More Evidence About Water Birth 

Amanda5

This week Evidence Based Birth released a statement of findings on the safety data available about water birth.  As you may recall, we blogged about water birth earlier this year, shortly after the American Congress of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatricians (AAP) released a joint statement warning about the possible risks of water birth.  This warning resulted in some Twin Cities area hospitals stopping their practice of water births.  Since then, many hospitals have reinstated their practice of water birth in light of overwhelming evidence that water birth is a safe option for many women.

Health Foundations did not alter their water birth practices as a result of this statement, as the evidence was not there to support any such change.  We were honored to serve many women in the Twin Cities who wished to have the option of water birth and chose to change providers to allow for this option.

Evidence Based Birth’s (EBB) recent thorough account of the evidence available on water birth echoes and extends the case for water birth set forth by the American Association of Birth Centers (AABC) and The American College of Nurse Midwives (ACNM) back in April. This EBB article focuses primarily on the safety information available for birth (that is, actual delivery) in water, as the safety of water immersion during labor has already been well established.

Kinds of Research on Water Birth

Discussed in this article are the types of studies that have been used to gather information about the safety of water birth, including but not limited to:

  • Qualitative descriptions of water birth
  • Retrospective surveys
  • Small randomized trials
  • High quality prospective studies
  • Case control studies
  • Case reports

Each of these kinds of studies has their benefits and drawbacks and varies in the quality and reliability of the information they produce. For example, case reports are considered the lowest level of research evidence available.  They only discuss a single event, which can potentially give us information about rare occurrences but cannot give us any reliable information about the overall safety and risks associated with water birth.  The ACOG/AAP statement issued earlier this year was based primarily on this kind of evidence, while it ignored other, higher quality forms of evidence available.  The EBB article also asserts that this statement relied on outdated literature review and made several significant errors of fact.

While the evidence presented in the EEB article is far too detailed (which is a good thing!) to cover in this blog, we wanted to share this resource as a great place for our clients to learn more about water birth safety research currently available.  We feel this is a prudent and thorough analysis that allows women and their families to gather the information they need to make an informed decision about water birth.

As a helpful high-level guide, available high-quality research is presented on the following topics:

 Effects of water birth on mothers:

  • Normal vaginal birth
  • Episiotomy rates
  • Perineal tear and trauma rates
  • Need for pain relief and pain scores
  • Length of labor, by stages
  • Postpartum blood loss
  • Birth positioning
  • Hands-off delivery
  • Maternal satisfaction with water birth
  • Pelvic floor function

Effects of water birth on infants

  • Perinatal mortality
  • APGAR scores
  • Respiratory complications
  • Birth injuries
  • NICU or Special Care Nursery admission
  • Umbilical cord pH
  • Shoulder dystocia
  • Newborn infections
  • Group B Strep
  • Newborn microbiome
  • Umbilical cord tears
  • Newborn resuscitation

The article goes on to cover frequently asked questions about water birth, such as:

  • “Why do women get out of the tub in labor?”
  • “What evidence is available about VBAC water birth?”
  • “What are the contraindications for water birth?”
  • “Why do some women report choosing or enjoying water birth?”
  • ‘What rare adverse events have been reported?”

The bottom line

In this article, EBB includes a section about what all this detailed information means for women as they consider this choice in pregnancy.

While new research continues to improve our understanding of water birth safety, the evidence suggests that low risk women experience a lower episiotomy rate, have higher rates of intact perineum, and use less medicine for pain relief when they choose water birth.  While the benefits to newborns are less clear, so far the evidence shows that fewer or equal rates of NICU admission are seen in babies born in water compared to on land.

This research review repeats the sentiment made in the 2014 AABC and ACNM statements that “water birth is a reasonable option for low-risk women during childbirth, provided that they understand the potential benefits and risks.”  The review further states that universal bans on water birth are not evidence based.

 

We encourage you to read this article on water birth and to ask us questions about this birth option during your prenatal visits.  It is supremely important that our families have the best evidence available to make informed and empowered decisions about their pregnancies, births and postpartum.

 

 

 

 

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Breech babies

breech babyWhile it is not common, only 1 in 25 babies present this way at birth, we wanted to talk a bit about breech babies today and ways to encourage optimal fetal positioning during pregnancy.  Most babies will move to a head-down position in the weeks prior to birth, although not all.  Breech presentation is when the baby, instead of being positioned head-down, presents with his or her buttocks (and sometimes knees or feet) first, closest to the birth canal.

