childbirth, labor, oxytocin, pregnancy

Pitocin Is Not Oxytocin

Pitocin-Is-Not-Oxytocin
The role of hormones in our body are so vast and dynamic!  Here is a quick article looking at only one of the hormones that help regulate us.

BY KELLY BROGAN MD

“The Love Hormone”.  Sounds important, no? Turns out that we know very little about the hormone oxytocin, beyond that it is incredibly relevant to multiple metabolic, behavioral, and endocrine functions. In a compelling review entitled Beyond Labor: The Role of Natural and Synthetic Oxytocin in the Transition to Motherhood, Bell et al explore the literature suggesting that, once again, we cannot outsmart, outdo, or circumvent nature with pharmaceutical products.

What is Oxytocin?

One of the known roles of oxytocin is in the complex physiology of labor and birth. Perceived by the obstetrical establishment to be a “contraction chemical”, oxytocin’s effects are bodywide, and most notably, brain-based. During pregnancy, oxytocin receptors increase in areas of the maternal brain related to mood, stress, and attachment behavior. Specifically, its activity has been studied in the hypothalamus, lateral septal nucleus, periaqueductal grey, Broca’s area, nucleus basalis of Meynert, locus coeruleus, vagus, solitary tract, trigeminal nerve, and lateral reticular formation. It is secreted continuously in the brain and in a pulsatile manner to the body through the posterior pituitary. Despite efforts, the brain-blood ratio has not been well-elucidated leaving major gaps in our understanding. When it comes to hormones, the production and release of the hormone is critical, but so is the receptor activity – the action of the baseball in the catchers mitt, and receptor sensitivity varies from person to person based on genetics and adaptation to experience.

What is Pitocin?

So, when we manufacture a synthetic version of this hormone and commandeer a woman’s labor physiology, it should come as no surprise that there are unintended and poorly understood consequences. Pitocin®  or “Pit” as it’s called on the floors, is the obstetrician’s whip. They snap this whip when your baby is not conforming to their non-evidenced-based schedules. When your due date is wrong, when you’re forced to birth in highly artificial circumstances, or when your physiology has been hijacked by an epidural.

Bell et al discuss a number of concerns related to the administration of synthetic oxytocin:

  • Because of its hydrophilic (fat-loving) nature and molecular size,Pitocin®  is unlikely to cross the blood brain barrier. But maternal oxytocin is very active in the brain, inducing secretion of other hormones including endorphins (buffering fear and pain). It is also active in the fetalbrain, protecting receptors such as GABA, from potential hypoxia of birth.
  • If, in fact, synthetic oxytocin does reach the maternal brain (because of barrier permeability or active transport of some kind), the authors state:

    “Whether the maternal brain will reliably respond to exogenous oxytocin by decreasing or increasing the synthesis or release of endogenous oxytocin is unknown.”

What about after labor is over?

Women are struggling to breastfeed in proportions likely never seen in human history. Bell et al reference a powerful study that implicates Pitocin in this phenomenon.

“Compared to all other study groups, women exposed to Pitocin® in labor combined with an epidural demonstrated significantly lower oxytocin levels during breastfeeding. Overall, the total quantity of synthetic oxytocin administered during parturition was negatively correlated to levels of oxytocin in plasma two days following birth.”

This may be related to the effects of a pharmaceutical-grade agonist stimulating the oxytocin receptor and causing modeling changes at the membrane level. When receptors are overstimulated, they are internalized and downregulated through changes in gene transcription. Bell et al reference a study demonstrating that:

Participants with oxytocin-induced labor had a 300-fold down-regulation of the OTR gene in uterine muscle, when compared to receptor availability in spontaneous labor.

The role of oxytocin in the HPA axis (hypothalamic-pituitary-adrenal) may explain why:

“Lactating women show increased vagal tone, decreased blood pressure and decreased heart rate when compared to non-lactating women, especially in response to a stressor.”

