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?

There are many documented reasons that support you and your baby going into labor naturally, and laboring for a while, even if you end up delivering via c-section.  So for VBAC mamas not sure on if they’d like a repeat c-section, mamas with a breech presentation, or other non-emergency indications for a c-section, going through labor can have benefits for you both.  Some include:

1.  Fewer breathing issues for baby after birth because the pressure of the contractions squeezes fluids out of baby’s airway
2.  Mom’s mature milk seems to come in earlier because she is able to experience the hormones of labor
3.  Baby and mom get the benefits of the laboring hormone oxytocin, which promotes maternal and baby bonding (as well as some new cool benefits coming out in recent scientific studies)

4.  Women that labor before a planned c-section have a lower risk of uterine rupture on their following VBAC because the uterus is made stronger by labor

As usual, I like to support my posts with evidence-based research.  So have at it people!  AS.

Here’s the study in AJOG about the fallacy of big babies:
I like big butts

Here’s are three good articles about benefit to going in to labor,
even if a c-section is necessary in the end:

Infants delivered by C-section prior to spontaneous labor are at
increased risk of respiratory problems vs. mamas who were allowed to
go into labor (even if a repeat c-section was required)
http://pediatrics.aappublications.org/content/100/3/348.short

Women allowed to go in to labor before a planned c-section have
decreased uterine rupture risk on their VBAC
http://journals.lww.com/greenjournal/Abstract/2008/11000/Labor_Before_a_Primary_Cesarean_Delivery__Reduced.14.aspx

Labor is necessary to get an oxytocin let-down, which has benefits
(many we don’t even know yet) for our babies.
http://notexactlyrocketscience.wordpress.com/2007/01/24/maternal-hormone-shuts-down-babys-brain-cells-during-birth/

C-section is the most common surgery now in the US.  ACOG came out
with an article just last month urging doctors to only perform surgery
if it was necessary for the health of mother or baby.  Being
potentially large according to ACOG is not a medical reason.
http://www.getbabied.com/2011-10-03/cesarean-delivery-is-now-the-most-common-operation-in-the-united-states

This month, we have three MTDN’s, so there will be ample opportunities to come meet the fabulous Get Babied doulas face to face!

This coming Tuesday, October 11, from 7-9 pm at our offices, is our Meet the Doulas Tea.  This is a really good opportunity to speak with us a bit more in depth because the entire evening is devoted to meeting all of the doulas.  We won’t have a formal presentation, guest speaker, or testimonial, just lots of time for you to get to know us.

On October 22, from 7-9 pm, also at our offices, we will be holding our classic Meet the Doulas Night.  Please note that we moved it up a week since the last Saturday of the month might conflict with Halloween festivities.  We will have a guest speaker and testimonial, snacks, doulas.  What could be better?  It will be a fun evening all around so please come!

On October 25, from 7-9 pm, we will be holding a Meet the Doulas Night at Baby Earth in Round Rock for all of our northern mamas (or anyone else!).  Our guest speaker will be the lovely Siobhan Kubesh, CNM, from OBGYN North, and we will have a birth testimonial from a recent client as well.  It promises to be an awesome night!  Come early if you want to shop!

There is no need to register for or RSVP to any of our Meet the Doulas events.  Please just stop by.  Don’t hesitate to let us know if you have any questions.

If you have your baby at home, or at a birth center, your medical care ends six hours after your delivery, with a home visit the next day. But essentially, with an uncomplicated delivery, you’re on your own. As it turns out, people end up being more satisfied with recovering in their own surroundings. The beeping, flourescent lights, and the constant in and outs of postpartum and infant nurses at the hospital make it a very stressful recovery time for a lot of moms. So if you and your baby are healthy, why not go home early?

I posed this question to a client recently as we were discussing her birth plan options, an idea she hadn’t really considered since she felt safer in a hospital environment. But she did have an unsavory postpartum hospital stay for her first baby, and when her second baby arrived a few weeks ago, and was healthy, and mom was healthy, she decided to take me up on it, and went home 24 hours after her delivery (so a one night stay instead of the standard two, or the three she had last time with her baby in the NICU for jaundice; on a PS she was able to do jaundice interventions on her own as an outpatient at her pediatrician’s office for baby #2 without the stress of being in the hospital).

She sent me her hospital bill charge info today to contemplate. Her babies were born one year apart at the same hospital, with the same doctor, both were vaginal deliveries, both with an epidural.  Her labor was longer with baby #1, and she had pitocin augmentation and an IUPC.  Those latter interventions cost more money (and weren’t itemized on the Aetna bill specifically) but ultimately with baby #1 she stayed 3 nights at the hospital and with baby #2 only one night.

Baby #1 hospital charges billed to mother (and not baby who is a separate patient): NAMC charges for mom were $17,530. The contracted price with Aetna PPO was $5356.

Baby #2–The NAMC charges for mom were $10,028. The contracted price was $3380.

Mama has good insurance, but still had to pay 20% of her contracted fee, so savings to her actual pocket were $395.20. She reported a calm, happy, un-stressful recovery at home and felt a call away from her OB or pediatrician or doula if she needed anything. So the recovery was better, and she saved $400. If you have crappy insurance, are self insured, or are paying cash, your savings will be much more!

The idea of early discharge isn’t a new one, but a hospital in California has recently been advocating for the idea. They know moms are more satisfied with their recovery when they recover at home, but why would they volunteer to take a lower hospital bill fee to send these moms home early? They’re in a business after all. Well – it turns out that some hospitals that are smaller in scale, and have rooms that are LDRP (the labor and delivery rooms are the same as the postpartum rooms) offer early discharge as an actual financial business decision. Sending moms home early actually opens up the room for moms in labor, and laboring moms garnish a higher bill rate than postpartum moms in recovery, so the beds are open to a higher revenue. That makes sense from a business perspective.

One hospital in particular actually partners with a doula service – offering mom an early discharge paired with 3 days of home visits from a postpartum doula. Hospital saves money, mom saves money, mom has a better recovery, and everybody has a happier world. Read the details of their program here: http://www.insuranceday.org/maternity-hospital-program-frees-beds-and-helps-new-moms/

Early discharge isn’t right for everybody, but if it’s something you’d like to consider, it makes sense for a lot of people. And with the savings you have from going home early, why not hire a postpartum doula from Get Babied! $414 will get you a full 5 days of postpartum doula care (4 hours per day). Do it! AS.

Does this bed look as comfortable as yours?