Cesarean vs, VBAC - a dramatic difference

This is such a touching video and eye opening video. Most people do not realize the force needed to get a baby out during a cesarean section - in the second birth, a vacuum is used as well as manual force. It is 16 minutes long, but worth the time.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

C-section Births Cause Genetic Changes That Could Increase Odds For Developing Diseases In Later Life

Swedish researchers have discovered that babies born by Caesarean section experience changes to the DNA pool in their white blood cells, which could be connected to altered stress levels during this method of delivery, according to the July issue of Acta Paediatrica.

It is thought that these genetic changes, which differ from normal vaginal deliveries, could explain why people delivered by C-section are more susceptible to immunological diseases such as diabetes and asthma in later life, when those genetic changes combine with environmental triggers.

Blood was sampled from the umbilical cords of 37 newborn infants just after delivery and then three to five days after the birth. It was analysed to see the degree of DNA-methylation in the white blood cells - a vital part of the immune system.

This showed that the 16 babies born by C-section exhibited higher DNA-methylation rates immediately after delivery than the 21 born by vaginal delivery. Three to five days after birth, DNA-methylation levels had dropped in infants delivered by C-section so that there were no longer significant differences between the two groups.

“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks” says Professor Mikael Norman, who specialises in paediatrics at the Karolinska Institutet in Stockholm, Sweden. “Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.

“That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment

. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells.”

The authors point out that the reason why DNA-methylation is higher after C-section deliveries is still unclear and further research is needed.

“Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNA-methylation that we found in human infants are linked to differences in birth stress.

“We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.”

The authors point out that the surgical procedure itself may play a role in DNA-methylation and that factors other than the delivery method need to be explored in more detail.

“In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels - proteins that provide a key marker for inflammation” says Professor Norman. “However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”

Professor Norman states that the Karolinska study clearly shows that gene-environment interaction through DNA-methylation is more dynamic around birth than previously known.

“The full significance of higher DNA-methylation levels after C-section is not yet understood, but it may have important clinical implications” he says.

“C-section delivery is rapidly increasing worldwide and is currently the most common surgical procedure among women of child-bearing age. Until recently, the long-term consequences of this mode of delivery had not been studied. However, reports that link C-section deliveries with increased risk for different diseases in later life are now emerging. Our results provide the first pieces of evidence that early ‘epigenetic’ programming of the immune system may have a role to play.”

The authors feel that their discovery could make a significant contribution to the ongoing debate about the health issues around C-section deliveries.

“Although we do not know yet how specific gene expression is affected after C-section deliveries, or to what extent these genetic differences related to the mode of delivery are long-lasting, we believe that our findings open up a new area of important clinical research” concludes lead author Titus Schlinzig, a research fellow at the Karolinska Institutet.

Canadian docs to stop automatic C-sections for breech babies

Unfortunately here in St. George, there are no providers at the hospital that will do a planned vaginal breech birth. Hopefully, the US will take notice of Canada's new stance on breech birth and follow.
Vaginal breech birth is possible and surgical birth should not be the only choice. Your best chance for a vaginal breech birth, if you find yourself in that position, is a homebirth midwife. Do your research.
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By Sharon Kirkey, Canwest News Service

In a major shift in medical practice and another assault on Canada's rising cesarean section rate, Canada's delivery doctors are being told to stop automatically scheduling C-sections for breech babies and attempt a normal delivery instead — something significant numbers of obstetricians aren't trained to do.

New guidelines issued Wednesday by the Society of Obstetricians and Gynaecologists of Canada say women carrying babies in the breech, or bottom-first, position should be given the right to choose to attempt a traditional delivery when possible.

The society says that women in Canada want the choice, and that some women with breech babies are delivering at home "because they knew if they went to hospital A, B or C it would not be offered," says Dr. Andre Lalonde, executive vice-president of the obstetricians' group and an adjunct professor of obstetrics and gynecology at McGill University and the University of Ottawa.

