ΞΑΝΑ ΚΑΙΣΑΡΙΚΗ Η ΦΥΣΙΟΛΟΓΙΚΟΣ ΤΟΚΕΤΟΣ ΜΕΤΑ ΑΠΟ ΚΑΙΣΑΡΙΚΗ ΤΟΜΗ; ΟΛΑ ΟΣΑ ΠΡΕΠΕΙ ΝΑ ΞΕΡΕΤΕ ΠΡΙΝ ΑΠΟΦΑΣΙΣΕΤΕ

Posted in ΥΓΕΙΑ by woman2womenblog

“Μια φορά καισαρική, για πάντα καισαρική”… υπήρξε σαν αξίωμα για πολλά χρόνια, εδώ στην Ελλάδα και σε πολλές άλλες χώρες. Όμως, τα συνεχώς αυξανόμενα ποσοστά καισαρικής τομής παγκοσμίως έχουν οδηγήσει στην επανεξέταση των κινδύνων της καισαρικής τομής σε σχέση με την κολπικό τοκετό μετά από προηγηθείσα καισαρική. Έντονη συζήτηση γίνεται γύρω από αυτό το θέμα, με τις απόψεις να είναι διχασμένες. Συνεπώς, όταν έρχεται η ώρα να αποφασίσουν πολλές γυναίκες αναρωτιούνται: εγώ τελικά τι πρέπει να κάνω, ξανά καισαρική ή να επιχειρήσω μια φυσιολογική γέννα;

Η αλήθεια είναι πως η απάντηση δεν είναι τόσο εύκολη. Και οι δύο επιλογές έχουν πιθανούς κινδύνους, ο οποίοι διαφέρουν σε κάθε γυναίκα και σε κάθε εγκυμοσύνη ξεχωριστά.

Σε αυτό το άρθρο θα βρείτε όλες τις απαραίτητες πληροφορίες σχετικά με τον φυσιολογικό τοκετό μετά από καισαρική τομή, ώστε να μπορείτε να το συζητήσετε με το γιατρό ή τη μαία σας, και να πάρετε μια συνειδητοποιημένη και υπεύθυνη απόφαση.

1) Τι είναι ο κολπικός τοκετός μετά από καισαρική τομή (VBAC);

Αν είστε έγκυος και γεννήσατε το προηγούμενό σας μωρό με καισαρική τομή, αυτή τη φορά έχετε δύο επιλογές για το πώς θα γεννήσετε:

μια εκλεκτική επαναλαμβανόμενη καισαρική τομή (ERCS: elective repeat caesarean section), ή
ένας φυσιολογικός τοκετός μετά από καισαρική τομή (VBAC: vaginal birth after cesarean section). Το VBAC αναφέρεται στη γέννηση μέσω του κόλπου σε μια γυναίκα που είχε ήδη κάνει μια καισαρική τομή σε προηγούμενη κύηση. Ο κολπικός τοκετός περιλαμβάνει και τις περιπτώσεις στις οποίες ο τοκετός υποστηρίζεται με εμβρυουλκία (“κουτάλες”) ή ανναρώφηση (βεντούζα).

Τόσο ο κολπικός τοκετός, όσο και η επαναλαμβανόμενη καισαρική έχουν οφέλη και κινδύνους (βλ. παρακάτω).

Η δοκιμασία τοκετού μετά από καισαρική τομή (αγγλικά TOLAC: trial of labor after cesarean delivery) είναι η προσπάθεια να διεξάγεται ένα VBAC. Εάν είναι επιτυχής, θα έχει ως αποτέλεσμα τη φυσιολογική γέννηση. Αν δεν είναι επιτυχής, θα χρειαστείτε ξανά καισαρική τομή.

2) Πόσες πιθανότητες έχω να γεννήσω κολπικά μετά από μια καισαρική;

Εφόσον έχετε τις κατάλληλες προυποθέσεις για VBAC, υπάρχουν πολλές πιθανότητες να το πετύχετε: περίπου το 60 έως 80% των γυναικών που επιχειρούν ένα VBAC θα γεννήσουν κολπικά.

Υπάρχουν ορισμένοι παράγοντες που επηρεάζουν τις πιθανότητες επιτυχίας, τόσο από την μητέρα όσο και από το μωρό (βλ. παρακάτω). Παρόλα αυτά, είναι αδύνατο να προβλέψουμε με βεβαιότητα ποια γυναίκα θα καταφέρει να γεννήσει φυσιολογικά και ποια θα καταλήξει σε μια επαναλαμβανόμενη καισαρική.

Ένας προηγούμενος φυσιολογικός τοκετός, ιδιαίτερα ένα προηγούμενο VBAC, είναι ο καλύτερος προγνωστικός δείκτης επιτυχούς VBAC, και συνδέεται με ποσοστό επιτυχίας 85-90%.

3) Είμαι καλή υποψήφια για VBAC;

Το VBAC είναι κατάλληλο για την πλειοψηφία των γυναικών που:

είναι έγκυος με ένα έμβρυο (και όχι με δίδυμα ή παραπάνω),
το μωρό είναι τοποθετημένο με το κεφάλι κάτω (κεφαλική προβολή),
έχουν μια τελειόμηνη κύηση (37 εβδομάδες ή παραπάνω),
έχουν μία προηγηθείσα εγκάρσια καισαρική τομή.

4) Πότε αντενδείκνυται το VBAC;

Το VBAC δεν συνιστάται στις ακόλουθες περιπτώσεις:

Τρεις ή περισσότερες προηγούμενες καισαρικές τομές. Δείτε παρακάτω σχετικά με δύο προηγηθείσες καισαρικές.
Έχει γίνει ρήξη μήτρας κατά τη διάρκεια προηγούμενης προσπάθειας τοκετού, καθώς αυξάνεται σημαντικά ο κίνδυνος (7 φορές υψηλότερος) μιας υποτροπιάζουσας ρήξης της μήτρας στην επόμενη εγκυμοσύνη.
Η προηγούμενη καισαρική τομή ήταν “κλασική”. Στη συντριπτική πλειοψηφία των γυναικών, κατά την διάρκεια της καισαρικής η μήτρα κόβεται οριζόντια, στο χαμηλότερο τμήμα της. Αυτό ονομάζεται κατώτερη εγκάρσια καισαρική τομή. Σπάνια απαιτείται μια κάθετη τομή της μήτρας, η οποία είναι γνωστή ως κλασική καισαρική τομή. Περιστασιακά, πραγματοποιείται τομή σε σχήμα J ή T. Και στις δύο περιπτώσεις της κάθετης και της J / T-τομής υπάρχει υψηλότερος κίνδυνος ρήξης της μήτρας. Επομένως, είναι πολύ σημαντικό να γνωρίζετε ποια τομή πραγματοποιήθηκε στην προηγούμενή σας καισαρική. Να έχετε υπόψη σας πως ο τύπος της ουλής στο δέρμα δεν αντιστοιχεί κατ ‘ανάγκη εκείνο της μήτρας.
Μια προηγούμενη χειρουργική επέμβαση της μήτρας, όπως η αφαίρεση ινομυωμάτων (ινομυωματεκτομή), καθώς αυξάνει τον κίνδυνο ρήξης της μήτρας.
Υπάρχουν και άλλες επιπλοκές της εγκυμοσύνης που αποτελούν απόλυτη αντένδειξη για φυσιολογικό τοκετό, ανεξάρτητα από την παρουσία ή όχι προηγηθείσας καισαρικής (π.χ. προδρομικός πλακούντας)
Ισχιακή προβολή του εμβρύου (το μωρό έρχεται πρώτα με τους γλουτούς ή τα πόδια) ή άλλες μη φυσιολογικές θέσεις.
Πολύδυμη κύηση (με δίδυμα ή περισσότερα έμβρυα).

5) Ποιοι παράγοντες μειώνουν τις πιθανότητες επιτυχίας ενός VBAC;

Γενικά, οι πιθανότητες επιτυχίας είναι χαμηλότερες όταν:

Ο λόγος για την προηγούμενη καισαρική είναι πιθανό να είναι πρόβλημα και αυτή τη φορά. Ας πούμε ότι μια γυναίκα που είχε ήδη μια κολπική γέννα και στη συνέχεια έκανε μια καισαρική επειδή το μωρό της ήταν σε ισχιακή προβολή (γλουτοί ή πόδια πρώτα) είναι πολύ πιο πιθανό να καταφέρει να γεννήσει με VBAC από κάποια άλλη που είχε κάνει καισαρική μετά την επίτευξη πλήρους διαστολή και εξώθηση για τρεις ώρες, το ότι μπορεί να υποδηλώνει πως αυτή η γυναίκα έχει στενή λεκάνη (η λεγόμενη κεφαλο-πυελική δυσαναλογία).
Γίνεται πρόκληση τοκετού (ο τοκετός δεν ξεκίνησε αυτόματα).
Είστε ηλικίας άνω των 40 ετών.
Είστε υπέρβαρη.
Το μωρό είναι μεγάλο (πάνω από 4 κιλά εκτιμώμενο βάρος).
Η κύηση είναι παρατεταμένη (περισσότερο από 40 εβδομάδες).
Υπάρχει μικρό χρονικό διάστημα ανάμεσα στις κυήσεις (λιγότερο από 19 μήνες).
Έχετε προεκλαμψία (υψηλή αρτηριακή πίεση) τη στιγμή του τοκετού.

Θα πρέπει να συζητήσετε με τον γιατρό σας σχετικά με τις πιθανότητες επιτυχίας συγκεκριμένα για την δικιά σας περίπτωση και να σταθμίσετε προσεκτικά τα οφέλη και τους κινδύνους.

6) Ποια είναι τα πλεονεκτήματα ενός VBAC;

Η καισαρική τομή είναι μια χειρουργική επέμβαση, και ως εκ τούτου συνδέεται με ορισμένους αυξημένους κινδύνους σε σχέση με την φυσιολοκιγή γέννα. Επομένως, ένα επιτυχημένο VBAC συνεπάγεται:

Βραχύτερη περίοδος ανάρρωσης.
Λιγότερος πόνος μετά τον τοκετό.
Χαμηλότερος κίνδυνος μόλυνσης.
Μειωμένη απώλεια αίματος, μειωμένη ανάγκη μετάγγισης αίματος.
Λιγότερες πιθανότητες να χρειαστεί μια επείγουσα υστερεκτομή (αφαίρεση μήτρας).
Χαμηλότερη πιθανότητα βλάβης άλλων οργάνων (ουροδόχου κύστης και εντέρου).
Χαμηλότερος κίνδυνος εμφάνισης θρόμβου αίματος (θρόμβωση) στα πόδια (εν τω βάθη φλεβική θρόμβωση) ή πνεύμονες (πνευμονική εμβολή).
Μειωμένος κίνδυνος πυελικών συμφήσεων (ουλώδης ιστός που σχηματίζεται μεταξύ των οργάνων, ο οποίος μπορεί να είναι υπεύθυνος για χρόνιο πόνο, υπογονιμότητα ή εντερική απόφραξη).
Μειωμένες πιθανότητες αναπνευστικά προβλήματα στο μωρό. Περίπου το 4-5% των νεογνών που γεννιούνται με προγραμματισμένη καισαρική έχουν αναπνευστικά προβλήματα, σε σύγκριση με 2-3% μετά το VBAC. Ο κίνδυνος είναι ελαφρώς υψηλότερος αν η καισαρική τομή έγινε πριν τις 39 εβδομάδες. Είναι γεγονός πως τα προβλήματα αναπνοής είναι αρκετά συνηθισμένα μετά από καισαρική τομή, αλλά συνήθως δεν διαρκούν πολύ.
Πολλές γυναίκες θέλουν να βιώσουν την εμπειρία μιας φυσιολογικής γέννας, και όταν το VBAC είναι επιτυχές, τις προφέρει αυτή την δυνατότητα.

Αν σχεδιάζετε να έχετε περισσότερα παιδιά, το VBAC μπορεί να σας βοηθήσει να αποφύγετε ορισμένα προβλήματα υγείας που συνδέονται με πολλαπλές καισαρικές τομές. Μάλιστα, κάποιες επιπλοκές της καισαρικής, όπως η αιμορραγία, η επείγουσα υστερεκτομή, οι τραυματισμοί του εντέρου ή της ουροδόχου κύστης, οι σχηματισμοί συμφήσεων είναι όλες πιο συχνές όσο αυξάνεται ο αριθμός καισαρικών τομών. Επιπλέον, κάθε καισαρική αυξάνει τον κίνδυνο σε μελλοντικές εγκυμοσύνες επιπλοκών του πλακούντα, όπως ο επιπωματικός πλακούντας (ο πλακούντας είναι χαμηλά στη μήτρα και καλύπτει τον τράχηλο) και ο στιφρός πλακούντας (η πρόσφηση του πλακούντα είναι πολύ βαθιά στα τοιχώματα της μήτρας και δεν αποκολλάται σωστά κατά τον τοκετό). Και οι δύο καταστάσεις μπορούν να οδηγήσουν σε μαζική αιμορραγία (απειλητική για τη ζωή) και σε υστερεκτομή. Εάν γνωρίζετε ότι θέλετε περισσότερα παιδιά, πρέπει και αυτό να το λάβετε υπόψη στην απόφασή σας.

