At Mount Sinai Hospital in Ontario, Canada, the NICU has implemented a new program putting parents in charge of their baby's care. From an article at CTV News:
Parents have long been encouraged to spend time with their babies in the NICU, but they were typically more observers than participants, often feeling helpless and lost as they sat by their child's isolette watching every breath, trying to make sense of the monitors and startling at every bell or buzzer around them.
"With family integrated care, we have done something quite different," explains Dr. Shoo Lee, pediatrician-in-chief and director of the Maternal-Infant Care Research Centre.
"What we've done is to say that for all babies in the NICU, the parents should be the primary caregivers, not the nurses. And the nurses are really teachers to the parents."
The program was instituted following a 2011-2012 pilot project in which the parents of 40 newborns were asked to spend a minimum of eight hours a day in the NICU and tasked with the overall management of their child's care.
That included bathing and changing diapers, monitoring the infant's vital signs, and recording feedings and weight gain on their medical chart. Nurses were responsible for the medical side of care -- looking after feeding tubes, adjusting ventilation apparatus and administering medications.
The babies' progress was compared with those whose care was primarily provided by nurses, and Lee says "the results were phenomenal."
"There was a 25 per cent improvement in weight gain of the babies who were looked after by the parents," he says. "Breastfeeding rates doubled from 40-something per cent to over 80 per cent. Infection rates fell from 11 per cent in the nurse group to zero in the parent group. Treatment errors dropped by 25 per cent. Parental satisfaction went up, parental stress went down.
What a fantastic idea! I hope this becomes standard practice across more NICUs.
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.
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.
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!
Reality Rounds has several amazing, heartwrenching posts about life as a NICU nurse, about the ethics of treating or not treating fetuses on the edge of viability. Read in this order:
This reminds me of the post I wrote in the middle of my last pregnancy about what I might do if I had an extremely premature baby. I still don't know all of the answers to that question--I am just glad that my two children were born at term, healthy, and ready to be earth-side. I'll give them an extra snuggle tonight.
A new study from the University of California has confirmed an association between pollution levels and prematurity and other birth complications. From a Discovery News article L.A. Traffic Causing Premature Births: Study:
As famous for its traffic jams as it is for Hollywood star power, the Los Angeles, Calif. area has another dirty little secret: Air pollution is sickening pregnant women who live near roadways, more than doubling their risk of a premature birth, according to a new study....
A comparison of medical records from 81,186 single child births to air pollution levels in the area revealed that high pollution exposure raised the risk of a severely premature birth by 128 percent. Moms-to-be were also between 33 and 42 percent more likely to develop preeclampsia, an affliction characterized by high blood pressure that often forces doctors to induce premature birth in order to save mothers' lives.
The team's study is in due to be published in the journal Environmental Health Perspectives.
The Motherwear Breastfeeding blog recently featured a fantastic guest post by a woman whose son was born 3 months early and weighed less than 3 pounds. She writes about how breastfeeding was her and her son's lifeline. Here is an excerpt from her post, My whole heart is in that incubator:
I was 37 years old. I thought I knew what love was. I thought I knew. But I have never loved anyone, anything, so fiercely, so terribly, so wonderfully, so achingly, as I did my little son, my only child, struggling in that incubator....
I loved and still love that boy with all I have. Because I couldn't hold him much, and felt terrible guilt for not being able to 'hold him in' for the entire 9 months he deserved, I was determined to breastfeed. I pumped every 3 hours for weeks on end. That pump and the milk that came out of me was my lifeline. It was somehow the way I was going to make it up to him for giving him such a lousy start in this world. So when I read stuff like "The Case against Breastfeeding" I get so angry. I believe that my breastmilk, and the good care we got at BC Children's, saved my child's life. It saved my life. If there is anything in this crazy, crazy world that is really is a gift from God it is the babies we can create and the milk that comes from our bodies.
If anything is pure and natural, and real and true, it's breastmilk. It made me feel like a mother when my baby was all alone inside a machine when he should have been inside me.
Anyone who dismisses breastfeeding so casually, or by their attitude or indifference creates an environment that doesn't hold up and encourage and cheerlead a new mom into a successful breastfeeding relationship, has lost touch with something. They've lost touch with a sense of what it means to be a mother, what feeding a baby is all about, what it means to nurture, how significant that breastfeeding can be to both mother and child.
It's time to clean out my files and bookmarks again.
Are antibiotics beneficial for preterm labor or PPROM? Preterm Abx beneficial for PPROM, but not for preterm labor. A newly published meta-analysis has concluded that antibiotic use prolongs pregnancy and reduces neonatal morbidity in women with preterm premature rupture of membranes (PPROM) at a gestation of 34 weeks or less. The same analysis found little evidence, however, of a benefit from using antibiotics in preterm labor occurring at 34 weeks or less. Source: American Journal of Obstetrics & Gynecology 2008;199:620e1-e.
