Comfortable Upright Birth (CUB)

http://www.cub-support.com/

I love the animation on this site and coming across a piece of useful gear at a reasonable price.  Also a great resource list for any midwifery student doing a project on birth positions.  I think an inflatable support like this will have limited appeal to many units (over and above birth balls for labour and solid birth stools for birth) but a great thing for homebirths. 

Proud to be breastfeeding her toddler.

It isn't often that the Mail comes up with anything that is a) good news or b) worth reading, but this is a great story from yesterday's Mail On Line http://www.dailymail.co.uk/femail/article-3270403/WAG-Melanie-Walcott-reveals-breastfeeds-18-month-old-son-Finley.html
For non-UK readers, Theo Walcott is a football/soccer player for Arsenal and England so about as famous in UK Man-World as they come.  A great use of celebrity to promote attachment parenting and long-term breastfeeding, well done Melanie Walcott.

Shoe size and risk of Caesarean section

In 1985 some midwives and doctors (Frame S et al.) from St Mary's in London published a beautifully simple and interesting study in the British Journal of Obstetrics and Gynaecology called "Maternal height and shoe size as predictors of pelvic disproportion: an assessment".

They found a clear correlation between foot size and giving birth by Caesarean section, that is they took shoe size to be an indicator of pelvic capacity.  Of course even in 1990, the CS rate in England was "only" 12% and BMIs were lower than they are 30 years on.  I think any replication of this study would have to see how much BMI affected the CS rate.  Whilst Frame and colleagues found that CS risk was poorly related to height, this may not hold true for BMI.

The findings are summarised below and give European shoe sizes with US shoe sizes in square brackets [...] (the original paper gives old British shoe sizes):

351 women who gave birth in the Paddington and North Kensington Health District were studied in order to establish a factual basis for recording height and shoe size as indicators of pelvic adequacy. Because only 19 women had radiological pelvimetry assessment, type of delivery and length of labour were used as proxy measures of disproportion. 

Of the 57 women with a shoe size less than 37.5 [7],  21% were delivered by caesarean section compared with 10% of the group with shoe size between 37.5 [7] and 39 [8.5] and only 1% of the group with shoe size of or greater than 39.5 [9].  Similar relations with height were not generally found. 

The data were further examined using logistic regression models of the expected percentages of mothers having an adverse delivery. The models confirmed and extended the more simple analysis.

This is such a simple finding and with risk screening for CS becoming quite the In-Thing, this is a piece of work worth revisiting.  Of course, whilst there is a significant linear trend in the percentage of women giving birth by CS and their foot size, the relationship is not a causal one and if we used foot size alone as a predictor of CS, we would be wrong most of the time, even in these days of The Great Caesarean Epidemic, although if you have size 39.5+ feet, I think you can be fairly confident that your pelvic diameters are very baby-friendly!

This interesting piece of work can still be found here:

https://epilab.ich.ucl.ac.uk/coursematerial/statistics/PDFfiles/maternal%20height%20and%20shoe%20size.pdf

More on Paracetamol (Acetaminophen) in pregnancy

Another study has confirmed earlier Danish findings that paracetamol use during pregnancy can have an adverse effect on male reproductive function.
FOR MORE ABOUT PARACETAMOL (ACETAMINOPHEN) PLEASE SEE MY POST OF 28TH MARCH 2015.

A team in Edinburgh have found that prolonged paracetamol use (aka acetaminophen or Tylenol) by pregnant women may reduce testosterone production in unborn baby boys.  The authors advise taking paracetamol only for the shortest time and the lowest dose during pregnancy.

This confirms earlier suggestions that the inhibition of prostaglandin synthesis caused by paracetamol has wider hormonal impact than has been thought.  The doses used by the Edinburgh team were close to the normal therapeutic dosage and this again suggests that paracetamol use in pregnancy and labour warrants more investigation.  So far scientists have looked at the effects on the unborn baby, but scrutiny of the effect on the mother and her labour is also overdue.

The Medical Research Council's press release can be found here: http://www.mrc.ac.uk/news-events/news/paracetamol-in-pregnancy-may-lower-testosterone-in-unborn-boys/

S. van den Driesche, J. Macdonald, R. A. Anderson, Z. C. Johnston, T. Chetty, L. B. Smith, C. McKinnell, A. Dean, N. Z. Homer, A. Jorgensen, M. E. Camacho-Moll, R. M. Sharpe, R. T. Mitchell. Prolonged exposure to acetaminophen reduces testosterone production by the human fetal testis in a xenograft model. Science Translational Medicine, 2015; 7 (288): 288ra80 DOI: 10.1126/scitranslmed.aaa4097

Anterior cervical lips and early pushing.

