Saturday, January 10, 2009

C-Section Too Early Risks Baby's Health
Babies Born by Surgical Delivery Before 39 Weeks May Suffer Health Problems

When 37-year-old Alicia Cooney of Cleveland was pregnant with her first child in October 2007, her doctor expressed no concern about scheduling her Caesarian delivery, or C-section, just 38 weeks into the pregnancy.

But when Cooney became pregnant with her second child last April, her doctor was singing a different tune about when to schedule a C-section.

"I did notice a change within the hospital that they really wanted to make sure my C-section wasn't before 39 weeks," Cooney explained.

Cooney said that her doctor expressed concern about the increased risk of wet lung -- or an accumulation of fluid in the newborn's lungs -- in babies delivered by C-section before 39 weeks of gestation.

Cooney's doctor may not be alone in changing his practice in the face of these risks. On Wednesday, a new study published in the New England Journal of Medicine found that C-section delivery before 39 weeks of gestation is, indeed, linked to increased health problems for babies.

According to the National Institutes of Health, a pregnancy of normal gestation lasts about 40 weeks, with "normal" pregnancies ranging from 38 to 42 weeks.

A team of researchers lead by Dr. Alan Tita from the department of obstetrics and gynecology at the University of Alabama at Birmingham examined the results of 13,258 women who had a scheduled, repeat C-section that was planned for no other medical reason than the fact that the woman had previously had a C-section.

The researchers found that, compared to babies delivered by C-section at 39 weeks of gestation, those born at 37 or 38 weeks had a higher rate of breathing problems, blood sugar problems and serious infections. Moreover, those babies were more likely to be admitted to the neonatal intensive care unit.

"Early elected delivery is associated with adverse outcomes for the baby," Tita explained. "And the earlier you deliver, the higher it increases the risk."

These findings are in line with current recommendations by the American College of Obstetricians and Gynecologists (ACOG).

Yet despite the long list of potential complications associated with C-section delivery before 39 weeks, the study also found that a large number of the women studied -- 36 percent -- chose to schedule a C-section delivery before 39 weeks anyway.

"I have seen women induced or have a scheduled C-section because they have family scheduled to be in town, because they want the baby to be born on an anniversary or someone else's birthday, because they want the baby born prior to Jan. 1 for tax purposes, or because they are simply sick and tired of being pregnant," said Dr. Elaine St. John, associate professor of pediatrics in the Division of Neonatology at the University of Alabama at Birmingham.

Other experts say that the increase in C-sections before 39 weeks is due to a lack of understanding of the dangers associated with elective late pre-term birth.
"Most women think the risks to their babies are the same whether the babies are delivered four, three, two or one week before the baby is due," explained Dr. Sessions Cole, director of the Division of Newborn Medicine at the St. Louis Children's Hospital. "This study should help mothers understand that there are significant risks to their babies associated with elective late preterm
Patient Pressure Figures Big

Approximately 30 percent of all babies born in the United States are delivered by C-section. A study published in April 2005 in the journal Obstetrics and Gynecology found that elective C-sections accounted for about 28 percent of all C-sections performed in the U.S. in 2001.

However, many experts report a growing trend toward encouraging women not to schedule an elective C-section before 39 weeks at hospitals all over the country.

"The recommendations for years have been to avoid elective delivery of any kind until after 39 weeks," said Dr. Lisa Jones, a gynecologist at the New Bedford Community Health Center in New Bedford, Mass. "So all this study really does is reinforce what we already knew."

Still, some experts say that the power of maternal insistence in scheduling an early C-section is enough to convince many doctors to go along with their patient's wishes.

"I think the practice of early [C-section delivery] will only end if hospitals ban the practice," Holzman said. "There is little reason for [obstetricians] to stop since they are often pressured by patients."

The study also outlines some of the risks women must consider when opting to deliver by C-section after 39 weeks.

According to Tita, one such risk is having an unexplained stillbirth while waiting for the 39-week-mark to deliver. This risk is very small, but Tita said that it is still best for women to follow ACOG recommendations by waiting the full 39 weeks before delivering by C-section.
Early Surgical Delivery Sometimes Appropriate

There are, however, certain instances in which an early delivery is appropriate.

"If there [are] firm medical indications of risk to the mother's or fetus's ... health [such as] worsening maternal high blood pressure [or] lack of fetal responsiveness ... then delivery is indicated," Cole explained. "However, the risks of these conditions should be weighed against the risks described by this study."