7) Ποιοι είναι οι κίνδυνοι ενός VBAC;

Μια από τις πιο επίφοβες επιπλοκές ενός VBAC είναι η ρήξης της μήτρας, δηλαδή όταν η ουλή της μήτρας σχίζεται ή διαχωρίζεται. Ακόμα κι αν έχετε τις καλύτερες προϋποθέσεις για ένα VBAC, υπάρχει ένας κίνδυνος 0,7% (δηλαδή 7 στις 1000 γυναίκες που υποβάλλονται σε VBAC) η μήτρα να σπάσει στο σημείο της προηγούμενης καισαρικής τομής. Εάν αυτό συμβεί, μπορεί να προκαλέσει μαζική, απειλητική για τη ζωή αιμορραγία στη μητέρα, και ενδεχομένως στέρηση οξυγόνου στο μωρό, με επακόλουθη εγκεφαλική βλάβη (σε 8 από τις 10.000 περιπτώσεις) ή ακόμη και θάνατος (2-3 στις 10.000 περιπτώσεις). Ενώ ο κίνδυνος αυτός είναι πολύ μικρός συνολικά, είναι υψηλότερος σε σύγκριση με μια προγραμματισμένη καισαρική τομή.
Ανεξάρτητα από τη ρήξη της μήτρας, το VBAC φέρει αυξημένο κίνδυνο μακροπρόθεσμης νευρολογικής βλάβης ή ακόμη και θάνατο του εμβρύου. Και πάλι, ο κίνδυνος είναι πολύ μικρός, αλλά είναι υψηλότερος στις γυναίκες που η προσπάθεια για VBAC απέτυχε σε σχέση με εκείνες που κατάφεραν να γεννήσουν κολπικά ή που γέννησαν με προγραμματισμένη καισαρική τομή.
Ενδέχεται να υποβάλλεστε σε πολλές ώρες προσπάθειας τοκετού και στο τέλος να κάνετε καισαρική. Η ανεπιτυχής δοκιμασία για VBAC συχνά προκαλεί μεγάλη απογοήτευση στις γυναίκες, καθώς οι προσδοκίες τους για φυσιολογικό τοκετό δεν πληρούνται.
Σε περίπτωση VBAC ενδέχεται ο τοκετός να χρίζει υποβοήθηση με αναρρόφηση ή εμβρυουλκία, τα οποία αυξάνουν τον κίνδυνο κάκωσης των μυών που ελέγχουν τον πρωκτό ή το ορθό (ρήξη του περινέου τρίτου ή τέταρτου βαθμού).
Μπορεί να χρειαστεί να γίνει μια έκτακτη καισαρική κατά τη διάρκεια της δοκιμασίας τοκετού. Αυτό συμβαίνει στο 25% των γυναικών. Μια επείγουσα καισαρική τομή φέρει περισσότερους κινδύνους από μια προγραμματισμένη καισαρική. Οι πιο συνηθισμένοι λόγοι για μια έκτακτη καισαρική είναι αν ο τοκετός επιβραδύνεται ή υπάρχει ανησυχία για την ευημερία του μωρού.

Πρέπει να επισημάνουμε πως ενώ ένα επιτυχημένο VBAC είναι λιγότερο επικίνδυνο από μια προγραμματισμένη καισαρική τομή, ένα ανεπιτυχές VBAC που απαιτεί καισαρική φέρει μεγαλύτερο κίνδυνο από μια προγραμματισμένη καισαρική. Και ο κίνδυνος επιπλοκών είναι ακόμη υψηλότερος αν χρίζει επείγουσα καισαρική τομή.

8) Μπορώ να προχωρήσω σε VBAC εάν έχω ήδη κάνει δύο καισαρικές;

Σύμφωνα με τις αμερικάνικες (ACOG) και της βρετανικές (RCOG) κατευθυντήριες οδηγίες, το VBAC μπορεί να προσφέρεται σε γυναίκες που έχουν δύο προηγηθείσες εγκάρσιες καισαρικές τομές, μετά από λεπτομερή συμβουλευτική. Παρόλα αυτά, πρέπει να γνωρίζουν ότι ο κίνδυνος ρήξης της μήτρας αυξάνεται έως και 5 φορές (0,9 έως 3,7%).

Το VBAC μετά από δύο προηγούμενες καισαρικές είναι εξαιρετικά αμφιλεγόμενο, και ενδέχεται να μην είναι αποδεκτό από ορισμένους γιατρούς ή ιδρύματα.

9) Τι να περιμένω κατά τη διάρκεια ενός VBAC;

Το VBAC πρέπει να λαμβάνει χώρα σε νοσοκομείο ή μαειυτήριο που μπορεί να διαχειριστεί επείγουσες καταστάσεις που θα μπορούσαν να απειλούν τη ζωή της γυναίκας ή του εμβρύου, και ΔΕΝ πρέπει να επιχειρείται στο σπίτι.
Θα πρέπει να πληρούνται όλα τα κριτήρια και να μην υπάρχει καμία από τις αντενδείξεις για VBAC που έχουν αναφερθεί προηγουμένως.
Οι παράγοντες που μπορεί να μειώσουν ή να αυξήσουν την πιθανότητα επιτυχίας θα συζητηθούν διεξοδικά, επειδή είναι ξεχωριστοί για κάθε γυναίκα και για κάθε εγκυμοσύνη.
Οι καλύτερες υποψήφιες για VBAC είναι οι γυναίκες στις οποίες ο τοκετός ξεκινά αυτόματα, καθώς η πρόκληση τοκετού (με φάρμακα ή άλλες μεθόδους) μειώνει τις πιθανότητες επιτυχούς κολπικού τοκετού και φέρει 3 φορές μεγαλύτερο κίνδυνο επιπλοκών.
Γενικά συνιστάται να προσέρχεστε στο νοσοκομείο με τα πρώτα σημάδια τοκετού, για προσεκτική και έγκυρη αξιολόγηση.
Ο καρδιακός παλμός του μωρού θα παρακολουθείται συνεχώς κατά τη διάρκεια του τοκετού για να εξασφαλίζεται η ευημερία του μωρού, αφού οι αλλαγές στην καρδιακή λειτουργία είναι ένα από τα πρώιμα σημάδια προβλημάτων με την προηγούμενη καισαρική τομή.
Ένας ενδοφλέβιος καθετήρας είναι απαραίτητος για την άμεση αντιμετώπιση οποιασδήποτε ενδεχόμενης επιπλοκής.
Να αποφεύγετε να τρώτε οτιδήποτε κατά τη διάρκεια του τοκετού, σε περίπτωση που χρειαστεί να γίνει μια έκτακτη καισαρική αργότερα.
Επιτρέπονται τα φάρμακα για την ανακούφιση του πόνου, συμπεριλαμβανομένης και η επισκληρίδιος αναλγησίας.
Τα ακόλουθα σημάδια μπορεί να είναι ένδειξη ρήξης της μήτρας και χρίζουν μια επείγουσα καισαρική:
1. Συνεχιζόμενη βραδυκαρδία στο έμβρυο (η καρδιακή συχνότητα του μωρού πέφτει, είναι το συνηθέστερο σημάδι ρήξης της μήτρας).
2. Κολπική αιμορραγία.
3. Ευαισθησία στην ουλή της καισαρικής.
4. Πόνος ανάμεσα στις συσπάσεις.
5. Παύση συσπάσεων.
6. Πόνος που επιμένει ακόμα και με την επισκληρίδιο αναλγησία, ή υπερβολικές ανάγκη για επισκληρίδια φάρμακα.
7. Ψηλαφήση εμβρυϊκών μερών έξω από τη μήτρα.
8. Αιματουρία (αίμα στα ούρα).

