Cesarean Sections

Mamas on Bedrest: What You Need to Know if Your Baby is Born Between 34-36 Weeks 6/7 Days

February 10th, 2014

VamessawavesMy daughter was a “late phase” preemie.

It’s kind of funny to me to recount those early days with her. She’s 11 now, pubertal and as sassy as they come! But in the beginning, everything was a juggling act to make sure that she had all that she needed to start her life off well.

My daughter was born at 36 weeks and 6 days and was literally 3 hours and 57 minutes shy of being a “term” infant. When she was first born the hospital staff kept referring to her as a “preemie” and I kept railing against this term knowing its implications. But as the days went by, she exhibited more and more of the signs of a preterm infant and I had to admit that she was in fact a preemie-no matter how close in hours and minutes she had been born to term.

When my daughter was born, she didn’t immediately cry. After the neonatal staff worked on her for a few moments, she did let out a wail that sent the biggest wave of relief through my body. But we weren’t out of the woods. On examination she had some fluid in her lungs and was in a bit of respiratory distress. So they wrapped her up, whisked her by my face and hurried her off to the nursery for a closer look.

In the days that followed, my daughter continued to have difficulty breathing. When I would nurse her, her oxygen saturation would drop into the low 80’s. She would also get quite tired while nursing and we had to supplement her feedings with bottle feedings. Although she never required supplemental oxygen nor slept in an incubator, she did initially have some problems with temperature regulation and slept on a little warming bed. The first time I saw her on this thing, with little eye covers over her face, it reminded me of a tanning bed and I asked “Why was my little brown baby was being tanned?” I was informed that the warming bed would help her regulate her temperature and help with bilirubin  metabolism (although she never did have an increased bilirubin level which is common in late phase preemies.) Overall, my daughter did really well and continued to progress during her 10 days in the NICU. By the time she was discharged, her father and I were providing the bulk of her care; holding her skin to skin, feeding her and changing her. I was increasingly frustrated that they would not allow her to go home and actually “had it out” with the neonatologist one day when he proposed yet another day of “watching”. But if I were to have my daughter today, knowing what I know, I would be (and I am now) ever thankful for the care of the NICU staff provided for my daughter.

In 2009, 71% of all preterm infants were late preterm infants, born between 34 and 36 weeks 6/7 days. The most common reasons for these early deliveries were:

 

  • Spontaneous Labor
  • Premature Rupture of Membranes
  • Pregnancy Induced Hypertension
  • Placental Disorders
  • Fetal Disorders
  • Intrauterine Growth Restriction
  • Multiple Gestation (Twins or higher order multiples)
  • Maternal Medical Disorders

Because many late phase preterm infants look like term infants, signs and symptoms of complications can be missed. But these can be a crucial errors. Late preterm infants born to mothers with antepartum hemorrhage ae 12 times more likely to develop problems in the early post partum compared to term infants. Infants born to mothers who had pregnancy induced hypertension are 11 times more likely to have post partum complications. The earlier the infant (i.e. the closer to the 34 weeks) the more likely they are to experience complications. And when an infant is an “early late phase preemie” and born to a mother with medical problems such as pregnancy induced hypertension, the more likely the infant is to have complications. The most common complication seen in late phase preterm infants are:

  • Elevated Bilirubin levels (hyperbilirubinemia)
  • Respiratory Issuesn (rapid, labored breathing and/or Pneumonia)
  • Hypoglycemia
  • Poor feeding (fatigue and poor weight gain)
  • Temperature instability (inability to regulate temprature due to lower amounts of brown and white fat on their bodies)
  • Infections

Any one or a combination of these issues may land the infant in the Neonatal Intensive Care Unit (NICU). However, not all infants who exhibit these complications need the expert skill rendered in the NICU. Well trained hospital staff and well educated parents can manage many of these infants.  So what do parents and care providers need to know?

Mamas, if at all possible, avoid having a cesarean section-especially if it is your first child. First time Cesarean section delivery of the 32-36 week infant increases the infant’s risk of developing the aforementioned complications as well as their risk of not surviving. Almost all of these infants end up in the NICU. While a cesarean section may be indicated if mama, baby or both are in distress, elective cesarean sections should be avoided.