Data analyzing the role of oxytocin in response to postpartum stress suggests that it is a buffer to the negative effects of the experience. When this buffering effect is inadequate, we may see the emergence of postpartum depressive symptoms. One study found that bottle feeding women had lower levels of oxytocin, higher heart rates, and higher cortisol, but that breastfeeding depressed women shared this profile, implicating low oxytocin levels in depression.

Amazingly, some of oxytocin’s effects may actually be mediated by gut bacteria (is there anything the microbiome doesn’t manage?) as was demonstrated in this study showing a lactic acid bacteria accelerated (doubled) wound healing in rodents by increasing oxytocin levels. In psychiatry, there is sparse literature supporting the use of intranasal oxytocin in autism, schizophrenia, OCD, social phobia, depression/postpartum depression, and anorexia but notable theoretical underpinnings for consideration in these cases and minimal risk.

While we attempt to understand the variables contributing to altered oxytocin response in the body, deliberately interfering with this feedback system through the use of synthetic hormone should be exposed for what it really is: a dangerous fix for the problems of a medicalized birth.

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breastfeeding, frenulum, inants, newborn, pregnancy, tongue tie

The Basics of Tongue and Lip Tie: Related Issues, Assessment and Treatment

By Melissa Cole, IBCLC, RLC and Bobby Ghaheri, MD., Portland OR.

“Tongue-tie” has become quite a buzz word in some circles and is still quite unknown in others.  Tongue-tie, professionally known as ankyloglossia, is a congenital condition in which the lingual (tongue) or labial (lip) frenulum is too tight, causing restrictions in movement that can cause significant difficulty with breastfeeding and, in some instances, other health concerns like dental, digestive and speech issues.  Mothers of infants dealing with feeding challenges are often desperate to find solutions; as awareness increases about tongue and lip tie, some mothers wonder if this is something their baby may be coping with.

Parents often want to know what some typical signs of tongue/lip tie are.  Each mother/baby dyad is very unique and therefore tongue/lip tie issues can present differently for everyone.  Some common symptoms that may point to the infant being tongue/ lip tied include: poor latch/inability to latch, sliding off the nipple, fatigue during feeds ,sleepy feeds, poor weight gain, clicking during a feed , maternal nipple pain/damage (can feel like the infant is compressing, chewing, gumming, pinching, scraping the nipple, etc), increased maternal nipple/breast infections, compromised maternal milk supply, dribbling milk at the breast/bottle, digestive issues (increased gassiness, reflux, etc due to extra are being swallowed and poor control of the milk during a swallow), and various other feeding related challenges. Some mothers and babies may cope with some of these issues, all of these issues or even none of these issues when a tongue/lip tie presents. We must keep in mind having a frenulum is not the problem; compromised tongue mobility and functionality that cause problems for the mother and/or baby are the problem!

Mothers are tech-savvy and often turn to the computer first to research what might be causing their feeding concerns. When moms go online, they will most likely encounter some discussion about how tongue and/or lip ties can cause feeding issues.  If parents suspect a tongue/ lip tie then families will often want to see a provider in-person to have their baby evaluated and treated.  Sometimes families are lucky enough to have a local provider well-versed in evaluating and treating oral restrictions like tongue and lip tie.  However, many mothers may not have access to this expertise in their local communities. If you suspect that your infant may have a tongue or lip tie and you’re not able to find a provider in your community to evaluate and treat this condition, consider connecting with a local international board certified lactation consultant (IBCLC) that should be able to help connect you with additional resources. Another resource is the website for the International Affiliation of Tongue-Tie Professionals (IATP) (please note that the website is just about to be launched and may or may not be live at present, do check back if needed).

