my 5th and risk for hemorrhage in general increase after a woman's 4th child. 2) I had *HORRID* venous problems, including extensive, large, painful vulvar and vaginal varicosities. 3) Historically, I give birth to large babies (8-13 to 10 lbs even). He was concerned that even "mild" macrosomia would lead to a major hemorrhage... so he framed it in the sense that he was putting my life ahead of the baby's.

    I knew enough to not be swayed, but I could *easily* see how someone, especially a primip, could be easily talked into an elective induction.

    I had to go in for several NSTs and u/s (I guess I could have refused those, too!) to put him at ease, and I just made sure that I ate food beforehand (so the baby would be active), and drank a LOT of water in the few hours leading up to it, so that my fluid wouldn't be low.

    (Once I was in labor, he was very favorable to natural birth practices, and the "worst" he suggested -- which I refused -- was breaking my water, after I was "stuck" at 8 cm for 5+ hours. He was very patient, much more so than the nurses assigned to me.)

  11. Thanks for the info. For the record, I did eat and drink a lot before the u/s and NST - I was warned and came prepared. It probably will always nag at me a little bit. My best guess is that he probably needed to come out sooner rather than later (he was pretty cooked, and my second, who was born at 41w4d after A LOT of help to get into labor, was much more robust in utero at 41 weeks), but I wish I could have tried some other stuff before going straight for induction.

    More than anything, I wish I'd known enough to ask more questions at the time - just so I would really know what happened and why.

    But gauging from many conversations I had or listened to at the Lamaze conference, it is a rampant practice and frustrates childbirth educators to no end.

    I know. My sister-in-law was induced at 40w2d with her first. Her OB told her on her due date that if she hadn't gone into labor yet, she probably never would go into labor on her own. She also was told "I know you really want a vaginal birth, and the longer you wait, the more your risk of a c-section goes up."

    She ended up with a c-section 12 hours into the induction.

    it just goes to show how SO LITTLE a change in the system can result in SUCH A POSITIVE outcome!

    This is what struck me, as well.

  12. Hi Rixa. Speaking of evidence about effects on breastfeeding and the interaction with interventions in birth -

    I recently came across a remark that could be turned into a hypothesis in Maureen Minchin's book 'Breastfeeding Matters'. She came across a dairy farmer who reports that cows given artificial oxytocin have reduced milk yield; and speculates as to whether the same effect happens with human mothers given large doses of synthetic oxytocin. Could explain why so many mothers seem to be struggling to produce 'sufficient milk' in industrialized countries?

    Do you know if anyone has tested this hypothesis? I've not found any evidence so far but wouldn't be too hard to design a good study.

  13. Are these findings including "natural inductions", things like membrane sweeps and cohash, AROM, etc? Or are they only appropriate for drug induced inductions? I'm speaking more of babies reaction and the bodies natural chemical response during labor.. Also, do you think that having an actual minute of conception ( like in IVF situations) rather than the guesstimate conception date from a spontaneous pregnancy makes a difference as far as the timing aspect of this research goes?


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