Rhogam Anti-D - A review of the evidence

I find the Rhogam arguments very interesting. I was thinking earlier that I should do a post about what it means to have a negative blood type during pregnancy and what the rhogam shot does.  Rhogam is blood from someone else. They still often make them with mercury. Each Rhogam shot contains the antibodies of several different donors pooled together which increases the liklihood of viruses slipping through undetected to the RhoGam recipient. It is virtually impossible to test and screen out all the various viruses that could be present in the donor blood! I am sure there's people in the medical community who don’t know what it’s all about! If you should questioned the nurse who gave a woman the shot  it would be beyond her scope of understanding. I think everybody should read Anti-D in Midwifery: Panacea or Paradox by Sara Wickham.

In the US in 1960's, Rh disease caused about 10,000 perinatal deaths each year, plus uncounted miscarriages. It's rare now, but only because of the conscientious use of Rhogam to keep women from becoming sensitized, and the aging of the pre-rhogam women out of their fertile years. It is common knowledge that every person has a blood type identified as either “O”, “A”, “B”, or “AB”. In addition to this primary blood type, a person’s blood is either Rh positive or Rh negative. This is known as the Rh factor. The Rh factor refers to a protein that may or may not be found on the surface of an individual’s red blood cells. A person who has this protein present in her blood is Rh positive and a person who does not is Rh negative.

Here is the argument: RH- blood does not like RH+ blood. If RH- blood comes in contact with enough RH+ blood, the RH- blood will begin producing antibodies to fight off the RH+ blood because it sees it as a foreign and dangerous invader. It is a natural response like an immunity response. If an RH- woman is pregnant with an RH- baby, everything is wonderful and honky dory. If both the mother and father are RH-, then the baby will also be RH-, however, physcians may very well treat the pregnancy with the assumption that the baby is RH+ anyway, on the chance that the mother may have been messing around, etc. In some European countries, they do not give the rhogam shot at all during pregnancy unless there is trauma that could increase the risks of blood interaction  eg. such as a car accident. In those countries, they give the rhogam shot after delivery

The rhogam shot puts antibodies into your blood stream letting the RH- blood know there is no need to produce antibodies, because they are already there (from the shot).  Sara Wickham's book on the topic is a great start. Here is her article that I like to share with you.  While the postnatal administration of anti-D immunoglobulin to rhesus negative woman who have given birth to a rhesus positive baby has been considered by many as an acceptable and beneficial routine intervention for the last thirty years, the question of whether it is appropriate to offer routine antenatal administration of this product has been hotly debated for almost as long. There is little question that women who experience potentially sensitising events in pregnancy should be given appropriate information and offered this as an option. Rather, the debate concerns the issue of so-called 'silent' feto-maternal transfusion - the existence (or otherwise) of which phenomena forms part of the basis for arguments in favour of routine antenatal prophylaxis.

The debate surrounding the routine administration of anti-D during pregnancy began in 1969, when Zipursky and Israels suggested that antenatal anti-D administration may prove to reduce the rate of sensitisation. Bowman and Pollock (1978) followed this up with the specific recommendation that anti-D should be administered to all rhesus negative women at 28 weeks to prevent sensitisation in pregnancy. The debate continued throughout the 1980s and 1990's, with opinions divided between those who saw antenatal anti-D as a wholly beneficial intervention, which would save babies, and those who urged caution for a variety of reasons. Antenatal anti-D has been offered routinely in some countries, including the USA and Germany, for a number of years. Yet Britain's first active discussion of the debate occurred in 1997, when a consensus conference decided to recommend routine antenatal administration in the UK; an issue which is currently being debated on practical, professional and political levels.

Why Offer Antenatal Anti-D?
Proponents of routine antenatal administration base their arguments around evidence that suggests that current protocols for the administration of anti-D do not prevent all cases of isoimmunization. They feel that routine antenatal administration is the best way forward in moving closer to one hundred per cent protection from isoimmunization. For example, Hughes et al (1994) carried out research in Scotland, and concluded that, in 53 of the 80 babies with rhesus disease, this had been caused by the failure of the current guidelines to protect against maternal isoimmunization.

