If I Was a Betting Woman...

Twelve days late, for the third time.  Same weight gain for momma; for the third time.  Birth weight identical to one sibling and 2 ounces less than the other.  If I was a betting woman, I would start placing bets on my pregnancies.  That is if there were going to be a fourth one.  I am (almost) positive this is the last baby for us.  I think. 

Little Miss has arrived.

VBAC Series: Once a VBAC always a VBAC?

www.freeimages.com/Jenny Kennedy-Olsen

You may be wondering, if I have one VBAC what happens in my next pregnancy?  Am I still viewed as a VBAC? 

The short answer, is yes, with a uterine scar there are risks associated with each subsequent pregnancy.  The good news is these risks decrease with each additional vaginal birth after your cesarean section birth.  There is not much available in updated research and literature, but there was a secondary analysis of a large study that looked at over 13,000 women attempting a VBAC in 2008.

VBAC Success

Vaginal delivery was achieved in women who had no prior VBAC 63.3% of the time, one prior VBAC 87.6% of the time, and two or more VBAC’s 90.0% of the time.  There seemed to be no statistical difference once a woman had experienced two or more VBACs. 

Uterine Rupture

The risk of uterine rupture decreased from 0.87% of women with no prior VBAC to 0.43-0.45% in women with a prior VBAC. 

Other Risks Associated with VBAC

These risks also decreased with 1 or more VBACs

·       Blood transfusion

·       Blood clots

·       Uterine infection

·       Uterine dehiscence

·       Hysterectomy*

·       Poor neonatal outcomes*

·       Maternal death*

* showed downward trends that were not statistically significant

So while the answer is yes, once a VBAC, always a VBAC, there is reassurance in the risks to a VBAC are decreased after one or more VBACs.  And since these risks are low to begin with, perhaps the substantial rise in vaginal delivery after one successful VBAC is some of the most hopeful data gleaned from this study.  When staring down your first VBAC, one of the greatest questions is, “will I deliver vaginally”?  When facing your second VBAC, you can almost assuredly say, “yes I will deliver vaginally!”

VBAC Series: April is Cesarean Awareness Month

April is Cesarean Awareness Month.  This seems to be designated by the International Cesarean Awareness Network, but I can't really find anything about its origin. 

Part of awareness is knowing your hospital's cesarean section and VBAC rates.  Leap Frog Group collects information from hospitals about their first time cesarean section rate.  This is under the classification of cesarean section, which is not immediately obvious that it is referring to only first time mother's whose baby is in the head down position.   

Consumer Reports recently reported on the variation in hospital’s first time cesarean section rate based on the Leap Frog Group data.  Neighboring hospitals may have very different cesarean section rates.  While some hospitals may claim they have a higher risk population driving their cesarean section rate, this statistic is based on low risk mother's only, leaving no room for that argument. 

While many larger New York City hospitals declined to submit their data to Leap Frog Group, New York State collects similar information.  However, in the NYS data there does not seem to be a difference between high or low risk mothers.  Additionally, primary cesarean section rate may also include mom's who had a previous vaginal delivery, but had a cesarean section in a following pregnancy.  Even without the separation of low risk to high risk pregnancies, the data is somewhat telling, especially between large academic medical centers where patient population should be similar.  NYS data also contains information on their VBAC rate, defined as the number of women delivering vaginally with a previous cesarean section, the denominator is all women delivering with a previous cesarean section. 

Other states may have cesarean section data available.  In a quick search New Jersey and Massachusetts seemed to have reports on the information, rather than an interactive website.  Have information for your state?  Feel free to post a link to it in the comments below. 

Caffeine During Pregnancy, Safe or Not?

There are a lot of mixed views on the safety of caffeine in pregnancy.  This uncertainty may come from the mixed research results.  Two immediate, probably uncontrollable flaws of caffeine research are, it is based on maternal recall/truthfulness and the inability to know the true caffeine levels consumed.  This makes interpreting the results more difficult.

What we do know is that caffeine readily crosses the placenta, and mothers metabolize caffeine more slowly during pregnancy.   Currently, ACOG recommends caffeine intake remains below 200mg a day.  A brewed drip cup of coffee has about 137mg of caffeine in 8oz (though their cited source now says 95 mg) and tea is estimated to be about 48 mg.  In ACOG's opinion, there does not seem to be a clear risk between moderate caffeine consumption and miscarriage, but they also don’t feel they can raise the recommendation higher at this point. ACOG also does not find a definite link between caffeine and preterm birth.  More research is needed to see if there is a correlation between caffeine and intrauterine growth restriction. 

I keep seeing a reference to the World Health Organization recommending less than 300mg per day, but I have yet to find this in a document.  The only thing close was a WHO European document from 2001, recommending intake be no more than 3-4 cups of coffee a day.  (If anyone finds a proper source, please let me know!)