Είναι σημαντικό να καταλάβετε πως η ρήξη της μήτρας μπορεί να είναι σιωπηρή, και ότι ακόμα και μια επείγουσα καισαρική μπορεί να μην αποτρέψει σοβαρές επιπλοκές, τόσο για εσάς όσο και για το μωρό σας.

Εν κατακλείδι:

Ένα επιτυχές VBAC έχει τις λιγότερες επιπλοκές.
Ο μεγαλύτερος κίνδυνος ανεπιθύμητων αποτελεσμάτων που σχετίζονται με το VBAC συμβαίνει όταν το VBAC καταλήξει σε επείγουσα καισαρική τομή.
Είναι συχνά αδύνατο να προβλέψουμε ποιες γυναίκες θα έχουν ένα επιτυχημένο VBAC και ποιες θα χρειαστούν μια επαναλαμβανόμενη καισαρική.
Ένα VBAC που ξεκινάει αυτόματα (χωρίς πρόκληση) έχει κίνδυνο 1: 150 ρήξης της μήτρας.
Η ρήξη της μήτρας είναι μια σπάνια, αλλά δυνητικά απειλητική για τη ζωή κατάσταση, τόσο για τη μητέρα όσο και για το μωρό της.
Ακόμα και όταν η καισαρική γίνεται αμέσως, ενδέχεται να μην μπορέσει να αποτρέψει σοβαρές επιπλοκές, τόσο για τη μητέρα όσο και για το μωρό της.
Ο απόλυτος κίνδυνος σοβαρών προβλημάτων και θανάτου του εμβρύου που σχετίζονται με το VBAC είναι πολύ χαμηλός, αλλά υψηλότερος από την προγραμματισμένη καισαρική.
Τα νεογνά που γεννιούνται μέσω προγραμματισμένης καισαρικής τομής έχουν αυξημένο κίνδυνο αναπνευστικών προβλημάτων, τα οποία όμως είναι συνήθως βραχύβια.
Η προγραμματισμένη καισαρική σχετίζεται με αυξημένο κίνδυνο επιπλοκών της πρόσφυσης του πλακούντα (επιπωματικός / στιφρός πλακούντας) σε μελλοντικές εγκυμοσύνες. Και άλλες επιπλοκές όπως οι πυελικές συμφύσεις είναι πιο συχνές όσο αυξάνεται ο αριθμός των καισαρικών.

Τα VBAC είναι πολύ αμφιλεγόμενο και μπορεί να είναι δύσκολο να αποφασίσετε αν είναι το καλύτερο για εσάς. Συζητήστε το διεξοδικά με τον/την γιατρό σας. Δώστε στον εαυτό σας αρκετό χρόνο για να ενημερωθείτε και να εξετάσετε προσεκτικά τα πλεονεκτήματα και τα μειονεκτήματα της κάθε επιλογής.

Βιβλιογραφία

The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth options after previous caesarean section – July 2016 (For patients)
Royal College of Obstetricians & Gynaecologists (RCOG) – Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
National Health System (NHS) UK – Clinical Guideline for: The Management of Vaginal Birth After Caesarean (VBAC). July 2016

Photo credits

1.Parents.com; 2.EvolutionaryParenting.com; 3.goldengateobgyn.org; 4.Healthymummy.com; 5.YouTube.com; 6.Scarymummy.com; 7.geoscripts.meredith.services

4Dec2016

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 3)

Posted in Health, Pregnancy by woman2womenblog

In the Part 1 of Home birth: Smart choice or risky business? we analyzed the issues of personal satisfaction, maternal safety and baby’s risks. Part 2 dealt with hospital transfers, water birth and the situation in the Netherlands. Check out the last three reasons women choose home birth, and read the final conclusion to decide whether home birth is a clever or a dangerous option…

7) “Home birth is cheap”

Home birth is cheaper… provided that no transfer is needed and nothing goes wrong

Cost-effectiveness is an important issue in every country with an organized health system. Countries like England or the Netherlands, where the National Health System (NHS) covers the cost of deliveries, have calculated that is cheaper that women deliver at home, avoiding a more expensive hospital admission. For example, the UK NHS “prices” home birth £1066 and birth at a hospital £1631. The economical factor is one of the reasons certain professional organizations support home labor, such as the Royal College of Obstetrics and Gynaecologists (RCOG) which states that: “home birth is the most cost-effective place for delivery”.

But this cost analysis has been challenged, as it does not take in consideration the high transport rates; in fact, a Dutch report calculates a general 3-fold increase of costs in patients transported during labor, when the costs of the midwife, the transport system, the obstetrician and the hospital are included. In addition, the costs derived from the maintenance of an adequate transport system (ambulances and trained staff) should not be neglected. Assuming increased neonatal risks, admissions to the neonatal intensive care unit, the lifetime costs of supporting neurologically disabled children and potentially increased professional liability costs resulting from a complicated home birth can potentially inflate the costs.

