When is the fetus better off outside the mother's uterus, and if so, how should that be brought about?

Abstract: Smith (2003) found unexplained stillbirth occurs once in 2000 births (0.5/1000) after 34 weeks among low risk second pregnancies, following a first vaginal birth in the absence of induction for postdates.  If induction for postdates could prevent stillbirth by expediting the deliver, one would expect to save 0.5/1000.   Four systematic reviews performing meta-analysis of the data regarding the effect of induction for postdates draw three different conclusions.  Cochrane (2012) concludes that inducing at 41 weeks can prevent 1 stillbirth/perinatal death for every 410 inductions or 2.5/1000 perinatal deaths, a number exceeding the rate of unexplained stillbirth at term without induction. Hussain (2011) looking at inductions after 41 weeks concludes that performing  inductions at 41 weeks does not prevent stillbirth but does prevent 1 perinatal death in the first week of life for every 650 inductions (1.5/1000) performed. None of the studies look at mortality after 7 days. Therefore it is not known whether those 'saved' babies die after the one week mark.  Wennerholm (2009) and Sanchez-Ramos (2003) look at the same data for inductions after 41 weeks and found no evidence supporting induction for postdates, stating, that induction for postdates is not supportable from a scientific point of view.   There is limited and inconsistent data suggesting that induction might improve outcomes in the cases of: Postdates, Oligohydramnios, Suspected worsening of fetal anomaly at 34-39 weeks, Fetal Demise, Multiple gestation with fetal death, Poorly controlled diabetes, Hypertension at 38-39 weeks, Maternal Chronic Pulmonary disease, Maternal Chronic Renal disease, Intrahepatic cholestasis of pregnancy, Mild (after 37 weeks) or Severe (after 34 weeks) preeclampsia,  Isoimmunization, and Premature rupture of membranes-  after 34 week. There is a complete lack of research evidence suggesting that induction improves outcomes in the case of: History of unexplained stillbirth after 39 weeks, logistical such as distance from hospital or risk of precipitous labor, Antiphospholipid antibody, severe growth restriction or chorioamnionitis. Consistent reliable evidence is lacking for all justifications for induction.

   Although unexplained intrauterine growth retardation is related to smoking, drugs and alcohol, missing nutrients or micronutrients and/or stress, that is not where obstetrics looks to improve outcomes.  Instead of refusing care to heavy smokers or using frequent visits to enforce life style changes in nutrition and exercise, the protocol is to do Doppler velocimetry to measure the velocity of fetal blood flow for pregnancies at high risk of suspected intrauterine growth restriction (IUGR).

  In 1995 Alfirevic called Doppler velocimetry 'promising'.( Alfirevic 1995) But after it had been studied on 10,225 at risk pregnancies, the 2010 review by Alfirevic found the effectiveness of Doppler velocimetry questionable due to the poor quality of the studies and publication bias. (Alfirevic et al. 2010)  Only small retrospective studies of extremely low birth weigh babies reflect a possible benefit of Doppler studies. (Chalubinski 2012)   

  IUGR is said to be the result of an undefined term called: placental insufficiency. This appears to be an undefined catch all phrase for lacking an explanation for stillbirths.  Placentas might always be sufficient.

It's hard to compete with 20 billion years of evolutionary selection, but the current medical management of the birth of the fetus and the placenta attempts to do just that, albeit rather unsuccessfully.   For eons, all animals including humans passed on genes and habits that ensured delivering a live healthy newborn without bleeding excessively or dying of postpartum hemorrhage at birth.  Among mammals, bleeding to death would not result in successful reproduction, until recently, because a live mother was required to nurse the newborn. 

Bleeding heavily makes a mother more prone to dying of infection.   Bleeding would attract predators near the newborn. No animal or mammal, other than humans, bleeds more than a spoonful postpartum. (1)  Only humans bleed and only humans bleed excessively after birth.   It is not clear when this started, but the first documentation of excessive postpartum bleeding, not death from bleeding, is from 1400 stating, "Women sometimes bleed too much after childbirth and this makes them very weak."(2)

Abstract: A recently coined term, unneCesareans, describes the mode of delivery for 25% of low-risk first births in most Western countries. Evaluation of Cesarean Delivery, published by the American College of Obstetricians and Gynecologists (ACOG) showed a lack of evidence of improved medical outcomes with the widespread use of cesareans for low-risk, full-term first births, therefore, they are medically "unnecessary". Eighteen causes for this common practice have been documented in published research. Since UnneCesareans have multiple causes, a reverse in current trends is unlikely.

When I tell people that I am a homebirth midwife, they often respond by asking, "Why do women choose to give birth at home?" It would be wonderful if the answer would be that hospital outcomes are comparable to attended homebirths and homebirth is just more comfortable. But since US hospitals delivered 32% of low-risk women by cesarean surgery since 2007 and 1 in every 3000 of those died from the surgery, the answer is simple: to avoid dying in childbirth or being scarred for life by unnecessary surgery.

Then, the second question the listener naturally asks is, "Why do doctors do unnecessary surgery?" Many doctors and midwives are also concerned with this question and have researched it extensively. The following is a review of the recent research, most of it published since 2006, regarding the causes of unneCesareans.

How often does Amniotomy cause Cord Prolapse after 36 weeks?