Rachel Reed, an Australian midwife, has written an excellent analysis of cervical lips - that is when there is a small (c. half to one cm) rim of cervix to the anterior of the baby's head.  It can be found at Rachel's blog, complete with pictures /http://midwifethinking.com/ and there is a pdf file of the same article at http://research.usc.edu.au/vital/access/manager/Repository/usc:7464?queryType=vitalDismax&sort=ss_dateNormalized\&query=Reed&f0=sm_creator%3A%22Reed%2C+R%22

This common scenario often results in women wanting to push but being urged not to do so.  In my personal experience, no multiparous woman who feels an overwhelming urge to push should be discouraged from doing so.  Rachel has also found this to be so, and has written a very useful summary of the whole phenomenon of anterior cervical lips.

However just in case the links don't work I have it quoted below minus the pictures and diagrams:

"Here is a scenario I keep hearing over and over: a woman is labouring away and all is good. She begins to push with contractions, and her midwife encourages her to follow her body. After a little while, the midwife checks to see what is happening‘ and finds an anterior cervical lip. The woman is told to stop pushing because she is not fully dilated and will damage herself. Her body is lying to her – she is not ready to push. The woman becomes confused and frightened. She is unable to stop pushing and fights her body creating more pain. Because she is unable to stop pushing, she may be told to have an epidural. An epidural is inserted along with all the accompanying machines and monitoring. Later, another vaginal examination finds that the cervix has fully dilated and directed pushing begins. The end of the story is usually an instrumental birth (ventouse or forceps) for an epidural related problem – directed pushing = fetal distress; failure to progress‘; mal-positioned baby due to supine position and reduced pelvic tone. The message the woman takes from her birth is that her body failed her, when in fact it was the midwife/system that failed her. Before anyone gets defensive – I am not pointing fingers or blaming individuals, because I have been that midwife. Like most midwives, I was taught that women must not push until the cervix has fully dilated. This post is an attempt to prompt some re-thinking about this issue, or rather this non-issue.
Anatomy and Physiology
Birth is an extremely complex physiological process but very simplistically three main things occur:
1. Dilatation of the cervix
2. Rotation of the baby through the pelvis
3. Descent of the baby through the pelvis
But this is not a step-by-step process – it‘s all happening at the same time, and at different rates. So, whilst the cervix is dilating the baby is also rotating and descending.
1. Dilatation of the cervix
The cervix does not open as depicted in obstetric dilatation models i.e. in a nice neat circle (Sutton 2001). It opens from the back to the front like an ellipse. The os (opening) is found tucked at the back of the vagina in early labour and opens forward. At some point in labour almost every woman will have an anterior lip because this is the last part of the cervix to be pulled up over the baby‘s head. Whether this lip is detected depends on whether/when a vaginal examination is performed. A posterior lip is almost unheard of because this part of the cervix disappears first. Or rather, it becomes difficult to reach with fingers first.
The cervix dilates because the muscle fibres in the fundus (top of the uterus) retract and shorten with contractions and pull it open (Coad 2005). This does not require the pressure of a presenting part i.e. baby‘s head or bottom (let‘s stick to heads for now). However, the head can influence the shape of the cervix as it dilates up around it. For example, a well flexed OA baby (see pic A above) will create a neater, more circular cervix. An OP and/or deflexed baby (see pic B) will create a less even shape. For more about OA and OP positions see this post. Most babies will be somewhere between these two extremes whilst the cervix is opening and will be changing their position as they rotate.
2. Rotation
Babies enter the pelvis through the brim. As you can see from the pictures below. this is easier with their head in a transverse position. As the baby descends into the cavity their head will be asynclitic – with the parietal bone/side of the head leading. This is because the angle of the pelvis requires the baby to enter at an angle – see the picture on the left. Once in the cavity the baby has room to rotate into a good position for the outlet which is usually OA. Rotation is aided by the pelvic floor and often by pushing.
3. Descent - the urge to push
The urge to push… and I‘m talking spontaneous, gutteral, unstoppable pushing… is triggered when the presenting part descends into the vagina and applies pressure to the rectum and pelvic floor. This is called the Ferguson reflex‘ – probably after some man. This reflex is not dependent on what the cervix is doing, but where and what the baby‘s head is doing. So, if the baby‘s head hits the right spot before the cervix has finished dilating the woman will spontaneously start pushing. An alternative but common scenario is when the cervix is fully open but the baby has not descended far enough to trigger pushing. Unfortunately, some practitioners will tell the woman to push and create problems instead of waiting for descent and spontaneous pushing.
Pushing before full dilatation