Indicative of these unexpected expenses is the article Home birth: What the hell was I thinking? A journalist from The Guardian went on a mission following a home birth. After managing to deliver her child at home, both the woman and her baby had a complication and needed to be transferred to a hospital. Since the baby and the mother were not allowed to be in the same ambulance, two ambulances were required…

Regarding the costs arising from a private home birth, the situation varies in different countries; in the USA home births are not covered by health insurances, and a couple is expected to pay $1500 to 4500 to the midwife. Hospital births can range from $3,296 to 37,227, although they are usually covered totally or partially by the insurance. Of note: a doctor gets paid about $2500-4000, same as a midwife. Ιn Europe, a couple is expected to pay about 2000-3000 €; recently the Italian newspaper La Stampa published the article Home birth: a 3000 € luxury that does not convince doctors.

8) “Birth is not a disease, it’s a natural thing. Mother nature can’t go wrong”

Unassisted childbirth: don’t try this at home – or anywhere else

Indeed, Mother nature is great. If you think about it, the whole process of labor and delivery seems to be so perfect, almost magical… But “natural” is not a synonym of “risk-free”. Sometimes Mother nature can play strange games. We may believe we have everything under control, but things may flip just in a second: think earthquakes, or tsunamis… Exactly the same thing applies to childbirth: even when someone seems to be “low risk”, disaster can strike without any warning …

“Childbirth is inherently dangerous,” writes in her blog Amy Tuteur, an American obstetrician gynecologist. “In every time, place and culture, it is one of the leading causes of death of young women. And the day of birth is the most dangerous day in the entire 18 years of childhood”. Finally, she adds: “Why does childbirth seem so safe? Because of modern obstetrics. Modern obstetrics has lowered the neonatal mortality rate 90 per cent and the maternal mortality rate 99 per cent over the past 100 years.”

The absolute confidence in a woman body’s ability to deliver is expressed by supporters of unassisted childbirth (UC), the “hard core” version of home birth, which, although practised already since the 70s, it has lately seen a resurgence. Also known as freebirth, DIY (do-it-yourself) birth, unhindered birth, or unassisted home birth, it refers to women that intentionally deliver without the assistance of a physician or midwife; they may be completely alone (“solo birth”) or assisted by a lay person, such as the spouse, family, friend, or a non-professional birth attendant. There are no data on safety of UC, except that coming from a religious group in Indiana (USA) that found a perinatal mortality rate 2,7 times higher, and a maternal mortality rate 97 times higher than the state average.

Among the most famous UC advocates is Janet Fraser who, ironically, lost her baby after five days of home labour; in spite of that she continues to advocate for freebirth. In fact, UC is not endorsed by any scientific organization, as it is considered too dangerous. According to André Lalonde, executive vice-president of the Society of Obstetricians and Gynaecologists of Canada (SOGC):“Freebirth is the equivalent of playing Russian roulette with your child”.

9) “I have the right to deliver wherever I want”

A home birth oxymoron: right to privacy vs. social media exposure

This is a very complex issue with ethical and legal connotations, which has originated intense debate among experts. Even scientific organizations differ in their recommendations. For example, The American College of Obstetricians and Gynecologists, until recently opposed to home births, has decided to temper its position: “…hospitals and birthing centers are the safest setting for birth, but it respects the right of a woman to make a medically informed decision about delivery.” On the other side, the American College of Nurse-Midwives (ACNM) maintains that “every family has a right to experience child birth in an environment where human dignity, self-determination, and the family’s cultural context are respected” and that “every woman has a right to an informed choice regarding place of birth and access to safe home birth services”. Let’s analyze the ethical and legal aspects of home birth:

Ethical issues

These are some of the ethicals dilemmas related to home birth:

Mother vs child safety. Although hospital birth seems to increase maternal interventions in all studies (apparently without increasing severe risk), the baby’s safety remains a subject of debate; taking though in consideration all the studies, there seems to be increased risk for the baby. Let’s take for example the Birthplace study (which is in somewhere in the middle). This study found that, particularly for first time mothers, the baby’s risk is 3 times higher (of which more that half of the cases are death and brain damage). Is it ethically acceptable for a woman to value her birth experience over her baby’s welfare? Is maternal emotional wellbeing so important to justify risking the baby’s health?

Respect for dignity and privacy. “Dignity” may have a different meaning for each person. Some home births supporters feel that the presence of a doctor and the hospital staff make them feel “degraded”; moreover “for some women the possibility of the loss of privacy is a major issue, because privacy is a valued possession”.

Is it not contradictory that so many women, zealous advocates of home birth and their right to privacy, do not hesitate to publish their home birth photographs and videos -some of them with incredible details- in every social media site, where they are exposed to the eyes of millions of people?

Self-determination. In order to make truly informed decisions about childbirth options, women need to be informed of what they are and have the possibility to discuss them. Is it ethical to offer the option of home birth knowing that there is increased risk for her baby?

In theory, the person informing the pregnant woman should inform her objectively and avoid being paternalistic. The problem is that, informed decision-making implies accurate assessment of risks and benefits, but the safety of home birth remains debatable. Is it possible to inform objectively a pregnant woman about home birth? Or the information will be biased according to the health care provider beliefs or experiences?

Other possible ethical issues:

In the home birth situation, are a woman’s reproductive rights and medical responsibility incompatible with each other?
Where do a woman’s rights end and medical responsibility begins, especially considering that the physician is also responsible for the baby’s welfare?
In case of a baby adverse outcome that could have been prevented in a hospital setting, what will be the psychological consequences for the couple?
What is the psychological burden of a home birth in a family’s older children witnessing a home birth? What if a complication occur in their presence?

Legal issues

Legal issues can affect a woman’s decision to give birth at home in different countries. In certain places, home births are restricted, and even possibly criminally punishable, and family homes have been turned into crime scenes when women who have opted for homebirths experienced complications. In others countries, there are no regulating laws.

In Europe, the European Court of Human Rights (ECtHR) ruled in 2010 that Hungary had violated Article 8 of the European Convention on Human Rights (ECHR) because it had interfered with a woman’s right to choose where to give birth. Ms Ternovszky wanted to give birth at home but argued that she was prevented from doing so because a government decree dissuaded health care professionals from assisting home births. This case was the first decision by an international human rights organization on the right to choose the circumstances of giving birth, and was heralded by home birth advocates across Europe.

However, in a recent case against the Czech Republic, the Human rights judges decided that national authorities of each country has “considerable room for manoeuvre” when regulating home births, a matter for which there is no European consensus and which involves complex issues of health-care policy as well as allocation of State resources.

So, is home birth a smart choice or a risky business?