Moreover, Holzman said, "For most of these [conditions], the risks to the fetus in delaying [delivery] are well known and predictable."

Many experts ultimately hope that this study will prove to the public that the risks of early C-section delivery greatly outweigh the benefits in most cases.

"Hopefully articles like this will help educate the general public and fewer babies will be placed at risk in the future," said Dr. Patricia Chess, associate professor of pediatrics at the University of Rochester Medical Center.

Wednesday, January 7, 2009

Early Maternity leave linked fewer C-sections and increased breastfeeding

Studies link maternity leave with fewer C-sections and increased breastfeeding

Berkeley -- Two new studies led by researchers at the University of California, Berkeley, suggest that taking maternity leave before and after the birth of a baby is a good investment in terms of health benefits for both mothers and newborns.

One study found that women who started their leave in the last month of pregnancy were less likely to have cesarean deliveries, while another found that new mothers were more likely to establish breastfeeding the longer they delayed their return to work.

Both papers were part of the Juggling Work and Life During Pregnancy study, funded by the Maternal and Child Health Bureau of the U.S. Health Resources and Services Administration and led by Sylvia Guendelman, professor of maternal and child health at UC Berkeley's School of Public Health. The research takes a rare look into whether taking maternity leave can affect health outcomes in the United States.

"In the public health field, we'd like to decrease the rate of C-sections (cesarean deliveries) and increase the rate of breastfeeding," said Guendelman. "C-sections are really a costly procedure, leading to extended hospital stays and increased risks of complications from surgery, as well as longer recovery times for the mother. For babies, it is known that breastfeeding protects them from infection and may decrease the risk of SIDS (Sudden Infant Death Syndrome), allergies and obesity. What we're trying to say here is that taking maternity leave may make good health sense, as well as good economic sense."

The study on the use of antenatal leave - time off before delivery with the expectation of returning to the employer after giving birth - and the rate of C-sections is the first examination of birth outcomes in U.S. working women, the researchers said. It will appear in the January/February print edition of the journal Women's Health Issues.

The researchers analyzed data from 447 women who worked full-time in the Southern California counties of Imperial, Orange and San Diego, comparing those who took leave after the 35th week of pregnancy with those who worked throughout the pregnancy to delivery. Only women who gave birth to single babies with no congenital abnormalities were included in the analysis. They adjusted for sociodemographic factors such as income, age and type of occupation, as well as for various health measures such as high blood pressure, body mass index, amount of self-reported stress and average number of hours of sleep at night.

Using a combination of post-delivery telephone interviews and prenatal and birth records, the researchers found that women who took leave before they gave birth were almost four times less likely to have a primary C-section as women who worked through to delivery.

The study authors pointed out that the United States falls behind most industrialized countries in its support for job-protected paid maternity leave. The federal Family and Medical Leave Act provides for only unpaid leave of up to 12 weeks surrounding the birth or adoption of a child.

The bulk of studies on leave-taking and health outcomes from other countries suggest that taking leave prior to birth can be beneficial. The authors point to a macroanalysis of 17 countries in Europe that linked failure to take such leave with low birthweight and infant mortality. Rates of pre-term delivery were lower among female factory workers in France if the women took antenatal leave, and a study conducted in several industrialized countries found that paid leave, but not unpaid leave, significantly decreased low birthweight rates.

According to the U.S. Census, among working women who had their first birth between 2001 and 2003, only 28 percent took leave from their jobs before giving birth while an additional 22 percent quit their jobs. Twenty-six percent of women took no leave before birth.

"We don't have a culture in the United States of taking rest before the birth of a child because there is an assumption that the real work comes after the baby is born," said Guendelman. "People forget that mothers need restoration before delivery. In other cultures, including Latino and Asian societies, women are really expected to rest in preparation for this major life event."

The authors added that financial need may also deter women from taking leave in the last month of pregnancy. Only five states - California, Hawaii, New Jersey, New York, Rhode Island - and the territory of Puerto Rico offer some form of paid pregnancy leave, and none offer full replacement of the woman's salary.

The study on maternity leave and breastfeeding is in the January issue of the journal Pediatrics. Using data from 770 full-time working mothers in Southern California, researchers assessed whether maternity leave predicted breastfeeding establishment, defined in this study as breastfeeding for at least 30 days after delivery. Phone interviews were conducted 4.5 months, on average, after delivery.

In this study, women who had returned to work by the time of the interview took on average 10.3 weeks of maternity leave. Overall, 82 percent of mothers established breastfeeding within the first month after their babies were born. Among women who established breastfeeding, 65 percent were still breastfeeding at the time of the interview.