Lalonde says the group is working aggressively to ensure future specialists are trained in breech vaginal deliveries and is organizing courses across Canada for practising doctors to refresh their training.

"Paramount is the safe birth of the child," he said.

Most babies are positioned in the head-down position when labour starts. With breech babies, the feet or buttocks come out first during birth.

Breech babies account for about three to four per cent of all pregnancies in Canada, or about 11,000 to 14,500 pregnancies each year.

"Breech pregnancies are almost always delivered using a cesarean section, to the point where the practice has become somewhat automatic," Dr. Robert Gagnon, a principal author of the new guidelines and chair of The Society of Obstetricians and Gynaecologists of Canada's maternal fetal medicine committee, said.

"What we've found is that, in some cases, vaginal breech birth is a safe option and obstetricians should be able to offer women the choice to attempt a traditional delivery."

An international, Canadian-led study reported in 2000 that the safest way for breech babies to enter the world was via C-section. The study of more than 2,000 women found babies of mothers in the cesarean group were three to four times less likely to die, or have serious problems in the first six weeks of life, compared to those in the vaginal birth group (1.6 per cent versus 5.0 per cent).

The study had widespread influence worldwide. Many doctors stopped doing vaginal deliveries for breech babies, and many medical schools stopped training doctors in how to do them.

But the doctor who led the study said the risks, while different, were never huge. "The risks were still quite low," says Dr. Mary Hannah, a professor in the department of obstetrics and gynecology at the University of Toronto and Sunnybrook Health Sciences Centre.

More recent studies, including a study of more than 8,000 French and Belgian women carrying breech babies, found no significant differences in risks to babies whether they were born vaginally or via C-section.

Hannah says that a planned vaginal delivery of breech babies can be a safe and reasonable option. But, she said, most women she knows "will still want the option that is possibly safer, and that will be a planned cesarean section."

The main concern has always been delivery of the head — that the body will deliver, but that the baby's head will get caught.

"You can push the baby all the way back up into the uterus and do a cesarean section. But that's very traumatic," Hannah says. "And by the time that you are able to do that the baby may have suffered severe hypoxia," or lack of oxygen.

The new guidelines say that many breech deliveries will still require a C-section, and that a vaginal birth is not recommended for a "footling" breech, where the baby is positioned feet-first, with one or both feet pointing directly down toward the birthing canal.

Vaginal breech births also aren't recommended if the woman's pelvis is narrow or small, if the umbilical cord is likely to become entangled or compressed during delivery, or for babies that are too big (weighing more than 4,000 grams, or 8.8 pounds) or too small (less than 2,500 grams, or 5.5 pounds).

Breech deliveries are one of the main reason for C-sections, "and, if you do one (C-section), you increase the risk for another" in future pregnancies, Lalonde says. Repeat C-sections account for 30 to 40 per cent of all cesareans.

Is the Cord Around the Baby's Neck Really Dangerous?

May 19, 2008 by Misha Safranski

As a confirmed birth junkie, I have heard over and over again birth stories where the baby was born by cesarean for either fetal distress or failure to descend, and the difficulties are blamed on "the cord was around the baby's neck". Is this condition - scientifically termed "nuchal
cord" - actually dangerous? A new study backs up previous research showing that nuchal cord is not the threat it's perceived to be.

A study published this year in the Journal of Perinatal Medicine showed there were no statistically significant differences in outcomes of post-term pregnancies involving a nuchal cord verses no nuchal cord. Drs. Ghosh and Gudmundsson performed color ultrasound on 202 women with post-term pregnancies. Nuchal cords were detected in 69 of the women. There were no significant differences in Apgar scores, umbilical cord anomalies, cesarean section, perinatal death or admission of the baby to the NICU (neonatal intensive care unit).