The Monty Python satirize the medicalisation of childbirth in The Meaning of Life

As an obstetrician who supports natural birth, I hear many times the women’s complaints about the excessive medicalization of childbirth. And I feel that sometimes they are right. However, being a mother myself, I never regretted my choice of a hospital birth for my children. After having helped so many women deliver their babies, I have seen many times complications that were totally unpredictable. Occasionally, these sudden complications are so serious, that we have to run -literally- from the delivery room to the operating room to save the baby or the mother! Therefore, even when having skilled professionals attending your home birth, even in countries with very organized structures, the distance to a hospital can prove fatal. Is for this reason that, in my opinion, a hospital birth is without any doubt the best choice for every woman. A birthing center attached to a hospital may also be a good choice.

True, the studies results are controversial, but for me “almost as safe as a hospital birth” is not enough to make me change my mind.

True also, a hospital birth is related to more epidurals, cesarean sections, instrumental deliveries and episiotomies. Regarding the epidural, if you can do it without one, that’s great! But sometimes labor pain is unbearable, and it’s not uncommon to see women without any pain relief who, when the moment to push comes, they are so exhausted and their pain is so overwhelming that they literally lose it. On the contrary, women with an epidural can be more focused and relaxed. The bottom line is: natural birth is not for everybody. And women don’t have to feel guilty because they chose to have an epidural. It’s better to have nice memories of your birth, and for that the epidural can help!

Whether too many cesareans sections are being done is a topic more controversial than home birth itself, and it would deserve a separate article. But what I can say is that, when cesarean sections are done in a judicious way by a conscious physician, they can save your life and your baby’s life. Since hospital births result in better neonatal outcome, it is clear to me that most interventions are an inevitable trade-off to save more babies or to avoid severe damage. The same goes for the controversial fetal monitoring, which may lead to more cesarean sections, it may not decrease perinatal mortality, but it reduces by 50% the risk of brain damage. Personally, I would do anything in my power to reduce the chances of having a brain damaged baby.

Of course, a lot that should be done -and can be done- to improve hospital birth: create home-like conditions to help women be relaxed and empowered, allow women to walk during labor, give them possibility to push and deliver in any position they wish, avoid unnecessary interventions such as systematic episiotomies, etc. I believe that some efforts are slowly being done worldwide, but we still have a long way to go!

In conclusion, a woman has the right to choose where to deliver; however, until the risks are clarified, maternal wellbeing may undermine the child’s welfare. Therefore, in my opinion, a natural hospital birth is the safest choice. Natural hospital birth IS possible! You just need motivation and a supportive team…

Hospitals should increase their efforts to provide women with a friendly environment so they can deliver their babies in comfort and total safety. Every baby is precious, every mother is precious!

Photo credits

7) screenterrier.blogspot.gr; 8) news.com.au; 9) vimeo.com, Wikimedia Commons, thebirthhour.com, Flickr.com, vimeo.com, homebirthaustralia.org, mindfulmamabirth.com, Flickr.com, huffingtonpost.co.uk, lifedaily.com

3Dec2016

HOME BIRTH: SMART CHOICE OR RISKY BUSINESS? (Part 2)

Posted in Health, Pregnancy by woman2womenblog

In the first part of this article we analyzed three important issues related to home birth: personal satisfaction, the mother’s safety and the baby’s risks. Check out the next three reasons women choose a home birth…

4) “I plan to have a home birth, but if something should happen I will go to a hospital”

Even when properly prepared for a home birth, transfer to a hospital is commonly required

As previously mentioned, hospital transportation is a common event: about 1 out of 2 first time mothers and 2 out of 10 second or subsequent time mothers need to be transferred to a hospital; moreover, hospital transfer is almost always perceived by the couple as a negative and disruptive experience (see part 1).

The need for transportation to a hospital can occur before, during of after birth, and can be related to the mother, the baby or both. The top reasons may vary in different countries, although prolonged labour is the first cause of transfer in almost every study, followed by pain relief or the midwife’s unavailability at the onset of labor.

In the UK, the most common reasons for transfer are:

Prolonged labour (32.4%)
Meconium staining (12.2%)
Repair of a perineal tear (10.9%)
Abnormal fetal heart rate (7.0%)
Retained placenta (7.0%)
Request for regional analgesia (epidural, spinal) (5.1%)
Neonatal concerns (postpartum) (5.1%)
Others (20.1%)

Australian Caroline Lovell died of complications after giving birth to her daughter in a pool. Justice found that her death was preventable.

Home birth activist Caroline Lovell died of complications after giving birth her second child at home. Her death was preventable, justice says.

Other reasons include:

–During labor: maternal fever, fetal malpresentation, shoulder dystocia (baby’s shoulders getting stuck inside the mother), cord prolapse, uterine rupture, acute bleeding, placental abruption, vasa previa, acute sepsis.

–After birth: tears of the vagina or cervix, sphincter rupture, uterine atony, placenta accreta, increta, or percreta.

–Baby-related (post partum): unexpected very low or very high birthweight, neonatal depression, signs of respiratory distress, unexpected malformations, acute sepsis.

These are some important facts to keep in mind:

Maternal and fetal necessity for transport is often impossible to predict.
For unpredictable, extremely sudden complications, even rapid transport may not prevent the baby or the woman from death or severe harm, such as shoulder dystocia, sudden cardiopulmonary arrest, or maternal exsaguination (bleeding to death, read Caroline Lovell story here).
Women with severe hemorrhage may already be in shock when arriving at a hospital. Even though the adequate treatment can be immediately instituted, death may nevertheless occur.
Perinatal mortality is higher when transport to the hospital is required.

5) “At home I can have a water birth”

The latest years there has been an increasing demand for water birth

Immersion in water during labor and delivery, although available for several decades, has seen a greatly renewed interest the latest years. In fact, even certain hospitals and birth centers have incorporated birth pools to their facilities. The results of studies analyzing maternal and fetal benefits and risks of water birth are inconsistent, and many times contradictory. The American College of Obstetricians and Gynecologists (ACOG) has just reviewed the subject and a few days ago (November 2016) published an updated statement. What are then the proposed pros and cons of water birth?

The benefits

For the mother. A Cochrane study found the following results:

Less need for regional analgesia (epidural, spinal, or paracervical; studies show a slight reduction, RR 0.90; 95% CI 0.82–0.99)
Shorter duration of the first stage of labor (32.4 minutes shorter in water immersion)
Improvement in satisfaction among those women delivering in water.
Studies results are contradictory regarding the reduced occurrence perineal tears (including third-degree and fourth-degree lacerations) and need for episiotomy.
One study found less antepartum transfers to hospitals, both from home and midwifery birth units.

Other possible benefits: Increased feelings of relaxation, warmth, privacy, improved ability to maintain control during labor (here, here, here).