Tongue and lip ties come in various shapes and sizes and can present uniquely in every baby.  Many providers have only been trained to look for very prominent, classic tongue ties that often create a heart-shaped tongue.  However, tongue ties can be sneaky and restrictions that are more posterior (toward the base of the tongue) cannot be easily visualized.  Proper assessment and evaluation are key when identifying these types of ties because they can easily be missed at first glance.  Not all providers know how to properly assess for all types of tongue and lip restrictions.  While there are various assessment tools and tongue-tied classification scales that have been published, there is still no universally accepted standard of assessment and care when it comes to tongue and lip tie.  This fluctuation in assessment and treatment standards can be extremely frustrating for parents trying to seek evaluation and care for their potentially tongue and lip tied infant.  If you are unsure of whether or not your provider is adept at assessing or treating various types of tongue and lip tie you may want to ask your provider the following questions:

  • How do you assess for tongue/lip tie?
  • How often do you treat tongue/lip tie in your practice?
  • Do you treat posterior tongue ties?
  • How do you perform the procedure?
  • What type of follow-up care to recommend after the procedure?

Providers that routinely assess and treat babies for tongue and lip tie should be able to easily answer these questions and provide parents with enough information so that they can make an informed decision.  Providers that may not be the best to assess or treat your baby include ones that rarely assess or treat for this condition, tell parents that the tongue tie will stretch or that it’s not a big deal, tell parents that they have never heard of it posterior tongue tie, or tell parents that this must be done under general anesthesia.  Parents should always feel empowered to seek additional opinions and advocate for the needs of their child if they are struggling to find a provider that understands and treat oral restrictions.

If a tongue or lip tie is present and parents wish to seek treatment, what can parents expect?  Various types of providers treat tongue and lip tie including: ear nose throat doctors (ENTs), pediatric dentist, oral surgeons, pediatricians, naturopathic physicians, and others qualified to do minor surgery.  In most all cases, releasing the frenulum for infants is an in-office procedure, with no sedation needed.  In some rare cases, or in cases with older children, sometimes light sedation is used if the parents or provider feel that the older child would be too stressed while alert, but in infants this is usually not necessary at all.  Some providers release the frenulum with sterile scissors, others use laser technology. The availability and types of providers in any given community will vary as will the course of treatment.  In general, this is what we tell parents coming to our practice to expect (please note that other providers may perform the treatment slightly different ways):

What to expect when your baby needs a frenotomy/frenectomy:

In general, the procedure is very well tolerated by babies.  We take every measure to ensure that pain is minimized.

1)    For a typical frenotomy (an incision of the frenulum), a topical numbing gel is applied once or twice and occasionally, if a frenectomy (frenulum tissue is removed) is needed, a small amount of local anesthetic is injected.  Often, ice chips are applied directly to the area before (and sometimes after), as this helps numb the area.

2)    Crying and fussiness are quite common, and most children lose only a small amount of blood.  They will frequently drool afterwards until the numbing medicine wears off.

3)    Pressure and ice are held to help minimize any bleeding, and the child will be returned back to you, where you have the option of immediate breastfeeding, bottle feeding or soothing depending on your preference.

4)    Tylenol may be used afterwards but is often not even needed.

5)    You may notice some dark brown stools or spit-ups afterwards as some blood may get swallowed after the procedure.

There is very little risk involved with the frenotomy/frenectomy procedure.  The biggest risk of the procedure is the potential for re-attachment to occur.  In order to prevent this from happening, we work with the patient’s in our practice to keep the newly-released area open and healing well by encouraging specific mouth-work after the procedure.  We encourage gently massaging/stretching the incised area, targeted oral motor work to help the tongue and mouth learning patterns, supportive bodywork, and other complementary healing modalities.  By incorporating this type of gentle aftercare, we do see a reduction in reattachment and better progress overall.

Over the decades, it is no doubt that many breastfeeding relationships have probably suffered greatly due to undiagnosed tongue or lip restrictions.  While more providers and parents are becoming educated about ties, we must be mindful not to think that every feeding challenge is created by a tongue or lip tie or that releasing restrictions will immediately improve the feeding situation.  Sometimes there is immediate improvement after the procedure and sometimes it is a gradual process as the tongue is supported in moving in new ways.  Feeding challenges can be complex and involve layers of issues.  In addition, tongue/lip tie can create other issues that may need to be proactively addressed.  Infants and mothers may cope with muscular tightness, nipple damage/pain, milk supply issues, infant weight gain concerns, etc. that need further support before and after a tongue/lip tie is evaluated and treated.  Working with a qualified, experienced board certified lactation consultant or other care providers that are familiar with oral restrictions is highly suggested.  Coping with feeding challenges in a tongue/lip tied infant can be an emotional and physical roller coaster for families.  It is our goal in writing this article that all mothers and babies receive the care they need and that awareness in regards to tongue/lip tie issues will continue to increase worldwide.