Watch your child’s feeding patterns. Because these infants often tire easily with nursing, infants who fall asleep while nursing my be mistaken for being full when they are actually fatigued. These infants may have long periods between feedings and fail to gain weight. Parents of such infants must adopt an every 2-3 hour feeding schedule and keep a close watch on weight gain to ensure adequate nourishment and development.

These infants should not be discharged early. Late preterm infants have a high rate of “bounce back admissions”. Many of the complications that arise do so within the first 48 hours to 2 weeks post partum. Careful monitoring in the hospital for 48 hours can allow medical staff to detect arising complications and treat them early to avoid major problems as well as readmission. While these infants should be assessed often, they don’t necessarily need to be in the NICU. They should be evaluated by a pediatrician 48-72 hours after discharge and at 2 weeks then 8 weeks. This may seem like a lot, but complications, if they are going to arise, will occur within the first 28 days of life.

Looking at my daughter today I can hardly believe she was the tiny little baby I held so close. Just 3 inches shorter than me (Okay, I’m only 5 ft, but she’s only 11!) and already developing the curves of a young woman, she has grown and developed really well. She has asthma that is well managed and does anything she wants to do. But those early days of keeping her bundled up (she was an October baby) and watching her feedings were hard-but well worth it. And the expert care of the NICU staff are much credited with her health success. I was a stressed out mama then, just wanting to take my baby home.  But I am forever grateful that the staff-the neonatologist in particular-stood firm, monitored her carefully and only sent her home when they were absolutely sure that she wouldn’t come back. And she never has!!!

IMG_1729

Resources:

Erica Saleski Forsythe, MSN, RN, Patricia Jackson Allen, MS, RN, PNP-BC, FAAN “Health risks associated with late-preterm infants: implications for newborn primary care.” Pediatric Nursing. 2013 Jul-Aug;39(4):197-201. 

MedScape OB/GYN Women’s Health

Mamas on Bedrest: Not all C-Sections are bad

January 24th, 2014

Mamas,

Vanessas-birth

My daughter at birth

Having a c-section is not the worst thing that can happen to you. I say this from the perspective of having had 2. While chatting with mamas in this community, one mama stated how she is terrified at the thought of having a c-section. I realized that c-sections have become demonized in the birth world and this is not a good thing.

On this blog, all over the web there and in numerous chats there are articles and points of view touting “normal”  and “natural” (meaning vaginal) delivery. I’ll admit that I am a proponent of minimal intervention. Having went through what I went through to have my children, I know the potential pitfalls of too much intervention. Intervention must be balanced with “watch and wait” and not overdone. Even though labor and delivery is a marathon process, there are many physiologic benefits for mamas and babies who endure the process and emerge victorious on the other side. So for women who can, I most certainly advocate for “natural, vaginal birth”  whenever possible.

Well, the sad truth is that this isnt always possible. Many years ago, many women (and babies) died as a result of being unable to deliver “naturally” and doctors and midwives of the day not having the skills or technique of cesarean section. Thankfully (for me and my daughter at least) clinicians have those skills and expertise and many mamas and babies are alive today. But what is a very viable and useful method of delivery and one that saves lives in critical situations has become an overused, overdone process. Cesarean sections are the second most performed surgery in the US second only to Hysterectoies. And while they are a critical tool in the obstetrical arsenal, their overuse has contributed to many mamas and babies are not faring so well during the childbirth process.

Currently cesarean sections account for a full one third of all births in the United States. According to the CDC, rates of C-section deliveries-especially first time c-section deliveries-have leveled off and are declining. This is good news because a first c-section is often an indication for subsequent c-sections. C-sections are often scheduled for the following reasons and these indications are responsible for 85% of all cesarean deliveries:

  • “large babies”
  • uterine/placental/vaginal issues,
  • fetal distress or shoulder dystocia
  • breech presentation
  • The leading indication for cesarean delivery is previous cesarean delivery

I doubt anyone would argue the necessity of a cesarean section for a mama and/or baby in distress; i.e. mama’s blood pressure skyrocketing and not responding to medication, a decrease in fetal heart rate, decreased fetal movement which may indicate a problem, or other complication. But in this country, c-section has (or had) become the norm for twins, mamas who have gone beyond 39 weeks (as late as 42 weeks is still considered full term!), induction (a whole other topic for a blog in and of itself!), “big baby” and several other “nebulous” reasons. C-sections became a way to “control” birth and to be able to dictate specifically when a baby would be born and who would be attending.