The effectiveness of the antenatal anti-D programme in Derbyshire - where women having their first baby are already offered antenatal anti-D at 28 and 34 weeks of pregnancy - was evaluated by Mayne et al (1997), who showed a fall in the mean overall sensitisation rate from 1.12 per cent in 1988-91 (before the onset of the antenatal programme) to 0.28 per cent in 1993-95. Another research study by McSweeney et al (1998) not only provides evidence in support of antenatal administration, but also highlights part of the argument against this. While these researchers estimate that over 80 per cent of women who became isoimmunized might not have experienced this had they been offered antenatal anti-D, they also found that professionals failed to offer anti-D in 48 per cent of cases where women experienced potential sensitising events in the antenatal period. This is one of the strongest arguments against the administration of routine antenatal anti-D.

The fact that most of the studies of this nature that are cited in support of routine antenatal anti-D are retrospective proves problematic. The use of women's case notes in such research is known to cause difficulties; many aspects of care are not always well documented by professionals and this can lead to bias in the results of the study. For instance, if a clinician had not documented the occurrence of a potentially sensitising event, or perhaps not even asked the woman about these, then it would look as if the woman had experienced silent fetomaternal haemorrhage if she then became isoimmunized.
Much of the evidence cited in this area, although interesting and useful in other ways, does not look at the effectiveness of antenatal anti-D in the light of prospective, randomised controlled trials. Only two antenatal anti-D trials of any real size and quality have been conducted - although it should be noted that neither of these was single or double blinded.

 Lee and Rawlinson (1995) gave women in the treatment group two doses of 50 micrograms (250 international units) of anti-D at 28 and 34 weeks, and showed no statistically significant difference between their outcomes and women in the group who had not received antenatal anti-D. However, researchers in Huchet et al's (1987) study gave a larger dose of anti-D (500 international units) at 28 and 34 weeks and showed a clear reduction in the incidence of isoimmunization at between two and twelve months, although no data which considered subsequent pregnancy in those women were available. In response to this data, Cochrane reviewers concluded that there was still a need for consideration of other issues, such as cost and supply of anti-D (Crowther and Kierse 1999). Of course, we should bear in mind that, even if we feel that the evidence shows antenatal anti-D administration to be effective, this does not necessarily mean it is necessary or beneficial for all women; this is another issue entirely.

Is there Evidence for Caution?
There are two main arguments against the routine administration of antenatal anti-D; although cost is a major issue, this will not be considered here - discussion of this can be found in Wickham (2001). The first of these arguments concerns the difficulty there exists with trying to establish how effective antenatal anti-D would be when there are still questions and problems regarding the current program of routine postnatal administration and antenatal administration in response to a potentially sensitising event. Ghosh and Murphy's (1994) Scottish study showed that just over 30 per cent of women who had experienced an antenatal sensitising event had not been offered anti-D. Tovey (1983) showed that 22 per cent of the women in his study became sensitised as a result of 'failure of administration' and Howard et al (1997) also propose that closer adherence to the 1991 recommendations might further reduce the incidence of isoimmunization. Their study found that only 20 per cent of women who had experienced abdominal trauma had been offered anti-D and only 95 per cent adherence to the recommendations in the area of postnatal administration.

Clearly, it is not helpful to begin an antenatal programme if a proportion of the women who are becoming sensitised during pregnancy are facing this as a result of professional failure to offer anti-D after a potentially sensitising event. Rather than subjecting all women to antenatal anti-D because some clinicians fail to offer this to the women that really need it, we need to consider how this trend can be reversed. We also need to establish how may women are becoming sensitised as a result of failure to implement the current guidelines, and not include these woman in figures which are being used to promote the uptake of routine antenatal prophylaxis.

It is not just midwifery and obstetric departments which are failing to offer anti-D. Huggon and Watson (1993) sampled 29 women who arrived in accident and emergency departments following a threatened miscarriage. Only eight women were tested to establish their blood group on admission and none of those women who were rhesus negative were offered anti-D. Gilling-Smith et al (1997) built on this small-scale study and researched 88 accident and emergency units, which treated women who experienced bleeding in early pregnancy. Seventy seven of these failed to administer anti-D when this was appropriate, and 37 per cent reported not even having access to Kleihauer testing to determine whether a woman had experienced a larger bleed than would be covered by the standard dose.

