The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS,
a homebirth midwife in Mountain View, CA
|
If you know any birth attendants who are still practicing premature clamping and cutting of the cord, encourage them to watch this video of a grand rounds with Dr. Nicholas Fogelson at USC. It's got lots of research and an open-minded perspective. |
Does anyone know if there is a recommendation re: following cervical
length if a woman has had a full term pregnancy since a LEEP or
conization
without problems, and is now pregnant again?? Is it recommended
to
still follow cervical length in this pregnancy??
I think it varies by clinician but I recommend a 'baseline'
measurement
at 12 weeks followed by a comparison when routine 20wk anatomy scan is
performed. If cervix is found to < 3cms and/or a significant
interval
change occurs, then increased surveillance would be indicated (which
would
be clinically coordinated based on the individual hx). IMO the
most
period is 24-28 and the time when patients with increased risk for
associated
'incompetent cervix/PTL' would typically declare.
Amniotic
fluid
index rejected for biophysical profile [20 July 2004] - The
amniotic
fluid index has both low specificity and sensitivity for identifying
women
with oligohydramnios at risk of cesarean delivery for fetal distress.
Feb. 7, 2003 (HealthScoutNews) -- A low level of amniotic fluid in the last trimester of a pregnancy, often thought to be sufficient cause to induce delivery, is not reason enough to do so.
Johns Hopkins researchers who studied the health of more than 250 babies born at 37 weeks of gestation say they found that babies whose mothers had low levels of amniotic fluid were of normal size. And the babies had no greater risk for health problems than babies whose mothers had normal levels of amniotic fluid.
"This study indicates that we don't want to intervene because of a Amniotic Fluid Index (AFI) of less than five if everything else is normal," says study author Dr. Ernest M. Graham, an assistant professor of gynecology and obstetrics at Johns Hopkins University.
Graham presented the results of his study on Feb. 7 at the annual
meeting
of the Society for Maternal-Fetal Medicine in San Francisco.
Perinatal
risks
associated with borderline amniotic fluid index.
Banks EH, Miller DA
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1461-3
The researchers conclude that borderline amniotic fluid index merits careful attention and twice weekly antepartum testing.
Does
an
amniotic fluid index of </=5 cm necessitate delivery in high-risk
pregnancies? A case-control study.
Magann EF, Kinsella MJ, Chauhan SP, McNamara MF, Gehring BW, Morrison
JC
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1354-9
High-risk pregnancies with an amniotic fluid index of </=5 cm appear to carry intrapartum complication rates similar to those of similar high-risk pregnancies with an amniotic fluid index of >5.
Midwifery Today, Autumn, 1999, carries a discussion of the apparent
contradiction in these studies and suggests that midwives need to take
many factors into account in deciding when to intervene during
pregnancy
and delivery.
Pregnancy
outcomes
after antepartum diagnosis of oligohydramnios at or beyond 34
weeks' gestation. [Medline
entry]
Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twickler DM, Ramus
RM, Leveno KJ
Am J Obstet Gynecol 2000 Apr;182(4):909-12
We believe that neither our results nor similar results reported by others necessarily prove that antepartum oligohydramnios requires intervention, Dr. Casey's group writes. They note that the amniotic fluid index measurement is not precise, and that individual physicians have their own thresholds for interventions.
OBJECTIVE: The purpose was to summarize five cases where subtotal
immersion
was associated with an increase in the amniotic fluid index. STUDY
DESIGN:
Five women with oligohydramnios, as defined by an amniotic fluid index
< 8 cm, who underwent subtotal (shoulder-deep) immersion therapy are
described. RESULTS: The mean pretreatment amniotic fluid index was 4.9
+/- 3 cm. After immersion therapy was instituted, the amniotic fluid
index
increased an average of 6 +/- 2.2 cm. In three subjects whose immersion
therapy was discontinued, the amniotic fluid index fell an average of
4.7
cm. CONCLUSION: Subtotal immersion may help reverse oligohydramnios
stemming
from uteroplacental insufficiency.
This is the 1st that I've heard of immersion for this purpose, but
does it occur in a heated pool? i.e. to increase the vascularity/flow
to the placenta? (I may be way off here... like I said, 1st I've heard
of any of this...) But it sounds like an interesting concept....Good
idea,
if it works.....(and they told me to stay out of the hot tub while I
was
pregnant.....)
Could this possibly be due to lowering of pressure on the cervix? Or
pressure on the placental blood vessels? I find this
interesting....thank
you.
I think it's due to the pressure exerted by the immersion fluid on the body, which raises interstitial fluid pressure, causing it to flow back intravascularly, in essence raising the intravascular volume (i.e., hydration) and causing increased uterine blood flow.
Doesn't everyone have to pee when they stay in a swimming pool for
about
20 minutes?
In the Sept/Oct issue of JNM, Michel Odent explains that the mechanism causing the pee-in-the-pool phenomenon is more than just a pressure gradient/increased perfusion thing:
A similar, though less potent effect can be observed in a patient
who
is confined to bed rest, where increased venous return from the lower
extremities
results in greater cardiac output, a higher glomerular filtration rate,
and a greater volume of urine output.
From Patty Brennan's Guide to Homeopathic Remedies for the Birth Bag, Fourth Edition:
"Too much fluid will keep the baby buoyant and the uterus overextended, so the baby can just float into an undesirable position. Too little fluid will likewise be problematic as the breech baby will not have enough buoyancy to turn. If fluid levels seem to be off in either direction, try the water-balancing tissue salt Natrum Muriaticum. Suggested regimens for varying potencies are as follows (see what works for you):
6X 3 times per day for 1 week or
30C 2 times per day for 3 days or
200C once per day for 3 days or
1M once"
Someone recently mentioned to me that when a pregnant woman sleeps
on
her back it disturbs the body's ability to get oxygen to the baby. It
sounded
very odd to me. Has anyone heard anything like this or that any
particular
sleeping positions interfere with the flow of oxygen or are bad for the
fetus?
If a woman sleeps on her back she is cutting off blood circulation
from
the large artery that runs along the back... Being on one's back
for very long can be very uncomfy for a pg woman
Actually, I think it is the inferior vena cava. And yes, by sleeping on the back a woman can cause the blood flow to be diminished.
That being said, I don't tell my ladies one way or another.
They
usually tell me. Many women just cannot lie on their back.
But some find that they always wake on their back and they are
concerned
because the books say they shouldn't. I tell them not to worry
about
it because if it bothered the babe, it would bother her and she just
plain
would/could not do it.
A woman in late pregnancy, when she lies on her back, can cause some compression of the vena cava-the main vein going to the trunk of the body. For some, not all, this causes discomfort and a feeling of lightheadedness due to constriction of blood flow. If you are constricting blood flow from that area, you are also slowing all circulation in the area, so you would also be possibly cutting some circulation of oxygen to the uterus, I imagine.
I think for most women, though, it is something they will feel
themselves
and be uncomfortable with if it is a problem for them. Even
slightly
elevating the shoulders or being slightly to one side can alleviate
this,
if she still wants to be on her back.
I agree that it makes sense to keep a laboring woman off her back.
But is there really any evidence that sleeping on your back causes any harm to the baby? Some of my clients are inveterate back sleepers, and they feel SO guilty about it. I have done some searches and not found any research about this, which is what I tell them.
I also figure that if their sleep position is causing circulation problems, they're going to wake up with swelling in their feet and legs, which would be a good reason on its own to change sleep positions.
I think of this issue as one of those "old midwives' tales", and I'd
love to see any actual research on the subject.