For additional resources on tongue and lip tie, please visit Luna Lactation’s website resource page and scroll down to the tongue tie section.

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birth, documentary, pregnancy

Microbirth

Have you heard of this? LSFF-2014-WinnerMicroBirth is a new feature-length documentary looking at birth in a whole new way; through the lens of a microscope. The film investigates the latest scientific research that is starting to link the way babies are born with health in later life, particularly the increased risk of children developing certain immune-related conditions, including asthma, type 1 diabetes, celiac (coeliac) disease, obesity, cardio-vascular diseases, mental health disorders and even some cancers.

The purpose of the documentary is to raise public awareness of the importance of “seeding the baby’s microbiome” at birth with the mother’s own bacteria – this bacteria helps train the immune system to recognise what is “friend” and what is “foe”. We believe “seeding of the baby’s microbiome” should be on every birth plan – for even if vaginal birth isn’t possible, immediate skin-to-skin contact and breastfeeding can still help to provide bacteria crucial to the development of the baby’s immune system. In the scientists’ view, if we can get the seeding of the baby’s microbiome right at birth, this could make a massive difference to the baby’s health for the rest of its life.

Check out the trailer at:  http://www.oneworldbirth.net/microbirth/

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birth, hood river midwife, pregnancy

10 Things I Wish All Women Knew About Giving Birth

Love this article by Aviva Romm in Pathways Magazine.  She hits on many points that are so true about labor, but can also be linked to our everyday life.
art-of-birth-baby

When I was pregnant, I seemed to be a magnet for birth war stories—cords around the neck, emergency cesareans, and more.
It took a lot of inner conviction to believe in birth as a natural, beautiful event that my body was capable of, rather than a “disaster waiting to happen,” as one obstetrician warned me it was.

But inner conviction I decided to have, and my four children were born at home, peacefully, without drama or trauma. I made sure I was in awesome health throughout my pregnancies, eating an organic, plant-based diet. I did yoga daily, spent time in nature, and meditated on the type of birth I wanted to have.

And then I surrendered to the forces of nature. The power I experienced as a woman has given me confidence in so many areas of my life, and I so wish this for other women.

Sadly, however, natural birth is becoming endangered. About one in three women in the United States will have their babies by cesarean section. Maybe that sounds like no big deal—but actually, cesareans are major abdominal surgery that increases your risk of complications over natural birth.

Cesareans are grossly overdone in U.S. hospitals. And they often make recovery and breastfeeding much more challenging. They expose your baby to an antibiotic (all moms having a cesarean are given antibiotics at the time of surgery) before she or he is even born. And most of the ones that are performed turn out to be unnecessary.

Also, many more women will have their labor induced or experience some form of obstetric intervention. The downturn in natural birth is so significant that a group of researchers wanting to study the natural course of labor couldn’t find a large enough group of women birthing naturally in any one place to study them!

But we can’t let natural birth go extinct, because it’s way more than just a romantic ideal. Babies born vaginally (and without medication) have many health advantages. For example, just being exposed to mom’s flora on the way out of the birth canal decreases the lifetime likelihood of developing digestive problems, allergies, and even obesity.

While we can’t fully control what happens in our births, and of course, sometimes interventions are necessary (though often they aren’t!), you can embrace core beliefs that will increase your chances of having the birth experience that is healthiest for you and baby.

Here are the 10 most important philosophies that helped me have my babies naturally, which I’ve used to support thousands of women in their birthing experiences. My hope is that these can help you have an optimal birthing experience…maybe even the birth of your dreams!

