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VAGINAL BIRTH AFTER CESAREAN SECTION (VBAC): ALL YOU NEED TO KNOW BEFORE MAKING YOUR EDUCATED CHOICE

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“Once a Cesarean, always a Cesarean” has been the standard recommendation for many years. But the increasingly high cesarean section (C-section) rates around the world have led doctors to reassess the risks of a cesarean section versus delivering vaginally after having a previous C-section.

Repeat C-section or VBAC? The answer is not straightforward. Both options do come with some risks, and those risks vary depending on the woman and the specific pregnancy.

Here’s what you need to know about a vaginal birth after cesarean section and what you should discuss with your doctor if you want to try delivering your next baby vaginally.

1) What is a vaginal birth after cesarean delivery (VBAC)?

If you’re pregnant again and your last baby was born via cesarean section, this time you have two choices about how to give birth:

  1. an elective repeat caesarean section (ERCS), or
  2. a VBAC. “VBAC” stands for “vaginal birth after cesarean” and refers to giving birth through the vagina after a woman has already had a C-section. Vaginal birth also includes deliveries assisted by forceps or ventouse.

Planning for a vaginal birth after caesarean (VBAC) or choosing an ERCS have different benefits and risks (see below).

A TOLAC (trial of labor after cesarean delivery) is the attempt to have a VBAC. If it is successful, TOLAC results in a vaginal birth. If it is not successful, you will need another cesarean delivery.

2) What are my chances of giving birth vaginally after having a C-section?

As long as you are an appropriate candidate for a VBAC, there are good chances to succeed: about 60 to 80% of women who attempt a VBAC will deliver vaginally.

There are certain factors which affect the chances of success, both related to the mother and the baby (see below). Nevertheless, it’s impossible to predict with certainty who will be able to have a vaginal delivery and who will end up with a repeat c-section.

A previous vaginal delivery, particularly previous VBAC, is the single best predictor of successful VBAC and is associated with a VBAC success rate of 85–90%.

3) Am I a good candidate for a VBAC?

Planned VBAC is appropriate for the majority of women who:

  • are pregnant with one fetus (as opposed to twins/multiples),
  • their baby is positioned head down (cephalic presentation),
  • have a pregnancy at term (37+0 weeks or beyond),
  • have had one previous lower segment caesarean delivery.

4) When is VBAC contraindicated?

Planned VBAC is strongly discouraged in the following cases:

  • Three or more previous caesarean deliveries. See below in case you have two previous C-sections.
  • The uterus has ruptured during a previous labor, as this increases considerably your risk (7 times higher) of a recurrent uterine rupture with the next pregnancy.
  • The previous caesarean section was “classical”.  In the vast majority of women, the uterus is cut horizontally, in its lower segment. This is called a low-transverse uterine incision. Rarely, a vertical incision in the upper uterus is required, this is known as a “classical” incision. Occasionally, a J- or T-shaped cut is performed. In both cases of vertical and J/T-shaped incision there is higher risk for uterine rupture. Therefore, it is very important to know which incision was performed in your previous C-section. You should note that the type of scar on your skin does not necessarily match the one on your uterus.
  • A previous uterine surgery, such as fibroid removal (myomectomy), as this increases the risk of uterine rupture.
  • There is other pregnancy complications that requires a C-section.There are certain absolute contraindications to vaginal birth that apply irrespective of the presence or absence of a scar (e.g. placenta previa)
  • Breech presentation (the baby comes with buttocks and/or feet first) or other abnormal presentations.
  • Multiple pregnancies (twins or more).


5) What factors reduce my changes of having a successful VBAC?

In general, the chances of success are lower in the following situations:

  • The reason for the previous c-section is likely to be problem this time around. Let’s say that a woman who already had a vaginal delivery and then had a c-section because her baby was breech (buttocks or feet first) is much more likely to have a successful VBAC than one who had a previous c-section after achieving full dilation and pushing for three hours, which may signal a narrow basin.
  • Labor is induced (did not start spontaneously).
  • You are older than 40 years old.
  • You are overweight.
  • The baby is big (over 4,000 grams estimated weight, or 8.8 pounds).
  • Advanced gestational age at delivery (more than 40 weeks).
  • Having a short time between pregnancies (less than 19 months).
  • You have preeclampsia (high blood pressure) at the time of delivery.

You should discuss with your practitioner about your individual chance of success and carefully weigh the benefits and the risks.

6) What are the benefits of a VBAC?