I agree. While Supine Hypotension can be a problem during labor, it is really not an issue before that time. Common sense tells you that if a woman has circulatory interruption before labor, she will experience symptoms - i.e. dizziness, edema, nausea, etc. - what I lovingly call "the beached whale" symdrome.....and she will change positions to eliminate that feeling.
During labor, however, with the demands of the uterus, the supine position can aggravate the compression of the inferior vena cava, and drop the blood supply available to the contracting uterus. So, avoid the position- simple solution to obvious problem.. NO laboring woman would ever assume the supine position voluntarily, because she would shortly feel the above mentioned symptoms and change positions so she could breathe, and work more efficiently.
Over the years, I have seen research on Supine Hypotension during
labor,
but never before labor.
I believe that if you are one of the ones who has that O2
deprivation
you will know it because you get either faint or sick to your
stomach.
Some of my ladies can't sleep any other way, and I say their baby will
tell them if it doesn't like that particular position. There
CAN'T
be a rule, an absolute. What did women do (and still do) when
they
didn't have someone to tell them all these "musts"? They
figure
it out. Right?
The link between sleeping on your back and trouble for the baby can clearly be inferred from the data which does exist. If we know an awake mom can have supine hypotensive syndrome (and the data is clear, then why would she NOT have it when she sleeps? The mechanism still exists and I can't think of anything about 'sleep" which would change that..
I say it's probably better to sleep on their sides, but if they were made as back-sleepers then that's probably what's best for them. Our particular bodies are our best guides for what's best.
And the condition only occurs pretty late in pregnancy when many women aren't at all comfortable sleeping on their backs any longer.
But.. I also tell them how easy it is to prevent any potential problem. All one has to do is get a slight tilt to the pelvis -- so a little pillow, or folded blanket or soft towel wedged under one hip does the job. Easy fix. No worries.
Swelling in the legs isn't a reliable indicator of supine
hypotensive
syndrome. It's not that type of circulation. It's a lowering of the
blood
pressure
which can affect placental flow and fetal heart rate (we see this often
when moms labor on their backs because we are monitoring then). There
shouldn't
be any effect on swelling of hands or feet.
I tell folks no to worry too much about it, because the affects are
mild in most people -- not existent in some people -- and are only
extreme
in a minority of people. But it's so easy to sleep comfortably in other
positions -- or even on the back with a little pillow on the side --
that
I think it's worth recommending. But if moms can't or wont do it -- I
have
no worries.
OK, I broke down and looked in PubMed:
Influence
of
compression of the inferior vena cava in the late second trimester on
uterine and umbilical artery blood flow.
Ryo E, Okai T, Kozuma S, Kobayashi K, Kikuchi A, Taketani Y
Int J Gynaecol Obstet 1996 Dec;55(3):213-8
CONCLUSION: The inferior vena cava is compressed in the majority of pregnant women in the second trimester, and the compression may affect the uterine artery blood flow but not the fetal circulation.
Semi-Fowler's
positioning,
lateral tilts, and their effects on nonstress tests.
Moffatt FW, van den Hof M
J Obstet Gynecol Neonatal Nurs 1997 Sep-Oct;26(5):551-7
CONCLUSIONS: No statistically or clinically significant differences were found in nonstress tests between the three groups. Lateral tilting did not shorten test time. Results do suggest that hemodynamic changes can occur in 3rd trimester women who are in semi-Fowler's position without a lateral tilt. Lateral tilting of gravidas in semi-Fowler's position during nonstress testing is thus supported to avoid hypotensive symptoms.Maternal and fetal effects of the supine and pelvic tilt positions in late pregnancy.
Neither the left or the right pelvic-tilt position was associated with a significant change in leg blood flow or maternal heart rate compared to the supine position. A possible 'sluice' effect in the placental circulation was not confirmed, as fetal heart rate and umbilical Doppler resistance did not change in any position. . . . Leg BP and Doppler ultrasound measurements of uterine artery resistance may not be adequate measures of the effect of posture on uteroplacental perfusion.
And . . . just when you thought it was safe to sleep standing up:
The
oscillating
'vena cava syndrome' during quiet standing--an unexpected observation
in late pregnancy.
Schneider KT, Bollinger A, Huch A, Huch R
Br J Obstet Gynaecol 1984 Aug;91(8):766-71
While studying the lung function of pregnant women at term in four different postures, we were surprised to note marked cyclic accelerations in the heart rate in two-thirds of the women when in a standing position. . . . About 70% of the fetuses showed reduction in the long-term variability, increase in fetal heart rate or periodic accelerations. Although no woman fainted during quiet standing, the maternal circulatory changes were consistent with those seen in the classical vena cava syndrome.But it is safe to sleep on your belly!!! All I can say is that these researchers have never been pregnant!
Effects
of
maternal prone position on the umbilical arterial flow.
Nakai Y, Mine M, Nishio J, Maeda T, Imanaka M, Ogita S
Acta Obstet Gynecol Scand 1998 Nov;77(10):967-9
"The maternal prone position can provide complete relief of uterine compression of the large maternal vessels. "
From Physiology in Childbearing by Dorothy Staples:
"Aortocaval occlusion - The alternative name for aortocaval occlusion is supine hypotensive syndrome. Bevis (1996) believes this is misleading as the fall in blood pressure is a late sign nd reduced placenta perfusion will have occurred before the drop in maternal blood pressure. a reduction in venous return and a fall in cardiac output are produced by the weight of the gravid uterus pressing on and partly occluding the inferior vena cava. It will occur whenever the woman lies supine in late pregnancy. If fetal distress is present the interference with placental circulation will increase the severity of hypoxia.
"Prevention - If the woman has to lie supine the sequence of events
can be avoided by placing a folded blanket or a small rubber wedge
under
the mattress to tilt her body 15 degrees to the left. Modern
operating
tables and delivery beds have this function built into their
design.
Enkin & Wilkinson (1997) reviewed the use of lateral tilt during CS
but found the data to be poor. However, they stated that low
Apgar
scores were fewer and neonatal pH measurements and oxygen tensions
appeared
to be better if lateral tilt was used. [This is from the poor
research.]"
Summary of the issues: avoid hot tubs in the first trimester, and then use common sense in enjoying them in the second and third trimesters.
NOTE - Exposure to heat is only a problem if it raises your body
temperature.
In general, if the water temperature is at or below normal body
temperature,
then it will not cause any problems, so pregnant women can still enjoy
warm baths. If the water temperature is too warm, then you will
start
sweating to try to cool down; if this happens, then you're too hot, and
you need to cool down the bath or get out of the water.
Doppler
flow
measurement of uterine and umbilical arteries in heat stress during
late pregnancy.
Vaha-Eskeli K, Pirhonen J, Seppanen A, Erkkola R
Am J Perinatol 1991 Nov;8(6):385-9
"The effect of a moderate heat stress (20 minutes 70 degrees C) on uterine and umbilical artery blood flow was studied . . . The fetuses of healthy pregnant women are not compromised during or after moderate thermal stress."
In language that most people can understand, this means that if you spend 20 minutes at 158 degrees Fahrenheit (which is really, really hot, even hotter than El Paso, Texas!), your baby will still be fine. Even assuming that this was dry heat (the least stressful on the body because the woman's perspiration would cool her down), this is still very, very hot.
From a practical point of view, you can note that this level of heat
stress caused an increase in the woman's pulse of 26 beats/minute on
average.
A conservative approach to using hot tubs would be to check your pulse,
and if it increases more than 20 beats/minute after 20 minutes, get out
and cool down a bit, and then get in and enjoy yourself some more!