Though a spiritual journey, birth is not all incense and candles. It asks us to call upon our primal instincts and sometimes even to get primal—making animal sounds, assuming poses that have us buck naked on our hands and knees, moving our hips in deep sultry belly-dancing undulations.

Planning to take a deep dive into your subconscious and intuition to let your primal self emerge can allow you to open and birth your baby with a raw strength and power you might not even realize lives within you.

1 Birth is a spiritual journey; it’s also primal.  Birth is, to say the least, a physically and emotionally demanding experience. Approaching the challenge as a spiritual journey can help you dig deep into your core for the resources to persevere, and to learn about yourself and your innate strength and power.

Birth should not be taken lying down.  Lying down simply doesn’t let gravity do the work of helping your baby come down and out! Walking, moving your hips like a belly dancer, and generally staying active facilitates a more physiologic process for your baby than lying on your back in a hospital bed, which increases your chances of a cesarean.

3 Contractions are amazing sensations that get your baby born. During my own births, I used my imagination and awareness to dive deep into the sensation of my muscles working to help my baby get born. This focused aware- ness transformed my perception of the pain of birth into the power of birth.

I even used the term “expansions,” rather than “contractions,” to help me think about the sensation in a new way. It did not make the experience less intense, but it made the sensation my ally rather than my enemy. As I welcomed each new wave of labor, I knew I was closer to bringing my baby into my arms.

4 Fear stops labor.
Mammalian mamas have powerful instincts that allow us to keep our babies safe from harm. For

example, mama giraffes on the tundra will spontaneously stop labor if they sense a predator in the area, rather than dropping a helpless newborn to the ground. We too, have hormones that can stimulate labor (oxytocin) and those can stop labor if pumped out early because of fear (adrenaline).

So learning to transform fear into power and confi- dence is essential for a smooth birth. How is this done? Make sure you feel safe where you are birthing, that you have good support in labor, and that you have talked with your birth provider about any fears you are harbor- ing or repressing about your health and safety, your baby’s health and safety, or the birthing process. Being educated and informed can help you to dispel fears.

5 Question authority! (Remember, nice girls can ask questions and say no.) Obstetrics practices are not always based on

the best science. The September 2011 issue of Obstetrics and Gynecology, the official publication of the American College of Obstetricians and Gynecologists (ACOG), reported that only one-third of all obstetrics guide- lines in the U.S. are based on good scientific evidence. Another third are based on limited or inconsistent evidence, and the remaining third are based on expert opinion, which is “subject to bias, either implicit or subconscious.”

So just because a doctor (or midwife) tells you something is required (lying down in labor, having a vaginal exam, wearing an external fetal monitor for your entire labor, having an IV drip routinely), doesn’t mean you have do it unquestioningly—
or at all. As girls and young women, many of us learn not to question authority—we’re encouraged to just be a “good girl,” and not be the geek who asks questions. Many of the procedures done in hospitals are done “just because”—they are routine, but often not necessary.

So if something is recommended or expected that makes you uncomfortable or you’re not sure of the reason, ask! And if you’re not comfortable with the explanation, you can decline. Having an advocate there who can help you sort through decisions, especially when you are otherwise occupied doing the work of labor, is especially valuable.

6 Women should eat and drink during labor. Current scientific evidence has demonstrated that women who eat and drink in labor are not at significantly increased risk of food aspiration in the event of a cesarean, which has been the much-feared reason for keeping women on an ice-chips and fruit-pops-only regimen in labor for the past few decades.

In fact, keeping up your energy with light and nourishing fare has been found, by many midwives and mamas, to facilitate labor and reduce the likelihood of labor petering out, or needing Pitocin or a cesarean.

Your body is a marvelous, perfectly crafted force of nature.  Believing in yourself is powerful medicine!

Yet most of us go into labor believing our bodies might be lemons—the reject in the batch that just doesn’t work properly and needs to be sent back to the factory on a recall.

The reality is, nature is amazing at creating power- ful systems that work. Setting intentions and learning to have confidence in the birthing process—and your body—are among the most powerful tools you can use to go with the natural flow of labor and birth and gain some self-enlightenment in the process.