These findings confirm what has been found in most of the past research on nuchal cord outcomes. A 2006 study from the Archives of Obstetrics and Gynecology was on a much larger scale, looking at the outcomes of 166,318 deliveries during a 15 year study period, 24,392 of which had a documented nuchal cord at birth. The authors, Sheiner et. Al, conclude: "Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary."
The interesting thing about the Sheiner study is that despite the equivalent outcomes among nuchal cord babies and those without the cord wrapped around the neck, there were higher rates of labor induction and non-reassuring fetal heart tones during labor among the nuchal cord cases.

These two factors are most likely related. We know without a doubt that induction of labor can cause fetal distress. The fact that there were higher induction rates in the nuchal cord group could very well explain the higher rate of transient fetal distress. Induction is nearly always accompanied by AROM (artificial rupture of membranes), which can cause undue pressure on the cord, which can in turn result in blips in the hearttones. Regardless of the cause, the outcomes were still good.

Finally, we look at yet another study which demonstrated that nuchal cord does not result in worse outcomes. In a 2005 study looking at the effects of nuchal cord on birthweight and immediate neonatal outcomes, Mastrobattista, et. Al examined the outcomes of 4426 babies, 775 of whom had a nuchal cord. They found that there were no significant differences between the two groups in birthweight, non-reassuring fetal hearttones, Apgar scores below 7, or operative vaginal deliveries. The cesarean rate was actually highest among the women whose babies did not have a nuchal cord.

The most important thing to keep in mind is that unborn babies do not breathe through their mouth and neck - they receive oxygen through the umbilical cord. This is why it normally doesn't matter if the cord is around the neck (unless the cord is being compressed too much, which is fairly rare). The baby cannot "choke to death" before she/he is born. What we can conclude from the overwhelming majority of data is that nuchal cord - or "cord around the neck" - is not pathological; that is to say, it's not an abnormality. It is a normal condition of the umbilical cord and typically causes no problems with the delivery, even though doctors frequently try to convince parents otherwise.

References:
J Perinat Med. 2008;36(2):142-4. Nuchal cord in post-term pregnancy - relationship to suspected intrapartum fetal distress indicating operative intervention. Ghosh GS, Gudmundsson S. Department of Obstetrics and Gynecology, Malmö University Hospital, Malmö, Sweden.

Arch Gynecol Obstet. 2006 May;274(2):81-3. Epub 2005 Dec 23. Nuchal cord is not associated with adverse perinatal outcome. Sheiner E, Abramowicz JS, Levy A, Silberstein T, Mazor M, Hershkovitz R. Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Beer-Sheva, Israel. sheiner@bgu.ac.il

Beautiful HBA2C Video

Check out this beautiful HBA2C (homebirth after 2 cesarean) video.

C-Section Birth Raises Risk of Asthma in Newborns by 79 Percent

(NaturalNews) Children delivered by cesarean section (c-section) are significantly more likely to develop asthma and allergies later in life than children delivered through natural, vaginal birth, according to a study conducted by researchers from National Institute for Public Health and the Environment in Bilthoven, the Netherlands.

A c-section is a procedure in which a child is surgically removed through a mother's abdomen, rather than emerging naturally through the vaginal opening. It is medically recommended only in cases where vaginal delivery would seriously endanger the life of infant or mother, but is becoming more common as many women's preferred method of childbirth.

Researchers compared the rates of asthma and allergies among 2,917 eight-year-olds, comparing the rates between those who had been delivered vaginally and those who had been delivered by c-section. They found that the risk of asthma was 79 percent higher in those delivered by c-section compared with those delivered vaginally. The correlation between c-section and asthma risk was even higher among children born to one or more parents with allergies.

"Our results emphasize the importance of gene-environment interactions on the development of asthma in children," the researchers wrote. "The increased rate of cesarean section is partly due to maternal demand without medical reason. In this situation, the mother should be informed of the risk of asthma for her child, especially when the parents have a history of allergy or asthma."

C-section is already known to raise a child's risk of diabetes by 20 percent, compared with vaginal delivery. In spite of this known health risk, rates of the procedure have been steadily rising in the United States over the last 25 years, increasing by 46 percent since 1985 to a current level of more than 30 percent of all births.