Maternal
heat
exposure and neural tube defects.
Milunsky A, Ulcickas M, Rothman KJ, Willett W, Jick SS, Jick H.
JAMA. 1992 Aug 19;268(7):882-5.
CONCLUSIONS--Exposure to heat in the form of hot tub, sauna, or
fever
in the first trimester of pregnancy was associated with an increased
risk
for NTDs. Hot tub exposure appeared to have the strongest effect of any
single heat exposure.
One of my clients called reporting something coming out of her
vagina.
I went and saw her and yup, it was her cervix. She is 13 weeks.
This should resolve when the uterus grows 'up and over' the pubes @
~16-18 wks (depending on maternal habitus/uterine growth) Meanwhile,
avoid
any activities which have potential valsalva, I'd substitute some? of
the
Kegels for the knee-chest posture prn, watch for UTI d/t potential
urinary
retention.
Sea
Pearls
Sea Sponge Tampons can be used to support a prolapsing uterus.
Retroverted
Uterus
more likely to become incarcerated in second trimester.
While apprenticing, I assisted with an Amish woman with a bicornate uterus through three pregnancies, and know of the outcome of her first and fifth pregnancies as well.
First pregnancy ended up in spontaneous abortion at 16 weeks.
Second pregnancy was a term breech presentation at home. uncomplicated.
Third baby born vertex at home at about 34 weeks gestation, no complications, precipitous labor, we missed the birth by about 7 minutes. Bicornate uterus was discovered during fundal massage in fourth stage of labor.
Fourth baby, came at about 34 weeks in footling breech/sort of transverse position with umbilical cord dangling down around the presenting part. Transferred to hospital at 8cm, BOW intact, Baby born vaginally w/o complication within 10 minutes of arrival at hospital.
Fifth baby born by C-sec, at 30 weeks with abruptio placenta.
[from ob-gyn-l]
She has conceived 2 more times, and carried to term uneventfully
twice.
She now is thinking about a 3rd child." I've told her my gut feeling is
that she would have another uneventful pregnancy, but that she still is
at a higher risk of prematurity, although probably not as high as the
literature
says given her clinical history.
I've got a nice review--"Reproductive Potential of the Anomalous
Uterus,"
Phillip Patton and Miles Novy. Seminars in Reproductive Endocrinology 6
(2):217-233, May 1988. 92 references.
It classifies the Mullerian anomalies into 5 categories and looks at
the literature on each. Unfortunately, for many categories including
bicornuate
uterus, it doesn't specifically address SUBSEQUENT pregnancies, though
the individual articles might.
Table 4 (reprinted without permission)--Pregnancy outcome in the
bicornuate
uterus
| authors | #pts | #preg | AB rate% | PTbirth% | Term% | Surv% |
|---|---|---|---|---|---|---|
| Buttram | 110 | 313 | 35 | 23 | 42 | 57 |
| Capraro et al. | 38 | 137 | 30 | 14 | 56 | 61 |
| Heinonen et al. | 44 | 98 | 28 | 22 | 50 | 63 |
The references above are:
Those references include:
My impression is that the more pregnancies they have, the more the
uterus
is "stretched out". Thus, they make their risk smaller and smaller
spontaneously.
I have a student/client with a bicornate uterus who is 29 weeks pregnant (1st pregnancy). Preterm labor is being well-managed (has stopped) with bedrest, oral terb, & cerclage (at 14wks/1cm). Having made it this far, she is now thinking ahead to delivery, and what problems she may have then.
Her OB has mentioned she is at increased risk for uterine rupture of the "non-pregnant" horn during labor/delivery. He himself admits he cannot give her percentages for this happening, but that it has happened to one of his patients with a bicornate uterus. But then, he also admits, that he has had very few patients with bicornate uterus, so his experience is limited.
Her OB will remove the cerclage at 36 weeks. He has mentioned
scheduling
a c-section to prevent rupture, but my client is concerned that this is
too drastic a decision without more information.
Leave her alone. The delivery will be natural. One is always
astonished
to see how many unicornuate or bi uterus are unknown before delivery.
I agree 100%.
I agree, she may deliver vaginally at term with no problem. I assume you will take the cerclage out at 38 weeks or so?
I have had two of these patients, both delivered vaginally. They
were
watched closely for pre-term labor, one had it; the other didn't.
Neither
had a cerclage, although I considered it and checked the literature.
Couldn't
convince myself to do it.
I concur completely. I have never heard of a rupture of the
non-pregnant
horn. It doesn't even make sense, since that is the thicker and hence
stronger
horn.
If he is concerned about rupture, then why not treat her as a VBAC.
I have read reports of rupture of a uterus without previous surgery,
but
I have never seen one. I have to think that they are very unlikely (but
not impossible). It seems that his approach is somewhat coloured
(that's
the Canadian spelling) by his past experience (as it is for all of us).
I would be just as concerned about an abnormal presentation (breech,
shoulder,
cord). I would think she should be given the option of vaginal delivery
in a setting where immediate C/S is possible.
If she presents in labor with a vertex presentation, I would let her
labor like anyone else.
If vertex, allow labor. As it has been said - we don't know how many
of these are never diagnosed because they conceive spontaneously, labor
and deliver spontaneously. If non vertex, I would hesitate about
version,
but I have tried and have taken care of one (undiagnosed as uterine
duplication
because needed no procedures) who (yes its anecdote and meant as such)
that was followed by a lay midwife, taken to two other places for
attempted
version, known to be footling breech, went into labor spontaneously at
42 weeks, known to have had a fast labor with her first baby, the lay
MW
went to her home (out in the boonies) found her to be 8 cm, then rushed
her to our hospital 'cause we were closest (she would usually use
another
hospital). Since footling breech and neither I nor my partners had
prior
rapport with her and it was footling, I did do a C/S. She thought we
were
great and came to us for her next pregnancy with a successful VBAC.
I've
taken care of another with complete duplication - First pregnancy in
side
A with normal labor and delivery. Second pregnancy in side B - She had
a First Stage that was like a "first" labor (first for that uterus) and
a Second Stage that was like a "second" labor - the vagina and perineum
had given birth before. Neat people with interesting stuff mom nature
did
to them, keeps us thinking and on our toes for all the variations we
see.
Incarcerated retroverted pregnant uterus is very uncommon, indeed many practitioners do not believe it exists. I wonder how many miscarriages are due to this. (I have no opinion, I really just wonder).
Anyway, what happens (according to the theory that I learned in a medical setting, which may be different from what midwives know) is that the fundus of a retroverted uterus gets trapped in the posterior portion of the pelvis and the uterus, as it expands, pushes against the urethra and obstructs the bladder. It can also put lots of pressure on the rectum and the nerves in the pelvis. This pressure can result in miscarriage, or the pregnancy can continue, expanding the anterior wall of the uterus--a very uncomfortable and unnatural condition.
I saw two cases of this in residency. My first clue was having a hard time finding the cervix during a speculum exam--it was very anterior and pointing posterior (imagine that the uterus is bent 90deg at the junction between the body and the cervix). Bimanual exam confirmed a firm mass in the posterior pelvis--unmistakably the pregnant fundus. Fetal heart tones could not be heard with the uterus in this position. I can't believe I have forgotten the exact details of these two cases--I know one miscarried and one had a full term baby. I think OB reduced one and I reduced the other.