C-section is a major abdominal surgery, and as such is associated with certain increased risks as opposed to a vaginal birth. Therefore, a successful VBAC entails:

  • Shorter recovery period
  • Less post-partum pain.
  • Lower risk of infection.
  • Less blood loss, reduced need for a blood transfusion.
  • Less chances of needing an emergency hysterectomy (uterine removal).
  • Lower likelihood of damaging other organs (bladder and bowel).
  • Lower risk of developing a blood clot (thrombosis) in the legs (deep vein thrombosis) or lungs (pulmonary embolism).
  • Reduced risk of pelvic adhesions (internal scar tissue that forms between the organs, which may be responsible for chronic pain, infertility or intestinal obstruction).
  • Decreased chances of breathing problems for your baby. About 4-5% of babies born by planned C-section have breathing problems, compared with 2-3% following VBAC; the risk is  slightly higher if you have a planned caesarean section earlier than 39 weeks. In fact, breathing problems are quite common after caesarean delivery, but usually do not last long.
  • Many women would like to have the experience of vaginal birth, and when successful, VBAC allows this to happen.

If you plan to have more children, VBAC may help you avoid certain health problems linked to multiple cesarean deliveries. In fact, C-section complications, such as haemorrhage, emergency hysterectomy, bowel or bladder injury, adhesion formations are all higher with the increased number of cesarean deliveries. Moreover, every C-section you have raises your risk in future pregnancies of placenta complications, such as placenta previa (the placenta lyes low and covers the cervix) and placenta accreta (the placenta implants too deeply and doesn’t separate properly at delivery). Both conditions can result in life-threatening bleeding and a hysterectomy. If you know that you want more children, this may figure into your decision.

7) What are the risks of a VBAC?

  • One of the most feared complications of a VBAC is the possibility of uterine rupture, that is, the scar of the uterus tears or separates. Even if you’re a good candidate for a VBAC, there is a 0.7% risk (that is, 7 out of 1000 woman undergoing a VBAC) that your uterus will rupture at the site of your C-section incision. If this happens, it may result in severe blood loss for you, eventually life-threatening, and possibly oxygen deprivation for your baby, which may result in brain damage (in 8 out of 10,000 cases) or even death (in 2-3 out of 10,000 cases). While this risk is very small overall, it is higher as compared to a scheduled C-section.
  • Regardless of uterine rupture, VBAC carries in increased risk of long-term neurological damage or even death. Again, the risk is very small, but is higher in women who undergo an unsuccessful VBAC than in women who have a successful vaginal delivery or a scheduled C-section.
  • If you end up being unable to deliver vaginally, you could endure hours of labor only to have an unplanned C-section. This may be very frustrating for certain women, as their expectations for a vaginal birth are not fulfilled.
  • You may need an assisted vaginal birth using ventouse or forceps, which may lead to increased risk of having a tear involving the muscle that controls the anus or rectum (third or fourth degree tear).
  • You may need to have an emergency C-section during labour. This happens in 25% of women. An emergency cesarean carries more risks than a planned C-section. The most common reasons for an emergency caesarean section are if your labour slows or if there is a concern for the wellbeing of your baby.

You should note that while a successful VBAC is less risky than a scheduled repeat C-section, an unsuccessful VBAC requiring a C-section after the onset of labor carries more risk than a scheduled C-section. And the risk of complications is even higher if you end up needing an emergency cesarean.

8) Can I have a VBAC if I have two prior C-sections?

According to the American (ACOG) and British (RCOG) guidelines, women who have had two prior lower segment caesarean deliveries may be offered VBAC after careful counselling. Nonetheless, they should be aware that the risk of uterine rupture is increased up to 5 times (0,9 to 3,7%).

VBAC after 2 previous C-sections is highly controversial, and may not be acceptable for certain physicians or institutions.

9) What to expect during a VBAC 

  • VBAC should take place in a hospital or maternity that can manage situations that threaten the life of the woman or her fetus, and should NOT be attempted at home.
  • You should meet all the criteria, and have none of the contraindications for VBAC above-mentioned.
  • Factors that may reduce or increase the likelihood of success will be thoroughly discussed, and are different for each woman and each pregnancy.
  • Best candidates for VBAC are those women whose labor starts spontaneously, as induced labor (started with drugs or other methods) reduces the chances of a successful vaginal delivery and carries 3 times higher risk of complications.
  • You will be advised to present yourself at the hospital at the earliest sign of labour for careful assessment.
  • Your baby’s heartbeat will be monitored continuously during labour; this is to ensure your baby’s wellbeing, since changes in the heartbeat pattern can be an early sign of problems with your previous caesarean scar.
  • An intravenous (IV) line is indispensable in order to promptly manage any eventual complication.
  • You’ll have to refrain from eating anything during labor in case you require an emergency c-section later.
  • You can choose various options for pain relief, including an epidural.
  • The following signs may be indicators of uterine rupture, and warrant an emergency C-section:
    • Persistent fetal bradycardia (the baby’s heart rate drops; this is the commonest sign of uterine rupture).
    • Vaginal bleeding.
    • Uterine scar tenderness.
    • Pain between contractions.
    • Cessation of contractions.
    • Pain “breaking through” the epidural analgesia, or excessive epidural requirements.
    • Palpation of fetal parts outside the uterus.
    • Haematuria (blood in the urine).