Because we are not telling women when to push (are we?!) they will push when their body needs to. If we are directing pushing we risk working against the physiology of birth and creating problems (see previous post). Spontaneous
pushing before full dilatation is a normal and physiologically helpful when:
1. Baby’s head descends into the vagina before the cervix has dilated. In this case the additional downward pushing pressure assists the baby to move beyond the cervix whilst pulling the cervix out of the way.
2. Baby is in an OP position and the hard prominent occiput (back of head) presses on the rectum. In an OA position this part of the head is against the symphysis pubis and the baby has to descend deeper before pressure on the rectum occurs from the front of the head. In the case of an OP position, pushing can assist rotation into an OA position.
I am yet to find any evidence that pushing on an unopened cervix will cause damage. I have been told many times that it will but have never actually seen it happen. I have encountered swollen oedematous cervixes – mostly in women with epidurals who are unable to move about. But, this occurs without any pushing. I can understand how directed, strong pushing could bruise a cervix. But, I don‘t see how a woman could damage herself by following her urges. In many ways the argument regarding pushing, or not, is pointless because once the Ferguson reflex takes over it is beyond anyone‘s control. You either let it happen or start commanding the woman to do something she is unable to do i.e. stop pushing.
Telling women to push or not to push is cultural and not based on physiology or research. For example, in some parts of the world e.g. Central Africa, women are told to push throughout their entire labour (on an unopened cervix!). This is often accompanied by their midwife manually stretching the cervix, too – ouch. Alternatively, in other parts of the world e.g. the US, women are told not to push until a prescribed point in labour. It seems midwives are bossy worldwide.
When left to get on with their birth, occasionally women will complain of pain associated with a cervical lip being nipped‘ between the baby‘s head and their symphysis pubis during a pushing contraction. In this case the woman can be assisted to get into a position that will take the pressure off the cervical lip (e.g. backward leaning). When undisturbed, women will usually do this instinctively. At a recent water birth, a mother (first baby) who had been spontaneously pushing for a while on all fours floated onto her back. A little while later she asked me to feel where the baby was (for her not me) – baby was not far away with a fat squishy anterior lip in front of the head. The mother also had a feel, then carried on pushing as before. Her daughter was born around 30 minutes later.
Suggestions
Avoid vaginal examinations (VEs) in labour. What you don‘t know (that there is a cervical lip) can‘t hurt you or anyone else. VEs are an unreliable method of assessing progress, and the timelines prescribed for labour are not evidence based (see this post).
Ignore pushing and don‘t say the words push‘ or pushing‘ during a birth. Asking questions or giving directions interferes with the woman‘s instincts. For example, asking, Are you pushing?‘ can result in the women thinking, Am I? Should I be? Shouldn‘t I be?‘ Thinking and worrying is counterproductive to oxytocin release and therefore birth. If she is pushing, let her get on with it and shush. For more about pushing in general and a link to a great audio by Gloria Lemay see this post.
Do not tell the woman to stop pushing. If she is spontaneously pushing (and you have not coached her), she will be unable to stop. Pushing will help, not hinder the birth. Telling her not to push is disempowering and implies her body is wrong‘. In addition, after fighting against her urge to push she may then find it difficult to follow her body and push when permitted to do so (Bergstrom 1997).
If a woman has been spontaneously pushing for a while with excessive pain (usually above the pubic bone), she may have a cervical lip which is being nipped against the symphysis pubis. There is no need to do a vaginal examination to confirm this unless she wants you to.
If you suspect or know there may be a cervical lip:
- Reassure her that she has made fantastic progress and only has little way to go.
- Ask her to allow her body to do what it needs to, but not to force her pushing.
- Help her to get into a position that takes the pressure off the lip and feels most comfortable – usually a reclining position.
- If the situation continues and is causing distress – during a contraction, apply upward pressure (sustained and firm) just above the pubic bone in an attempt to lift‘ the cervix up.
- If the woman is requesting further assistance, the cervical lip can be manually pushed over the baby‘s head internally. This is extremely uncomfortable!
Note: This nipping situation is rare and usually a cervical lip will simply move out of the way without causing any problems.
Summary
An anterior cervical lip is a normal part of the birth process. It does not require management and is best left undetected. The complications associated with an cervical lip are caused by identifying it, and managing the situation as though it problem." [The Anterior Cervical Lip: how to ruin a perfectly good birth
— posted 22 January 2011 by Rachel Reed: independent midwife, educator and birth nerd.]

Wondering where to give birth?

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. 

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.

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)

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.