To reduce the uterus: Place the woman in knee/chest position
and
push hard on the fundus. In addition, you may wish to place a
tenaculum
on the cervix so you can pull it towards the perineum. I have
felt
the satisfying "plunk" of the uterus moving into the pelvis and then
been
able to hear heart tones. I have also read about somehow using
the
same position, then introducing a flexible sac containing mercury and
allowing
this weight to more gradually reduce the uterus.
See also: Well Woman /
Uterine
Fibroids
Treatment
of
Uterine Fibroids with Complementary Medicine By Lewis Mehl-Madrona,
M.D., Ph.D.
Transcatheter
Uterine
Artery Embolization for the Treatment of Symptomatic Uterine Fibroid
Tumors [Medscape registration is free]
Uterine
Artery
Embolization for Uterine Fibroids [Medscape registration
is free]
Uterine
Vessel
Coagulation Method Shows Promise in Treatment of Fibroids [Medscape
registration is free]
Uterine Fibroids
- Natural Medical Protocols
Integrative Medicine articles about uterine fibroids:
Stress Reduction for Relief of Fibroids & Endometriosis by Susan M. Lark M.D.
Uterine Fibroids by David L. Hoffmann B.Sc. (Hons), M.N.I.M.H.
Uterine Fibroids from Naturopathy Online
Lewis Mehl-Madrona, M.D., Ph.D talks about a study they're
conducting
about uterine fibroids at Shadyside
- "We have a study under way on complementary medicine treatment of
uterine
fibroids, which has three components. Guided imagery or visualization
is
one; Chinese medicine with acupuncture and nutritional modification and
herbs is the second treatment; and the third treatment is a kind of
deep
tissue body therapy primarily related to the pelvis and We have a study
under way on complementary medicine treatment of uterine fibroids,
which
has three components. Guided imagery or visualization is one; Chinese
medicine
with acupuncture and nutritional modification and herbs is the second
treatment;
and the third treatment is a kind of deep tissue body therapy primarily
related to the pelvis and abdomen.
About Uterine Fibroids from Women First Healthcare
Uterine Fibroids from MEDLINEplus.
We were talking about non-pharmaceutical pain relief, and we talked about warm baths, and it occurred to me that a TENS unit might provide some pain relief.
Does anyone know anything about TENS use during pregnancy? Any
thoughts
on safety? Placement of the electrodes (same location as for
labor?)
I cared for my daughter-in-law with a twisted fibroid stem in pain.
A homeopath recommended colecynth 30x that cut the pain before she got
home and although' the fibroid grew until about 26/40 wks. she never
had
a problem.
I'm here to suggest hypnosis. This is a very safe and
effective
option for pain relief; no negative side effects and many positive
effects:
pain relief, constant availability, self empowerment, a
skill
with a broad range of applications that the woman takes with her
through the rest of her.
I understand the pain she is going through as I had a necrotic
fibroid
myself. I did find that pain was well controlled with Tylenol #3. The
codeine
is not that bad for the baby and it made things easier for me. Without
proper pain control she just might go into prem labor........from
the irritable uterus. Alcohol could also help. Be assured that
the pain will eventually go away probably about 30 weeks, but in the
meantime
she needs to get the pain under control!
I am looking for information on fibroid tumours during pregnancy or
more specifically what I might expect the impact of fibroids to be
postpartum.
I have a client G3P1 who has a fibroid located in the fundus of her
uterus.
My concern is postpartum hemorrhage.
What size is the fibroid?
I'm not sure. I got the impression it was 2-3 inches in diameter
when
picked up by u/s last pregnancy. This seems big to me but I have no
experience
with these at all. I can't palpate it but will try more carefully next
time. It was picked up by u/s last pregnancy. I wonder if it would be
worthwhile
for her to have an u/s now?
a 2-3 inch fundal fibroid should cause no problems at all with PP
bleeding.
The ones to worry about are those grapefruit sized ones, which are
obvious
on abdominal exam (I suppose if they were posterior you might not feel
them). If she is s=d and you can't feel irregularities, I would not
worry.
Gemmotherapy recommendations for uterine fibroids (from Dolisos):
European Ash (Fraxinus excelsior) Buds 1DH: 50-100 drops 3 times per
ay t help relieve uterine congestion
Raspberry (Rubus idaeus) Young Shoots 1DH: 50-150 drops 3 times pre
day to help with hormonal equilibrium
"SEQUOIA GIGANTEA: Prostatic hypertrophy and adenoma, uterine fibroids. " from Shrinking Fibroids with Pycnogenol
One of the studies that I haven't had time to do any serious work on lately is the use of pycnogenol, a natural proanthocyanidin extract from such sources as grape skins and pine bark.
The study will get done within the next two years, but until then, I can tell you that since there are no other nonsurgical possibilities, it's worth a try. If it works, she'll probably have about 50% shrinkage at the end of 3 months, 75% at six months, and 90% at a year. They'll probably never go away with pycnogenol but may well become symptom free. And three months isn't too long in the grand scheme of things to be doing intermittent cathing if you can save a surgery from it. As a side benefit, once we have big enough numbers, we may be able to show significant anti-cancer effect from this extract.
If she uses it, do me a favor, please, and report the details to me
so that I can incorporate the data point. Dose is 1 mg/lb body
weight/day.
Client pregnant with her 10th baby, has an umbilical hernia which protrudes about 3 1/2 inches most of the time but when she lies down she can move her stomach in such a way that it goes down to about an inch. She is 38 weeks pregnant. The hernia is not bothering her now but it bothered her quite a bit at the beginning of pregnancy. She is planning to have it surgically corrected some time after the birth.
To our questions:
I've seen these handled three ways:
One -- mom holds her hands over the area when she pushes
two -- mom wears a "wrap" during labor
three -- it is simply ignored.
The outcome has always been the same -- no problems with either approach.
I do think mom should be advised to refrain from heavy-duty pushing. She's a multip and if she wanted could probably deliver without any pushing at all -- or only the most gentle pushes. I think it'd be advantageous to "breathe" the baby out. Since she is high parity, she probably won't have more than a couple second stage contractions anyway.
Can't see how the maternal position could be relevant to anything.
I wouldn't advise trying any sort of exercise during pregnancy.
PS -- these are actually pretty common. I've seen some pretty good sized ones -- especially in high multips. I don't think I've ever heard of any problem with them -- has anyone?
I don't think they carry the same risk of intestinal protrusion as
other
types of hernia sine the peritoneum covers the area quite well.
I have only seen one umbilical hernia in a pregnant woman. and it didn't need any support. this mom had three babies with it till she got around to getting it fixed. didn't seem to bother her once she was 6 1/2 months or so.
I have run into this situation twice in the past couple of
years.
I used a wide abdominal binder on these ladies during labor for
support.
The same kind one would apply after abdominal surgery.. Cost about $13
through a surgical supply house. Might only be available by
prescription,
but you could rig one up with material. The fancy ones are
stretchy
elastic with velcro closures, and I always carry a couple of sizes with
me for my moms with pendulous abdomens. Sometimes will help guide
the head into the pelvis.
We have many women with beta thal trait. They really do quite well, and no special care is needed. You will never correct the anemia if it is due to beta thal. These women should have the normal amount of iron that other pregnant women get.
Here is a good "one stop shopping" website on hemoglobinopathies.
Management
of
ASCUS with High-Risk HPV Present in Pregnancy [Medscape
registration
is free]
If you read the above carefully, you realize that molar pregnancies can co-exist with normal pregnancy, so hearing a heartbeat doesn't rule it out, AND . . . this one kind of blew me away . . . choriocarcinoma can develop after a normal pregnancy, but is easily ruled out by a negative pregnancy test.