It is important that you understand that uterine scar rupture may be silent, and that even an emergency C-section may not prevent serious complications, both for you and your baby.

In conclusion:

  • Successful VBAC has the fewest complications.
  • The greatest risk of adverse outcomes associated with VBAC occurs when a VBAC results in an emergency caesarean section.
  • It is often impossible to predict who will be able to have a successful VBAC and who require a repeat C-section.
  • Spontaneous (not induced) VBAC has a 1:150 risk of uterine rupture.
  • Uterine rupture is a rare but potentially life-threatening condition, both for the mother and her baby.
  • Even an immediate emergency C-section may not prevent serious complications, both for the mother and her baby.
  • The absolute risk of severe fetal problems and death associated with VBAC are very low, but higher than for planned C-section.
  • Babies born via planned C-section have increased risk of neonatal respiratory problems, which are usually short-lived.
  • Planned C-section is associated with an increased risk of placenta praevia/accreta complicating any future pregnancies; other complications such as pelvic adhesions are higher as the number of C-sections increases.

VBACs are controversial, and it may be challenging to decide whether is the best choice for you. Find a practitioner willing to support VBAC, discuss with him/her your options. Give yourself plenty of time to inform yourself and consider carefully the pros and cons of each option.

References

  1. The American College of Obstetricians and Gynecologists (ACOG) – Vaginal Birth After Cesarean Delivery FAQ 070, December 2017 (For patients)
  2. ACOG Practice Bulletin Number 184 – Vaginal Birth After Cesarean Delivery, November 2017
  3. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth options after previous caesarean section – July 2016 (For patients)
  4. Royal College of Obstetricians & Gynaecologists (RCOG) –  Birth After Previous Caesarean Birth – Green-top Guideline No. 45, October 2015
  5. 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

EGG DONATION IN GREECE: ALL YOU NEED TO KNOW

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Assisted reproduction techniques help thousands of couples with infertility to circumvent their problem and become parents. Nevertheless, when it is not possible for a woman to conceive due to poor egg quality or from having no eggs at all, she may still become pregnant by using eggs from a donor.

The first pregnancy with egg donation was reported in 1983, and ever since, more and more women are choosing this procedure to achieve their dream of having children. The main reason for this trend is that women are increasingly postponing childbearing until later on in life, when their fertility is often reduced; another reason is that over the years, the process has become highly successful due to recent technologies advances and improved freezing techniques.

What is egg donation?

Egg donation is a form of assisted reproduction by which a woman donates her ova to enable another woman to conceive. These oocytes are fertilized by the recipient’s husband sperm, or alternatively by a donor sperm.

The resulting embryos are transferred into the recipient uterus, which has been adequately prepared to receive them. The difference with routine in vitro fertilization (IVF) is that the egg donor is not the recipient; that is, they are two different women.

If pregnancy occurs, the recipient will have a biological but not a genetic relationship to the child, and her partner (if he provided the sperm) will be both biologically and genetically related.

What are the indications for egg donation?

Egg donation may be considered in the following situations:

  • Premature ovarian insufficiency: a condition in which menopause begins earlier than usual, usually before the age of 40 years old. In most cases the cause is unknown, but it may be the result of certain diseases, chemotherapy, radiotherapy or surgical removal of the ovaries. Egg donation is also suitable for women who were born without ovaries.
  • Low ovarian reserve: when there is a decrease in the number of eggs, resulting in reduced chances of pregnancy. Generally, this is due to advanced reproductive age, as the number of oocytes -and therefore fertility- decreases rapidly after the age of 35-40 years old.
  • Genetically transmitted diseases: women affected by, or carriers of a significant genetic disease who would prefer not to pass this disease on to their child.
  • Previous history of failure with IVF: especially when egg quality seems to be the problem.

Who are the egg donors?

1) Anonymous, voluntary donors: According to the Greek law, candidate egg donors are covered by anonymity and are required to sign a specific consent for the donation of their genetic material. In order to accept a woman into an egg donation program she should meet the following requirements:

  • Age between 18 and 35 years old.
  • She should be healthy, non-smoker, with no personal or family history of genetic diseases.

