Monday, April 21, 2014

Intrahepatic Cholestasis of Pregnancy - what you should know

A friend recently told me her daughter had ICP - intrahepatic cholestasis of pregnancy.  I had only heard a little about it and decided to investigate.  Here's what I found:

ICP is a pregnancy-specific liver disorder and is also called obstetric cholestasis.  First introduced in the literature in 1883, ICP was first called "recurrent jaundice in pregnancy".  Complete resolution is found with the birth of the baby, and there is a high recurrence in subsequent pregnancies.  For the mother, there is no lasting hepatic damage and symptoms resolve within
approximately 48 hours post delivery.

ICP appears to be more common in the winter months and is slightly more common in twin pregnancies and following IVF (in vitro fertilization).  According to www.icpcare.org, 1 to 2 pregnancies in 1000 is affected with ICP.

The most common initial symptom of ICP is pruritis, or the irresistible urge to scratch - specifically the palms of the hands and soles of the feet.  It can, however, affect other areas of the body.   Many women say that the itching is worse at night, so much so that it interferes with sleep. Nearly 80% of women present with itching after 30 weeks, and some have reported it as early as 8 weeks gestation. Women may also experience dark colored urine, light/gray stools, pain in the right upper quadrant of the abdomen, exhaustion and loss of appetite.

The exact etiology of ICP is unknown, although some researchers feel there is a genetic component.  Likewise, the etiology of fetal complications is also poorly understood.  Some studies have shown these questionable contributing factors as to cause:


  • Low serum selenium levels
  • Seasonal variation (more common in winter)
  • Increased incidence of hepatitis C
  • IVF
  • Possible hormonal component
  • Geographic component (higher rates seen in Scandinavia, and South America)


Since this condition is not well understood, medical management options are put in place to minimize the risk of fetal distress, preterm delivery and sudden fetal death.  Some research shows good outcomes with induction of labor between 37 and 38 weeks.  ICPCare says that "Ursodeoxycholic Acid (UDCA), also known as Actigall or Urso is currently the front-line medication for the treatment of ICP.  UDCA is a naturally occurring bile acid that improves liver function and helps reduce total bile acid concentration in the bloodstream."
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To learn more about Intrahepatic Cholestasis, please click on the links below:

Treatment of ICP

ICP Support

ICP in the literature:

http://www.icpcare.org/images/ICPmedicalarticle.pdf

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2678574/

http://emedicine.medscape.com/article/1562288-overview







Wednesday, April 09, 2014

The NFL Expert Speaks Out On…… Cesareans?

NFL analyst Boomer Esiason couldn’t have picked a worse (or better) month in which to say “Quite frankly, I would have said ‘C-section before the season starts’” in regards to New York Mets second baseman Daniel Murphy’s decision to miss Opening Day of baseball to take paternity leave.

April is annual Cesarean Awareness Month, and while Mr. Esiason feels like a cesarean should take priority over physiologic birth, the American Academy of Family Physicians and ACOG have a different thought about scheduling an early delivery:

  • Babies will miss essential development of fat stores in week 37 and 38 that help them regulate their body temperature.
  • Brains and lungs are also still developing in week 37 and 38.
  • Early babies are more likely to develop breathing and eating problems, jaundice, cerebral palsy, sensory development issues, and require intensive care.
  • The risk of infant mortality is also higher.
  • The mother is more likely to develop postpartum depression. Specialists advise this is most likely as a result of the baby spending additional time in intensive care and not being able to bond more immediately with the mother.
  • Early induced deliveries are more likely to be risky and complicated as the mother’s body is not naturally prepared for delivery, so cesarean sections are increasingly more common.
  • Cesarean sections are major surgery. Any time a patient goes under anesthesia, not to mention undergoes surgery, there is risk for incident not only during surgery but in the recovery that follows.

The latest revised guidelines by ACOG may focus on the rising cesarean rate in the US, now standing at 31.3%.  However, in a press release on2/27/14, International Cesarean Awareness Network president, Christa Billings said ““There has been a disconnect between what medical research says and the way that hospitals and providers have practiced medicine for a long time.  These guidelines support what ICAN has been educating women on all along.  While this report is encouraging, it fails to address the nationwide problem of hospital and provider vaginal birth after cesarean (VBAC) bans.  With the primary cesarean rate at a high level, many women are seeking VBAC’s.  This important issue needs to be addressed by ACOG.”
The press release continues:
‘Part of ICAN’s stance, as outlined in their Statement of Beliefs, is that “It is unethical for a physician to recommend and/or perform non-medically indicated cesareans (elective). Women are not being fully informed of the risks of this option in childbirth, and therefore make decisions based on cultural myth and fear surrounding childbirth.” These new guidelines, as set forth by the ACOG and Society for Maternal-FetalMedicine (SMFM), are on track to help make sure that “non-medically indicated cesareans” happen less frequently and that women are given more opportunities to experience the natural process of labor and birth.
Since 2012, AWHONN (Association of Womens Health, Obstetrics and Neonatal Nursing) has promoted “Go the full 40” Campaign encouraging the natural onset of physiologic labor.  The March of Dimes has a similar campaign titled “Healthy Babies are Worth theWait.”