So . . . what does all this mean in terms of providing responsible (ethically and legally) midwifery care?
HCG levels with first lab work to rule out molar pregnancy, with or without normal pregnancy?
If done early, should they be repeated later in pregnancy to confirm
fallen levels?
Varney's suggests 100 days post-LMP if molar pregnancy is suspected.
Postpartum pregnancy test - how many days? Or would low HCG levels in mid pregnancy be sufficient.
Anyone know ACOG recommendations on all this?
I've had 2 molar pgs in my career. The deal with them is, if the pregnant mom doesn't know until, say, quickening, or, fhts heard with fetoscope, the situation can get more malignant. Early diagnosis is important which is why I try to see clients at 11 weeks to listen with a Doppler.
I understand the importance of early diagnosis of molar pregnancy, but I'm uncomfortable with frightening moms into routinely allowing me to use a doppler when they're otherwise opposed, especially when it's to try to detect such a relatively rare occurrence.
And, of course, I find myself asking what you do if you aren't able to pick it up with the doppler. Do you send all clients for a "real" ultrasound if you haven't heard FHT by 11 weeks? (Or maybe you have an U/S machine in your office?)
Do you have any ready references for the increased risk in waiting an additional 8 weeks for other positive signs of pregnancy?
I will use this information to inform my clients and expand the
ever-increasing
universe of informed consent choices.
Wouldn't it be a reasonable compromise to get HCG levels with
initial
labs? A normal HCG level would rule out molar pregnancy without
exposing
the baby to ultrasound.
I'm working with a woman who is bleeding from the nipples. It is a
bit
watery, but very much blood and she says that if she wears a sports bra
it goes through that and her shirt in a day, so this isn't a small
amount
either. Her doc has never heard of this and so she was sent to an
specialist who had never heard of it. She will get a mammogram after
the
birth, but I am thinking that it must be a tumor, but in both
breasts?
Have any of you ever heard of this?
I had a lady doing this with her first baby last year. Had
done
some breast pumping during labor and got lots of bloody discharge, and
she said that had been going on for awhile. I took her to see a
specialist
pp and he said it was normal. But if it didn't clear up in days
to
come back, but it did clear up and she breast fed.
Bleeding from the breast is rare and could be several things. Of course the mom should be referred to a physician in case she did have something serious going on or even a benign intraductal papilloma, but I would ask if she had had any breast trauma such as wearing breast shells or trying to express colostrum.
Sometimes the reason for the bleeding is not known. Chele marmet calls this "rusty pipe" syndrome. It is most common in first-time moms. It usually resolves itself and in no way interferes with breastfeeding.
Sometimes bleeding is due to warty type growths in the ducts.
They are not really tumors and do not preclude breastfeeding.
I am a La Leche League Leader and have some information about blood from the nipples.
If it helps to know that there's a benefit to profuse salivation during pregnancy, it is that it helps to keep your teeth and gums were in excellent shape!
She has tried the suggestions of limiting starchy/acidic foods,
small
frequent meals, gum, upping water consumption, various teas. Does
anyone
else have something along these lines to suggest as a way to help out
with
this problem?
Often sucking on hot (atomic) fire balls helps.
Those tiny little sherbet pip sweets helped one woman I know of for
the excess saliva.
Any thoughts what to do with pregnant women with constant
salivation?
Have a 18 week OB who must carry a cup to spit in because she has such
excess salivation. (Much as I hate to admit this, I find this
absolutely
disgusting....although I know she has no control over this, I just hate
spit. It's hard to even write this!!!!)
One of my OBs suggested an anticholinergic drug which he uses for over active bladder, and which has particularly nasty dry mouth as a side effect, but we are both reluctant to use this in pregnancy.
So how about midwifery remedies?
Some say that eating celery helps. This is recommended by
Traditional
Chinese Medicine.
Has she tried one of the really drying type of mouthwashes?
(Listerine
comes to my mind!) Also, have you talked to a dentist about ideas?
Homeopathy
might also have some remedies.
Keeping mints or hard candy to suck on sometimes helps as adjusting
starches in the diet (usually lessening). Astringent mouthwashes
are recommended, but my ladies haven't reported that this helped for
very
long. I wonder if comfrey tea would help. It usually helps
to balance mucous membranes - if they're too wet, dry them up; if too
dry,
help make them moist.
In the book, "Natural Healing for the Pregnant Woman," the
homeopathic
remedy Tabacum (I'd never heard of it) was recommended for "profuse
salivation."
It is recommended to take a 6C or 30C potency every 15-30 minutes for 3
doses, then one to four times daily.
I had this with all three of my pregnancies and have had a few clients experience it also. It is usually concurrent with not just nausea but vomiting and dehydration.
My only relief was B6 shots. In between I kept Kleenex or
paper
towels in my mouth to absorb the "fluids" :-). (I still don't like the
word SPIT.) Of course - I was too sick to go out and about - so
no
one else, outside of family, was really offended. When my husband
was going though a checkout at the grocery store with my 6 year old,
the
gal asked what all the Kleenex were for. "Oh, my mom's
pregnant!",
my daughter pronounced! I'm sure that kept the checkout gal
wondering
:-) Anyway - I feel for the gals with ptyalism - it's kind of a
vicious
circle thing.
Attached are the articles, I think are most helpful in answering these types of questions (what can we do to maximize good outcomes?)
As I mentioned in the AIM talk, there are a number of problems with these types of broad based studies
The risks associated with advanced age include:
Abruption, previa, low birth weight, preterm birth, perinatal mortality (IUFD and neonatal mortality)
The absolute risks are modest - for instance the perinatal morality in those >45 in the Jacobsen paper are 1.4%. The table (hazard ratio) from the Reddy paper is chilling >8/1000 pregnancies in those >40. in this paper the risk increased in those >37 weeks
Important to keep in mind, that most women will not have this outcome but when you compare it to those aged 20-20 (0.5%) it is statistically different.
If you look at low birth wt (and we know these babies are at a higher risk of IUFD) – again the risks are modest (Aldous – from WA state).
There is no study proving the efficacy of antenatal testing, but I do believe that is helps avoid CD, and IUFD.
UCSF recommendations for antenatal testing are attached
Jacobbsen-AMA_ObGyn2004.pdf
CnattingusS1992_JAMA-AMA_Perinatal
outcomes.pdf
AldousMB-JAMA-1993AMA-PerinatalMorbidity.pdf
ReddyU_MatAge_Stillbirth2006AmJObGyn.pdf
Fet Guide '09 short.pdf
In one of DeLee's books he makes the observation that elderly primips do as well as younger primips as long as two conditions are met:
1. the woman is in general good health with no underlying medical conditions (heart disease, hypertension, diabetes etc.)
2. the primip who got pregnant "easily" can generally expect a
better
outcome than the woman who conceives with difficulty. If a woman takes
years to conceive, then we have to wonder about her hormonal function.
If she marries late and gets pregnant in the first year, it proves she
probably has normal functions.
The
duration
of labor in healthy women.
Albers LL.
J Perinatol. 1999 Mar;19(2):114-9.
RESULTS: The mean length of the active-phase, first stage was 7.7
hours
for nulliparas and 5.6 hours for multiparas (statistical limits of 2
standard
deviations from the mean were 17.5 and 13.8 hours, respectively). The
mean
length of second stage was 54 minutes for nulliparas and 18 minutes for
multiparas (statistical limits 146 and 64 minutes, respectively).