What are the Risks?
The second argument against routine antenatal anti-D concerns the potential risks of this, both to the woman and to her unborn baby (who will not herself benefit from this - anti-D effectively being a protective measure for her siblings). The fact that there has been no research investigating the effects of anti-D on the unborn child is one of the factors of concern to those currently calling for caution (Gaskin 1989, Coombes 1999). Gaskin (1989) cites several potential risk factors where babies are exposed to anti-D, including immune system compromise and potential problems during later reproduction for rhesus negative baby girls exposed to anti-D in utero.

Two further potential risks of antenatal anti-D are discussed in the medical literature; this does not, however, mean that these are the only possible risks; there may be others not yet predicted. The first risk is that of augmentation; or enhanced anti-D immunisation (Urbaniak 1998), where a woman who is given passive anti-D during the antenatal period could, upon exposure to rhesus positive cells (via transplacental haemorrhage) mount a primary immune response to these.

The second concern is the effect of passive anti-D on the unborn baby. There has been no systematic study, which looks at the short and long-term side effects of anti-D in babies (Urbaniak 1998). Although Gaskin's (1989) evidence concerning immune system compromise seems to have been ignored, other risks to the baby have been discussed in the literature. Some of these concern the fact that about ten per cent of the anti-D given to the mother will cross the placenta to the baby (Hughes-Jones et al 1971, Urbaniak 1998). Studies have shown that this causes a proportion of babies to test positive for antiglobulins (via a direct Coombs test) after they are born (Tovey et al 1983, Bowman and Pollock 1978, Herman et al 1984). The few studies which have looked at this have suggested that, while babies may suffer some anaemia, this does not require treatment in the immediate postnatal period.

Although Romm (1999) points out that the manufacturers of anti-D clearly state that this should not be given to babies, no-one has considered the question of whether there are long term consequences of this. It should be remembered that unborn babies will also be exposed to the risks which women face, such as that of virus transmission (Wickham 2000). This can only be exacerbated by the fact that the optimal dose of antenatal anti-D is not known; women and babies may be exposed to more of this product than they need.

Debating the Issues
In 1997, a Consensus Conference was held so that a group of experts could determine national recommendations for antenatal anti-D administration. These experts gathered to assess the evidence, including many of the studies here and make recommendations to the Royal College of Obstetricians and Gynaecologists and the Royal College of Physicians of Edinburgh. This group included haematologists, obstetricians, general practitioners and even a medical journalist. Significantly, a number of groups were not represented; no consumer-focused childbirth organisations or childbearing women were invited for their opinions, and there was no clinical midwifery representation on the group. This may seem undemocratic to some, as it is women who receive the product and usually midwives who inform them of the issues and administer it.

In relation to current failures of implementation, the conference noted their concern that; 'there is abundant evidence that the recommendations are not being fully applied.' (Urbaniak 1998: 1). They did not, however, feel that this issue warranted further investigation before making the decision to recommend routine antenatal anti-D. Another recommendation concerned the suggestion that, 'information leaflets concerning the recommendations should be given to RhD negative women and their partners'. This may be an issue which the midwifery profession needs to debate in relation to informed choice and the need for balanced information; the vast majority of the information leaflets currently available - mostly donated by the pharmaceutical companies producing anti-D - are biased towards women's acceptance of anti-D rather than the facilitation of informed choice. If more midwives became involved in the process of writing and evaluating this kind of information, women may have more of a foundation upon which to make their choices.

Where do we go from here?
The Royal College of Midwives (RCM 1999) and the UKCC (Coombes 1999) have raised concerns about the guidelines advocating the use of anti-D in the antenatal period; specifically the lack of testing of the product for routine use and the lack of sound evidence which suggests that antenatal administration is beneficial. Coombes (1999) is also among those who have highlighted the fact that around 40 per cent of the 100,000 or so women who would receive antenatal anti-D each year in the UK would be carrying rhesus negative babies, and therefore would have received this unnecessarily. Should paternal blood testing be one of the options which women should be offered at this time? Women who are pregnant with their last child are also among those who would not benefit from antenatal anti-D. Should it become routine practice for midwives to discuss these issues with women in relation to their personal need for anti-D?

Many questions remain in this area, which suggest the need for midwives to become more involved in this debate. Is there enough sound evidence to support the routine antenatal administration of anti-D, or should midwives - as women's advocates - be concerned about this prospect? How can the issues be addressed and the remaining questions answered in such a way that we know that the options we are offering women are beneficial rather than harmful and based on what is truly optimal for those women rather than being deemed necessary as a result of our own failures in other areas? More than ever, midwives need to be able to explain and discuss the evidence with the women who face this decision. Whatever recommendations are put in place, either locally or nationally, women have a right to make their own informed choices and midwives have a duty to enable these choices to be freely made.