While ACOG looked at two large studies in regards to caffeine and miscarriage, a recent meta-analysis included 14 studies.   The authors' conclusion was high levels of caffeine consumption (>350mg per day) was related to increased miscarriage risk. 

In looking at low birth weight, another meta-analysis found that high levels of caffeine were associated with lower birth weight.  High level was not defined.  13 studies were included.

This was the only study I could find related to a possible increase risk of preterm birth.  It seems there might be an association between preterm birth and Japanese and Chinese Tea; soft drinks and coffee did not have the same effect.

It appears that 200-300mg of caffeine a day is safe during pregnancy.  Knowing this, it is a good idea to consider all sources, and know the amount you consume. 

For someone who personally loves coffee, limiting my consumption during pregnancy is tough, especially once the nausea subsides.  Part of the love is related to the feeling of a warm mug in hand, so I try to find some substitutes.  I will make my coffee half decaf.  And while drinking a cup of total decaf coffee is often not palatable, I do like decaf black tea.  This year I have tried hot water with lemon and honey.  Though not my loved cup of coffee, overall it hits the warm mug in hand spot. 

Thoughts of caffeine?  Any good substitutes you have found?

A Taste of Ina May

I hope that you have heard of Ina May Gaskin.  She is an amazing woman who became a midwife on a commune in Tennessee.   This TEDx talk just scratches the surface of her passion and work.  I encourage you to check out anything she has written or videos about her work and life.  

On her website can you more information about the books she has written.  inamay.com

Enjoy and let me know what you think about Ms. Gaskin!

Anemia During Pregnancy

During pregnancy you may be tested to see if you are anemic.  The blood count level your provider is most often looking at is your hematocrit/hemoglobin levels.  The criteria for anemia changes during pregnancy, as your blood volume changes. 

The American College of Obstetrics and Gynecology recommends that women who are anemic during pregnancy have further work-up to determine the source.  If you are borderline anemic or have struggled with anemia in the past, you may want to attempt to increase your iron stores if a work-up isn’t indicated. 

When looking up ways to increase your iron intake, you may have heard that calcium interferes with the absorption of iron.  However, it actually seems like the evidence is unclear.  In the immediate sense, calcium does block the absorption of iron, but the long-term effect does not seem to have a strong negative impact.  On the flip side, Vitamin C (ascorbic acid) has been shown to increase the iron absorption.  It is easy enough to find a list of high iron foods, but where do you go from there. 

Because the evidence is unclear, moving from information to intake can be a little perplexing.  Adding extra iron to your diet might be enough without changing your calcium/Vitamin C intake if you are looking to make a slight bump in your numbers.  But what if you want to go a step further?  It would seem reasonable to consider adding in one or two high meals or snacks that maximize the absorption.  Here are a few suggestions to potentially increase the amount of absorption:

Leafy green salad: Skip the cheese and dress with lemon juice and oil.  Top with chickpeas, pumpkin seeds, and broccoli, perhaps raisins for a touch of sweetness.  Making this for dinner, and top with steak.

Chili: Find a ground beef recipe that is heavy on the beans.  Again skip the cheese and consider avocado as a topping.  If you can’t live without the creaminess, use sour cream instead of cheese.  If you stick with the two tablespoon serving suggestion, the amount shouldn’t change the iron absorption. 

Hummus: Made from chickpeas, hummus is rich in iron.  Squeeze a little extra lemon juice on your serving.  Not feeling the hummus, try eating the beans whole as a snack. 

Simple switches:

Soup for lunch? Consider lentil, black bean, or a broth based one that includes beans.

Cereal for breakfast? Check out the labels on your favorites.  Go for the one that has the highest iron content. 

Craving a little sweet?   While I wouldn’t use the iron content as an excuse to indulge, if you are going there anyway consider dark chocolate.  Real black licorice candy also contain a small amount of iron.  

Apparently spices such as thyme, parsley, and cumin can also add to your iron intake. 

In general, babies take what they need from mom, so unless she is severely anemic the baby will still be able to build enough iron stores for after delivery.  However, if mom’s levels are already low, it could mean that mom is the one left in need.  Making small diet changes can help increase mom’s iron stores, letting her feel less depleted. 

Listening to Mother's III

Have you heard about the Listening to Mother's surveys?  In 2013 the third report was published, where over 1000 women in the United States were interviewed about their childbirth experience.  This report gives a snapshot of the state of maternity care in the United States.  

Some of the results are mind blowing!  One of the most startling results was about women being told their baby would be "big" at the end of their pregnancy.  In the shared decision making section, 32% of women reported they were told their baby may be big.  The majority of these mother's said their practitioner brought up an induction (62%) and 44% reported a discussion about cesarean.  In the end, the average size of the baby's actual birth weight was 7lbs 13oz.

Another startling response was that 47% of first time moms reported being induced.  Almost half! 