Variables
associated with longer labors were electronic fetal monitoring,
ambulation,
maternal
age over 30 years, and narcotic analgesia. Morbidity was not
increased
in longer labors.
Expectation
of
pregnancy outcome among mature women.
Porreco RP, Harden L, Gambotto M, Shapiro H.
Am J Obstet Gynecol. 2005 Jan;192(1):38-41.
"When controlled for parity and plurality, mature women over 45
years
conceiving largely through ART with donor eggs can expect newborn
outcomes
similar to younger women cared for in the same setting of a high-risk
maternal-fetal
practice."
Pregnancy
blues
worsen with age [10/12/04] - Older mothers are more anxious during
their pregnancy and less likely to have the social support younger
mothers
enjoy, a study has found. But they are also less starry-eyed about
parenthood,
and will perhaps make better mothers for it.
Delayed
childbearing--are
there any risks?
Roberts CL, Algert CS, March LM
Med J Aust 1994 May 2;160(9):539-44
The risks associated with pregnancies in women over 35 are primarily
related to pre-existing medical conditions such as hypertension.
Overall health appears to be more important than age.
Midlife Mommies - A
treasure
chest of resources for first-time moms over 35. We offer info on
business,
health and fitness, in addition to providing a place to tell your
personal
story.
Do
obstetric
complications explain high caesarean section rates among women
over 30? A retrospective analysis
BMJ 2001;322:894-895 ( 14 April )
Please, I want to hear your stories of your oldest clients, and how
they did. Good births, problems, SAB's, etc.
My experience of older mothers giving birth at home has been very
positive.
Just staying away from a hospital improves their chances of having an
ecstatic
birth. I'm interested to know what their job history has been.
Women
who have been airline stewardesses, x-ray technicians, firewomen,
Kinko's
employees, etc. may be at higher risk for birth defects because they
have
been exposed to radiation or chemicals. If there is no history of
work related pollution, I have only found one thing consistent with
over
38 yr old mothers and that is "The older the woman, the cuter the
baby."
I assisted a woman this summer that was 45yo, g6p4 ages 24, 13, 9,
6yo.
1st forceps breech, 2nd C/s for active HSV, 3rd induced ybac, 4-sab,
5-ybac
at home (got tired of docs and hospitals looking for problems) 6-sab, 7
6mo after sab. very supportive and same husband with last 3 children .
excellent diet. Living 40 miles from the closest hosp. She had her 1st
2 visits at the local clinic with FP docs, who strongly recommended
hosp
birth d/t age and distance to hosp and refused referral for HB. She and
here family were well aware of her risk factors, they also were aware
of
the risks of going to the hospital for routine birth with her "risk"
factors.
she used a lot of herbs throughout, chiro care for her back, she was in
a lot a back pain at the end. she was totally receptive to transferring
to hospital/docs at the earliest signs of problems. she gained the most
she had of all preg, and felt her yrs at the end of preg. 9 hrs latent,
4 hrs active, 20min pushing. 17min3rd followed by 450-500cc bldg. (I
saw
my partner inadvertently put a lot of tension on the cord right after
birth
which probably may have contributed.) Mom and babe are great!
My oldest mom was 46 when she gave birth to her sixth child. She was a nice Mormon woman, had a pretty decent diet, no major health problems other than being over weight. It seemed like her biggest problem was feeling overwhelmed with having yet another child somewhat unexpectedly. Her pregnancy was uncomplicated, and she gave birth at home without any problems.
Another mom I cared for, who is a friend of mine, was 45 when she gave birth to number 6 also. She had a number of SAB's prior to her last pregnancy, with no history of earlier SAB's. Her husband had had a vasectomy which had been reversed as they decided they wanted one more baby! The SAB's began occurring after the reversal, and it took about 3 years before she was able to conceive and carry to term. She felt pretty tired and run down in the last pregnancy, and mostly scared of losing the baby, but the birth and postpartum was uncomplicated.
The oldest first time mom I took care of was 43. Other than having many anxieties that I don't see as much in younger women, she was fine. She did develop a severe type of gestational pruritis (I don't remember which type as there are several -- I was not her primary care giver) that made it difficult to sleep or get comfortable at all. She had a normal vaginal birth, and had no real difficulties. She had a second baby about one year later and was induced, I believe, because the itching problem made her so miserable. She had no birth complications but did have problems with breastfeeding afterwards, related I suspect to meds in labor.
The highest parity mom I have cared for is 8 now. I am not sure what
you are looking for. I have the impression over the years that parity
may
make more of a difference as moms get older than the actual age........
Let's see, you want good stories for primips 35+?
This is a bit clinical sounding, but I wanted to give you some numbers to show primips over 35 can have "normal" births. However, as you can see there was significant intervention compared (ie, arom) to what we, as natural birth advocates, would like to see.
As far as the length of their labor from about 3cm and relative ease:
38 yr old = 5 hrs/arom/epidural
40 yr old = 15 hrs/arom/epidural
36 hr old = 7 hrs/arom/epidural
35 yr old = 5 hrs/augmentation/epidural
36 yr old = 6 hrs/augmentation/non-medicated
37 yr old = 13 hrs/arom/epidural
36 yr old = 6 hrs/non-medicated
39 yr old = 6 hrs/narcotic
40 yr old = 6 hrs/augmentation/spinal during pushing
39 yr old = 5 hrs/augmented/non-medicated
37 yr old = 6 hrs/non-medicated
38 yr old = 7 hrs/narcotic
35 yr old = 13 hrs/induction/narcotic
35 yr old = 9 hrs/induction/epidural
38 yr old = 9 hrs/induction/no meds
36 yr old = 14 hrs/epidural
36 yr old = 9 hrs/augmentation/epidural
I never thought any thing different due to their age. I find that if the woman is generally healthy, has a good mind set, and frequent exercise is a factor, I don't see much difference if their labors. I find that sedentary life style and mind set are the biggest factors for difficult births in my book. Just my 50 cents worth.
I purposefully left out the complicated births, but there were only
6 that went much longer and became complicated due to fatigue,
intervening
or natural phenomenon. Far less of them than what I listed above.
Last year I looked after a 43 year old primigravida who was a GP. We both did a (not particularly rigorous) search of the literature and too found inconsistent results. Neither of us could find any good quality research to support the use of a high risk label being applied to a primigravida on age alone.
She had a Registrar give her a full run down of all the 'risks' and suggested an elective LSCS at 38 weeks to be on the safe side. My client listened to his advice and considered her options but in the absence of any other complications went on to have a quick (OP) birth at home with no complications and a speedy recovery.
In fact my colleagues and I look after many older primigravida (I
guess
we would class that as 40 and over) with several women being 42 or 43.
What has surprised us has been the trend that these women, if low risk
in all other ways, appear on the whole to have very quick and 'easy'
labours.
Clearly our clientele are not a cross section of older primigravida but
we have wondered what influences this.. a healthy lifestyle, social
support,
preparation (plus time and money for this) or just a weaker pelvic
floor
(not our own observation - that of a client!)
Oldest mom was 47; oldest primip was 44. I've heard of a few
at
50. Never heard of any problems (my few moms in their
forties
have done great)
Polycystic Ovarian Syndrome Association
PCOS increases risks associated with pregnancy and birth. If the
mom's
hormonal levels are aberrant enough, that placenta just doesn't get
properly
situated and that can lead to the other problems down the road that,
statistically,
are more common in women with PCOS - PIH, pre-eclampsia, abruptio,
etc.
Abnormal placentation can lead to additional problems during the
birth.
