Antenatal heparin thrombopropylaxis

A randomised trial has found no benefit to antenatal low molecular weight heparin/dalteparin prescription (commonly prescibed in the UK during pregnancy).  Thrombophilia simply means an increased risk of blood clots, for example many women find themselves being offered/given heparin in pregnancy because they have three or more of the following characteristics:

Age >35 years
BMI > 30
Para 3 or more
Smoker
Serious varicose veins
Twin pregnancy
Previous DVT
Pre-eclampsia

The article is here:
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2814%2960793-5/abstract

It's conclusions are:
"Antepartum prophylactic dalteparin does not reduce the occurrence of venous thromboembolism, pregnancy loss, or placenta-mediated pregnancy complications in pregnant women with thrombophilia at high risk of these complications and is associated with an increased risk of minor bleeding."

"Using low molecular weight heparin unnecessarily medicalizes a woman's pregnancy and is costly."

The third stage of labour (placenta and membranes)

http://www.ncbi.nlm.nih.gov/m/pubmed/20226752/

 "CONCLUSION: This study suggests that 'holistic psychophysiological care' in the third stage labour is safe for women at low risk of postpartum haemorrhage. 'Active management' was associated with a seven to eight fold increase in postpartum haemorrhage rates for this group of women. Further prospective observational evaluation would be helpful in testing this association."

Just read this and will look into it a bit more when I have time (what was the "holistic psycho-physiological management, was it a homogeneous approach or did it comprise a variety of practices?  I personally have found that a number of approaches work equally well, depending on the woman, her position, where the placenta is, how long the third stage has lasted, maternal effort/tiredness etc) but it should certainly affect practice and the information given to women with regard to active management.

Antenatal Anti-D - Who needs it?

A paper has appeared that asks the important question as to why all Rhesus negative (Rh-) women are offered and given Anti D in pregnancy when one third of them are carrying a Rh- baby and therefore do not need it?  Given that Anti-D Immunoglobulin is a blood product made from pooled plasma from North American donors, many women would probably prefer not to be injected with it unless it was of benefit to them i.e. their babies.  

15% of women are Rh- and approximately 1/3 are carrying a fetus who is also Rh-.  This means that up to 40,000 pregnant women a year in the UK are given anti-D immunoglobulin in pregnancy that they simply do not need.  A blood test can identify the baby's Rhesus status but is not currently offered.  This paper reviews the current situation and makes important points that all Rh- women should be aware of.

Routine administration of anti-D: the ethical case for offering pregnant women fetal RHD genotyping and a review of policy and practice. Julie Kent, Anne-Maree Farrell and Peter Soothill. 2014. BMC Pregnancy and Childbirth.

http://www.biomedcentral.com/1471-2393/14/87

Of course, a woman may know the blood group of the father.  I have known women who refuse Anti-D on the grounds that their partner is also Rh -.  The counter argument is about the uncertainty of paternity.  But surely that is for the woman to decide - if she is unsure of paternity, she has the option of Anti-D and/or genotyping?  To dismiss any refusal of Anti-D made on the grounds that the blood group of the father is known to be Rh - as unreliable is an insult to women.  Even in our liberal society, most women know who the father of their baby is.

The Lancet's new (free, online) midwifery series

The Lancet has a new on-line birth/midwifery section with some interesting stuff on it:

http://www.thelancet.com/series/midwifery

This is the introduction to the series:

"The essential needs of childbearing women in all countries, and of their babies and families, are the focus of this thought-provoking series of international studies on midwifery. Many of those needs are still not being met, decades after they have been recognized. New solutions are required. The Series provides a framework for quality maternal and newborn care (QMNC) that firmly places the needs of women and their newborn infants at its centre. It is based on a definition of midwifery that takes account of skills, attitudes and behaviours rather than specific professional roles. The findings of this Series support a shift from fragmented maternal and newborn care provision that is focussed on identification and treatment of pathology to a whole-system approach that provides skilled care for all."
 
The first editorial http://download.thelancet.com/flatcontentassets/series/midwifery/midwifery_exec_summ.pdf continues the theme of strengthening midwifery and placing of mother and baby at the centre of care and decision-making, and it also talks about relationships between health professionals and the women they care for.  Lots of good articles, a welcome development given The Lancet's reputation and spread.  The articles are free - simple to register and then download.

It is the appearance of this on The Lancet site that is such a welcome change.  There is nothing particularly radical here in the content (good though it is), but it is good to see it coming from one of the intellectual bastions of western medicine.

