http://onlinelibrary.wiley.com/doi/10.1111/j.1542-2011.2011.00091.x/full

Cool article in this months journal of midwifery. They break up all the doula skillz (with a z of course) and rate their effectiveness by type of skill. The big winners in reducing epidural and cesarean:

Providing water/juice
Counterpressure
Ambulation
Birth Ball
Double Hip Squeeze
Hydrotherapy

Things like emotional support, verbal encouragement, massage and breathing aren’t as valuable to the numbers…..

Take home? Unrestricted movement reduces pain and encourages better fetal positioning. So labor at home longer, no IV or continuous monitoring to restrict position changes, no drugs to impede walking and showering. I guess it’s not rocket science.

Another thought that perhaps pats a doula on the back – these are all very specific skills that doulas have and most nurses may not suggest/employ. And skills that dads feel a lack in confidence executing on. So perhaps doulas are important after all.

Steph does a killer double hip squeeze

If you are planning a delivery at Seton hospital (on 38th and Lamar) here are some instructions for how to secure your placenta.

It turns out the doctors have nothing to do with the placentas, they get thrown in a bucket and then a hazardous waste bin, unless you advise them otherwise (at a provider visit I attended with MamaJ,  Dr. H told us to remind her that MamaJ had previously requested to take her placenta home so Dr. H wouldn’t throw it away automatically).

Step 1:  Call the hospital to secure the release of your placenta.  Karen Brinkman is the woman you need to speak to, she is the director of risk assessment.  (512)324-9999, ext 14730.  You can also call the maternity services desk and ask for the charge nurse who will direct you to Karen.  Or, you can go in person to the maternity desk and do the paperwork onsite and bring it up to Karen’s office (go during business hours).  You may be able to get approval over the phone to take your placenta home, but you may also have to go in person to have a release signed.  It’s better to have this release signed before you go in to labor, but I’ve also seen mamas do it the day of (with a little more confusion and run around from the staff since it’s still a rare request).  But that’s it.  One piece of paper, and you’re good to go (no court order or other silliness).

The only other speed bump is that Seton requires the placenta to stay in-house for 72 hours (just in case they need to do a cord gas analysis if baby has any health concerns etc).  So they put it in their medical coolers on your behalf until you are discharged, and at that point they bag it up for you, so yes, do have an ice chest ready for the transport home, and give your placenta encapsulator (like Megan N) a call as soon as you’re on your way and she’ll make arrangements to meet you to start the encapsulation process if that is your plan.

After having to stand in line at court in the past for placenta release this is a piece of cake relatively speaking.  Apparently when MamaJ called to speak to risk management, they said this is a new policy, because they are getting so many more requests, and they want
to do this as a value added service at no cost to patients in their maternity services.  (ie Seton is one upping the other hospital
corporation in town that has more hurdles to get the placenta).

Be prepared to repeat the request multiple times throughout the process because this is definitely out of the ordinary and they don’t have a standard process for it unfortunately.  But they will do it and are still very supportive and helpful!

Good luck in your placenta adventures!

From my friend Heather J., who adds humor to her birth plan, and is actually serious about all of her requests. Just had to share for all of y’all out there stressing about creating the perfect birth plan.

“Here is my birth plan – i have put alot of time and thought into it already as you can see. i am just so proud of it -i think i am really on to something

1. Drugs -early and often
2. Don’t belabor the labor- just get it done already
3. Make it stop…and then pour me a glass of champagne which i will have chilling while all the other grody stuff is happening that i dont need to know anything about
4. Hand over my sweet little cuddle bunny so i can snuggle him

that’s it!

that’s doable, right????”

Association of induction of labor and uterine rupture in women attempting vaginal birth after cesarean: a survival analysis

Presented as a poster at the 58th Annual Scientific Meeting of the Society for Gynecologic Investigation, Miami, FL, March 16-19, 2011.

I’m looking forward to attending Kerri’s birth next month.  She and Mark are awesome!  They ask all of the right questions, do all of the diligence on research and reading, and are super prepared for the arrival of their little “Cubbie”.  We discussed their birth plan last week, and they brought in a color copy of their plan, with pictures of them, me, their baby, their doctor, and are planning to laminate it so that they can write in the name of the nurse and their room number.  I’ve seen like five zillion birth plans, and they are all great of course, but this one has the most eye candy of the ones I’ve reviewed to date, so I asked her if I could share, and she said sure!  Nice work Professor Kerri!  :)  AS.