Also, PCOS is an inflammatory condition (most will have elevated CRP
values)
and that inflammation probably also contributes to the increased
incidence
of the above diagnosed conditions.
See also: WaterBirth for Large
Women
Exami-Gowns -
OB/Gyn
gowns available up to 4X sizes.
Excessive
Weight
Gain During Pregnancy Impairs Breast-Feeding Ability [Medscape
registration is free] - This article suggests that the elevated levels
of progesterone supplied by fat in the body may reduce milk
supply.
However, it also suggests that more attention to a proper latch and
baby
and maternal position may reduce this problem. Personally, as a
midwife,
most of the breastfeeding problems I've seen have been in women who are
on the thin side - they may not have enough fat to support
breastfeeding
hormones, or they may already have body image issues that make it
difficult
for them to appreciate their breasts as a source of nutrition and
comfort
for their babies.
Plus-Size Pregnancy
Website
- Kmom's site
Baby Becoming -
Clothing
for the Big, Beautiful, Pregnant and Nursing Woman.
Charlotte
is proud to be the Pregnancy Advocate for NAAFA. (National Association
for the Advancement of Fat Acceptance) PHONE: 401.658.0688 or
1-888-MOMMY10
(1-888-666-6910) FAX: 401.658.3008
King
Edward
Memorial Hospital in Western Australia is considering opening a
specialized antenatal clinic for obese women, which they define as
weighing more than about 265 pounds. (It's not clear whether this
is pre-pregnant weight or admission weight. I think it's
admission
weight, since much of the concern is about the hospital staff having to
lift heavier moms, presumably those who have epidurals and aren't able
to move themselves.)
Where
can
I find maternity fashions for plus size women?
Is Weight a Contraindication for Homebirth?
A Dad Talks about His Wife's Experience as a
Large Woman
I would especially appreciate any words of encouragement that any of
you could offer to me as a healthy, but overweight woman (with normal
blood
pressure and no family history of GD). I'm on a mailing list for
overweight
and pregnant ladies, but they seem to embrace the medical establishment
and there seem to be a frighteningly high number of c-section and
induced
births on that list. Is there anyone on this group who could share with
me a story of a plus-sized homebirth?
I'm on a midwife email list where the subject of heavy women having
babies has come up more than once. Our assessment is that the medical
system
is discriminatory toward overweight women and treat them as walking
disasters
with no willpower. The experience of most midwives is that overweight
woman
who are healthy and take care of themselves during pregnancy have no
more
problems during labor and birth than anyone else. Your perception that
overweight women have higher C/S rates is based in fact - it's true. I
truly don't think that should be happening. It's known that obese women
(perhaps as opposed to large-framed, heavy women) have a higher
incidence
of gestational diabetes and high blood pressure during pregnancy, but
that
doesn't mean that EVERY, or even most obese women will have these
problems.
I advocate a lot a attention to diet during pregnancy, a low weight
gain,
lots of activity, and a positive attitude on the part of the woman and
her support people. There shouldn't be any reason why you can't look
forward
to a rewarding homebirth!
Kliegman, R.M. & Gross, T (1985). Perinatal Problems of the Obese Mother and Her Infant. Obstetrics and Gynecology. 66(3), 299-305.
This article used wt. greater than 200 lbs prior to pregnancy or
during
pregnancy as its definition of obesity and did not consider height. It
is a literature review. More gestational diabetes was found in obese
moms.
A, the risk of pre-eclampsia was increased. There was also a higher
incidence
of twins. Fetal macrosomia was more common but when obesity was defined
as more than 50% of the ideal wt for height, there was similar Csection
rates as for the general population. Even when moms did not gain much
wt.
during the pregnancy, the incidence of low birth wt., and IUGR was
reduced
by 50%. Perinatal mortality was improved or at the least equivalent to
compared to that of non-obese moms.
Feelings about Being Naked and Bodily
Emanations while Birthing
Junk Science about Obesity and
Childbearing
- I was moved to write this subsection after reading an article that
smacks
of junk science: Big
Moms,
Big Problems - For Obese and Overweight Women, Pregnancy Ups
Risks To Selves, Babies By Suz Redfearn [2/22/05]
We all know how some people like to scare Moms with the Big Baby theory. What I LOVE to mention to my families, is what a huge benefit it is to have a Big Baby. (let's turn the tables her ladies and look at the glass half full instead of half empty) I say things like: Oh big babies are great because we never have to worry about a prolapse of the cord, the head is nice and big and round and fills up the pelvis so beautifully, there's no cord slipping past your baby's head; how great that you have a big baby, it is so much less likely to have a problem with being asynclitic; your body knew exactly what is was doing when it was growing this baby, you are avoiding so many problems with the floating baby syndrome that nurses love to use as another negative comment. (all of my babies were high until I was ready to push). Your body gets to produce more relaxin, the hormone which softens the pelvic structure to make it more flexible for baby, and we all know that more hormones will aid in the entire labor process.
THESE WOMAN ARE LUCKY TO BE HAVING BIG BABIES-------and we need to
tell
them that. Sorry for yelling, but I LOVE big babies. Moms
with
big babies in my experience have an EASIER TIME. Yes, I said
EASIER........
Had it in June. Momma wanted to get level II u/s with MFM docs. All was well. Didn't hear it again until the end of labor just when I was starting to get concerned about the baby. All was fine, baby born not long after I heard the arrhythmia episode. Baby now 7 weeks old.
Many years ago now we had a client whose baby had an arrhythmia ,
that
I heard with a fetoscope , baby was fine, normal nursed.... But at 18
months
he tipped head first into a mop bucket was rescued quickly enough in
his
rural home and air evaced to the hospital where he checked out fine as
far as the drowning went but they found a heart anomaly that needed
surgery,
so any more I want these babies checked out, not necessarily
immediately
cuz we would be seeing signs and symptoms of a baby not doing well but
at some point in the first month.
The few times I've consulted with our back up doc about fetal
arrythmias,
he usually says "stop listening so long that you have a chance to hear
it!". We have never had to risk out of OOH for it (or send to
MFM)
and most of the time it resolves spontaneously either before labor or
after
birth. I agree with the caffeine - also d/c cold meds, etc.
Anyone have any experience of 'abdominal clicks / sounds' in
pregnancy?
I have a client who's 30 weeks, 4th pregnancy, describing loud clicks
emanating
from abdomen, loud enough for husband to hear in same room, not like
hiccoughs,
several at a time, associated with fetal movements. Any thoughts?
This is the first time I have EVER had confirmation that this can happen! I thought it was just me!!
When I was pregnant, I sometimes heard exactly what you describe - loud 'clicks' coming from my tummy. They could be heard across the room, sometimes. My mum heard, my DH heard - even the dog heard - but when I mentioned them to HCPs they just looked at me as if I was mad, and said things like 'you must have imagined it', or, it was your stomach growling - which it wasn't - not like that at all.
I have never had any idea what caused the clicks. To me, they sounded like bones creaking, only more a 'click...click...click' - but there was an almost 'electronic' squeak to it, on occasion. It was only every now and then that this happened - and of course, NEVER when a HCP was there. I also associated it with baby moving.
Baby turned out to be breech with a low lying placenta (partial
previa,
I believe - not right over the cervix, but in the way). The
clicks
seemed to me to come from the lower part of my abdomen - I wondered if
it was her legs? Or maybe it was a noise from the placenta?
Baby doesn't squeak or click anywhere now, by the way - and she didn't
at
birth.
It was weird.