This demonstrates that we, as maternity health care professionals, STILL have a long way to go to reach the general public (as well as the medical establishment) with the evidence-based information.

Thursday, April 03, 2014

Top 10 Reasons Why YOU Should Attend the 2014 ICEA Convention!

Thinking about attending a conference this year?  Need CEUs or CERPs?  Well, here are the top ten reasons to attend the 2014 ICEA Convention, September 10-13!

10. What a fun get-away! We'll be touring the Biltmore Estate and having dinner there!

 9.  Great location! In breath-taking Asheville North Carolina in the fall as the leaves turn!

 8.  See old friends and meet new ones!

 7.  Network, network, network!

 6.  Get the latest evidence-based research updates plus great poster presentations!

 5.  This is an opportunity for professional immersion, with the great pre-con workshops!

 4.  View our exhibits in the Exhibit Hall - another great opportunity for learning!

 3.  Meet the ICEA Leadership, find out what we've been doing and how you can get involved!

 2.  Learn from the fantastic content brought to attendees by our......

 1.  Amazing Speakers including Dr. Sarah Buckley, Kathy Kendall-Tackett, and more!


For more information about this amazing convention, click here!  Registration opens soon!


Tuesday, April 01, 2014

Blog Carnival Deadline is 29 Days Away - no April Fool!

Each year, Childbirth Today hosts a blog carnival during the week before Mother’s Day (May 5-12, 2014). This week has also been referred to as Childbirth Education Awareness Week and May is traditionally Doula Month.

So……

If you would like to submit to the 2014 Childbirth Today Blog Carnival, here is the info!

A blog carnival is a themed collection of entries during a specific time period. 

Guest bloggers send their 500 word (evidence-based, referenced) submission to birthguru@birthsource.com no later than April 30, 2014.  The context of the submission must be childbirth (which also includes breastfeeding and the postpartum period).

Guest bloggers must provide proof of original/or permission to use photos if photos are included with the submission. Childbirth Today and Perinatal Education Associates encourages copyright protection.

Guest bloggers should also provide a 3-5 line bio of themselves, including credentials.  The addition of the guest blogger’s contact information is highly encouraged, as sometimes readers would like to speak to you directly!

Guest bloggers can be from anywhere in the world.  Submission is not limited to the US.

Submissions may be edited for punctuation and/or grammar.

We will use the first seven blog submissions during our Blog Carnival.  Should we receive more than seven (and we have in the past!), we will continue to run the submissions until all submissions have been published.

Why would you want to submit to our Blog Carnival?

Helps you to network through social media.
Assists you in honing your writing skills.
Establishes you as a birth authority and birth blogger!
Promotes your birth-related business!


Remember, 500 words by April 30!  Now…..get writing!

Friday, March 21, 2014

Water Labor/Water Birth: The latest weigh in by ACOG and AAP and What You Should Know

The latest issue (3/2014) of the journal Pediatrics features a report assessing the use of water as a part of labor and birth, relieving or shortening labor and adding to maternal satisfaction.

The American Academy of Pediatrics (AAP) Committee on Fetusand Newborn and the American College of Obstetricians and Gynecologists (ACOG)Committee on Obstetric Practice examined the available data on water births, distinguishing between early and late stage labor.  According to a Time Magazine e-Zine article 10, the committees concluded that waterbirth should be considered an experimental procedure, since the studies looking at “safety and benefits were not large and robust enough” to make a decision pro or con.

However, a Cochrane Review2 of the literature included 12 trials (3243 women).  Water immersion during the First Stage of Labor significantly reduced epidural/spinal analgesia without adversely affecting labor duration, operative delivery rates or neonatal well-being.  One trial showed that immersion in water during the Second Stage of Labor increased women’s reported satisfaction with their birth experience.