Source: Sara Wickham

by

Bachelor of Midwifery

A one and only three year Bachelor of Midwifery program should be offered in South Africa and the rest of the world  which should prepares any midwife to offer primary health care to women during pregnancy, through childbirth and in the first six weeks of their babies’ lives. Such a curriculum should emphasize normal birth options at home, a birth centre, clinic or hospital and the alternative therapies open to women.

Basic Anatomy and Body Systems

The midwife needs to have in-depth knowledge of basic anatomy, specifically, relating to women and infants, as well as an understanding of the female reproductive system and fetal growth and development. Midwives must monitor the health of the mother, fetus and infant; therefore, they need to know the specifics of how each of the body systems work and how to determine potential problems. They need to be able to regulate and monitor the body systems of the mother, fetus and infant.

Procedures during Pregnancy and Childbirth

Before becoming a midwife, it is essential to have proven knowledge and skills dealing with every aspect of pregnancy, labor and delivery. Midwives must know how to tell a normal pregnancy from one with the potential for complications. They need to know how to recognize complications, how to handle complications and when to refer the mother for medical intervention. Midwives need to be trained in proper sterilization procedures, umbilical cord care, premature or past-due labour and newborn infant care. In addition to being trained for a normal birth, the midwife must be properly trained and prepared to deal with any complication that could arise with the mother or the infant during pregnancy, through labor and delivery or within the first six months to a year after birth.

Nutrition during Childbirth and Pregnancy

The approach to healthy nutrition during pregnancy we advocate is simple.  Understanding the physiologic changes that underlie the nutritional demands of pregnancy can help present basic guidelines for eating, without suggesting that we become rigid and bogged down by rules. Guidelines are based on the changes your body goes through while pregnant and the needs these changes pressent. The midwife also needs to have training in proper antenatal, postnatal, foetal and infant nutrition.

Breastfeeding

Midwives need to know the basics of lactation including normal lactation, nutrition for lactation, problems with lactation and how to increase or decrease lactation. They need to understand infant behavior with regards to lactation and suckling, as well as be able to identify and correct problems with latching on or suckling. Midwives must be able to help the mother and infant with lactation, suckling and nutrition issues.

Counseling and Support Services

The midwife provides basic counseling and support services in order to ensure the overall well-being of the mother and her family. Basic training in counseling and mental health is necessary for the midwife to identify mental, emotional or psychological stress and to effectively help and support the mother and family throughout the childbearing year. Midwives also need to have knowledge in family system and cultural differences in order to meet the needs of the family.

Adult Education and Communication

Midwives need a minimal amount of training and skills in teaching and educating adults. The midwife provides education on pregnancy, birth, infant care and postpartum care to the mother and her family. The midwife must be able to effectively communicate and educate the family members based on their individual needs and educational level

 

Michel Odent Interview

Can someone with HPV, but no warts, have a homebirth?
Human papillomavirus (HPV) infection is extremely common. It does not influence the way women give birth.

What are the risks associated with a vaginal birth after an abdominal myomectomy? I am in my first pregnancy and my doctor is suggesting a c-section as the safest method. Is it possible to attempt a vaginal birth and how significant are the risks?
It is difficult to answer your questions because there are many types of myomectomies (surgical removal of fibroids) according to the location of the fibroid(s). If the docotr is suggesting a c-section to prevent a possible uterine rupture, it is probably because the fibroid was 'intramural' (inside the wall of the utereus). If the fibroid was 'subserous' (outside the wall of the utereus) or 'pedunculated' (connected to the utereus by a stalk), you should not hesitate to try to give birth vaginally. You need a detailed report of the operation.

I would love to have a waterbirth, but there are not many people in our area who do them. Do you have any advice on how to pick a good midwife for a waterbirth? I am 28, healthy, and in great shape. Is there anything I need to do to prepare for our little arrival's waterbirth?
Your midwife does not need any special training. She does not need any previous experience of the use of birthing pools. She just needs to be aware of a small number of recommendations. All these recommendations are based on the fact that immersion in water at the temperature of the body tends to make the contractions more effective during a limited length of time, which is in the region of an hour or two. The first practical recommendation is to give a great importance to the time when the laboring woman enters the pool. If she is patient enough to wait until the middle of the dilation, if she does not feel observed or guided, and if the room is dark enough, there is a high probability that she will reach complete dilation in an hour or two, even for a first baby.