Though many babies have been safely delivered from the breech position throughout time, this type of birth scenario is considered out of the scope of birth center practice.  In cases of breech birth at the birth center, we transfer to the care of a hospital-based team.  However, there are many ways to encourage baby to move into a more optimal position if they are breech and ways to lower the risk of breech presentation before it occurs.

Reasons for breech presentation

Many believe that babies will get into the best position possible given the space they occupy in the womb.  This space can be affected by mom’s pelvic alignment and ligament length.  For example a twist, or torsion, of the pelvic joints can throw the uterine ligaments out of balance.  Broad ligaments may also be too tight and can hold a baby in a breech position.  Uterine tone can affect fetal positioning, as can the amount of amniotic fluid present.  Mom’s physical and emotional experiences can also affect baby’s position in the uterus (such as a car ride, or emotions such a fear, grief, or a sense of safety).

Fortunately, many babies that are presenting breech late in pregnancy flip before labor begins.  In these cases, they are often aided by the increased relaxin hormone levels made by mom’s body at the very end of pregnancy, which can relax her ligaments and uterus enough to allow baby room to shift.

In some cases, the natural shape of mom’s uterus, which may have a center membrane (septum) or a heart shape (bicornate) may contribute to breech presentation.

Evidence also indicates that women with a history of breech presentation in their personal or family history may have a greater chance of breech.

The location of the placenta, such as with placenta previa (placenta covers part or all of mom’s cervix), can also increase the likelihood of a breech presentation.

A short or wrapped cord may also be preventing a baby from getting into optimal position.  (This scenario is rare and doesn’t necessarily indicate an impending danger during birth.)

Lastly, premature birth also increases the risk that a baby will be born breech.  However, only 3 to 4 % of babies born between 37 and 42 weeks present in the breech position.

Types of Breech Positions

There are four ways a baby can present breech:

  • Frank breech: the buttocks presents first with legs extended towards baby’s trunk
  • Complete breech: the buttocks presents first with the legs folded so feet are close to the buttocks
  • Footling: one or both feet present first
  • Kneeling: when both knees present first, with the feet folded up behind baby’s thighs.

Oblique (diagonal) and transverse (lying sideways) positions are not considered breech presentations, although these positions carry their own risks.

Natural ways to help a breech baby turn

Before 30 weeks many babies are breech and it is generally not a concern at this time, as most of these babies will get into position in plenty of time before birth.  Midwives are trained and experienced at feeling for fetal position at every visit in the later months of pregnancy.  Breeches are often addressed between 32 and 37 weeks of pregnancy.

It is important to manage situations of breech presentation with the guidance of an experienced care provider.  Together, mom and care provider can talk about the options and what actions might be most appropriate, safe and beneficial to you.  Many factors, such as gestational age, known or suspected cause of breech, mom’s physiological health, and positioning may affect the course of action with a breech baby.

Homeopathy, chiropractic, craniosacral therapy, and Traditional Chinese Medicine (including acupuncture and moxibustion) can all assist in cases of breech.  In fact, many of these treatments utilized throughout pregnancy can help prevent any of the pelvic conditions that may contribute to breech.  A particular technique of chiropractic care known as the Webster technique has high success rates in turning breech babies.

Mayan abdominal therapy is another modality in which women have experienced success in turning a breech baby.  Massage, particularly myofascial release, can also be helpful in preventing or addressing breech.

Mothers can use certain positions to help turn a breech baby or prevent a baby from becoming breech in the first place.  This includes what is called the forward-leaning inversion.  Spinning babies is a great resource for more information about this.

In cases where low amniotic fluid is the case, women can increase their fluid intake and modify their diet (again with support from an experienced care provider) in addition to receiving bodywork.

You may also been seen by an OB for an External Cephalic Version (ECV) in which a doctor manually turns the baby head down through the abdominal wall.  This may be a good choice for some women after other options have been explored.

If you have questions about breech babies, please feel free to speak with us at an upcoming appointment.

Water Birth

maiabirth_0027Health Foundations Birth Center ~ Water Birth Delivery

With the recent release of an opinion statement on immersion in water during labor and delivery (water birth) by the American Congress of Obstetricians and Gynecologist (ACOG) and the closure of water birth programs at several Twin Cities hospitals, we wanted to explore this issue in greater detail.

The use of water during labor and birth, known as hydrotherapy, has been growing ever more popular in the United States both inside and outside of the hospital setting.  We offer the option of water birth at Health Foundations Birth Center because the best available evidence demonstrates that hydrotherapy offers physiological and psychological benefits in labor and birth. 