Mark and Kerri’s Birth Plan

By Patty Brennan, BA, CD(DONA), PCD(DONA)

Excerpted from Brennan’s cookbook, “Whole Family Recipes:  For the Childbearing Year & Beyond” © 2007

Women birthing in most hospitals are told that they cannot eat during labor and can only drink clear liquids once they are admitted.  The reason behind these instructions is to prevent aspiration of stomach contents in the rare instance that the mother requires general anesthesia for an emergency.  The following are tips to enhance energy and progress in a mother if her labor goes longer than her blood sugar can hold out.

Strategies

Some women experience an urge to load up on carbohydrates in the 24-hour period before the onset of active labor, similar to what an athlete may do in preparation for running a marathon on the following day. Go for it! (I had a bread, salad and pasta dinner at a local restaurant 12 hours before my second child was born and never felt nauseated in labor, which started about five hours after the meal.) This strategy is especially recommended for women facing a scheduled induction. Avoid having the hard work to hit after essentially fasting for 24 hours or more.

EAT IN EARLY LABOR. This is essential and must be maintained throughout the day. Don’t just settle for breakfast and stop there. Eat every 2–3 hours, whatever is appealing. You may want to avoid heavy, greasy foods such as pizza or fast food (which don’t digest easily under the best of circumstances).

Avoid substances that will cause a blood sugar level spike, such as soda and other forms of concentrated sugar (read labels!). These are dehydrating and ultimately lead to blood sugar crashing.

If planning a hospital birth, eat a banana on the way to the hospital. Despite most TV depictions of how women go into labor (i.e., a sudden contraction alerts her to the need to rush to the hospital where she gives birth soon after on her back, typically involving various emergencies for dramatic effect), most women have plenty of time to take care of themselves with little need for high drama.

During labor, try a variety of the suggestions below, alternating them. A little protein here, some electrolytes there, something sweet to boost your energy, the Pregnancy Tea—you get the idea. That will keep a mom going if the labor is long.  This is especially important for women who might be admitted to the hospital early in labor or whose labor is being induced.

Drink lots of water, at least 4 oz per hour throughout labor, more if it’s a hot day and you’re sweating a lot. Have your support team help you with this. (Note to all attendants: Your job is to encourage the mom to drink throughout her labor. If she is willing to drink, asking for liquids and consistently taking several gulps when offered, then just keep the supply coming and keep an eye on her to ensure she doesn’t stop drinking at some point. However, if the mom is disinterested in drinking and reluctant to do so, then frequent small sips will be necessary. Keep offering!)

Finally, don’t hesitate to accept IV fluids if you can’t keep anything down over a long period of time and are getting dehydrated. While healthy women will not need routine IV fluids, dehydration can cause your labor to be dysfunctional and non-productive. An IV can turn the picture around and is an appropriate use of medical intervention.

Recipes for Nutritious Clear Fluids

Raspberry leaf tea labor cubes. Before labor begins, make up a very strong tea (two quarts of boiling water with two cups of dried red raspberry leaves added).  Simmer with the lid off for at least 20 to 30 minutes as the volume reduces considerably. Strain and add one quarter cup of honey (raw is best if possible).  Pour into ice cube trays and freeze, adding water if necessary for at least one tray’s worth.  Store in a zippy bag at home or take with you to the birth center/hospital.  (Usually you can store them in the freezer of the small room refrigerator or in the common nutrition room refrigerator).  The honey gives mom a boost of energy, while the concentrated raspberry leaves provide minerals and may assist in bringing back strong contractions.  In between the contractions, mom can easily crunch the cubes into a satisfying slush.

Electrolyte-balanced sports drinks. There are a large variety of sports drinks on the market these days.  Avoid the overly-sweet, chemically-generated metallic blue and other colored products not found in nature.  Encourage mom to see what is available at her local health food store and experiment until she finds one she likes.  Recharge is my personal favorite and is available in several flavors. Have two to three quarts on hand for labor.