By law, the donor receives financial compensation only for the loss of working days, travel and other expenses incurred during the treatment cycle in which she participates. In any case, egg donation is an altruistic, anonymous and voluntary act.

2) Egg sharing: Women undergoing IVF may agree to donate their surplus oocytes to other women with infertility.

3) Known donor: a person who is known to the recipient, usually a close relative of friend. According to the Greek law, oocyte donation is an anonymous procedure, that is, the donor has no access to the child born, nor the recipient to the donor. Therefore, in Greece the donation of ova to known persons is forbidden by law.

Evaluation of the egg donor


Each candidate donor, after being fully informed about the egg donation program, completes a thorough questionnaire on her family, medical and psychological history. In addition, she is the subject of a series of exams to determine whether her health is in good condition and she can respond properly to the hormonal therapy.

The evaluation involves a comprehensive physical and gynecological examination, as well as the assessment of her psychological and mental status, her genetic material and reproductive system.

In addition, donors undergo the following laboratory testing:

  • Blood type and Rhesus
  • Hepatitis B & C
  • HIV 1 & 2
  • Syphilis
  • Hemoglobin electrophoresis
  • Sickle cell trait testing
  • Cystic fibrosis (CF) mutation
  • Fragile X testing
  • Conventional karyotype. It is also possible to a perform a molecular karyotype, upon request of the recipient couple.

A donor is ineligible if either the questionnaire or the screening tests indicate the presence of risk factors, or clinical evidence of an infectious or genetic disease.

Evaluation of the recipient couple 


Adequate screening and preparation of the recipient couple are essential for the success of an egg donation program.

According to the Greek law, a woman is considered suitable to receive oocytes when her uterus has normal morphology and functionality and has not exceeded the age of 50 years.

The evaluation of the recipient couple is similar to that of couples undergoing routine IVF. First, the physician obtains a thorough medical history from both partners.

The assessment of the woman includes an in-depth physical and gynecological examination, a detailed pelvic ultrasound and laboratory testing. Briefly, the ovarian function, her blood group, and exposure to certain infections are examined. In addition, a Pap smear test and cultures for certain microbes (Neisseria gonorrhoeae, Chlamydia trachomatis, etc) are obtained.

In some cases, the uterine cavity is evaluated with hysterosalpingography (HSG), sonohysterography or hysteroscopy. If the woman is over 45 years old, a more thorough assessment of her cardiac function, pregnancy-induced hypertension and gestational diabetes risk are recommended. The effect of advanced maternal age on pregnancy will be discussed extensively, as well as any medical conditions that may affect pregnancy.

An embryo transfer trial before the actual procedure (“mock” embryo transfer) is strongly recommended. It allows to determine the best way to place the embryos into the uterus, and ensures that there are no unexpected obstacles along the way. Sometimes the cervix is very narrow and hinders the transfer of the embryos into the uterus; this may result in significantly reduced chances of pregnancy. In case of a narrow or distorted cervical canal, a cervical dilation may be recommended.

A treatment trial in a previous cycle with the same medications used for the endometrial preparations is proposed when possible, in order to assess the uterine response to hormone therapy.

The male assessment includes a semen analysis, blood group and genetic testing, among other exams.

According to the Greek law, the recipient couple should be tested for syphilis, hepatitis B and C, HIV-1 and HIV-2 within the six months preceding the treatment cycle.

The procedure

Preparation of the donor for egg retrieval 

The donor follows the procedure of a standard IVF. Initially, she undergoes ovarian stimulation, that is, she receives a combination of hormonal medications in order to achieve the development of a sufficient number of oocytes within the ovaries; egg development is monitored by ultrasound and blood exams at regular intervals. When the oocytes are at the appropriate size, ovulation is triggered by an injection of human chorionic gonadotropin (hCG). Oocyte retrieval, scheduled approximately 34-36 hours after hCG administration, entails the use of a needle which is inserted through the vagina into the ovaries, whereby the eggs are aspirated under ultrasound guidance. The procedure is carried out under a mild sedation.

The ova obtained are evaluated for their maturity and then fertilized with the partner’s sperm, which has been processed in the laboratory. Donor sperm may be also utilized when indicated.

The male partner should provide the semen sample the day of the donor’s egg retrieval. Alternatively, if the presence of the partner is not possible on that day, the semen can be cryopreserved (frozen) at an earlier time.

Preparation of the recipient for embryo transfer

In order for the embryos to implant into the recipient’s uterus, the endometrium (uterine lining) must be prepared and synchronized with the donor cycle.