What the experts say

According to The American College of Nurse Midwives, “labor and birth in water can be safely offered to women with uncomplicated pregnancies and should be made available by qualified maternity care providers. Labor and birth in water may be particularly useful for women who prefer physiological childbirth and wish to avoid use of pharmacological pain relief methods.”

They further state: “Warm water immersion hydrotherapy during labor provides comfort, supports relaxation, and is a safe and effective non-pharmacologic pain relief strategy that promotes physiologic childbirth.”

The American Association of Birth Centers posits that, “water birth, with careful selection criteria and experienced providers, does not negatively affect mothers or newborns.”

Prevalence of Water Birth

Overall, approximately 6% of women in the United States experience the pain relieving benefit of hydrotherapy during labor and/or birth.  This rate is higher among midwifery and midwife-led collaborative practices.  Among midwives, water birth rates are between 15 and 64% during labor and 9 to 31% during birth.

Evidence on hydrotherapy during the first stage of labor

The first stage of labor includes early labor, active labor, and the transition into pushing and involves the thinning and full dilation of the cervix, among other things. 

Evidence for the safety and effectiveness of laboring in water during this first phase are well established.

Pain relief is the most clearly established benefit of laboring in water.  Evidence also suggests the possibility that first stage hydrotherapy can also:

  • Hasten the process of cervical dilation/shorten the duration of this stage of labor
  • Resolve labor dystocia (difficult labor or abnormally slow labor progress)
  • Increase postpartum maternal satisfaction with childbirth

There is no evidence of a positive or negative correlation between hydrotherapy during this stage and any of the following:

For mom~

  • maternal infection during or after labor and delivery
  • the length of second or third stage labor
  • type of delivery
  • perineal laceration (incidence or severity)
  • postpartum blood loss
  • rate of hemorrhage
  • postpartum depression

For baby~

  • abnormal fetal heart rate patterns
  • meconium stained amniotic fluid
  • umbilical cord blood pH values
  • newborn Apgar scores
  • infections
  • admissions to special care nurseries
  • or rate of breastfeeding at 6 weeks postpartum

Evidence on hydrotherapy during the second & third stages of labor

The second stage of labor involves pushing and delivery of the baby.  The third stage involves the delivery of the placenta. 

At present, evidence is not as conclusive as experts would like with regards to hydrotherapy during the second stage of labor.  Additional research is needed.

It can be hard to weave through the language of medical research.  Most professionals agree that Randomized Control Trials (RCTs) will produce the most reliable evidence.  However, to date, most evidence about birth in water has been gathered from clinical audits and observational studies rather than these randomized controlled trials.  Some case studies are also being examined but they produce a very limited picture of water birth and should not be used as the basis for recommendations or practice decisions, cautions the American College of Nurse-Midwives.

Observational studies are considered more reliable and offer some of the best evidence about water birth at the present time. This evidence suggests that women who experience uncomplicated pregnancies and labors with limited risk factors and evidence-based management have comparable outcomes whether they choose to birth in water or not.

When it comes to the best available evidence, data generated by midwifery care provides the most accurate view of the safety of water birth because midwives practicing in birth centers are trained water birth providers.

The American Association of Birth Centers has gathered data on over 15,500 births among low-risk women birthing at a birth center from 2007 to 2010.  Of these births, nearly 4,000 were water births in birth tubs (57.6%), Jacuzzis (34.6%), and standard bathtubs (7.8%).

This data revealed the following:

  • Rates of postpartum and neonatal transfer from the birth center, and neonatal procedures were low in general, and were slightly lower for births in water when compared to non-water births.  This has been reported elsewhere.
  • If labor was not progressing smoothly, women were unlikely to give birth in water
  • Rates of newborn transfer to a hospital were lower after water birth (1.5%) than non-water birth (2.8%)
  • Rates of adverse newborn outcomes were below 1.0% in the water birth population.  The total rate of any respiratory issues was 1.6% in the babies born in water and 2.0% in those not born in water.
  • There were no cases of pneumonia, sepsis or other respiratory infection following water birth and there were no reports of ruptured umbilical cords or newborns breathing water into their lungs associated with birth underwater.

Safe Water Birth at Health Foundations Birth Center

At Health Foundations Birth Center, we follow the best evidence available in every aspect of care we offer to our families, including water birth.  Each of our midwives is highly trained and experienced in offering water birth safely and when appropriate to low risk mothers.