The second recommendation is to avoid planning a birth under water. In general it is better when a pregnant woman has no precise pre-conceived script of what the birth of her baby will be. When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of a long second stage followed by difficulties for the delivery of the placenta. There are no such risks when a birth under water follows a short series of irresistible contractions before the mother feels the need to get out of the bath. A birth under water can happen. It should not be the primary objective. The primary objective is to reduce the need for drugs.

Of course you need a deep enough birthing pool, so that your body can be completely immersed. Today it is easy to rent such birthing pools. You also need a way to check that the temperature of the water is never above the temperature of the body (37 degrees Celsius). A too hot bath is dangerous for the baby. It is better if your husband, or partner, has to prepare the bath while you are already in hard labor. Remember that a century ago the secret for an easy home birth was to make the husband busy: he was spending hours and hours boiling water. Are we rediscovering the value of old rituals?

Dr. Odent, it is an honor. I am in the USA, studying to become a midwife and noticed a peculiar quote in my Anatomy & Physiology textbook. It states that "The pain of human childbirth, compared to the relative ease with which other mammals give birth, is an evolutionary product of two factors: the unusually large brain and head of the human infant, and the narrowing of the pelvic outlet, which adapted hominids to bipedal locomotion." (Kenneth S. Saladin, Third Edition). Do you agree with this statement, or is this merely an assumption made due to the high levels of intervention and passivity of the woman during childbirth? Thank you for your time; I truly respect all that you havedone.
We cannot deny that human beings must overcome several handicaps in the period surrounding birth. The main handicap is not mentioned in your textbooks. It is the huge development in our species of that part of the brain called the neocortex. The neocortex is not basically different from what we might call the brain of the intellect. The point is that during the birth process (and during any sort of sexual experience), if there are inhibitions, they come from the powerful neocortex.

Nature found a solution to overcome this human handicap. The maternal neocortex is supposed to be at rest, so that primitive brain structures supporting our survival instincts can more easily release the necessary hormones. That is why women who give birth by themselves, with their own hormones, tend to cut themselves off from our world, to forget what they read or what they have been taught; they dare to do what a civilized woman would never dare to do in her daily social life (daring to scream, to swear, to be impolite, etc.); they can find themselves in the most unexpected, bizarre, primitive, often quadrupedal postures; I heard women saying afterwards: 'I was on another planet'. When a labouring woman is 'on another planet', this means that the activity of her neocortex is reduced. This reduction of the activity of the neocortex is an essential aspect of birth physiology among humans.

This aspect of human birth physiology implies that laboring women need to be protected against any sort of neocortical stimulation. This helps us to understand the importance of quiet (since language is a powerful stimulant of the neocortex) and of a dim light. It explains also the importance of privacy (when we feel observed our neocortex is stimulated) and the need to feel secure (when we perceive a possible danger we must be attentive and alert). Because the most important aspect of birth physiology is not understood in our cultures, there is no reference in your textbooks to the handicap related to a highly developed neocortex.

It is commonplace, on the other hand, to focus on the mechanical difficulties of the birth of Homo Sapiens. In fact, these difficulties are also related to brain development. Today Homo Sapiens is classified as a chimpanzee with an enormous brain. At term, the smaller diameter of the baby's head (which is not exactly a sphere) is roughly the same as the larger diameter of the mother's pelvis (which is not exactly a cone). The evolutionary process adopted a combination of solutions in order to reach the limits of what is possible.

The first solution was to make pregnancy as short as possible, so that, in a sense, the human baby is born prematurely. Furthermore we have realized recently that the pregnant mother can, to a certain extent, adapt the size of the fetus to her own size by modulating the blood flow and the availability of nutrients to the fetus. That is why small surrogate mothers carrying donor embryos from much larger genetic parents give birth to smaller babies than might have been anticipated. From a mechanical point of view, the baby's head must be as flexed as possible, so that the smaller diameter is presenting itself before spiralling down to get out of the maternal pelvis.