8.  Obstetrics is big business.
There is a whole system of medicine out there, called obstetrics, making a fortune off of your body! In fact, there is enormous financial incentive for obstetricians to do ultrasounds (in my community, a doctor’s office charges the insurance company $700 per ultrasound), offer endless tests, and perform cesareans rather than support natural, vaginal births.

Want to avoid unnecessary medical interventions? Then make your body your business by getting educated. Read about birth. Some good places to start: Ina May Gaskin’s Ina May’s Guide to Childbirth, Henci Goer’s The Thinking Woman’s Guide to a Better Birth, and my book, The Natural Pregnancy Book.

Birth is something you do, not something that is done to you.
Whether you dance, groan, or Hypnobirth your way through labor, it ain’t called labor for nothing. It takes work, focus, and sweat to get a baby out. Powerful muscles move a 6- to 8-pound being (on average) a short distance through a relatively small space. This means effort is required.

Just as with any hard task, being realistic about what’s involved, setting your mind and heart to it by getting psyched ahead of time, and then having strate- gies to call upon when your energy or determination wavers will get you to the other side of the finish line with power and pride.

10 Birth can be ecstatic.
While there might be some huffing and puffing, grunting and groaning, and even a holler or two if you need to vocalize the intense energy moving through you as you bring your baby out into the world, birth can be an ecstatic experience, particularly when you appreciate yourself for the accomplishment of a hard job done with determination and experience the ecstasy of holding your new baby in your arms.

As you get closer to your baby’s birth, and even in labor, here’s a simple mantra to tell yourself:
I’ve got this!

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birth, caffeine, health, pregnancy

Caffeine Rules for Pregnant Women Are Changing Again

pregnantDrinking coffee during pregnancy is still a debated topic. Some believe it’s fine to have a cup of coffee a day when pregnant, and others decide to avoid it altogether just in case. It’s hard to imagine my life without coffee — and I did have a small cup a day during my pregnancy. (Except for those early days when I had morning sickness all day long.) My OB/GYN said coffee in moderation was safe, so I indulged. But new research is saying that pregnant women need to avoid coffeeand all caffeine or else risk miscarriage, early delivery, or the likelihood of your child having leukemia.The Center for Science in the Public Interest (CSPI) believes that the current guidelines regarding caffeine intake during pregnancy are outdated. Remember that there is caffeine in tea, chocolate, soda, and energy drinks as well as in coffee. (It’s the chocolate that puts me over the edge.) The USDA has maintained that up to 200 milligrams a day of caffeine is safe — that’s about two cups of home-brewed coffee. But after carefully looking at other studies, you may question pouring yourself another cup.

CSPI points out that the European Journal of Epidemiology recently revealed that drinking the equivalent of about one cup of coffee a day (100 mg of caffeine) increased the risk of a miscarriage by 14 percent. There was a 19 percent increase in the chance of having a stillbirth, and there was a link to low birth weight babies.

The American Journal of Obstetrics and Gynecology concluded this year that there is a link between childhood acute leukemia and how much coffee a mother drinks during pregnancy. Are you slowly backing away from your coffee mug?

All researchers felt that more studies need to be done to make firm conclusions, but that’s exactly why there is concern. We don’t know for sure. So for moms, there is this question: Are you an overly worried parent or not? We know there are risks in almost everything we do. But what CSPI wants to point out is that we shouldn’t have a casual attitude on our caffeine intake when pregnant. The risks need to be known, even if more research needs to be done regarding those risks.

Does this information change the way you feel about caffeine during pregnancy? Will you still drink coffee?

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home birth, pregnancy

What’s an Ethical Response to Home Birth?

Paul Burcher, MD, PhDFrank Chervenak, MD, a maternal-fetal medicine specialist from Cornell, has published numerous articles in the last few years arguing that home birth is less safe than hospital birth and that the professional responsibility of physicians is to provide no support or participation in home birth.1,2 While his data has been contested by many, I would agree with Drs Ecker and Minkoff (of Harvard Medical School and Maimonides Medical Center) that the data are still inconclusive regarding the safety of home birth in America but that home birth in America probably incurs a small increase in absolute risk of poor outcomes for newborns delivered at home. 3,4

However, the data seem much more solid if instead we ask whether home birth can be safe. An observational study from The Netherlands that evaluated more than 500,000 births in homes and in hospitals showed no increase in adverse outcomes of any kind with home birth in low-risk women.5 So home birth, in ideal conditions where midwives and physicians work together as a team and where transport to hospitals in an emergency is highly efficient, appears as safe as hospital birth. Put another way, the data suggest that if home birth in America is more dangerous than hospital birth, it may be because of contingent factors that can be remedied.

While the distances in The Netherlands from home to hospital are obviously smaller than in many rural areas of this country, if obstetricians want a seat at the table to make recommendations regarding when women should travel to a hospital or birth center because of their remote home location, they are going to need to take a position that acknowledges home birth as a reasonable option that some women will choose. Similarly, physicians should oppose laws that make midwifery difficult to practice, or even illegal, in a home birth setting.6 Since obstetricians as a political lobby are largely responsible for these punitive laws, we should work to have them overturned if we seek to renew the trust of our midwife colleagues.

Professional Obligations?

What, then, are our professional obligations as obstetricians working in hospital settings to women who choose to stay home with a midwife for their birth? At the risk of sounding glib by answering a question with a question, do we enhance the safety of childbirth for all women by shunning home birth or by treating midwives collegially? I believe the correct answer is the latter, and since maternal-child safety was one of the founding reasons for ACOG’s existence, I believe we have an ethical obligation at a minimum to accept transports from home with the respect and professional dialogue we afford our colleagues.

For some of us, the collaboration can include providing consultation and medical advice for home birth clients with medical issues that do not “risk them out” of home birth care. My argument for this is empirical if anecdotal.

I was a speaker recently at the Home Birth Summit in Seattle. Duncan Nielson, the chief of Women’s Services for Legacy Hospitals in Portland, Oregon, described how by implementing a “home birth friendly” institutional culture, they saw a dramatic increase in transports to their hospital system from home birth midwives and that none of these transports were “train wrecks.” That is, by being openly supportive and collegial, they had increased the interactions between the two models of care, and midwives brought in patients who were struggling at home sooner because they did not fear verbal reprisals or nuisance reports to the midwifery board by the physicians accepting care.

We saw a similar trend when we embraced a model of informal collaboration in Eugene, Oregon. We (myself and several of my OB partners) agreed to provide ultrasounds, prenatal consultations, and an occasional script for UTIs and other minor problems in home birth clients, and we encouraged our midwife colleagues to seek consultation early if medical complications arose either in labor or prior to labor. We did a number of medically indicated inductions on midwife patients with pre-eclampsia, gestational diabetes, or IUGR. By inviting the midwife into the hospital and encouraging their participation in the birth, even though we provided the management decisions during labor, we made women who desired home birth more comfortable with their now medically indicated hospital births.

While I realize this level of collaboration is beyond the comfort level of many physicians, I found it re-invigorated my own practice to sometimes share patients with home birth midwives. In turn, the midwives were much less likely to vilify hospital practices when they saw medical interventions used appropriately on their patients.

Home birth rates in America have risen significantly in the last few years. I believe this is driven both by a positive desire to give birth at home and by the negative associations that hospital birth has created, including the popular perception that we are doing too many unnecessary cesarean sections. While I agree with Dr Chervenak that we should make hospitals more accommodating to our patients, if we wish to make birth as safe as possible then shunning our home birth colleagues cannot possibly be the way to achieve greater safety for pregnant women and babies.

In contrast to Dr Chervenak’s views, it is my assertion that our professional responsibility must include supporting all of the birth options women have and to make each as safe as possible. The Netherlands has shown that safety comparable to a hospital is achievable. We should strive to replicate their results.

– See more at: http://www.obgyn.net/pregnancy-and-birth/whats-ethical-response-home-birth#sthash.YpcJIrXI.dpuf

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birth, homebirth, pregnancy

British Regulator Urges Home Births Over Hospitals for Uncomplicated Pregnancies

LONDON — Reversing a generation of guidance on childbirth, Britain’s national health service on Wednesday advised healthy women that it was safer to have their babies at home, or in a birth center, than in a hospital.

Women with uncomplicated pregnancies — about 45 percent of the total — were better off in the hands of midwives than hospital doctors during birth, according to new guidelines by the National Institute for Health and Care Excellence. For these low-risk mothers-to-be, giving birth in a traditional maternity ward increased the chances of surgical intervention and therefore infection, the regulator said.

Hospital births were more likely to end in cesarean sections or involve episiotomies, a government financed 2011 study carried out by researchers at Oxford University showed. Women were more likely to be given epidurals, which numb the pain of labor but also increase the risk of a protracted birth that required forceps and damaged the perineum.

The risk of death or serious complications for babies was the same in all three settings, with one exception: In the case of first-time mothers, home birth slightly increased that risk. Nine in 1,000 cases would experience serious complications, compared with five in 1,000 for babies born in a hospital.

The findings could affect how hundreds of thousands of British women think about one of the biggest questions facing them. Nine in 10 of the roughly 700,000 babies born every year in England and Wales were delivered in a hospital.

As recently as 2007, the guidelines had advised women to be “cautious” about home birth in the absence of conclusive risk assessments.

Mark Baker, clinical practice director for the health institute, said first-time mothers with low birth risks would now be advised that a midwife-led unit would be particularly suitable for them, while mothers who already have given birth would be told that a home birth would be equally safe for the baby and safer for the mother than a hospital. But women are still free to choose the option they are most comfortable with, Dr. Baker said. “This is all about women having a choice,” he said.

Not everyone was at ease with the new guidelines. “Things can go wrong very easily and we do feel this advice could be dangerous,” Lucy Jolin of the Birth Trauma Association told the BBC.

So far doctors have not expressed any outrage over the decision. “If we had done this 20 years ago there would have been a revolution,” Dr. Baker said. “The penny has dropped. We’ve won the argument.”

With the exception of the Netherlands, where home births have long been popular and relatively widespread, few developed countries have significant numbers of women opting for nonhospital deliveries. In the United States, where a culture of litigation adds a layer of complication, only 1.36 percent of births took place outside a hospital in 2012. Two-thirds of those nonhospital births took place at home and 29 percent at free-standing birthing centers, according to the National Center for Health Statistics.

“We believe that hospitals and birthing centers are the safest places for birth, safer than home,” said Dr. Jeffrey L. Ecker, the chairman of the committee on obstetrics practice for American College of Obstetricians and Gynecologists. Under Britain’s integrated health system, if there is a complication, “they have a process and protocol for appropriately and quickly getting you somewhere else,” said Dr. Ecker, who added that he did not believe the British-style guidelines would come to America anytime soon. If such a recommendation were made in the United States, doctors might worry about losing patients to midwives.

That concern is absent in Britain’s taxpayer-funded system. “There are no financial incentives in the U.K. for doctors to deliver in a particular setting because there is no personal gain,” said Dr. Baker of the health institute. Childbirth is “effectively an N.H.S. monopoly,” he said, referring to the National Health Service, Britain’s public health system.

Holly Powell Kennedy, the immediate past president of the American College of Nurse-Midwives, an organization in the United States, praised the guidelines, saying, “This is how the practice should be happening.” In a hospital, “you are less able to labor without interventions,” Dr. Kennedy said.

Reducing the number of hospital births would save the health service money, but British officials said budgets had not factored into the new guidelines. A traditional hospital birth costs the country’s health system about $2,500, with a home birth roughly $1,500 and a birth center about $2,200.

“Yes, it’s a very expensive way to deliver healthy babies to healthy women,” Dr. Baker said about hospital births. “Saving money is not a crime.”

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