Childhood asthma rates have also been on the rise, particularly among urban populations, with rates increasing by two to four times in the last 30 years in some countries.

Sources for this story include: www.reuters.com.

Breech Vaginal Birth is NOT an Emergency

This blog was written by a blogger friend. It was so good, I asked if she would mind me posting it here. Thanks Emily (http://jeremyscorner-grifter.blogspot.com) for letting me share this with my readers!

In my continuing crusade to shoot down OB myths, this week I am tackling breech vaginal birth. This post has taken a lot longer to write than I thought it would. At first I thought I was having trouble with the amount of information available about it, but that isn't the problem. The problem is that I can't really understand why breech vaginal birth is considered an emergency in the first place. Sure, I know that there are risks associated with breech vaginal birth, but I just can't shake the idea that babies are born breech all over the world with little fanfare or issue. Nevertheless, obstetricians continue to look for more and more excuses to avoid the topic entirely by just cutting the babies out. So, in the interest of being thorough, here is some food for thought.

According to this article, "Vaginal breech deliveries were previously the norm until 1959 when it was proposed that all breech presentations should be delivered abdominally to reduce perinatal morbidity and mortality." Typical of obstetric mentality, instead of looking at the cause of morbidity and mortality in the first place, they chose to focus on the correlative factor instead - that many babies who presented breech had a high rate of injury or death. But as far as I know, no one thought to ask if medications, managed, or instrumental delivery could have contributed to those injuries or deaths.

Fast forward to today, and more than 90% of all breech births in the U.S. are delivered by c-section. This has happened largely because of a study that was done in 2000 by Hannah, et al, that shows a higher rate of perinatal morbidity and mortality associated with breech vaginal birth, as compared to planned c-section. Consequently, the American College of Obstetrics and Gynecology (ACOG) has systematically condemned breech vaginal birth, and it is no longer offered as a choice to women today. Henci Goer does a good job here of explaining why the conclusions of that 2000 study are not valid.

However, the ACOG has a history of picking and choosing those studies that support its own position. They also prefer to ignore any studies not done in the United States, as those studies are often contrary to American obstetric practics. For example:

A study out of Sweden in 2003 in the European Journal of Obstetrics & Gynecology and Reproductive Biology showed no difference between elective cesarean vs. planned vaginal birth for term breech deliveries.

Another study actually published with the American Journal of Obstetrics and Gynecology in 2006 examined planned breech delivery in France and Belgium, and found no discernable difference in outcome with more than 8,000 breech patients studied.

A different study from France in 2002 and published in European Journal of Obstetrics & Gynecology and Reproductive Biology looked at more than 500 patients and found no difference in outcome.

The International Journal of Gynecology & Obstetrics published a study in 2004 from the United Emirates which found no clear difference in breech vaginal vs. cesarean, but did find more maternal morbidity associated with cesarean section.

The Malaysian Journal of Medical Sciences, published a study in 2007, which concluded, "Most of the perinatal mortality was due to IUD, congenital abnormality and prematurity and there
were no perinatal death related to mode of delivery or due to birth trauma."

and there have been other studies to support these findings.

Danell Swim writes in her article, A Breech of Trust,

So I ask you, what are the United States hospitals doing wrong for their vaginal breech deliveries?

It is NOT that cesarean section is safer for breech deliveries in this nation, it is that vaginal breech is more dangerous in this country. US hospital policy and procedure are killing more breech babies than their European counterparts.

And to remedy the situation, it’s been recommended that nearly all babies in a breech presentation be delivered via cesarean section. This is despite the study published with the American Journal of Obstetrics and Gynecology that discovered that France and Belgium are able to safely deliver them vaginally, and safely.

So rather than teach our doctors how to safely deliver a breech baby, the ACOG's answer to the breech problem is to simply take them by c-section at term.

