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In light of this finding, the authors conclude that “estimated fetal weight should be included in the decision-making process for all women contemplating a trial of labor after cesarean delivery.”

Prior research has linked fetal macrosomia with various adverse obstetric outcomes, including emergency cesarean delivery, perineal laceration, first and second stages of labor dystocia, and shoulder dystocia, according to the report in the February issue of Obstetrics & Gynecology. Few trials, however, have examined these outcomes in women undergoing vaginal birth after cesarean delivery.

To investigate, Dr. Emmanuel Bujold, from Universite Laval, Quebec, Canada, and colleagues reviewed the medical records of all women who underwent a trial of labor following a prior low transverse cesarean delivery at Sainte-Justine Hospital from 1987 to 2004.

The women were divided into categories based on their infants’ birth weights. The reference group, designated group 1, had infants weighing less than 3500 g. Groups 2 and 3 had infants weighing 3500 to 3999 and 4000 g or more, respectively.

Of the 2586 women who were seen during the study period, 1519 (59%) were in group 1, 798 (31%) in group 2, and 269 (10%) in group 3, the researchers report.

Birth weight was directly linked to the rate of failed trial of labor. For group 1, the rate was 19%, whereas for groups 2 and 3, the rates climbed to 28% and 38%, respectively (p < 0.01).

Likewise, the authors found direct correlations between birth weight and the rates of uterine rupture (0.9%, 1.8%, and 2.6% for groups 1, 2, and 3, p < 0.05), shoulder dystocia (0.3%, 1.6%, and 7.8%, p < 0.01), and third- and fourth-degree perineal laceration (5%, 7%, and 12%, p < 0.01).

After accounting for potential confounders, a birth weight of 4000 g or more was associated with more than twofold increased risks of uterine rupture (OR, 2.62), failed trial of labor (OR, 2.47), and third- and fourth-degree perineal laceration (OR, 2.64). For shoulder dystocia, a particularly elevated risk was seen: OR, 25.13.

“Current recommendations of the American College of Obstetricians and Gynecologists and the Society of Obstetricians and Gynecologists of Canada state that fetal macrosomia should not be a contraindication for a trial of labor although it is associated with a lower likelihood of successful vaginal birth after cesarean delivery,” Dr. Bujold’s team notes.

“Based on our data,” they continue, “we believe that women with a previous cesarean delivery and an estimated fetal weight of 4000 g or more should be informed about their higher risks of uterine rupture and other adverse outcomes. Such women with no previous vaginal delivery should be told about the high risk…of uterine rupture.”

Obstet Gynecol. 2010;115:338-343. Abstract

Reuters Health Information 2010. © 2010 Reuters Ltd.

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Breastfeeding has been linked to many benefits for babies

Mothers who find breastfeeding so hard that they give up should not blame themselves, researchers say.

A Norwegian study concludes that difficulty feeding a newborn may be down to higher levels of the male hormone testosterone during pregnancy.

Having reviewed all of the available evidence, researchers also cast doubt on the health benefits of breast milk over formula.

The work features in Acta Obstetricia and Gynacologica Scandinavica.

The team from the Norwegian University of Science and Technology followed 180 pregnant women.

These included those at risk of delivering a small baby – births which are known to be influenced by higher levels of the male sex hormone testosterone.

A mother should do what makes her happy Professor Sven Carlsen Norwegian University of Science and Technology

After taking into account other factors such as age, education and smoking, they still found a clear relationship between low rates of breastfeeding at three and six months and higher levels of testosterone.

There are many reasons why a mother might have high levels of this male hormone in her womb during pregnancy as the placenta – an engine of hormone production – kicks into action.

The team suggest that the hormone may impact negatively on the development of glandular tissue in the breast, in turn affecting her ability to feed her baby.

Lead researcher Professor Sven Carlsen said: “Basically a mother who finds she has difficulty shouldn’t feel guilty – it probably is just the way it is, and her baby will not suffer for being fed formula milk.

“A mother should do what makes her happy.”

Benefits ‘exaggerated’

He argues that it is the hormone balance in the womb which explains both a mother’s ability to breastfeed and any apparent health benefits of a baby who is breastfed – rather than the breast milk itself.

Last year Professor Carlsen’s team reviewed 50 international studies on the relationship between breastfeeding and health.

Based on this work he concludes the benefits of breast over formula milk may have been exaggerated.

“These health differences are really not so significant in any event.

“When you look at the epidemiological studies and try to strip away the other factors, it is really hard to find any substantial benefits among children who were breastfed as babies.”

The government recognises that breastfeeding is the best form of nutrition for infants Department of Health

Professor Ashley Grossman of the Centre for Endocrinology at Barts in London said the suggestion that male hormones may influence the ability to feed was an interesting one.

“There may be all sorts of biological factors which affect a woman’s ability to breastfeed, and when women are always being told to go away and try harder it’s important to stress some simply cannot.

“We are learning more and more about how the environment of the womb may influence a child’s future development – this is really where it’s all happening, and it has a much greater impact than whether or not a child is breastfed or not.”

The Department of Health recommends that all babies be exclusively breastfeed for the first six months.

A spokesman said: “The government recognises that breastfeeding is the best form of nutrition for infants.

“It gives health benefits for both the baby and the mother – even after they are no longer breastfeeding.

“It protects against stomach bugs and chest infections, provides perfect nutrition for the first six months and reduces the likelihood of becoming obese in later childhood.”

BBC News

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White mothers stop breastfeeding sooner than women from ethnic minorities

Having a Caesarean or instrumental birth does not appear to impact upon how long a mother breastfeeds, British research suggests.

A study of 2,000 mothers who received breastfeeding support also found little association with how soon after birth the baby was put to the breast.

What did have an impact was ethnicity, and the number of previous births, the study in BMC Pediatrics reported.

White mothers were 70% more likely to stop than non-White contemporaries.

The Department of Health recommends exclusive breastfeeding for the first six months of a baby’s life, but the majority of UK mothers have abandoned it altogether by this point – giving the country one of the lowest breastfeeding rates in Europe.

There have been a series of measures aimed at increasing prevalence, from better support to a ban on any promotion of infant milks.

This latest study, conducted by the University of Manchester and East Lancashire Primary Care Trust, followed more than 2,000 mothers who all received breastfeeding help from the same peer support group, to enable a fair comparison of other factors.

Bucking the trend

On average these supported mothers were giving some breastmilk for 21 weeks, and half of them for more than 27 weeks, markedly higher than the national average. But there were differences between sub-groups.

What is really exciting about this research is the rates of breastfeeding – both exclusive and mixed – that have been achieved among all groups Professor Mary Renfrew, infant feeding expert

White women tended to stop a number of weeks before non-white, with mothers of black and Indian ethnic origin breastfeeding the longest, closely followed by Pakistani.

But the relative economic status of the women made no difference, with the poorest as likely to continue or abandon breastfeeding as the wealthiest, nor did it matter whether the mothers were married.

Having an instrumental or Caesarean birth had no statistically significant impact on the duration of breastfeeding, contrary to some suggestions that a “non-natural” birth, possibly as a result of the analgesics used, may hamper feeding.

Also babies who were put to the breast within an hour of being born – as recommended by the World Health Organisation – were not breastfed any longer than those with whom breastfeeding was initiated within 48 hours.

Previous deliveries

The study did however find that the number of babies a mother had previously delivered impacted upon breastfeeding duration, with women having their third or fourth baby more likely to continue than those having their first.

The study’s authors noted that while breastfeeding support was clearly important in mitigating a number of obstacles to prolonged feeding, there were other factors at play.

Dr Gabriel Agboado of East Lancashire PCT said: “The results suggest that infant feeding practices associated with maternal ethnicity and previous experience of having children may be more difficult to influence by peer support interventions.

“Peer support programs, particularly those in multi-ethnic settings, will need to identify the needs of their various client groups in order to appropriately support them to breastfeed longer”.

Professor Mary Renfrew, who researches infant feeding practices, said: “We know that rates are higher among ethnic minority groups and that previous experience of breastfeeding has an effect on whether the mother does it again, and the study confirms this.

“But what is really exciting about this research is the rates of breastfeeding – both exclusive and mixed – that have been achieved among all groups. They are doing something right in this area, and it does seem to point to peer support, although there may be other factors involved.

“Tailored support is recommended for all mothers, but some places have been much more pro-active on this front than others. When people say you simply cannot get breastfeeding rates up, it’s clear there are policies which can have an effect.”

Sue Ashmore, head of Unicef’s UK Baby Friendly Initiative said: “evidence shows that women are more likely to breastfeed if they are supported by someone who believes they can do it. This is the point of peer support programs.

“In the UK peer support work is varied, and therefore the results are varied. It is vital that robust monitoring and evaluation processes are in place so that strengths and weaknesses can be identified and addressed; this would lead to a more successful peer support programs nationwide.”

BBC News

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Smoke exposure during pregnancy damages a baby’s blood pressure control, which may explain why such babies’ risk of cot death is higher, say experts.

Maternal smoking remains one of the biggest risk factors for cot death.

A team at Sweden’s Karolinksa Institute found smoke-exposed babies had abnormal surges in blood pressure, even when sleeping undisturbed in their cots.

These surges put extra demand on the heart, making it pump faster and harder, the journal Hypertension says.

The study suggests damage to the circulation may be a factor in sudden infant death syndrome (SIDS), although it set out to look at the effects of smoking on the newborn rather than cot death per se.

We have known for some time that there is a cardiovascular element to sudden infant death Lead researcher Dr Gary Cohen

Dr Gary Cohen and his team studied 36 newborn babies – 17 of whom had mothers who smoked during the pregnancy.

When they examined the babies they found the ones that had been exposed to cigarette smoke showed abnormal heart rate and blood pressure responses.

And these abnormal responses got worse throughout their first year of life.

Dramatically different

At one week of age the smoke-exposed babies showed abnormally large blood pressure rises as they were lifted up from lying down.

By the age of one, the same babies appeared to have adapted to this and now showed abnormally low blood pressure responses to the same posture change.

The hypothesis presented here is highly plausible and agrees with work from other research groups Professor George Haycock Foundation for the Study of Infant Deaths adviser

Usually, when a person stands the heart rate increases and the blood vessels tighten, raising blood pressure slightly, to keep up the blood flow to the heart and brain.

Dr Cohen said: “Babies of smokers have evidence of persistent problems in blood pressure regulation that start at birth and get worse over time.

“This study reveals for the first time that early life exposure to tobacco can lead to long-lasting reprogramming of the infant blood pressure control mechanism.”

He said this might explain why babies of women who smoke are at increased risk of cot death.

“We have known for some time that there is a cardiovascular element to sudden infant death.

“It’s not just breathing, but blood pressure control and heart rate control.

“This is another piece of the jigsaw.”

He plans to continue to study the babies as they grow up to see if the damage is lasting and whether it leads to problems, such as high blood pressure, in later life.

Professor George Haycock, scientific adviser for the Foundation for the Study of Infant Deaths (FSID), said: “The hypothesis presented here is highly plausible and agrees with work from other research groups.

“FSID’s top piece of advice remains, cut smoking in pregnancy – fathers too, and don’t let anyone smoke in the same room as your baby.”

Experts say a third of cot deaths could be avoided if mothers-to-be did not smoke.

Janet Fyle, Professional Policy Advisor at the Royal College of Midwives, said: “These findings support what we know; that smoking during pregnancy can harm the developing foetus.

“The RCM would urge pregnant women who smoke to seek advice and support from their midwife about stopping smoking, for the benefit of their own long-term health.

“This would also benefit the health of their child.”

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Zavier Baredsen Born 11 December 2009 Weight 3090gms Midwife Kelly Manninen

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