The birth of humans is a complex asymmetrical phenomenon, the maternal pelvis being widest transversally at the entrance and widest longitudinally at the exit. A process of 'moulding' can slightly reshape the baby's skull if necessary. When mentioning the mechanical particularities of human birth, one cannot help referring to and comparing ourselves with our close relatives the chimpanzees. The head of a baby chimpanzee at term occupies a significantly smaller space in the maternal pelvis, and the vulva of the mother is perfectly centered, so that the descent of the baby's head is as symmetrical and as direct as possible. It seems that since we separated from the other chimpanzees, and all along the evolution of the hominid species, there has been a conflict between moving upright on two feet and, at the same time, a tendency towards a larger and larger brain.

The brain of the modern Homo is four times bigger than the brain of our famous ancestor Lucy. There is a conflict in our species because the pelvis adapted to the upright posture must be narrow to allow the legs to be close together under the spine, which facilitates transfer of forces from legs to spine when running. An upright posture is the prerequisite for brain development. We can carry heavy weights on our head when we are upright. Mammals walking on all fours cannot do the same. That is apparently why the process of evolution found other solutions than an enlarged female pelvis in order to make the birth of the 'big-brained ape' possible: the faster our ancestors could run, the more likely they were to survive.

Nature found several other solutions to overcome the mechanical difficulties. One of them is that when the neocortical control is reduced, the laboring woman can spontaneously—instinctively—find postures that are usually complex, asymmetrical, and adapted to the different phases of the process of rotation. Another solution is the capacity human mothers have to give birth thanks to a powerful 'fetus ejection reflex', that is to say a series of irresistible contractions without any room for voluntary movements... on the condition that the neocortex is at rest.

We must add that Nature found solutions to compensate the physiological pain of labour. One of them is an appropriate release of natural morphines. Another one is the reduced activity of the new brain, so that the painful stimuli are not processed and imprinted in the upper parts of the nervous system, and so that the memory is depressed. We cannot deny the human handicaps in the period surrounding birth. The point is to understand the many solutions the evolutionary process found to overcome a great diversity of difficulties. Understanding these solutions is the prerequisite to rediscover the basic needs of laboring women. It is a difficult task after thousands of years of culturally controlled childbirth and a recent proliferation of theories that have mislead most schools of "natural childbirth." What a responsibility for the generation of midwives you belong to!

Conventional pregnancy magazines are full of ads and articles on banking cord blood. Is this just a profit-driven trend or is there value to it?
Women who are supposed to give birth to the baby and to deliver the placenta without any drug should be reluctant to bank cord blood. When the physiological processes are not disturbed, human mothers have the capacity to reach a very high peak of the hormone oxytocin soon after the birth. This peak of oxytocin is vital, first because it is necessary for a safe delivery of the placenta without any blood loss, and also because oxytocin is undoubtedly the main hormone of love. This release of oxytocin is possible (in a warm place) if the mother, who is still 'on another planet', is not distracted at all and has nothing else to do than to feel the contact with the baby's skin, to look at the baby's eyes, and to smell the baby. Imagine a mother who has just given birth and who has forgotten the rest of the world while discovering her newborn baby. Then a practitioner arrives with clamps and scissors to collect a sufficient amount of blood from the cord. What a dangerous distraction! The risk is a difficult and bloody delivery of the placenta. Furthermore the baby will be deprived of a certain amount of precious blood.

Well-informed women would not take such risks, while the odds that the average baby without risk factors will ever use his banked cord blood are negligible. It is another matter in the case of medicalized births (cesarean-section, drip of pitocin, or drugs injected routinely to deliver the placenta). In such cases, the cord is clamped anyway soon after the birth of the baby. Then the risks are mostly financial. The point is that until now there has been little experience with transplanting self-donated cells (stem cells from bone marrow are currently given by relatives or strangers). Some experts have hypothesized that an ill baby who receives his or her own stem cells during a transplant would be at risk of repeating the same disease. Long-term studies are needed. Meanwhile we must be cautious.