There are numerous protocols for endometrial preparation. Briefly, women who still have menstrual period may receive an injectable medication for temporary suppression of the ovarian function. When the donor starts ovarian stimulation, the recipient receives a hormone called estradiol to achieve endometrial growth. Estradiol can be administered orally or through a transdermal patch. Ultrasound assessment of endometrial thickness -and occasionally blood tests- are performed during this period. On the day after the donor receives hCG, the recipient begins treatment with progesterone. Progesterone causes endometrial maturational changes that allow the embryo to implant. Progesterone can be administered by intramuscular injection, vaginally or orally. Besides estradiol and progesterone, other medications may be prescribed if required.

The embryos are transferred into the recipient’s uterus, usually within three to five days after fertilization of the eggs in the laboratory. Embryo transfer is done using a thin catheter inserted through the cervix into the uterus. If the recipient couple has extra embryos, they will be cryopreserved (frozen). Thus, it is possible to transfer these embryos at a later time without the need for another egg donation.

Hormonal therapy with estradiol and progesterone continues until the recipient takes a blood pregnancy test (β hCG). If the test is positive, the hormones are continued during the first trimester of pregnancy.

Success rates with egg donation

Since egg donors are young and healthy women, success rates are higher than those obtained with conventional IVF. The age of the recipient does not seem to affect the success of the procedure. According to data from the National Agency of Medically Assisted Reproduction, the pregnancy rate with egg donation in Greece is 54%.

Nevertheless, the greater the number of attempts with donor-egg IVF, the higher the odds of success. Thus, it is estimated that the success rates after the third attempt reach almost 90% in most cases.

Many factors play an important role in the success of the procedure: adequate evaluation and preparation of both donors and recipients, optimal synchronization between them, high laboratory standards and well-trained scientific staff, will all have a positive impact on pregnancy rates in an egg donation program.

Risks of egg donation 

1) For the donor:

Egg donation is a very safe procedure. Nevertheless, it is not entirely risk-free. Medicines taken to stimulate the ovaries, oocyte retrieval and the anesthesia required are all possible sources of complications. Briefly, the side effects of medications are usually mild, as one of the most feared complications in assisted reproduction, ovarian hyperstimulation syndrome is very rare in these cases. The remaining risks are estimated as follows: anesthesia risks: 1 / 10,000; risk of severe bleeding from oocyte retrieval: 1 / 2,500; risk of infection: less than 1/500.

It should be noted that the fertility of women who become egg donors is in no way affected. In fact, the eggs donated would have been otherwise discarded by their bodies.

2) For the recipient:

The possibility a donor transmits an infectious disease to the recipient is virtually non-existent, provided that proper evaluation of the egg donor has been performed, as dictated by the Greek law.

The most common risk for the recipient is the occurrence of a multiple pregnancy (twins) if more than one embryo is transferred. In any case, in egg donation cycles, the transfer of more than two embryos is strictly forbidden by the Greek law. If the couple is opposed to the possibility of a twin pregnancy, then only one embryo may be transferred (single embryo transfer, SET).

Pregnancy complication risk in recipiens with advanced age should be assessed individually for each case.

3) For the child:

To date, thousands of children have been born with this procedure, and the available data is reassuring, and equivalent to that of conventional IVF: the rate of birth defects is the same as the general population.

THE LEGISLATION IN GREECE 

On Egg Donation

  • Egg donation is an altruistic act, voluntary and with no financial benefit. Donors are compensated only for the working days they lose as part of the donation process and their travel expenses.
  • Donation of ova and sperm is allowed in Greece provided donor anonymity is ensured.
  • Egg donation is not allowed to women over 50 years old.
  • Donors must sign an oocyte concession consent.
  • Recipients sign a document stating that they are married and accept to undergo in vitro fertilization with egg donation. If they are not married, they should sign a notary act stating that they wish to undego IVF using the egg donation method.

On Assisted Reproduction

On January 27 2005, the law 3305/2005 on the application of assisted reproduction techniques was reported.

The Greek law on medically assisted reproduction is one of Europe’s most flexible. It safeguards the couple who wants to have a child based on medical, biological and bioethical principles. Its main purpose is, ultimately, the protection of the child to be born.

Basic principles of the current legislation

Some of the key points of the in-force law are the following:

1) Assisted reproduction methods are legal and allowed for women up to the age of 50 years, as this is considered the limit for natural conception.

2) The donation of ova and sperm is permitted, but the consent of the spouse or partner is also required.

3) Pre-implantation genetic diagnosis is allowed with the purpose of diagnosing whether the resulting embryos are carriers of genetic diseases. Consent of the concerned individuals is required.