That is where we here in the US fell into problems. Birth is a wild and unpredictable process. Because we can never be exactly sure when conception and implantation occur (except in cases of assisted reproductive technology), clinicians really are guessing the age and developmental status of an infant in utero. Granted, we have some very sophisticated technology that we can use now and get a pretty accurate “guestimate”. But we are still guessing, and sometimes the guesses are off way more that expected. there also seems to be this need to control the process. Birth should not be controlled. It is as it is for a reason; so that mama’s and baby’s physiologies can interplay and together navigate the birth process. That process, that delicate physiologic communication is disrupted when clinicians intervene. Again, sometimes intervention is waranted. But historically in the US, the interventions are often more disruptive than beneficial.

So what should a mama do? How does she decide? Mamas, always have frank and open discussions about your care with your health care providers. Ask them what they hope to accomplish by performing a cesarean section and why they believe it is the best course of action in your particular case. Get as much information as you can; read, get second opinions if you feel uneasy. Make sure that in the end, whatever route of delivery you choose, you are comfortable with the decisions made and the procedures being performed.

Not all c-sections are bad. Many are lifesaving (as was the case with me and my daughter!). Just be sure that you are fully informed and fully at peace with your decision for the procedure before you signed the “informed consent”.  Remorse and regret following a birth that has not gone well can haunt a mama for years. It can have lifelong (negative) implications for the baby. And sadly, it cab alter the interaction between mama and child if not just initially, for many years to come.

What are your thoughts of C-section? Share your thoughts in the comments sections below.

Mamas on Bedrest: No more C-Sections for Breech Births?

July 8th, 2013

If you are a mama in Australia or New Zealand, you may well be advised to have a vaginal birth-even if your baby is in breech position.

Reported in The Canberra Times by Kate Hagan, Revised guidelines from the Royal Australian and New Zealand College of Obstetricians and Gynecologists are advising that vaginal births are possible with breech presentations and should be attempted in appropriate women.

While this is a 180 degree shift from previous position statements, members of the college are recognizing that more breech presentation infants could have been born vaginally if health care staff were properly trained. According to College vice president Steve Robson,

“Only 3% of babies were in the breech position late in pregnancy and most were delivered by cesarean section, meaning few young doctors had the skills to perform vaginal births.”

In Australia and New Zealand, vaginal deliveries of breech births dropped from 23% in 1991 to 3.7 % in 2005 due to the shift to cesarean sections.  The shift occurred after an correspondence published in The Lancet in 2000 cited fewer risks delivering by cesarean sections. However, many doctors skilled in breech delivery question the study and the reported results.

Dr. Kobus du Plessis, a physician trained in South Africa, is particularly skeptical of the studies and is now training young doctors and midwives to attend breech births. According to du Plessis,

“Most deliveries are hand-off with breech births, and if all the criteria are fulfilled most of the time we don’t have to do anything. The reason you need experience, and the thing most people afraid of, is the head getting stuck.”

This is great news for mamas and babies worldwide. Whenever one nation or even one group makes major headway in a given treatment or technique, its not long before others seek them out to learn the skills and to disseminate the information and “technology”. Interestingly, in this case, it isn’t technology being sought, but lost skills and as Dr. du Plessis says, “lost art”. Long ago, physicians and midwives both used Leopolds Maneuvers and other manual manipulations to turn babies and facilitate vaginal births. As technology became more sophisticated, medical training became more focused on the technologies, setting aside many of the more “basic” skills needed.

And while technology is good, we are all becoming more aware that technology is not a suitable replacement for nature. The intricate interplay between mother and baby stimulating labor and delivery, passage of the infant through the birth canal and the immediate interaction between mother and baby in the immediate post partum cannot be replicated or substituted.  Removing these critical interactions via induction, cesarean delivery and by separating mama and baby in the immediate post partum are now being noted to be detrimental and the practices halted.

How will this affect births in the United States? Hopefully, obstetricians and midwives will take notice of the changes being made in Australia and New Zealand and will follow suite. Given the Cesarean Section rates and the maternal and infant morbidity and mortality rates, we need to make changes in this country. It would certainly be nice to keep it simple and do things as much in line with nature as possible.