Miso broth. If you are unfamiliar, miso is a paste made from fermented soybeans.  It is high in protein and tastes salty.  If you haven’t tried miso, there are a number of different flavors available in the refrigerated section of your local health food store.  Give them a try and find one you like.  The paste can be brought with you to the hospital and kept in the refrigerator.  Mix one tablespoon of miso into one cup of hot water.  Avoid boiling miso as it kills may of the nutrients.  There are also packets of instant miso soup on the market.

Concentrated homemade chicken or beef broth. Place one whole (preferably organic) chicken or a couple of beef bones in a large soup pot.  Bring to a boil and spoon off the scum that will rise to the surface over a 10 minute period and discard.  Roughly cut up one onion, three carrots (washed, with skins on) and three stalks of celery, including tops.  Chop up two to three garlic cloves and throw those in too (you can even leave the skins on as a timesaver).  Cover and reduce heat, simmering for one and a half hours or more.  Cool and strain out the solids (make chicken salad with the meat).  Put the broth in the refrigerator overnight so that the layer of fat on top solidifies.  In the morning, remove and discard the fat layer.  Return the broth to the stove, uncovered and bring to a boil, allowing the liquid to reduce to a rich-colored (and tasty!) broth.  Add in Celtic sea salt (for the extra minerals) to taste at the very end.  Freeze in small containers to have on hand for labor.

Herb tea and honey. Encourage mom to bring a variety of her favorite herbal teas and some raw honey with her to the hospital.  When energy flags, especially in the second stage of labor, a cup of tea with a generous spoonful of honey can give her the boost she needs to get the job done.  Ginger tea may help settle the stomach if nausea is an issue.

Hot drinks. Americans are big on iced drinks, but in many parts of the world, ingesting iced drinks is not recommended.  An number of cultures, from China to South America, have prohibitions against iced drinks for women in labor or postpartum.  The wise women grandmas-to-be will not allow it.  Feed the fire.  Women are supposed to get hot in labor!  She will sweat.  She will be uncomfortable.  It’s okay.  It’s more efficient.

Footnote from Ame: A couple of other “sneaky” clear fluids I like to recommend to mamas to keep their energy up:  Emergen-C to add to ice water at the hospital, coconut water, Shot Blocks, agave nectar sticks, grapes with the peels removed, anything transparent (even if it has color) is officially OK, so use your imagination.

A great way to wile away early labor, peeling graps!

A good study in Obstetrics this month shows that there is no difference in duration of pushing (2nd stage labor) and c-section rates for Skinny bitches (sorry ladies I’m not one of you) and modestly plump (overweight) and extra plumb (obese) women.  Good news for women who face a lot of prejudice from doctors putting them in high risk categories for being overweight.  This study is interesting because it’s only comparing women who make it to 2nd stage labor, aka 10cm.  When you get there, then all things are even.  But it is still problematic that women of size are still over-represented in the cesarean usage rate, which may still be prejudice on the part of doctors scheduling surgery or inductions without cause, it could also be that women of size are more prone to high blood pressure and gestational diabetes, both separate risk categories that also have higher rates of intervention.  Just a shout out to my ladies of size, thinking of you and thanking the authors for this study.  :)  AS.

Increasing Maternal Body Mass Index and Characteristics of the Second Stage of Labor

Robinson, Barrett K. MD, MPH; Mapp, Delicia C. MS; Bloom, Steven L. MD; Rouse, Dwight J. MD; Spong, Catherine Y. MD; Varner, Michael W. MD; Ramin, Susan M. MD; Sorokin, Yoram MD; Sciscione, Anthony DO; Mercer, Brian M. MD; Thorp, John M. Jr MD; Malone, Fergal D. MD; Harper, Margaret MD, MS; Ehrenberg, Hugh MD

Abstract

OBJECTIVE: To evaluate the length of the second stage of labor in relation to increasing maternal prepregnancy body mass index (BMI) among nulliparous parturient women, and to determine whether route of delivery differs among obese, overweight, and normal-weight women reaching the second stage of labor.