4) Sex selection is prohibited unless a serious sex-related hereditary disease is avoided.

5) Cloning for reproductive purposes is prohibited.

6) Cryopreservation of genetic material or fertilized eggs is permitted.

7) The use of a gestational carrier (surrogacy) is allowed. A surrogate is a woman who carries a pregnancy for another couple or woman, who wishes to have a child but is unable to get pregnant for medical reasons. The surrogate woman must undergo medical and psychological examination. There should be no financial transaction other than the costs resulting from pregnancy exams, loss of work, etc. The procedure requires a special permit from a judge.

8) Assisted Reproduction Units are established and operate with the permission of the competent Authority, which shall give its agreement and verify that the legal requirements are met. For any violation, it sets administrative and criminal penalties.

9) The law sets age limits for sperm donors (younger than 40 years old) and egg donors (younger than 35 years).

10) Single women are allowed to conceive with assisted reproduction.

11) Donors must undergo clinical and laboratory testing and are not admitted to donation programs if they suffer from hereditary, genetic or infectious diseases. The use of fresh semen from donor is not permitted; only frozen semen may be used.

 

More info at gofertile.eu

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

Posted in Health, Pregnancy by

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”

home-birth-preparing-for-home-birthEven 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”

home-birth-poolThe 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?

home-birth-waterbirth-babyThe 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.

home-birth-water-birth-realThe 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:home-birth-bloody-water-birth

  • 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”

home-birth-netherlands-1948The 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

FASHION VICTIM? 14 FASHION TRENDS THAT CAN BE BAD FOR YOUR HEALTH

Posted in Health by

Models present creationby British fashion designer Alexander McQueen for his Ready to Wear Spring Summer 2010 fashion collection, presented in Paris, Tuesday Oct. 6, 2009. (AP Photo/Michel Euler) France Fashion

As the saying goes, “Beauty is pain”… And that’s so true: those six-inch stilettos may be killing your feet, but your legs look amazing; you can hardly breath when wearing your spanx, but it smoothes beautifully your contour; tattoos and piercing are the ultimate fashion accessory, even if you have to suffer to get them…

But can fashion trends be harmful for our health?

While people are becoming increasingly aware of the devastating effects of extremely low body weight, the health risks of what we wear are less known…

Check out these 14 fashion trends that can represent health hazards, and read what you can do to overcome them…

UNDERWEAR

1) Thongs, strings, synthetic underwear

Fashion thongWhile they may look great under your skinny trousers, thongs and strings have been blamed for causing yeast infections, urinary infections, vulvar irritation and hemorrhoids.

Actually, no scientific evidence supports these claims, but some women do realise that, when wearing thongs, some problems show up. And there are possible explanations for that:

  • Thongs and strings are usually made of synthetic fabrics, which are non-breathable, as opposed to cotton underwear. This means that more moisture remains trapped in the genital area, favouring the development of infections, particularly yeast infections.
  • The thin and close-fitting band of material at the crotch of the thong may transfer bacteria from the anus to the vagina and the urethra, predisposing to bacterial vaginosis and bladder infections (read more here).
  • Thongs can also provoke genital irritation. Either because they are too narrow to provide effective barrier effect against clothes-induced irritation, or due to excessive rubbing, tight underwear may cause micro-abrasions of the genital area, resulting not only in vulvar pain and burning sensation, but also predisposing to vaginal infections and urinary tract infections.
  • Whether thongs cause hemorrhoids is less clear, but women who already have hemorrhoids may eventually get intense irritation due to constant underwear rubbing.

The bottom line: If you are prone to urinary or vaginal infections, or if you find that every time you wear thongs you get an infection, then you should avoid them. For a woman without predisposition to infections, thongs, strings and synthetic underwear do not seem to be dangerous, especially if worn occasionally.

2) Tight bras, wired bras

Fashion braBras are sexy, they provide support and mould breast contour, they can even help “increase” or “reduce” breast size. However, bras have been linked to different health problems.

It has been suggested (mostly by internet rumors and badly-designed studies) that bras, especially those underwired, may cause breast cancer by obstructing breasts’ lymphatic flow, which is in charge of clearing different toxins that may be present in the breasts. Several studies have been conducted to address this issue, none of them confirmed these fears (read more here).

However, too-tight bras do seem to pose other health problems, such as breast pain, back and neck pain, breathing problems, impaired digestion and skin diseases (such as lipomas and fungal infections) due to intense pressure.

The bottom line: A recent French study has challenged the benefits of bra wearing. While most of us won’t dare to go braless, avoid ill-fitting bras, as well as continuous use of wired bras.