Along with the American College of Nurse-Midwives and the American Association of Birth Centers, we believe women should be given the opportunity to remain immersed during labor and birth if they wish to do so within the context of a shared decision-making process with their care providers. We also believe women have the right to make informed choices regarding water birth and are happy to discuss the best evidence available regarding hydrotherapy in childbirth with all interested clients.

We strictly follow the best practice guidelines we’ve learned in our rigorous educations, and as set forth by The American Association of Birth Centers and The American College of Nurse Midwives.  All of our midwives are qualified to provide education, risk assessment, and care to women who desire water immersion for labor or birth.

If you are a current client and have questions about water birth, please do not hesitate to call us or speak with us during an upcoming visit.  We want you to feel empowered to make informed decisions about all aspects of your care.

Sources:

The American Association of Birth Centers Position Paper on Water Birth

The American College of Nurse Midwives Position Paper on Water Birth

Collective Wisdom: Describing our Ideal Birth

BlogIcons_Collective

While it is impossible to know all the elements that influence our perception of birth, our thoughts and intentions can be powerful shapers of our birth experience.  Imagining the conditions under which we wish to birth is an empowering experience in pregnancy.  While many aspects of our birth and delivery are beyond our control, we can manage our own minds and expectations: herein lies tremendous power.  How we envision our birth matters even if it doesn’t go exactly as we imagine it.

This week, we asked our mamas-to-be…

“What words would you use to describe your ideal birth?”

These were the answers we received:

 

Calm

Peaceful

Encouraging

Empowering

Uneventful

Fully Present

Easy

Beautiful

Strength

Safe

Normal

Uncomplicated

Quiet

Confident

Supported

Serene

Sacred

Trust

 

 

 

What words would you use to describe your ideal birth experience?

Collective Wisdom: Birth Affirmations

 

 

BlogIcons_Collective

 

Birth MantrasA birth mantra or affirmation is a positive statement and intention for the pregnancy or birth experience. A mama may select her own affirmation or affirmations and repeat it/them to herself or out loud during times of relaxation, upon waking and going to sleep, during the birth experience, or any time she needs encouragement during pregnancy or labor.

Positive birth affirmations can profoundly affect our outlook and our experiences—the thoughts we choose about our birth can seep into the unconscious and powerfully influence our actual experiences.  They can calm, relax, encourage and support us as we move through our journeys of pregnancy, childbirth, and motherhood.

Birth affirmations tend to be the most powerful when they are set in the present tense (as if they are happening to us right now).  Writing them down in a journal or something you hang in your space and repeating them often also make affirmations more potent.  During labor, you may even want your support team to repeat your chosen mantras to you.

We asked a few of our mamas-to-be to share their current or favorite birth affirmation.  Here’s what they shared:

I was made to do this – Leah

I get to make all the decisions about my birth – Cassie

I am strong.  I can do this! – Hanni

I trust my body – Angie

I am strong enough – Michaela

Here is a list of other birth affirmations expectant mamas can browse to find something that perfectly resonates with them.

What is your favorite birth mantra?  How have birth affirmations helped you through pregnancy and birth?

Benefits of probiotics in pregnancy, postpartum and for baby

probiotics

Probiotics (which roughly translates to “for life”) are beneficial forms of bacteria/microbiota that can assist the human body in preventing and treating many types of illness and disease—from cancer to diarrhea.  We have these beneficial bacteria in our body naturally, but supplementation can greatly support the body in health and healing.

While nearly everyone can benefit from consuming probiotics, using probiotics is especially important and advantageous during pregnancy and once baby is born.  Read on to learn all about the amazing benefits of probiotics for mom and baby.

What are probiotics?

Probiotics are the beneficial bacteria living in your body that help protect against illness.  We can take supplements of these beneficial bacterial or obtain them from some food sources.  There are hundreds of different strains of probiotic, which are all important to overall health.  Certain strains are particularly good for pregnant women and others best for new mamas and babies.

While we typically think of probiotics as being good for digestive health, they do more to promote health in the body.  Probiotics are found lining the mucous membranes of your digestive, urinary, and vaginal tracts.  This last one is particularly important in pregnancy, because we want to foster healthy vaginal tissues before and during delivery (more about why below).

Additionally, probiotics are key to a healthy immune system.  These beneficial bacteria make up approximately 70% of your immune system, making them an important part of your daily defense mechanisms.  Ensuring a healthy balance of good bacteria in the body can foster overall wellness.