METHODS: We performed a secondary analysis of a multicenter trial of fetal pulse oximetry conducted among 5,341 nulliparous women who were induced or labored spontaneously at 36 weeks or more of gestation. Normal weight was defined as BMI of 18.5–24.9 kg/m,²overweight was a BMI of 25.0–29.9 kg/m,² and obese was a BMI of 30 or higher.

RESULTS: Of the 5,341 women, 97% had prepregnancy BMI recorded. Of these, 3,739 had BMIs of 18.5 or higher and reached the second stage of labor. Increasing maternal BMI was not associated with second stage duration: normal weight, 1.1 hour; overweight, 1.1 hour; and obese, 1.0 hours (P=.13). Among women who reached the second stage, as BMI increased, so did the likelihood that the woman had undergone induction of labor. Even so, the lack of association between second-stage duration and BMI did not vary by method of labor onset (P=.84). The rate of cesarean delivery in the second stage did not differ by increasing BMI (normal weight 7.1%, overweight 9.6%, obese 6.9%, P=.17).

CONCLUSION: Among nulliparous women who reach the second stage of labor, increasing maternal BMI is not associated with a longer second stage or an increased risk of cesarean delivery.

LEVEL OF EVIDENCE: II

My plus-sized self when I was pregnant 3 years ago

http://www.bmj.com/content/343/bmj.d7157

Abstract

Objective To investigate the effects of delayed umbilical cord clamping, compared with early clamping, on infant iron status at 4 months of age in a European setting.

Design Randomised controlled trial.

Setting Swedish county hospital.

Participants 400 full term infants born after a low risk pregnancy.

Intervention Infants were randomised to delayed umbilical cord clamping (≥180 seconds after delivery) or early clamping (≤10 seconds after delivery).

Main outcome measures Haemoglobin and iron status at 4 months of age with the power estimate based on serum ferritin levels. Secondary outcomes included neonatal anaemia, early respiratory symptoms, polycythaemia, and need for phototherapy.

Results At 4 months of age, infants showed no significant differences in haemoglobin concentration between the groups, but infants subjected to delayed cord clamping had 45% (95% confidence interval 23% to 71%) higher mean ferritin concentration (117 μg/L v 81 μg/L, P<0.001) and a lower prevalence of iron deficiency (1 (0.6%) v 10 (5.7%), P=0.01, relative risk reduction 0.90; number needed to treat=20 (17 to 67)). As for secondary outcomes, the delayed cord clamping group had lower prevalence of neonatal anaemia at 2 days of age (2 (1.2%) v 10 (6.3%), P=0.02, relative risk reduction 0.80, number needed to treat 20 (15 to 111)). There were no significant differences between groups in postnatal respiratory symptoms, polycythaemia, or hyperbilirubinaemia requiring phototherapy.

Conclusions Delayed cord clamping, compared with early clamping, resulted in improved iron status and reduced prevalence of iron deficiency at 4 months of age, and reduced prevalence of neonatal anaemia, without demonstrable adverse effects. As iron deficiency in infants even without anaemia has been associated with impaired development, delayed cord clamping seems to benefit full term infants even in regions with a relatively low prevalence of iron deficiency anaemia.

Trial registration Clinical Trials NCT01245296.

We want you to save money.  Having a baby is expensive.  Hiring a doula will already save you nearly $600 on average (because we reduce the incidence of many routine and non-routine medical interventions reducing your bottom line bill).

Here’s one tip from Roslyn (new mama) to go one step further in reducing your final charges.

“When I got the bills from the hospital for myself and for my new baby, I called and asked if there was a discount for paying in full versus asking for a payment plan. Without any hesitation at all, both times I was offered 20% off the amount that I was supposed to pay. We have a $964 per person deductible, so the savings were close to $300 when you add up both bills. The hospital must permit the discounting. It’s worth the 5 minute phone call to ask.

CPL labs gives you a 20% discount if you pay on their website in full. I didn’t know that either when I was paying with a check by mail.   Many OBGYNs use CPL, so I could have saved a lot if I had known that from the beginning. So, just one other way to get a discount on top of the contracted price.”

And don’t forget about your option to do an early discharge – if you and your baby are doing great – why not recover at home and save a few bucks?