Researchers found that women who took less than six weeks of maternity leave had a four-fold greater risk of failure to establish breastfeeding compared with women who were still on maternity leave at the time of the interview. Women who took six to 12 weeks of maternity leave had a two-fold greater risk of failing to establish breastfeeding.

Having a managerial position or a job with autonomy and a flexible work schedule was linked with longer breastfeeding duration in the study. After 30 days, managers had a 40 percent lower chance of stopping breastfeeding, while those with an inflexible work schedule had a 50 percent higher chance of stopping.

Overall, the study found that returning to work within 12 weeks of delivery had a greater impact on breastfeeding establishment for women in non-managerial positions, with inflexible jobs or who reported high psychosocial distress, including serious arguments with a spouse or partner and unusual money problems.

"The findings suggest that if a woman postpones her return to work, she'll increase her chances of breastfeeding success, especially if she's got a job where she's on the clock and has less discretion with her time," said Guendelman. "Also, women who are in jobs where they have more authority may feel more empowered with how they use their time."

The American Academy of Pediatrics (AAP) recommends that babies be breastfed for at least the first year of life, and exclusively so for the first four to six months.

According to the AAP, increased breastfeeding has the potential for decreasing annual health costs in the U.S. by $3.6 billion and decreasing parental employee absenteeism, the environmental burden for disposal of formula cans and bottles, and energy demands for production and transport of formula.

The study authors noted that just having maternity leave benefits offered by an employer was not helpful in breastfeeding establishment unless the leave was actually used, indicating the importance of encouraging the use of maternity leave and making it economically feasible to take it.

"These new studies suggest that making it feasible for more working mothers to take maternity leave both before and after birth is a smart investment," said Guendelman.


Other co-authors of the paper in Women's Health Issues are Michelle Pearl and Steve Graham, senior research scientists at the Sequoia Foundation, a California-based non-profit organization focused on public health research; Alan Hubbard, UC Berkeley assistant professor of biostatistics; Dr. Nap Hosang, lecturer at UC Berkeley's Maternal and Child Health program and a practicing obstetrician; and Martin Kharrazi, research scientist supervisor in the California Department of Public Health Genetic Disease Screening Program.

In addition to Guendelman, Pearl, Graham and Kharrazi, the Pediatrics paper was co-authored by Jessica Lang Kosa, research associate, and Julia Goodman, former graduate student, both at UC Berkeley's School of Public Health.

The study published in Women's Health Issues received additional funding from the Center for Health Research at UC Berkeley. The paper in Pediatrics also received support from the UC Labor and Employment Research Fund and the UC Berkeley Institute for Research on Labor and Employment.


103 out of 115 delivered VBAC after 2 Cesareans - How awesome if given the chance!

Author: Chattopadhyay-S-K. Sherbeeni-M-M. Anokute-C-C.
Title: Planned vaginal delivery after two previous caesarean sections
[see comments]
Source: Br-J-Obstet-Gynaecol. 1994 Jun. 101(6). P498-500. Comment:
Comment in: Br-J-Obstet-Gynaecol. 1995 Mar.102(3). P 262-3. Journal


OBJECTIVE: To determine the outcome of trial of labour after two
caesarean sections.
DESIGN: Prospective observational study.
SETTING: Maternity and Children's Hospital, Riyadh,Saudi Arabia.
SUBJECTS:Women with two previous caesarean sections considered
suitable for atrial of vaginal delivery.
MAIN OUTCOME MEASURES: The rates of vaginal delivery, scar
dehiscence, uterine rupture and associated complications among 115
women with two previous sections who underwent trial of labour were
compared with 1006 women with two previous sections who did not have
a trial of labour.
RESULTS: Trial of vaginal delivery was requested by 230 out of 1136
women (20%) who had two previous caesarean sections. Of the 115 women
accepted for the trial, 103 (89%)were delivered vaginally
. Labour
started spontaneously in 78 (68%)of the 115 women and was induced
with prostaglandin (PGE2) in the remaining 37. Augmentation of labour
with oxytocin was required in 32(28%) of the trial labour group.
There were no scar dehiscences among the women delivered vaginally.
There was one scar dehiscence and one woman required hysterectomy
after failed trial of labour, a frequency comparable to the
occurrence of these complications in women who did not have a trial
of labour.
CONCLUSION: A trial of labour in selected patients with two previous
caesarean sections appears a reasonable option.