3) Shapewear

Fashion spanxThese undergarments, intended to slim our body and smooth its contour, have become an essential piece in most women closets, with many celebrities swearing by them. They do make us look fabulous, but watch out! They can cause serious health problems: heartburn, breathing problems, yeast infections, nerve compression (see skinny jeans), and even potentially lethal blood clots.

The bottom line: Choose the size of shapewear that fits correctly on you; if you don’t feel comfortable, most likely you are not wearing the adequate size or type for you, therefore increasing the risk of health problems. Moreover, do not wear them for long periods of time.

ACCESORIES 

4) Heavy bags

Fashion Chanel-Hula-Hoop-BagLarge bags are trendy, and very practical as we can carry plenty of things inside them: our wallet, make-up, a water bottle, umbrella and sunglasses, even our laptop! But how burdensome are they for our body? Experts agree on that: heavy bags are responsible for neck, back and shoulder pain; and when used repeatedly, they may lead to muscle spasm, arthritis, sciatica, even spinal misalignment. This is also true for heavy backpacks.

The bottom line: Find ways to avoid carrying excessive weight all the time. It may not be easy, but it is certain that you will find inside your bag some items that can stay at home…

5) Jewels

Fashion large earrings resizedYou can find a great deal of beautiful and cheap jewelry around, but be careful! They can pose serious health risks. Costume jewelry can lead to nickel allergy in susceptible women, causing rash, itching, and redness. But more worrisome, dangerous heavy metals have been found in faux-bijoux, such as lead, cadmium, chromium, mercury and even arsenic…

In addition, many cases of ear lobe tears or “split” occur in women wearing heavy, large earrings, which in some cases require surgical repair.

The bottom line: Try to “get real” and choose hypoallergenic jewelry made from stainless steel, titanium, yellow gold (white gold can contain nickel), sterling silver, copper and platinum.

To avoid earring accidents, do not wear them very often or when injuries are possible, i.e., while practising sports.

6) Piercing

Fashion piercingBody piercing has become increasingly trendy; according to a study, people get piercing mainly “to express individuality”. But piercing is not devoid of risks:

The bottom line: Before taking the decision of getting pierced, get informed, know the risks, choose a reputable piercing studio and be very careful while your piercing is healing.

7) Tattoos

Fashion tatto waistTiny or full-body, black or colorful, minimal or true artwork, we can find them in the most unimagined body parts (think the eyeballs!).

They have huge fans and sworn detractors, but there is no doubt that tattoos have become a social phenomenon: according to the Pew Research Center, 38 percent of Americans aged 18 to 29 have at least one tattoo… The reasons why tattoos became so popular have to do with the influence of the television (the reality show Miami Ink), some celebrities getting inked, and of course, social media… Therefore, it is very pertinent what Pew researchers pointed out: tattoos represent something of a trademark for Millennials…

But could this must-have fashion accessory be literally “to dye for”?

There are certainly risks related to tattoos, some of which have been known for a long time now, such as:

  • Infection: most commonly bacterial infections (caused by Staphylococcus), usually at the tattoo site, but more rarely evolving to serious, generalized infections; in addition, hepatitis, HIV, warts and herpes may occur with use of contaminated needles.
  • Allergies: to ink pigments, causing itching, swelling and redness of the tattooed area; red pigments seem to be the most allergenic. These reactions can be very difficult to treat, and rarely, the tattooed area needs to be surgically removed.
  • Scarring: this can happen from getting, but also when removing a tattoo.
  • Granulomas: they are small bumps that may develop as a body reaction to pigments.

As tattoos became increasingly common, more rare side effects have come out:

  • Rare infections: besides the above-mentioned, infections with a bacteria called mycobacteria, which had contaminated ink pigments have been reported.
  • MRI complications: tattoos may get burnt while undergoing MRI, due to the presence of iron in black pigments (red pigments can also have iron).
  • Reactions to sun exposure (photosensitivity): tattoos exposed to the sun may become itchy, red and swollen.
  • Hiding skin cancer: there are case where tattoos covered up skin cancers, preventing them from being found at an earlier stage.
  • Severe allergic reactions: leading to ulcerations, gangrena and even leg amputation.

You may click here to see some serious complications of tattoos  (I warn you though, some pictures can be shocking).

The bottom line: Think before you ink!  Inform yourself, understand the risks… And if you still decide to go ahead, plan carefully:

  • the tattoo’s design: it would be a good idea to start with a small one, to check for possible bad reactions;
  • on which body part: there are places that may be more painful, with more difficult healing, or with higher risk of complications;
  • when: while healing, you should avoid tattoo’s exposure to sun and water bodies;
  • where: it is essential that you choose a reputable tattoo studio with experienced artists, where hygiene standards are respected and good quality inks are used.

