https://kclpure.kcl.ac.uk/portal/files/33242518/Birth_place_decision_support_Generic_2_.pdf
This leaflet, from Kings College London, is based on this biggest UK study of place of birth - the Birthplace Study. It is an excellent, easy-to-read and illustrated discussion of the risks associated with place of birth, and some of the key factors to take into consideration when making this decision. It explains what is meant by "risk" and it also has excellent links to other useful resources and websites.
Wherever you are thinking of giving birth - home, hospital or birth centre - this will help you make and understand your decision and explain it to other people.
Tuesday, 31 March 2015
Saturday, 28 March 2015
Paracetamol and Labour
Take
Two: Paracetamol and Labour.
One
of the changes I have noticed over the years is the rise and rise of
the Latent Phase of Labour. I can't remember it even being mentioned
during my training and, checking my textbook [Bender's Obstetrics for
Student Midwives], indeed it doesn't get a mention. There are a
couple of passing references to “false labour” as being an
indication of impending labour and nothing else. There is certainly
no mention of paracetamol, unlike in the hundreds of advices for
women on the internet for coping with the latent phase. Every one of
the hospital guides to the latent phase that I found contained the
advice to take paracetamol, including those of independent midwifery
practices.
I
just do not remember, either as an NHS or independent midwife in the
1980s and 1990s, women having such long exhausting and problematic
latent phases as they do now. I also don't remember anyone telling
women to “take a couple of paracetamol”. Recently I informally
supported someone at home who had had 4 or 5 days of latent labour.
I asked her about her paracetamol intake and was shocked to find that
she had consumed 25 to 30 grams of paracetamol over that period. The
midwives she had been ringing on the local “triage unit”, each
one different, had told her to take paracetamol regularly and this
she had done. I asked if it was helping and she said it wasn't, so I
suggested she stop taking it which she did. Quite apart from the
impact on the liver, could the ubiquitous advice to take paracetamol
be impacting on labour and, more particularly be affecting, or even
creating, the latent phase of labour as we have come to know it
today?
Paracetamol or Acetaminophen is a
widely used, cheap and relatively safe analgesic. Its actions are
poorly understood but it is known to be an inhibitor of prostaglandin
synthesis. It inhibits cyclo-oxygenace (COX), especially COX-2.
COX-2 is responsible for the metabolism of arachidonic acid into
prostaglandin, and the inhibition of this pathway specifically leads
to a reduction in the amount of prostaglandin E.
Prostaglandins (PGs) are important
mediators of uterine activity, and viewed as possibly more important
than oxytocin (O'Brien, 1995)! They cause:
- contractions of the smooth myometrial muscle of the uterus;
- the biophysical changes in the cervix known as “ripening”;
- the maintenance of fetal ductal flow and renal blood flow;
- changes in membrane structure (do these, I wonder, play a role in SROM?).
Hence PGs have a therapeutic role in
obstetrics, especially Prostaglandins E and F in the induction of
labour.
PGs are synthesised in the amnion,
chorion and decidua, and increase in the amniotic fluid prior to
labour. Myometrial tissue contains prostaglandin receptors and PGs E
and F cause uterine contractions. PG E is particulary important in
this and key to cervical ripening. According to Webb (1998)
“Prostaglandins are important for the onset of both term and
preterm parturition”. Blesson and Sahlin (2014) state, “Increased
local production of PGs may be important for pregnancy-associated
elongation of the lower uterine segment, cervical softening and
effacement in primate labour”. There is no doubt that these
hormones are vital to preparing the body to go into labour and the
successful onset of labour.
Then why are we telling women to pop
pills that are known to inhibit this physiological wonder?
My friend had taken 25 to 30 grams of
paracetamol during her latent phase. No record is made or interest
shown in how much paracetamol women are taking. If the drug is
inhibiting labour and causing a dysfunctional and long latent phase,
it will not only be her who has ingested astonishing amounts. And it
is midwives who keep repeating the “take some paracetamol”
mantra.
The use of paracetamol in pregnancy is
associated with crypto-orchidism undescended testes) and an increased risk of childhood asthma (Kristensen et al, 2010; Eyers et al, 2011). A recent New Zealand study found that it was associated with
the development of ADHD (Thompson et al, 2014). This study looked at
children born between 1995 and 1997, before the ubiquitous advice to
women to take paracetamol in early labour. What impact could this
have on tomorrow's children?
I am concerned that paracetamol is
having an insidious effect on women's labours and its use effectively
puts the body into a battle against itself. As the woman struggles
to get into established labour, the drugs she is advised to take are
working against her physiology, never quite over-powering it and
stopping labour, but leading to long, slow and demoralising latent
phases.
How has this all come about? As
hospitals become over-stretched, it has become the norm to “triage”
women, to prevent them going to hospital “too soon”, before they
are in “established” labour. In the drive to keep women whose
cervices are less than 4cms dilated out of hospital, a menu of
self-comforting and self-medicating measures has come into being –
warm baths, walks, massage, long-acting-carbohydrates, relaxation
tapes, TENS machines........... and paracetamol. This is offered up
to women over the phone and through leaflets in lieu of actual
face-to-face care. Not all of this is bad of course, but a drug that
women never used to take has crept into widespread use without being
looked at closely. Few if any women are told of the possible effects
on their unborn children.
I think it is time we looked at the
use of paracetamol in early labour more closely and critically.
See also UM's blogs of 26.5.15 and 25.6.17.
See also UM's blogs of 26.5.15 and 25.6.17.
References
Blesson,
C & Sahlin, L (2014). Prostaglandin E and F receptors in the
uterus. Receptors
and Clinical Investigation. 1e115,
1-8.
Eyers
S, Weatherall, M, Jefferies S, Beasley R (2011). Paracetamol in
pregnancy and the risk of wheezing in offspring: a systematic review
and metanalysis. Clinical
and Experimental Allergy Journal. 41
(4), 482-9.
Gibb,
W (1998). The role of prostaglandin in human parturition. Annals
of Medicine.
30 (3), 235 – 41.
Graham,
G & Scott K (2005). Mechanism of action of paracetamol.
American
Journal of Therapeutics.
Jan-Feb, 12 (1), 46-55.
Kristensen D, Hass, U and 14 others (2010). Intrauterine exposure to mild analgesics is a risk factor for development of male reproductive disorders in human and rat. Human Reproduction (2010) doi: 10.1093/humrep/deq323 First published online: November 8, 2010.
O'Brien
W (1995). The role of prostaglandins in labour and delivery.
Clinical
Perinatology. Dec,
22 (4), 973-84.
Thompson
J, Waldie K, Wall C, Murphy R, Mithcell E and the ABC study group
(2014). Associations
between Acetaminophen Use during Pregnancy and ADHD symptoms Measured
at Ages 7 and 11 years. Open
Access PLOS ONE,
9 (9) 1-6
en/wikipedia.org/wiki/Paracetamol
(accessed 15.3.15)
Wednesday, 18 March 2015
Group B Strep Explained - new AIMS book by Sara Wickham
New Book from AIMS available - go to their website via the links section to the right of this page. Also available as an e-book. An excellent resume of the evidence, the issues and the decisions facing women, written by the redoubtable Sara Wickham. Hard copies £8.