Is Acupuncture Effective at Inducing Labor? Acupuncture to induce labor: a randomized controlled trial. ObstetGynecol. 2008 Nov;112(5):1067-74. For women with a scheduled postterm induction, acupuncture sessions before the induction did not reduce the need for inductions or the length of labor. This trial used sham acupuncture, which is a great way to lessen the placebo effect of acupuncture. The conclusion from the abstract: "Two sessions of manual acupuncture, using local and distal acupuncture points, administered 2 days before a scheduled induction of labor did not reduce the need for induction methods or the duration of labor for women with a postterm pregnancy."
Precipitous births in the news:
A UK mum gives birth in an ambulance outside restaurant. She had planned a home birth, but decided to transfer when the baby unexpectedly presented breech. On the way to the hospital, the baby flipped back to vertex and was born en route.
Baby boy arrives on bathroom floor. The couple was planning a home birth anyway; the midwife dind't arrive on time. So dramatic! How amazing that the mother and father managed to deliver their own baby!
Call for Abstracts for the Australian College of Midwives 16th Biennial Conference: "Midwives & Women: A Brilliant Blend" is being held at the Adelaide Convention Centre, from the 22 - 25 September 2009. I wish I could go!Any way I could get funding for this?
Home Delivery: The Movie. From the website: "This film documents the lives of three women in New York, who for very different reasons have decided to go up against social trends and take the birth of their children into their own hands… and homes." I haven't seen this one yet. It's available for purchase here.
BirthLove is back (don't know how long, though) on this website!
Woman to Woman Childbirth Education shares her thoughts about the UK documentary on Freebirthing. She argues that "if doctors or midwives want to stop [unassisted births], they have two choices — scare women out of doing it, or make the alternatives more appealing."
Pregnant women are risk magnets, attracting every sort of scare about potential damage to their babies at a time of their lives when they are most fearful, for themselves and for the new life they carry. Not only are food scares (too much liver, too much fish, etc) aimed squarely at mums-to-be, but there are also horror stories about the maternity services. The irony is that the perception of risks may be more harmful than the actual risks.
Sewing/crafting:
Babywearing Coat Instructions: this tutorial shows you how to alter a normal jacket or winter coat into a babywearing coat. A great project to try with a secondhand coat! I'll have to make one of these for next winter.
CPSC grants one-year reprieve for certain products. This news has handcrafters relieved, as many were worried they'd have to shut down because of the prohibitive costs of lead & phalate testing. Forbes op-ed piece on the CPSC law (written before the reprieve was announced).
A recent editorial in the LA Times, Octuplets--why?, explores the issues of high-order multiple births and extreme prematurity. The author is himself familiar with multiples, prematurity, disability, and death: one of his 24-week twins died shortly after birth, and the other has mild cerebral palsy. I thought this editorial was interesting in light of last month's discussion about extreme prematurity.
I've been musing about what I would do if I were to go into preterm labor. The answer is obvious if the baby were 30 weeks: go to a hospital with a good NICU. My own cutoff for an out-of-hospital birth would be around 36-37 weeks, depending on the particular situation, access to oxygen and a midwife skilled at recognizing signs of respiratory distress or other prematurity-related complications.
But what about 28 weeks? 26? 24? 22? At what point would I allow the baby to pass on peacefully, rather than attempting heroic efforts at resuscitation with a small chance of survival and high likelihood of major disabilities if the baby were to live? My own gray area is between 24-28 weeks. By time a baby hits 26 weeks gestation, survival rates are between 80-90%, and about 15% of those surviving babies will have major disabilities as a result of prematurity. I think this would be the earliest point at which I would consider intervening.
General estimates of survival for live born infants who receive neonatal intensive care in the USA in the late 1990's are:
Completed Weeks of Gestation at Birth (Using last menstrual period)
Survival
21 weeks and less
0%
22 weeks
0-10%*
23 weeks
10-40%
24 weeks
40-70%
25 weeks
50-80%
26 weeks
80-90%
27 weeks
>90%
30 weeks
>95%
34 weeks
>98%
*Most babies at 22 weeks are not resuscitated because survival without major disability is so rare.
A more accurate way of predicting survival is by birth weight, rather than gestation.
Still, survival rates and even major disability rates are not the only practical or moral considerations that I would have to account for. Having a very premature baby, in my own family setting, would mean I would have to commute to a hospital with an advanced enough NICU: probably 40 minutes away and most likely an hour or more. The stresses on our family, the realities of trying to spend my time in a NICU while caring for a nursing toddler, and the emotional and financial drains that an extremely premature baby would entail are all things I'd have to carefully think about.
In addition, my own moral/religious understanding of our life on earth would influence my decisions as well. I strongly believe that life is sacred, but that it is not always appropriate to take heroic measures to prolong life. Death is something to embrace when it is the right time, since we understand it as a passage(and at times a welcome release) from one sphere of existence to another, just as our coming to earth was. It is a temporary separation, although still painful and difficult for those left behind missing their loved one. (For another LDS woman's perspective on this, read Descent's post.)
I hope I will never have to make this kind of decision. Have any of you ever been faced with such a dilemma? If not, have you thought about your own personal criteria for intervening versus letting the baby go?