Once you got your tattoo, you should be extremely careful until it heals, usually a couple of weeks.

You should consider tattoos a something permanent; tattoos’ removal may be difficult, and have eventually bad aesthetic results.

FOOTWEAR

Stilettos, peep-toes, wedges, flats, sandals, lace-ups: it is not a secret that we LOVE shoes. Manolo Blahnik, Christian Louboutin and Jimmy Choo’s have become our objects of desire… But can we be stylish and have “happy feet” at the same time? Well, you should know that certain shoe styles can hide some dangers:

8) High heels

Fashion high heelsFrequent high-heel use for extended periods can cause many problems, from ankle strains to muscle fatigue, osteoarthritis of the knee, irreversible damage of the Achilles tendon, to headaches and sciatic pain. Stilettos are particularly harmful, as the leg’s weight is concentrated in a tiny area, increasing the risk of ankle sprain.

9) Ill-fitting shoes

Fashion narrow shoesWearing shoes that are too loose or too tight can lead to a series of foot problems, such as corns, calluses, bunions, in-grown toenails, or intense foot pain (metatarsalgia).

10) Flats

Fashion flatsTheir lack of arch support can cause knee, hip and back pain, as wells as a painful foot condition know as plantar fasciitis.

11) Platforms and wedges

Fashion wedgesThe higher the platform, the less foot flexibility, “locking” the foot and leading to ankle sprains or even fractures.

12) Flip-flops

Fashion flip flopsSince feet are so exposed, they predispose us to foot injuries or splinters; this is the reason why diabetic persons should not wear flip-flops. In addition, due to the lack of arch support, they can lead to plantar fasciitis or painful knees, hips, or back when used for long periods of time.

The bottom line: You don’t have to say goodbye to your favourite spike heels, but try not to use them every day, all day long. Prefer well-fitted, anatomic shoes or those with heels that are no more than 2 inches high. Orthotic inserts can provide support and padding to relieve aching feet, especially when wearing flats.

CLOTHING

13) Synthetic fabrics

Fashion spandex outfitPolyester, acrylic, nylon and spandex may cause skin irritation, known as dermatitis, and this can be a greater problem in susceptible, allergic persons. Dyes and other chemicals added to fabrics may also pose health risks.

In addition, since these fabrics do not allow adequate sweat evaporation, they can lead to vaginal yeast infections, skin or foot fungi (the latter known as athlete’s foot).

The bottom line: Go natural by wearing cotton, silk, linen, wool or other natural fabrics; check the clothing tags! If your skin is too sensitive or if you are just conscious about the environment, avoid chemical dry cleaning and wash your clothes in a “green”detergent.

14) Tight pants, skinny jeans

Fashion skinny jeans 2Most of us have been occasionally struggling to get into our favourite skinny jeans. But these garments do not come without risks; what’s more, they have even earned their own syndrome!

  • Tight pants syndrome: abdominal discomfort and distention, palpitations and heartburn, all happening in women -and men- wearing ill-fitting pants with waistbands smaller than their bellies…
  • Skinny pants syndrome: or “ tingly thighs” (the scientific name is meralgia paraesthetica), a tingling or burning sensation on the outer part of the thigh due to the compression of a nerve of the leg.

Other more rare health problems may the consequence of wearing tight trousers:

  • The compartment syndrome may happen in women wearing very tight jeans which provoke intense leg compression, this in turn interrupts the leg’s blood flow, potentially leading to muscle and nerve injury.
  • Persistent pressure exerted by tight trousers may lead to a breakdown of fatty tissue of the thighs, causing a condition called lipoatrophia semicircularis.

The bottom line: Do not wear tight, skinny pants for long periods of time, and be aware of any sign of compression; if so, stick to wider pants for a while… There are plenty of stylish models to choose from!

 

Related reading:

  • Safety of cosmetics: read here
  • Beauty treatments during pregnancy: read here

 

Photo credits:

Model catwalk: 5why.com.au; thong: etsy.com; bras: s8thisnext.com; shapewear: target.com; heavy bags: popsugar.com; jewels: beautytipsntricks.com; piercing: bubblegumink.com; tattoos: pinterest.com; high heels:  pinterest.com; ill-fitting shoes: polyvore.com; flats:pinterest.com; platforms and wedges: pinterest.com; flip-flops: etsy.com; synthetic fabrics: pinterest.com; tight pants, skinny jeans: wheretoget.it