This article describes how best to safely deliver a breech baby. Included in the highlighted points are:

• Spontaneous onset anytime after about the 37th week.
• No augmentation if labour is slow or there is poor progress - caesarean section.
• Mother encouraged to assume positions of choice during the first stage.
• Fetal heart listened to frequently with a Pinard stethoscope or a hand held Doppler Sonic aid using ultrasound.
• Food and drink encouraged, but remembering that women in strong progressing labour rarely want to eat.
• Membranes not ruptured artificially.
• Vaginal examinations restricted to avoid accidental rupturing of the membranes.
• If, and when spontaneous rupture occurs conduct a vaginal examination as soon as possible.
• Second stage by maternal propulsion and spontaneous expulsive efforts guided by the attendant if judged appropriate.
• Mother encouraged to be in an all-fours position.
• No routine episiotomy.
• Third stage without chemical or mechanical assistance, usually managed according to woman's wishes.

Of that list, tell me how many of those are likely to occur in a medically managed birth in a US hospital today?

The most dangerous aspect of this trend is that American health care providers are losing, or have completely lost, the art of safely delivering breech babies. While some doctors may envision a 100% c-section rate for breech births, that will never be possible. The World Health Organization (WHO), in this publication about planned c-section for breech says,

It will be impossible to deliver all term breech pregnancies by caesarean section. The systematic review showed that 9% of women with breech presentation still have a vaginal breech delivery because the mother may insist on vaginal delivery, breech labour may be precipitate, or special situations such as the second fetus in twins. It is therefore imperative to continue providing expertise in vaginal breech delivery to all the intrapartum care providers.

This atmosphere of fear and foreboding surrounding breech births is leading women to choose dangerous options to avoid having a breech baby at all costs. The current recommendation is to attempt an external cephalic version (ECV), in which the care provider attempts to turn the baby from the outside into a head-down position. But ECV is not without risks. According to this publication:

The largest review which included 44 studies and 7377 patients found the most common complication of ECV to be transient fetal heart rate abnormalities (5.7%). The risk of placental abruption, emergency cesarean section, vaginal bleeding, and perinatal mortality were less than 1 percent combined. Because of the risk of alloimmunization, Rhogam is recommended for non-sensitised Rh negative women following ECV. There currently is not enough evidence from randomized controlled trials to assess complications of ECV.

In addition, in order to perform an ECV, tocolytics such as terbutaline, and epidural anesthesia are sometimes used. The risks of epidural anesthesia are well-documented. Risks of terbutaline to the baby include fetal tachycardia, hyperinsulinemia, hyperglycemia, myocardial and septal hypertrophy, myocardial ischemia. Terbutaline not only does not have FDA approval but the FDA disapproves of its use as a tocolytic.

ECV is only successful 50-60% of the time (various sources). When ECV is unsuccessful, the only other option is to schedule a planned c-section for some arbitrary date. The problem with this is that breech babies can and do turn, up to, and even during labor. So planning a c-section may be taking a baby even before it is ready to be born, and without giving it a chance to get itself into a favorable position.

It is clear to me that breech birth, while carrying some risk, is not unreasonably dangerous in itself. The danger lies in breech birth in a highly managed hospital setting. For this reason, I would suggest that if a woman plans to birth in the hospital in the U.S, and her baby is breech, she should plan to have c-section. In fact, if a woman is planning a hospital birth and her baby is breech, she probably won't have a choice about it. If she does not want to have a c-section, she should stay home. But she should know a c-section for breech is not necessary! In fact, I don't even believe any undue concern should be attributed to breech presentation, especially if one has a midwife who is experienced and skilled in delivering breech babies.

If you find yourself pregnant, approaching term, and your baby is breech, please try these suggestions for gently encouraging your baby to turn. If you want to avoid unnecessary surgery, start now looking for a midwife who is experienced in breech delivery. Don't schedule a c-section - allow baby all the time it needs to turn itself. You can visit spinningbabies.com to learn how to tell whether your baby is head-down.

Twins & Triplets...a new standard of care?