Judy Slome Cohain, CNM

Abstract

Of the 33 English-language studies evaluating risk factors for cord prolapse, close to 80% evaluate every possible factor other than artificial rupturing of the membranes (amniotomy).  Of the 7 studies which evaluate amniotomy, 2 observational studies concluded amniotomy can cause cord prolapse, while 5 case controlled studies conclude amniotomy does not cause cord prolapse on the basis that amniotomy does not always cause cord prolapse, which is invalid logic.  Not looking before you cross the street also does not always result in being run over.  Intercourse with a woman with AIDS does not always result in contracting AIDS, but to conclude that AIDS is not transmitted by sexual intercourse is incorrect.  A comparison of amniotomy rates to cord prolapse rates at full term births found cord prolapse to increase with increasing amniotomy rates near term. Cord prolapse did not occur among 6000 attended full term labors when no vaginal exams or amniotomy were performed.

Cord prolapse, a cause of permanent disability and death, can be caused by amniotomy at or near term. To achieve optimal neonatal outcomes, the amniotic sac should not be ruptured artificially to speed up labor or induce labor.

Since the beginning of hospital birth, research supporting its use for low risk women has been lacking. The last 15 years has produced 17 studies all supporting attended planned homebirth as safer for low risk women. 

Research reveals that there are only 2 acute conditions that might occur at homebirth in which the mother or baby may have a better outcome had they planned a hospital birth, namely: Cord prolapse and Amniotic Fluid Embolism (AFE). Although tragic, cord prolapse and AFE occur rarely at homebirth, 1/5000 and 1/500,000 respectively, when balanced with the dozens of acute emergency conditions endangering the health of mother and baby that occur at planned hospital birth caused by intervening in the birth process, the scales tip easily in favor of planned attended homebirth for low risk women.  Acute conditions caused by hospital birth are discussed here, to allow low risk women to make informed choices as to place of birth.

Abstract: Case controlled studies show no benefit to inducing for postdates. Routinely inducing for postdates is based on 3 uncontrolled, retrospective studies showing 1/1000 less stillbirths while ignoring possible increases in brain damage to newborns as a result of induction. Induction or Elective cesarean for Precious pregnancies is justifiable.

Summary: To date, bioeffects studies in humans do not substantiate a causal relationship between diagnostic ultrasound exposure during pregnancy and adverse biological effects to the fetus. However, all epidemiologic studies were conducted with commercially available devices predating 1992, having outputs not exceeding 94 mW/cm2, whereas since 2002 obstetric ultrasound devices are allowed by the FDA to reach 720 mW/ cm2. Available evidence is insufficient to conclude that there is a causal relationship between obstetric diagnostic ultrasound exposure and adverse effects to the fetus. However, all agree there is a need for further investigation of potentially adverse developmental effects. Ultrasound produces heat in the tissues it irradiates. The fetus before 10 weeks has no blood circulation and therefore is unable to rid itself easily of the thermal effects of ultrasound until after 10 weeks gestation. The FDA in 2002, the SOGC in 2005, The American Academy of Family Practitioners in 2009 and ACOG in 2009  all agree that because of the potential for 'adverse effects’, prenatal ultrasound should not be offered or used routinely.  It is revealing that the term adverse effects is always used in favor of "dangers" of obstetric ultrasound.  A search for "Danger obstetric ultrasound" comes up with 0 hits on Medline whereas "Danger radiation" produces over 400."

Risk-benefit issues are extremely important in clinical practice. In situations where risks of adverse effects appear so low and clinical benefits are great,  there is no justification to withhold the use of ultrasound.

In the following cases, the benefits outweigh the possible risks:

1) To Turn Breech:  If the baby is breech, ultrasound dramatically improves outcomes of external version at 37 weeks.  When attempting to turn breech fetus without ultrasound, every once in a while a head down baby is turned to breech by accident.

2. Locating Placenta Before vbacs: To confirm placenta is not located in the scar, at term, prior to attempting vaginal birth after cesarean.  Fifty years ago, placenta accreta was rare, occurring 1 in 3,300 births.(Esh-Broder 2011) .   Today, the rates are much higher.  The highest reported rates are for IVF births for which the reported rate of placenta accreta in 1/60 (Esh-Broder 2011).  After one cesarean, the reported rate of placenta accreta is  between 1 in 150 to 1 in 300.(Marshall 2011)  If the placenta is deeply imbedded in the scar, then during repeat CS, the surgeons can attempt to save the uterus, or at least save the woman before she bleeds to death.  Placenta accreta is a known risk for hysterectomy but the actual rate of hysterectomy in the presence of placenta accreta has never been reported.

[Reprinted with the explicit permission of the author, J S Cohain. In-links added by GreenMedInfo.com. © 2003 Midwifery Today, Inc. All rights reserved.]

by Judy Slome Cohain, CNM

Garlic kills yeast. Those who bake bread know not to add garlic while the dough is rising or it will kill the yeast. Instead, garlic is added to the dough after it has risen, just before baking it in the oven.

A fresh garlic clove can easily cure a yeast infection. The trick is to catch the infection early. A woman who suffers from frequent yeast infections knows the feeling well. The first day, she feels just a tickle of itchiness that comes and goes. The next day, or sometimes two or three days later, the vaginal discharge starts to look white and lumpy like tiny bits of cottage cheese. By this time, she has a full-blown yeast infection and the lips of the vagina are often red and sore.

If a woman can pay attention to the first tickling of the yeast infection, she can use the following treatment. Take a clove of fresh garlic and peel off the natural white paper shell that covers it, leaving the clove intact. At bedtime, put the clove into the vagina. In the morning, remove the garlic clove and throw it in the toilet. The garlic often causes the vagina to have a watery discharge. One night's treatment may be enough to kill the infection, or it might have to be repeated the next night.

Continue one or two days until all itchiness is gone. The reason that the treatment is done at bedtime is that there is a connection between the mouth and the vagina. The moment the garlic is placed in the vagina, the taste of the garlic travels up to the mouth. Most people will find this strong flavor annoying during the day, so the treatment is recommended for nighttime.