For the baby. Supporters of water birth believe that the transition to the outside world is less traumatic for babies born in water as the warm water of the pool may feel like the amniotic fluid; thus water-born babies are supposedly calmer than babies born in air. In fact, no benefits for the newborn were found with maternal immersion during labor or delivery, neither in 2 systematic reviews including 12 studies and 29 studies respectively, neither in the 2009 Cochrane systematic review, or any individual trials included in ACOG’s review.

The risks

For the mother. ACOG’s review did not find increased risk for maternal infections or postpartum hemorrhage. However, this conclusion must be tempered by the lack of data on rare serious outcomes, such as severe morbidity and mortality.

For the baby. Most studies found that immersion during labor does not increase fetal or neonatal risk. However, concerns have been expressed that immersion during delivery may predispose the infant to potentially serious neonatal complications. Several studies have reported several serious adverse outcomes among neonates delivered in water, these include :

Infection: cases of severe infections with certain bacteria, mainly Pseudomonas aeruginosa (here, here) and Legionella pneumophila (here, here, here, here) have been observed, some of which were fatal. The bacteria causing infections my come from the woman’s body, the water or the pool itself. Recently, a fatal infection by a virus (adenovirus) was reported in a baby born from a mother with gastroenteritis giving birth in a pool.
Water aspiration (drowning or near-drowning): it has been claimed that babies delivered into the water do not breathe or swallow water because of the protective “diving reflex”; however, it has been demonstrated that in compromised newborns the diving reflex is overridden, leading to gasping and aspiration of water. Actually, it seems that even healthy babies may be at risk of water aspiration, which may result in hyponatremia and seizures.
Umbilical cord avulsion (cord “snapping” or cord rupture): this complication may happen in 1 out of 288 water births and occurs when the baby is lifted out of the water; in some instances the affected newborns have required intensive care unit admission and transfusion.

Other possible inconvenients:

The mess: setting a pool at home may be messy and even challenging in certain situations, such as living in a small apartment.
Unpleasant environment: women may feel uncomfortable about accidentally defecating in the pool; which, as stated above, may also predispose the baby to severe infections.
Disappointment with pain relief: for some women, immersion in water is not enough to relieve pain.
Monitoring and emergencies: it may be difficult to quantify blood loss (see photo); in cases of concern about the baby’s heartbeat, monitoring may be difficult; moreover, in the event of a severe maternal complication (such as fainting or heavy hemorrhage) it may be difficult to move the pregnant woman out of the water.

Several professional organizations, including the Royal College of Obstetricians and Gynaecologists and the American College of Nurse–Midwives, support healthy women with uncomplicated pregnancies laboring and giving birth in water. According to ACOG, immersion in water during the first stage of labor may have benefits for the mother and may be offered to healthy women with uncomplicated pregnancies; however, there are insufficient data regarding the relative benefits and risks of immersion in water during the second stage of labor and delivery. Therefore, until such data are available, “it is the recommendation of the American College of Obstetricians and Gynecologists that birth occur on land, not in water”. The British National Institute for Health and Care Excellence (NICE) recommendations are in agreement with the ACOG.

6) “In the Netherlands women have been delivering at home for more than fifty years”

The Netherlands has the highest percentage of home births in the Western world

The Netherlands is a country with a long tradition of home birth, with well-trained midwifes, organized transport system and short distances to hospitals. However, it is one of the few countries in the world where the incidence of home births is decreasing: in 1965, two-thirds of Dutch births took place at home, but that figure has dropped to about 20% in 2013. Moreover, Dutch women have to pay an extra amount (around €250) when deciding for a “nonindicated hospital birth” under the guidance of an obstetrician or a midwife (here). According to Professor Simone Buitendijk, head of the child health programme at the Netherlands Organisation for Applied Scientific Research, “… home birth rates have dropped like a stone. Soon, there will not be enough demand to justify the infrastructure” she says. “Then the system will collapse – and let there be no misunderstanding: we won’t be able to rebuild it”.

This drop in home births seems to be related to the increasing awareness of the media, patients, and obstetricians about the risks of home birth (here). Even more skepticism originated the results of the Euro-Peristat study: the Netherlands is one of the countries with the worst perinatal outcomes of Western Europe.

Read the third part here: Home birth: smart choice or risky business? (Part 3)

Photo credits

4) birthbootcamp.com, dailymail.co.uk; 5) flickr.com, mthoodwomenshealth.com, popsugar.com, gravidanzaonline.it; 6) currystrumpet.com

29Mar2016

CONTRACEPTION: 14 COMMON MYTHS – BUSTED

Posted in Health by woman2womenblog

How good is your knowledge on contraception? Statistics show that even if contraception awareness is on the rise, there are still a lot of important gaps, and many misconceptions persist.

If you are like most young people, your “education” on birth control comes mainly from your friends, and the internet. And you may have learnt valuable things from them! But there is still a lot of misinformation going around, leading in many cases to misunderstandings and unpleasant surprises…

Following are some of the most common myths, rumours and misperceptions regarding birth control that you should know in order to avoid an unplanned pregnancy.

MYTH # 1: I won’t get pregnant if my partner pulls out before he comes

This is one of the most common misconceptions, responsible for many unwanted pregnancies. Also known as the withdrawal method, it has a high rate of contraception failure. This is because some pre-ejaculation fluid (or pre-come) may be released before the man actually ejaculates; this pre-come contains spermatozoids, and it takes only one sperm to get you pregnant! In addition, some men may not have enough self control to withdraw in time…

Keep in mind that pre-ejaculation fluid can also contain sexually transmitted infections, so pulling out will not prevent you from getting an infection.

MYTH # 2: I don’t get pregnant if I have sex during my period

The chances of getting pregnant while on your period are low, but it may happen, mainly in women with shorter cycle –i.e., if you get your period every 21-24 days. In such case, your ovulation occurs around the 10^th to 12^th day after the beginning of your period. Since sperm can live up to 5 days inside your body, if you have sex towards the end of your period, sperm can wait for the egg to be released and you may become pregnant.

But even in women with longer, regular cycles, the ovulation may eventually take place earlier… So remember, you can get pregnant at any time of the month if you have sex without contraception.

MYTH # 3: The morning after pill is dangerous, you can’t take it more than once or twice in your lifetime

It has been suggested (mostly by internet rumours) that it is dangerous to take the emergency contraception pill more than one or twice in your life. According to the World Health Organisation: “Emergency contraceptive pills are for emergency use only and are not appropriate for regular use as an ongoing contraceptive method because of the higher possibility of failure compared with non-emergency contraceptives. In addition, frequent use of emergency contraception can result in side-effects such as menstrual irregularities, although their repeated use poses no known health risks.” Emergency contraception pills are very safe and do not harm future fertility. Side effects are uncommon and generally mild. Read more about the morning after pill here.