 Probiotics in pregnancy

Regular use of probiotics in pregnancy can offer women many benefits.  These benefits include lower risk of:

  • illness (colds and flu)
  • constipation
  • gestational diabetes
  • preeclampsia
  • urinary tract infections
  • yeast infections
  • premature labor

Use of probiotics in pregnancy has also been found to keep levels of Group B Streptococcus (Group B Strep) low.  Group B Strep is a common bacterium of the vaginal lining, but if levels of these bacteria get too high at the end of pregnancy it can pose some risks to baby.  When this issue presents itself, it is often managed during labor/delivery with antibiotics.  However, steps in pregnancy, including probiotic use, can reduce the risk of this condition.

Healthy vaginal flora is crucial to baby’s health.  Babies are born with a sterile gastrointestinal system and exposure to mom’s vaginal flora is their first exposure to the bacteria their systems will be colonized by.  Healthy vaginal flora helps give baby’s immune system a good start.  Babies also continue to receive beneficial bacteria through breastfeeding, being held skin to skin, and via saliva exchange (think pacifier “cleanings,” shared spoons, and the like) in the first year.

Postnatal Probiotics Benefits 

Recent studies have found that consuming probiotic supplements beginning in the first trimester of pregnancy and continuing their use through at least the first six months of exclusive breastfeeding can help women lose weight after the birth of their baby.  Supplements with Lactobacillus and Bifidobacterium were linked to less central obesity (defined as a body mass index (BMI) of 30 or more or a waist circumference over 80 centimeters).

Probiotic use can be especially important if you need to take antibiotics for any reason in the postpartum period (really any time you take antibiotics, you can benefit from use of probiotics).

When mamas consume probiotics, the health benefits also find their way into breast milk and are passed on to baby. Breast milk is actually the source of our first immune-building “good” bacteria.  Since baby’s gut bacteria continues to culture throughout the nursing time, it is great for mama to continue taking probiotics in the postpartum and as long as she breastfeeds.

Probiotics for baby 

In addition to receiving probiotics via breast milk, probiotics can also be given to baby directly.  Supplementation to baby can take a few forms: you can add a bit of probiotic to a bottle of milk, you can take a little probiotic on your finger to give to baby orally, or you may even put a little on your nipple and baby will ingest it during a feed.

Probiotics have numerous potential benefits for babies including the prevention and treatment of:

  • allergies
  • asthma
  • eczema
  • food sensitivities, especially in infants with a family history of allergy
  • colic, one study found decreased crying times by up to 75% (look for product containing Lactobacillus reuteri)
  • diarrhea
  • ear infection
  • illness (colds and flu)

Research shows that good probiotic exposure in infancy can actually help optimize baby’s weight later in life.  Early probiotic exposure may modify the growth pattern of the child by restraining excessive weight gain during the first years of life.

Probiotics: Sources and Guidelines

Different blends of different strains of probiotic may be optimal depending on whether you are pregnant or taking them in the postpartum (or giving to baby).  We have a few excellent supplements at the clinic and we can talk to you further about what to look for in a probiotic.

Generally speaking, recommendations tend toward 1 to 10 billion Colony Forming Units for infants, and 10 to 20 billion CFU for older children and adults. To achieve and maintain a therapeutic effect, probiotics must be used consistently to ensure a sufficient and consistent population levels over time.  It can be difficult to say exactly what dose is ideal, as products vary.  Different probiotics have been shown to be effective at different levels.  Products containing a higher number of live probiotics may not be better than one with fewer.  It’s best to go with a reputable high-quality brand, ideally one that has been vetted by your health care professionals (such as us!).

There have been no reports of adverse reactions to supplementation of probiotics in moms or babies.

Food sources of probiotics

While supplementation is great, there are also many foods rich in probiotics.  Fermented foods are particularly rich in probiotics.

Food sources of probiotics include:

  • Yogurt
  • Kefir
  • Sauerkraut
  • Spirulina (with other great benefits in pregnancy and in general)
  • Miso soup
  • Pickles
  • Tempeh
  • Kimchi
  • Kombucha tea

If you have questions about probiotics, be sure to discuss them with your midwife at your next appointment, give us a call, or stop in.  We’d be happy to talk with you further about what to look for in a probiotic or connect you with a great supplement we carry.

Sources:

http://www.nutraingredients.com/Research/Probiotics-may-help-women-regain-their-figures-after-pregnancy

http://www.ncbi.nlm.nih.gov/pubmed/20231842

http://www.ncbi.nlm.nih.gov/pubmed/24164813

http://cdrf.org/home/checkoff-investments/usprobiotics/probiotics-basics/

http://www.ncbi.nlm.nih.gov/pubmed?Db=pubmed&Cmd=ShowDetailView&TermToSearch=11172991&ordinalpos=36&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum