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Feb 8
February 5, 2010 — As neonatal weight increases, so do the risks of adverse obstetric outcomes — including uterine rupture — in women giving birth vaginally after a prior cesarean delivery, new research suggests.
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.
Children whose mothers were overly stressed during pregnancy may themselves be more vulnerable to anxiety as a result, research suggests.High levels of stress hormone may cross the placenta and affect the baby in the womb in a way that carries long-term implications, UK scientists believe. A Bristol University team found anxiety in late pregnancy was linked to higher cortisol levels in children aged 10. The work in Biological Psychiatry tallies with earlier animal findings. Stress effects Past studies have shown stress in animals during pregnancy affects the body’s stress response system – the hypothalamic-pituitary-adrenal (HPA) axis which controls stress hormone levels, including cortisol. But scientists have not been able to show that it also affects humans in the same way. US psychologist Dr Thomas O’Connor, from the University of Rochester in New York, working with UK colleagues from Bristol University and Imperial College London, studied 74 children aged 10. They analysed saliva samples first thing in the morning and three times a day on three consecutive school days to monitor levels of stress hormones. The children’s mothers had completed questionnaires 10 years previously, when they were expecting, about any stress or anxiety they were experiencing during their pregnancy. Alleviating anxiety The researchers looked back at this data to compare the results with those of the saliva tests. The children with high levels of cortisol in their saliva tended to be born to the mothers who reported the most stress during their pregnancy. Dr O’Connor said: “These results provide the strongest evidence to date that prenatal stress is associated with longer term impact on the HPA axis in children.
“Several human studies of children and adults suggest that elevated basal levels of cortisol are associated with psychological risk…notably depression and anxiety. “Our findings point to a possible mechanism by which prenatal stress or anxiety may predict these disturbances in early adolescence, and possibly into adulthood.” However, he said much more work was needed to check that this was the case. He also pointed out that it was not clear whether high cortisol itself could cause psychological disturbance. Some psychiatric disorders have been linked with low rather than high cortisol levels. Other factors, such as the personality of the child and the environment they are living in, may play a part in childhood stress too. Gillian Fletcher of the National Childbirth Trust said: “It’s certainly something we need to look at in more detail. “We don’t want to make women who are pregnant more anxious than they already are by saying stress could have long term implications for the growing child.” She said there were many things pregnant women could do to alleviate stress and anxiety. “Antenatal classes can help allay fears women might have about pregnancy, the birth and the health of the baby. “They can also teach a women about stress and relaxation and taking life more slowly can help. It’s trying to find a balance.” |
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Antenatal classes can help allay fears women might have about pregnancy, the birth and the health of the baby 
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.
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.”
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.” |
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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.
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.” |
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Blood pressure harm from smoke ‘may explain cot death’ |
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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.
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.
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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What started as a happy family reunion in Minnesota to show off the new baby has turned into a heart-wrenching bedside vigil for Palmerston North parents Sarah and Edan Meyer.
Five-month-old Degen has spent a month in intensive care in Cincinnati Children’s Hospital fighting liver cancer, and the family’s plans are on hold.
The couple’s first child showed signs of constipation and a distended tummy last month while visiting his grandparents, and after a biopsy confirmed a cancerous tumour, he was rushed to Cincinnati on September 16.
About 40 per cent of his liver had to be surgically removed, and he has now begun a 28-week course of chemotherapy.
The couple’s friend back in Palmerston North, Nicola Reid, is turning her worry into action, organising fundraising to help the family through the devastating change of fortune.
“Our babies were born on the same day, we had the same midwife. Our Micah is just lovely, and Degen is so sick. He should be sitting up and gurgling, just crying about cutting teeth.”
Mrs Reid said it was a comfort, at least, to know that Degen was in one of the best places in the world to get the best chance of successful treatment. Early CT scans have shown some improvements.
At this stage nobody knows how long the Meyers will stay in Cincinnati, or whether they will be able to continue Degen’s treatment back in New Zealand at some stage.
“But what we’re hoping to do is to keep up the mortgage payments, and keep paying their bills back here for as long as they need.”
Mr Meyer, a diesel mechanic, is on extended leave from his work in Palmerston North. His mother, Jill, flew to Cincinnati to offer her support with help from the Rongotea Lions Club.
Degen’s other grandparents, Leroy and Sylvia Thorstad, live in Minnesota and have stayed close by their grandson through the ordeal.
“We would hope that the more people that know about this poor wee boy, the more people can send healing thoughts and prayers to the team in Ohio,” said Mrs Reid.
There will be a benefit evening to support the family on December 1 at the Convention Centre featuring Wellington fashion stylist Lisa O’Neil, with an auction and raffle to follow.
“Already we have felt the community’s reaction to the Meyers’ plight and it is humbling; people and businesses are being incredibly generous.”
Anyone who wants to help can contact Mrs Reid on 355 2634 or email kelly@midwife4u.co.nz
Women who are overweight or obese when they get pregnant are more likely to give birth to children with congenital heart defects.
The US study, conducted by the US Centres for Disease Control and Prevention, concluded that women who were overweight or obese at the time they became pregnant were 18 percent more likely to give birth to babies with heart defects, while severely obese women had a 30 percent increased risk.
The babies had problems including obstructive defects on the right side of the heart and defects in the tissue separating the heart’s two upper chambers, the researchers reported in the American Journal of Obstetrics and Gynaecology.
“Congenital heart defects are the most common types of birth defect, and among all birth defects, they are a leading cause of illness, death and medical expenditures,” said Dr Edwin Trevathan, a CDC expert on birth defects and developmental disabilities.
The CDC, the US government’s disease watchdog, recommends that overweight women work with their doctors to achieve a healthy weight before pregnancy.
Researchers examined the health of 6440 infants with congenital heart defects and 5673 infants without problems, all of whose mothers were interviewed as part of the CDC’s National Birth Defects Prevention Study.
They assessed obesity according to each woman’s body mass index, or BMI, which relates weight to height. A woman 165cm tall and weighing 86kg would have a BMI of 31.6, while a woman of the same height who weighs 72kg would have a BMI of 26.6.
The researchers defined overweight as a BMI of 25 to 29.9, moderate obesity as a BMI of 30 to 34.9 and severe obesity as a BMI of 35 or above.
The results showed links between obesity and 10 out of 25 kinds of heart defects. Five of the 10 were associated with women who were overweight before pregnancy.
The study accounted for important factors such as maternal age and race-ethnicity. Mothers who had diabetes before pregnancy, a strong risk factor for heart defects, were excluded from the research.
The deaths of three Wellington babies while sleeping beside adults has prompted yet another warning from the coroner.
Wellington coroner Garry Evans called on the Ministry of Health to strengthen guidelines on safe sleeping practices for newborns in May and again in August after investigating the sudden deaths of eight infants.
Another warning has now been issued by fellow Wellington coroner Ian Smith after findings were issued on three more deaths.
Hope Kuti was 10 weeks old and living with her family in Wainuiomata on September 19 last year.
Hope was one of four young children, but at the time of her death only one other – a three-year-old – remained at the house due to “an extensive need for Child, Youth and Family Service (CYFS) to become involved”, Mr Smith said.
He said there had been issues with the parent’s continual domestic violence and neglect and CYFS had not yet been informed of Hope’s birth.
Her mother came home around midnight, going to bed an hour later having drunk upwards of 10 pre-mixed bourbon and colas.
The next morning she discovered Hope lying face down and not breathing.
The three-year-old had since been removed from the house and placed in the care of extended family, Mr Smith said.
A month later, in Cannons Creek, Porirua, Dante Tahuri-Uren died while sleeping on a couch beside his mother .
His mother admitted “spotting” cannabis oil and said they had stopped sleeping in her bed as she did not like the “vibes” upstairs.
They went to sleep at 8.30pm and the mother was woken around 11pm by Dante crying. She woke again at 12.30am and went to change Dante’s nappy but Dante was no longer breathing.
On January 26, 2009, Summer Lamsam was less than three weeks-old, having been born prematurely , when put to bed with her parents in their Porirua home .
She had been sharing the queen-sized bed after refusing to settle in her cot.
When her mother awoke at 4.30am she saw Summer’s father had moved and his back was on the child’s face.
An ambulance was called but Summer could not be revived.
In all three deaths the subsequent coroners’ investigations found the sleeping arrangements were unsafe and likely led to accidental asphyxia.
Mr Smith issued a letter to the Director General of Health, Stephen McKernan, urging that “the public health advice in relation to safe infant care practices and safe sleeping environments be strengthened and broadened”.
He said it should be made clear that bed sharing by adults with infants under six months exposed the child to the risk of death and the safest place for babies to sleep during this period was in a cot beside the parental bed.
The coroners’ warnings followed similar statements from child health experts in December.
Paediatrician Dawn Elder, who studied the last 10 years of unexplained baby deaths in the Wellington region, said work needed to be done on getting information to parents.
Auckland University professor of child health research Evan Mitchell said about half the cases of sudden infant death syndrome occurred in “bed sharing situations”.
South Australian deputy Coroner Tony Schapel also voiced concerns last year, warning against bed sharing as well as placing infants on overly soft mattresses and the use of V-shaped pillows.
Screaming babies – it’s all mum’s fault for fussing
12:07PM Sunday Sep 06, 2009
By Susie Mesure
Sleep deprivation is every new parent’s worst nightmare. It is a form of torture that can leave them sobbing louder than their child. Yet a new study claims babies’ sleep problems are all in the mind – the mother’s mind before her child is even born.
Parents have only themselves to blame for all those hours of lost sleep, according to researchers in Israel who found that a mother-to-be’s expectations about infant sleep will affect how her baby sleeps after it is born.
If an expectant mother thinks that babies who cry at night are suffering distress and need comforting and soothing back to sleep, then her newborn is likely to wake more frequently during the night than if she believes babies should learn to settle themselves, according to a study in the latest issue of the journal Child Development.
Expectant mothers who believed crying babies needed their mums – or dads – tended, once their child was born, to be more active in trying to soothe them, cuddle them, feed them or let them snuggle up in the parental bed to try to get their baby back to sleep, the research showed.
The downside, the study found, was that the more a baby’s mum tried to help her child sleep, the worse that child’s sleep then became.
“Increased parental involvement at bedtime and at night predicted a higher number of reported night wakings at 12 months,” said Liat Tikotzky and Avi Sadeh, who followed 85 mothers through pregnancy and the first year of their baby’s life.
The flipside was that expectant mothers who felt it important to “limit parental night-time involvement [and use] less active soothing” techniques would go on to have infants who slept better.
Experts warn the findings will heap guilt on many new mothers who already hold themselves responsible for every element of their baby’s behaviour.
The study vindicates those parents favouring the less-is-more, “cry-it-out” method of encouraging infants to sleep through the night.
But, in a note of caution, the authors highlight the current debate regarding the consequences of leaving children to cry, pointing to a series of articles by the co-sleeping advocate James J McKenna that argue that expecting infants to self-soothe runs counter to their basic biological and emotional needs.
Sleep deprivation, which can continue well past an infant’s first birthday, is a major contributor to post-natal depression.
Studies have suggested new parents can miss out on the equivalent of two months’ sleep in the first year of their child’s life, putting pressure on their relationships with their new baby and each other.
Elizabeth Danowski, executive director of OXPIP, an Oxford-based charity that supports new parents who are finding life tough, said it was easy for anxious parents to hit a “negative loop” of creating anxious babies who would then sleep or eat badly.
“If parents have struggled with anxiety in the past that will be a good predictor that they will have difficulties [with their babies] after birth,” she said.
A huge industry has sprung up to help parents tackle the problem of broken sleep, covering books, gadgetry and even night nannies. But exhausted parents can take heart from the fact that they are not alone n studies have shown that one in three babies still wake up several times a night even past the age of one.
And Liat Tikotzky and Avi Sadeh say: “It is important to emphasise that night wakings are a natural phenomenon, characteristic for most infants and children.”
- THE INDEPENDENT