MYTH # 4. I don’t get pregnant if I have sex standing up or if I’m on top

Some women believe that having sex in certain positions, such as standing up, sitting down, or if they jump up and down afterwards, they won’t get pregnant as sperm will be forced out of the vagina. In fact, sperm are very strong swimmers! It has been showed that within 5 minutes, sperm are able to reach the tube, where the fertilisation of the egg takes place, and this happens regardless of the position you have sex in.

There’s no such thing as a “safe” position if you’re having sex without a condom or another form of contraception. There are also no “safe” places to have sex, including the bathtub, the shower or the sea.

MYTH # 5. There are only 3 contraceptive options: the condom, the pill and the IUD

Although these three methods are the best-known, there are 15 different methods of contraception (the available options differ in each country). Unfortunately -for women- there are only two choices for men (the male condom and permanent sterilisation). Women have a choice of about 13 methods, including several of long-acting reversible contraception -this means you don’t need to remember to take it or use it every day or every time you have sex.

MYTH # 6. The IUD is not suitable for teenagers and women without children

In the USA, 44% of adolescent girls ages 15 to 19 have had sexual intercourse. Although most of them have used contraception, teenagers frequently use methods with high failure rates -such as withdrawal, or they incorrectly use more reliable methods -such as the pill. In fact, 8 out of every 10 adolescent pregnancies are unintended.

The intrauterine device (IUD), a small device that is inserted into the uterus, has been traditionally reserved to women who have had children. However, new guidelines issued by the American College of Obstetricians and Gynecologists have changed this old perception: the IUD, together with the contraceptive implant, are considered now first-line contraceptive options for sexually active adolescents and young women, as they are the most effective reversible contraceptives for preventing unintended pregnancy, with about 99% effectiveness.

Of course, the IUD and the implant do not protect against sexually transmitted infections, therefore you should also use condoms for that purpose.

MYTH # 7. You can’t get pregnant if it’s the first time you have sex, or if you don’t have an orgasm

These persistent misconceptions are, unfortunately, still responsible for many unplanned pregnancies. If the intercourse takes place during your fertile period, you may become pregnant, whether it’s the first or the hundredth time you’ve had sex, whether you liked it or not.

MYTH # 8. Two condoms are better than one

Condoms may occasionally break. Many people think that using two condoms (also known as “double bagging”) is safer than using one. Actually, it’s exactly the opposite: using two condoms causes friction between them, increasing the risk of breakage. Thus, two condoms should not be used, neither for pregnancy prevention or for safer sex; this is also true for using a male and a female condom at the same time. When used properly, a male condom is 98% effective at preventing pregnancy, a female condom is 95% effective.

MYTH # 9. I can use any lubricant together with the condom

During intercourse, adding lubricant may ease penetration, so sex is pleasurable and not painful. This is important when, for many reasons (such as stress, medications, taking the pill, etc) the natural wetness of the genital area is reduced.

Lubricants can be made from water, oil, petroleum or silicone; however, when using condoms, water-based lubricants should be used: oil-based products such as petroleum jelly, creams, or baby oil and can damage the latex and make the condom more likely to split, resulting in no contraceptive protection.

Silicone-based lubricants are a newer form of lubrication; they are safe to use with condoms. However, they can be harder to wash off and may cause irritation.

MYTH # 10. If you take the pill for many years, you won’t be able to have children in the future

This is another very common misconception. After stopping the oral contraceptive pill you may get pregnant immediately, but sometimes it may take two or three cycles for your fertility to fully return, no matter how long you have been using it. Some studies have shown that, within a year after going off the pill, 80% of women trying to get pregnant will get pregnant – exactly like women who were never on the pill.

MYTH #11. You don’t get pregnant if you douche right after sex

Vaginal douching (washing out the vagina) after sex won’t help to prevent a pregnancy. Again, this has to do with spermatozoa being fast swimmers. By the time a woman starts douching, sperm are already well inside the uterine cervix, where no douching solution can reach them.

In fact, you should never douche: douching can lead to many health problems, including problems getting pregnant, vaginal infections and sexually transmitted infections.

MYTH #12. I’m breastfeeding so I can’t get pregnant

While you’re less fertile when breastfeeding, you may become pregnant; there is no accurate way to predict when fertility returns, even if you breastfeed exclusively. You may not menstruate for several months after giving birth, but at some point you will have your first ovulation -where you can get pregnant- and this will occur two weeks before you get your first period.

Thus, when nursing you should use birth control if you wish to avoid pregnancy.

MYTH # 13. You’re only fertile one day a month

If you have a regular cycle of 28 days, the ovulation usually occurs the 14^th day of your cycle. But it’s not only that day that you are fertile. As said before, sperm can live in the cervix for up to 5 days, waiting for the egg to be released. Studies have shown that most pregnancies result from intercourse that takes place during a six-day period ending on the day of ovulation. Once the egg leaves the ovary, in about 24 hours it dies, and the fertile period is over.

However, even in women with a perfectly regular cycle, the hormonal balance involved in the ovulation process can be disrupted by many factors: stress, medications, etc, leading to an earlier or delayed ovulation. Thus, trying to avoid a pregnancy by just having intercourse on the “safe” days can be difficult and may eventually result in an unwanted pregnancy.

MYTH # 14. I don’t need a condom because I’m taking the pill

A survey conducted in France showed that “…one in ten young women ages 15 to 20 is not aware that the pill does not protect against HIV and sexually transmitted infections”. In fact, the only contraceptive method that offers protection against STIs is the condom. Even other barrier methods, such as the diaphragm, do not to keep bacteria out of the vagina, and the pill and IUD offer no STI protection at all.

The bottom line:

Don’t be afraid to talk to a doctor about birth control! True, discussing contraception and sexual practices with a healthcare professional may be embarrassing… but it’s better to discuss ways to prevent an unintended pregnancy rather than dealing with one after it happened!

You can do your research before scheduling an appointment -there are many good sites to learn useful information about birth control – but a doctor will help you decide which is the best contraceptive method for you, and how to use it in a proper way.

Knowledge is empowerment! Learn your choices, be aware of the dangers of irresponsible sexual practices, be the advocate for your own sexual health!

Find out more about contraception here:

Centers for Disease Control and Prevention, USA. Contraception

National Health System, UK. Your contraception Guide

FPA UK. My contraception tool