"A canary in the coal mine: the growing popularity of unassisted childbirth" by Amy Wright Glenn

http://mobile.philly.com/blogs/?wss=%2Fphilly%2Fblogs%2Fbirth-breath-death%2F&id=255198201

A thoughtful on-line article summarising the freebirth situation in the USA.  

I have been unable to track down the New Scientist article Amy Wright Glenn mentions but I did find this which is where I think the stats come from:

http://www.cdc.gov/mmwr/preview/mmwrhtml/00000345.htm

Also this article about a sect I had never heard of which describes more recent (2009) events in what I think is the same religious community:

http://www.religiondispatches.org/archive/sexandgender/1618/my_womb_for_his_purposes__the_perils_of_unassisted_childbirth_in_the_quiverfull_movement

and which shows that dogma, and especially patriarchal dogma, is not good for women.

Freebirthing? - AIMS devotes its latest journal to Freebirth.

The Association for Improvements in Maternity Services (AIMS - see links to right) has devoted its latest journal (Vol 25, No 4) to Freebirth and an excellent volume it is too.  Articles include why women choose freebirth, the concept of undisturbed birth, the "latent" stage of labour, the efficacy or otherwise of antenatal care, social services and freebirth, the legality of freebirth, and four in-depth accounts from women who have given free birth.

What struck me about the birth accounts was the slow, gentle, and undulating nature of undisturbed labour - the pattern of physiological labour written about here shows little in common with the regimes imposed by hospital policies and obstetric doctrine.

If you are considering freebirth or your friend, sister, daughter is doing so, then get hold of this journal and enjoy the read.  It has a huge amount of information in its 28 pages.

To buy a copy, visit the AIMS site via the link on this page, go to the Journal page, find vol 25 no 4 and click on the "buy this journal" option, or find it on the publications order page.

WHICH? launches birth guide

WHICH? the consumer guide has launched an on-line guide to help women find out about birth choices locally that fit their preferences and choices.  It is easy to use and, as it develops, should prove more and more helpful in informing women about what is on offer.  UM played around with it and used the "compare" facility to view the "best fit" facilities.  There was a surprising amount of information available, including guidelines and some birth statistics for all the units presented, and it is certainly a welcome and useful tool for gleaning information about which units locally are likely to suit you.

http://www.which.co.uk/birth-choice

It asks some basic questions about your preferences, where you live, age, parity etc and comes up with a list of choices for consideration.  Top of my list came "Your Home" and there was plenty of information about homebirth as well as the other units around.  All-in-all it presented me with the options I would have wanted and expected it to.

If you have any feedback on the site, you can contact BirthChoice on birthchoice@which.co.uk

Article about Freebirth from USA

Here is quite a nice article telling the stories of a few clearly rational and sensible women:

http://www.mercurynews.com/health/ci_25012330/extreme-home-birthing-alone-and-unassisted

Is Ultrasound Safe for Unborn Babies?

Well this issue continues to haunt us - the AIMS booklet Ultrasound Unsound www.aims.org.uk covers the main questions well and here is another, slightly more detailed discussion of the possible intracellular and intracellular dangers.
http://scienceoveracuppa.com/2013/01/10/the-biology-of-ultrasound/
It remains true that, given the absence of Randomised Controlled Trials with long-term follow-up, it is impossible to quantify the level of risk or the exact nature of that risk.  However it also remains true that circumspection when it comes to the use of ultrasound on unborn babies is probably a wise approach.

An articulate comment on current maternity care.

http://www.bestdaily.co.uk/your-life/news/a543050/nhs-midwife-speaks-out-why-british-women-are-really-being-failed-in-birth.html

This is sad reading but a very well put and, I am sorry to say, an accurate portrayal of many obstetric units.  I do believe that the culture of most birth centres and community midwifery services is less woman-unfriendly but the general point still pertains in that midwives working in those settings actively struggle against the attitudes and practices described.  That struggle is part of their daily lives and also takes its toll.

We have placed human birth so far into a medico-legal paradigm that we have almost lost sight of the fact that it is a natural, social and sexual event at the heart of healthy family life.  To heal this situation requires midwives and women to work together and for homebirth, community midwifery, doula, hypnobirthing, independent midwifery and birth centre services to be cherished and strengthened.  Placing these services at the CENTRE of maternity care and not viewing them as frills is the way forward.  Continuity of care and the relationship between midwife and mother is crucial to the humanisation of maternity care.  How can such dismissive, unsupportive and demeaning attitudes and behaviours described in the article survive the building of proper relationships?