ACOG and AAP say that delivering in water provides no health benefits for the baby or mom, can be dangerous, and even fatal.  In an interview with friend and colleague Barbara Harper RN, and Director of Waterbirth International, Barbara staged that “once you look at the anatomy and physiology of the newborn breathing mechanism – this prevents babies from taking their first breath until their faces come in contact with air.”

On Harper’s website www.waterbirth.org, she has published the scientific explanation of why babies will not drown in water:

What prevents a baby from taking a breath under the water? There are several factors that prevent
a baby from inhaling water at the time of birth. These inhibitory factors are normally present in all newborns. The baby in utero is oxygenated through the umbilical cord via the placenta, but practices for future air breathing by moving his intercostal muscles and diaphragm in a regular and rhythmic pattern from about 10 weeks gestation on. The lung fluids that are present are produced in the lungs and similar chemically to gastric fluids. These fluids come out into the mouth and are normally swallowed by the fetus. There is very little inspiration of amniotic fluid in utero. 24-48 hours before the onset of spontaneous labor the fetus experiences a notable increase in the Prostaglandin E2 levels from the placenta which cause a slowing down or stopping of the fetal breathing movements (FBM).7   With the work of the musculature of the diaphragm and intercostal muscles suspended, there is more blood flow to vital organs, including the brain. You can see the decrease in FBM on a biophysical profile, as you normally see the fetus moving these muscles about forty percent of the time. When the baby is born and the Prostaglandin level is still high, the baby’s muscles for breathing simply don’t work, thus engaging the first inhibitory response.

A second inhibitory response is the fact that babies are born experiencing acute hypoxia or lack of oxygen. It is a built in response to the birth process. Hypoxia causes apnea and swallowing, not breathing or gasping. If the fetus were experiencing severe and prolonged lack of oxygen, it may then gasp as soon as it was born, possibly inhaling water into the lungs.5  If the baby were in trouble during the labor, there would be wide variabilities noted in the fetal heart rate, usually resulting in prolonged bradycardia, which would cause the practitioner to ask the mother to leave the bath prior to the baby’s birth.

Another factor which is thought by many to inhibit the newborn from initiating the breathing response while in water, is the temperature differential. The temperature of the water is so close to that of the maternal temperature that it prevents any detection of change within the newborn. This is an area for reconsideration after increasing reports of births taking place in the oceans, both now and in eras past. Ocean temperatures are certainly not as high as maternal body temperature and yet the babies that are born in these environments are reported to be just fine. The lower water temperatures do not stimulate the baby to breathe while immersed.

One more factor that most people do not consider, but is vital to the whole waterbirth and aspiration issue, is the fact that water is a hypotonic solution and lung fluids present in the fetus are hypertonic. So, even if water were to travel in past the larynx, they could not pass into the lungs based on the fact that hypertonic solutions are denser and prevent hypotonic solutions from merging or coming into their presence.

The last important inhibitory factor is the Dive Reflex and revolves around the larynx. The larynx is covered all over with chemoreceptors or taste buds. The larynx has five times as many as taste buds as the whole surface of the tongue. So, when a solution hits the back of the throat, passing the larynx, the taste buds interprets what substance it is and the glottis automatically closes and the solution is then swallowed, not inhaled.6  God built this autonomic reflex into all newborns to assist with breastfeeding and it is present until about the age of six to eight months when it mysteriously disappears. The newborn is very intelligent and can detect what substance is in its throat. It can differentiate between amniotic fluid, water, cow’s milk or human milk. The human infant will swallow and breathe differently when feeding on cow’s milk or breast milk due to the Dive Reflex.

A study in the Sao Paulo Medical Journal3 concluded that evidence suggests that water immersion during the first stage of labour reduces the use of epidural/spinal analgesia and duration of the first stage of labour. There is limited information for other outcomes related to water use during the first and second stages of labour, due to intervention and outcome variability. There is no evidence of increased adverse effects to the fetus/neonate or woman from labouring in water or waterbirth.”  Several more studies substantiate this.

To say that birthing in water provides no health benefits for the baby or mom, is erroneous at best.  One study in particular sites the positive physiological effects of hydrotherapy can facilitate the neurohormonal interactions of labor, reducing pain and facilitation of the progress of labor8.  Results show that the pain felt by the women were lowest among women having water birth, even lower than the women laboring with analgesia.  This reduces the need for pain medication and analgesia.  Additionally, laboring in a tub has been found to reduce stress hormones and catecholamines which inhibit oxytocin and therefore, labor progress.  Several studies have found the duration of the Second Stage of Labor to be shorter due to the baby more likely adopting more relaxed and flexed positions and the mother more easily assuming positions to maximize the diameters of her pelvis.1,9 The length of the Third Stage of Labor is also reduced, minimizing the amount of blood loss due to the reduced duration and the hydrostatic pressure in the tub.

Both the Royal College of Obstetricians and Gynecologists and the Royal College ofMidwives believe that to achieve best practice with waterbirth, it is necessary for organization to provide systems and structures to support this service to women. The RCOG and RCM have outlined parameters to safely meet the needs of women requesting this birthing option.

Hopefully, the U.S. organizations can come together to focus on the needs of the laboring mother who desires waterbirth, in the same way they have done with many other maternity practices with the similar research data outcomes.


References:

  1. Chaichian, S.et al. (2009)  Experience of water birth delivery in Iran. Archives of Iran Medicine. 12:468–71.
  2. Cochrane Review http://summaries.cochrane.org/CD000111/immersion-in-water-in-labour-and-birth
  3. Cordioli, E. (2013) Immersion in water in labour and birth.  Sao Paulo Medical Journal, 212(5):364.
  4. Dahlen, H.G., et al. (2013)  Maternal and perinatal outcomes amongst low risk women giving birth in water compared to six birth positions on labor.  A descriptive cross sectional study in a birth centre over 12 years.  Midwifery. 29:759-64.
  5. Fewell, J.E., Johnson, P. (1983) Upper airway dynamics during breathing and during apnea in fetal lambs. Journal of Physiology Vol 339, pp 495-504
  6. Harding, R., Johnson, P., McClelland, M. (1978) Liquid sensitive laryngeal receptors in the developing sheep, cat, and monkey. Journal of Physiology, Vol 277, pp 409-422
  7. Johnson, Paul (1996) Birth under water – to breathe or not to breathe. British Journal of Obstetrics and Gynecology, Vol. 103, pp.202-208
  8. Mollamahmutoglu, L. et al. (2012) The effects of immersion in water on labor, birth and newborn and comparison with epidural analgesia and conventional vaginal delivery.  Journal of the Turkish-German Gynecological Association. 13(1): 45-49.
  9. Otigbah, C.M. et al. (2000) A retrospective comparison of water births and conventional vaginal deliveries. European  Journal of  Obstetrical and Gynecological Reproductive Biology.91:15–20. 
  10. Time Magazine http://time.com/31872/water-births-not-safe-enough-to-recommend-say-pediatric-experts/

Tuesday, March 18, 2014

Examining the Use of 6 cm Dilation to Assess Labor Progress

Yes, 6 is the new 4.

The definitions are changing. In a recent issue of ACOG's "revitalize",  obstetric data definition issues and rationale for changing the definition of active labor were explored. 

The Early or Latent Phase is now recognized by the onset of labor to the onset of the Active Phase. Active Phase is now defined as the accelerated cervical dilation generally beginning at 5 cm for multiparous and at 6 cm for nulliparous.

Below, a CNM discusses the rationale.

To access the ACOG "revitalize" document, click here.




Monday, March 17, 2014

What to Suggest to Your Clients Who Want to Read About Birth

Whether hardcover, paperback or electronic version, books are still one of the top ways expectant parents get information.  As childbirth professionals, we need to have the most current list of great books to which to refer our clients.  

Below, are nine books that are great for pending parents!

  1. The Pregnant Body Book by DK Publishing
  2. Natural Hospital Birth by Cynthia Gabriel
  3. Mindful Birthing: Training the Mind, Body and Heart for Childbirth and Beyond, Nancy Bardacke
  4. The Birth Partner: 3rd Edition: A Complete Guide to Childbirth for Dads, Doulas and All Other Labor Companions by Penny Simkin
  5. Rediscovering Birth by Sheila Kitzinger
  6. The Official Lamaze Guide: Giving Birth With Confidence by Judith Lothian RN, PhD, LCCE, FACCE and Charlotte DeVries
  7. Birth Matters: How What We Don’t Know About Nature, Bodies and Surgery Can Hurt Us by Ina May Gaskin and Ani Difranco.
  8. Pregnancy, Childbirth and the Newborn: The Complete Guide by Penny Simkin, Janet Walley, April Bolding, and Ann Keppler.
  9. Ina May’s Guide to Breastfeeding by Ina May Gaskin


For the more technical reader/client, you might also include these amazing books:


  1. Optimal Care in Childbirth: The Case for a Physiologic Approach by Henci Goer and Amy Romano
  2. Supporting a Physiologic Approach to Pregnancy and Birth: A Practical Guide edited by Melissa Avery
  3. Understanding the Dangers of Cesarean Birth: Making Informed Decisions by Nicette Jukelevics