In teaching childbirth classes, there is often this disconnect where you sometimes feel like you are teaching women to fight for their rights.  Many elements in this report underscore the importance of women learning to be advocates for their care.  But is that fair?  Should a woman in labor or at the end of her pregnancy be expected to stand her ground when it comes to unnecessary interventions, or rather should it be expected that she will be offered good quality care based on evidence and putting her first?

I encourage you to check out the results and consider the state of maternity care in the US.

Episiotomy or Not?

Episiotomy use in the United States has decreased dramatically in the last few decades.  In the year 2000, about 30% of women still underwent an episiotomy during delivery.  Currently the recommendation is that episiotomy should not exceed 5-8% of use during vaginal deliveries.

So what is an episiotomy?  Essentially it is a cut made is the delivering woman’s vaginal opening while she is pushing out the baby.  Historically, there were thought to be multiple benefits to this procedure.  Most, if not all, have not been supported by research.  In fact, woman who have an episiotomy tend to have more pain after delivery (and during the procedure!), further risk of tearing, and increased risk of pelvic floor dysfunction to name a few disadvantages to the procedure.

In 2006, yes 10 years ago, the American College of Obstetrics and Gynecology recommended against the routine use of episiotomies.  However, what we in the obstetric world know is this varies greatly by physician practice.  In fact, some research has found that private practitioners (as opposed to residents or hospital based physicians) have the highest rates of use.   

There are very few acceptable reasons for an episiotomy and even those aren’t always concrete.  I think most practitioners would agree that if a baby is in distress and the episiotomy will expedite the delivery, then yes an episiotomy is appropriate.  However, another reason often considered acceptable, is to prevent severe maternal perineal tearing.  This benefit would be difficult to prove.  How does the physician know how severely the woman will tear?  I haven’t heard or read a good prediction of tearing yet.

It is important to ask your practitioner what their episiotomy rate is.  They should know the answer to this question.  And if they claim they don’t, ask “50%? 33%? Less than 10%?”  Then I think the next question is, when would you do an episiotomy?  They should speak to expediting delivery when the baby is in trouble.  If you hear, “easier to repair, protect the pelvic floor, or every first time mom needs one” this should raise some red flags. 

Feel like you need more information about episiotomies? This is a summary of the ACOG recommendation.

Choices in Childbirth has more information about the procedure itself and how to potentially avoid the procedure. 

Pregnancy and Infant Loss Remembrance Day

Pregnancy and infant loss affects more families than is probably realized.  It is the grief, especially in pregnancy, that often goes unnoticed or perhaps ignored.  Today we remember.  We remember those who may never have had a breath, a heartbeat or a voice, whose lives ended far too soon. 

And to the families who lost their babies, their hopes and dreams, we are so sorry.  We know the words we say will never change your situation or make it all better.  We can only hope you may rest in the comfort of a community who supports you and acknowledges your great loss. 

Today October 15th, we pause on Pregnancy and Infant Loss Remembrance Day, and we remember. 

Can Pregnant and Breastfeeding Women Eat Honey? Yes!

Finding the reason why it is ok for pregnant and breastfeeding women came from an understanding of why infants should not eat honey.  Let me lead you through what I found.  It was hard to find a single scholarly source of the risks to infants under 12 months, and it took reading a few to have a complete understanding.  This online resource from Kid's Health had the best overview based on all the reading I did. 

All honey carries the risk of being contaminated with spores from a bacteria that causes the illness infant botulism.  The digestive tract of a baby under one year old is immature in several ways.  Infants do not have all the normal flora (healthy bacteria) of an older child or adult to compete with the bacteria spores that cause botulism.  The spores are then able to set up shop in the infant’s digestive tract.  Additionally, the pH and decreased mobility of the infant’s bowel may also place a role in their susceptibility.  

Adult botulism from food ingestion is extremely rare.  The digestive tract of adults and child older than 12 months is able to move the spores out before they can cause harm.  Thus honey is considered safe for pregnant and breastfeeding women. 

While the number of cases of infant botulism remains low, less than 100 per year, avoiding honey is a smart tip to protecting your little one.  Infants do not need honey and avoiding is generally easy.  However, it is good to note that cooking or baking the honey will most likely not destroy the spores (need to boil for 20-30 minutes). 

In addition, after all of my reading, I would probably avoid feeding a baby under 12 months home canned vegetables for the first year of life.  This is not something we routinely eat, so avoiding would be easy for me.  If you do consume home canned vegetables, make sure the cook is following proper canning techniques and it may be best to boil before consuming.  This resource has more details

http://goo.gl/UkSJY6

Pregnant or breastfeeding?  Eat your honey!  Under the age of one?  Steer clear!  If you do find out your little one consumed honey, don’t panic.  While the risk is low, I would keep my eye out for any concerning symptoms mentioned in the first link, as it could take up to one month for symptoms to present.