Oh - should also mention that the clicks started quite late on - I
think
after 28 weeks, though I can't be sure. Of my 4 pregnancies, I
only
had clicks in that pregnancy.
I've heard quite a few women talk about this, so it can't be *so*
desperately
unusual.
Maybe congenital dislocation of the hip. Not experienced it but have
heard other midwives speak of it!
One of my clients reported this with all of her babies . . . maybe
joint
and disc pops could be a normal part of development as the muscles
strengthen?
New Treatment for Genital Warts
[from ob-gyn-l]
I had Dr. Shah for our lectures on HPV (it pays to go to school in the same city as the guys "across town"). Quoting from our handout, which is a chapter in press...about respiratory papillomatosis:
"RRP of juvenile onset is acquired most often by transmission of HPV-6 or HPV-11 at the time of birth, during fetal passage through an infected birth canal.
Children with RRP rarely give a history of birth by cesarean
delivery,
an indication that most of the infection occurs by intrapartum
transmission.
The possibility of transmission in utero is raised by occasional
reports
that RRP was present at birth or in the first weeks of life. The risk
factors
for RRP of juvenile onset are vaginal delivery, being first-born and
having
a teenage mother."
Does this mean we should section all teenage nulliparas ????
The information I am lacking is the prevalence of HPV6 and 11 in
pregnant
women, and the probability of transmission. Shah's paper did imply that
almost all childhood cases were delivered vaginally, but if, as has
been
suggested here, the prevalence in mothers is high and the prevalence of
respiratory papillomas in neonates is low, then no action is probably
warranted.
Since most children are delivered vaginally, this is an expected
finding.
Consider looking at the proportional data for VD and CS.
I'll still go with the vaginal route. Thanks again.
SECONDED !
In the U.S. there have been lawsuits where patients won huge awards
because their doctor "did not perform a c/section to prevent
papillomatosis"
but I try not to let juries get in the way of science :)
The current (1993) STD treatment guidelines from the CDC also
recommend
AGAINST c/s for neonatal indications. I would only consider c/s for
large
condyloma which may bleed or obstruct delivery...
As a doula, MT, and a trainer for MT & pregnancy, I would not
recommend
that you find a table with a cut out. Those tables are extremely
bad on the pregnant body they put a tremendous amount of strain
on
the low back, the round ligaments.
In the unit where I work, we deinfibulate women antenatally. There is a specialist midwife who does it, usually at about 26 weeks. If the woman prefers, we can do it in labour.
The woman sits with her legs in a stirrupy position (we have a
special
bed which is like a cross between a dentists chair & a birthing
bed).
The midwife uses lignocaine to anaesthetise the laabit and then
carefully
cuts through the infibulation. We find that most women have
complete
genitalia underneath the infibulation. She continues cutting
upwards
until the urethra is visible. Then she blanket stitches the cut
sides
to prevent them fusing. The woman is given topical
lignocaine
gel to apply to the wounds to stop the area stinging. Apparently
the main discomfort is because the sensitive tissues underneath are
exposed
for the first time in many years, and it can take a few weeks to get
used
to the sensations.
Five
ways
to avoid germs while traveling (and the rest of the time,
too!
REMINDER - Even mild viruses can cause blindness, deafness and cerebral
palsy in your baby.)
Pregnancy,
Breast-Feeding,
and Travel from the CDC
Pregnancy
and
Flying from the Health Physics Society
[InfoBeat News, 12/12/01] - Most pregnant women who want to travel
this
holiday season should not fear that flying will cause complications or
bring on motherhood a little sooner than expected. According to new
recommendations
from the American College of Obstetrics and Gynecology, healthy women
with
low-risk pregnancies can safely fly up until their 36th week, or one
month
prior to their due date.Women who should not fly at any time during
their
pregnancy are those at risk for complications or pre-term delivery,
including
women with poorly controlled diabetes, pregnancy-induced high blood
pressure,
or sickle cell disease - which can be worsened by high altitude.
The
Pregnant Traveller from the British Columbia Ministry of Health
Should
a
pregnant flight nurse be allowed to fly?
Drew KG
J Air Med Transp 1991 Jul;10(7):11-2, 15, 19-21
Physical
activity
at altitude in pregnancy.
Huch R
Semin Perinatol 1996 Aug;20(4):303-14
[Altitude
exposure
and staying at high altitude in pregnancy: effects on the mother
and fetus]. [Article in German]
Baumann H, Huch R
Zentralbl Gynakol 1986;108(15):889-99
When I see a nullip not engaged at term, I'm concerned about CPD,
polyhydramnios,
malpresentation but might also consider placenta previa or
fibroids
as obstructing the head from entering the inlet of the
pelvis.
I'd bet on CPD or malpresentation.
Questionable dates? Fibroid or mass in the pelvis? BPD very large?
Cord
in front of head? Face presentation? Placenta low lying?
What is normal for a grand multip (G10 P6) as far as fundal heights in the first trimester?? Do you even bother with them?
This mom was feeling her uterus above the pubic bone at supposedly 4.5 weeks, which stimulated her to buy a pregnancy test (which was positive). Solid menstrual dates by NFP charting.
She is now 10 w 4 days. In the AM before emptying her bladder, she can feel the fundus at the umbilicus, but it is "resting" in the abdominal cavity, and her abdomen barely bulges up when she is laying flat. At this point, the fundus measures 18. After using the bathroom, it goes back down to around 16. No fetal movement has been felt.
With her last baby, at 11 weeks, she had an ultrasound due to feeling the fundus halfway between the umbilicus and the pubis. There was only one baby in there, and her dates were exactly correct, the baby even being born on her due date. By 20 weeks the measurements had normalized.
So, how normal is it for the uterus to be floating around even as high as the umbilicus at 10.5 weeks? Should she be thinking twins? Last time the uterus seemed large for dates in the beginning as well. Is it just that the ligaments are so stretched out that the uterus can seem to come "loose from it's moorings?"
I just have not had my hands on a grand-multip uterus before,
especially
in the first trimester.
Anything is normal for grandmultips. No, I don't measure them before 20 weeks; I'm just looking for a consistent increase but don't worry about the correlation between centimeters and weeks of pregnancy.
I've known of moms having to go into maternity clothes at 8 weeks,
but
I do expect them to "normalize" by 20 weeks, when I start measuring.
This has been moved to: H1N1 Novel
Pandemic
Flu (Swine Flu)
Why do pregnant women get so hot, as if there's "a bun in the oven", and they're the oven?
Engine
and
radiator: fetal and placental interactions for heat dissipation.
Schroder HJ, Power GG.
Exp Physiol. 1997 Mar;82(2):403-14.
Single Umbilical Artery - Two-Vessel Cord
Low Platelet
Levels
- Thrombocytopenia during Pregnancy
Guidelines for
Vaccinating Pregnant Women - from the CDC.
Stone
Baby - 32-week intra-abdominal pregnancy which had died and
calcified.
APLA is a an abnormal clotting condition. The blood is more coagulatable than usual. People are at higher risk of stroke and thromboembolism. There are many many degrees of the condition though -- and some people are at low risk and some are very high risk. There are some blood tests which can show a person's individual risk....but family history is a good guide.
some people benefit from taking blood thinners like low-dose aspirin. Some need medications. Some simply need to avoid things which increase their risk (like smoking or birth control pills).
During pregnancy the hyper-coagulable state may be increased further, putting women at risk for embolism and (maybe) at higher risk for early miscarriage. Anyone with APLA should be evaluated to see if they need treatment during pregnancy and postpartum.
| About the Midwife Archives / Midwife Archives Disclaimer |