My planned natural birth turned out to be very traumatic. I had severe abruptio placente. I was 24, I don't smoke or have any of the risk factors for it, I was very healthy, I ate right and was not overweight. It happened while in the early stages of labor at home and things didn't seem right to me. My husband rushed me to the hospital. I was in severe pain and only 4 cm dilated, my baby's heart rate was at 70, I was hemorrhaging. They rushed me to perform an emergency c-section. My daughters had to be intubated for a short time and spent a few days in the NICU. I thought I could never be thankful for such medical intervention, but I am for it saved our lives. My daughter is two now and we are thinking about having another child. I have not found much information on what happened to me. Is it because they aren't sure why it happens? Is it likely to happen again? Should I still try for a natural birth? How can I find out more information on it?
Abruptio placentae means that the placenta separated from the uterus before the birth of the baby. It can happen before the labor starts or during labor. The separation may be complete or partial. In your case it was probably a quasi-complete separation. Your daughter was rescued thanks to an emergency c-section. Abruptio placentae is an important chapter of the program of 'first aid in obstetrics' we include in our information sessions for doulas. We understand why your doctors could not give you much information on what happened to you. More often than not it is impossible to find a cause for such an accident. It is noticeable that a previous abruption placentae is not usually mentioned as a significant risk factor for the advent of a similar accident at the end of the following pregnancies.

The conclusion is that when you give birth to your second baby, you'll be in the usual situation of a mother trying to give birth vaginally after a previous c-section. This means first that labor induction will be an absolute contraindication. Because you cannot extinguish in your memory the dramatic complication you previously had, you'll probably prefer to labor in a hospital. The point is to find a hospital where they accept your project of a trial of labor and at the same time where they understand the meaning of the word privacy.

Can artificially rupturing the membranes contribute to fetal distress? I know that it can speed up labour, and that shorter labors can be less distressing, but my daughter's heartbeat dropped considerably not long after my doctor broke my water.
We cannot be sure that, in your particular case, there was a cause and effect relationship between the artificial rupture of the membranes during labor and the changes in your daughter's heartbeat. However it is well understood that, after a rupture of the membranes and therefore after an acceleration of labor at a time chosen by the doctor (or the midwife!), the baby's head is suddenly subject to greater pressure during contractions and the cord is more likely to become compressed. The baby must protect herself by releasing in particular the hormone ?noradrenaline?, which tends to slow down the heartbeat. The best way to prevent the common temptation of breaking the bag of water is to avoid assessing the progress of labor with vaginal exams. This is easier when the laboring woman has complete privacy and does not feel guided. In this case an experienced birth attendant can more often than not follow the progress of labor thanks to the noise the mother-to-be is doing, the way she is breathing, and the complex postures her body can find spontaneously.

Regarding waterbirth, I have two questions: 1. Is there a point at which it is too early to get in the pool? 2. Is it really possible to get so relaxed that labour can stop? I wouldn't say I was relaxed - just removed from the present and in a deep state of concentration.
1. Entering the bath too early is the most common misuse of the birthing pool. Originally we introduced the concept of birthing pool in a French hospital in order to replace drugs when the first stage is long, difficult, very painful, and when the dilation of the cervix is already well advanced. It is essential to understand that immersion in water at body temperature makes the contractions more effective during a limited period of time, which is in the region of an hour and a half. Helping the laboring women to be patient and to avoid entering the bath too early is a new aspect of the art of midwifery. However, in some cases, a bath can be useful to stop the contractions of a painful pre-labor, and therefore to make the difference between labor and pre-labor.

2. When a woman is so relaxed that apparently labor stops, it means that it was not labor, but pre-labor. In general the release of adrenaline (which induces the opposite of a state of relaxation) inhibits the release of oxytocin (the hormone necessary for effective uterine contractions).

How would you define "normal" birth?
The term 'normal' is useless when applied to birth. In 'normal' there is a cultural connotation. A birth can be considered normal in Rome, but not in Santa Fe. It is only in retrospect that a birth can be qualified 'normal' (the same about 'natural'). What we need today is to qualify an attitude. That is why I suggested the concept of 'biodynamic attitude in childbirth'. A biodynamic attitude (in farming, in childbirth, etc.) is based on a good understanding of the physiological processes. In other words it means: working with the laws of Nature.

What are the risks associated with routine ultrasound for low-risk pregnancies?
In general the most authoritative studies of the long term effects of being exposed to ultrasound during fetal life are reassuring. A Swedish study, for example, involved 19 prenatal care clinics and more than 4000 children.(1) After randomization (after drawing lots) only the pregnant women belonging to the 'screening group' were offered a scan at 15 weeks. After follow-up of the children, no statistically significant differences in body weight or height at 1, 4, 7 years of age between exposed and unexposed children were found. There were no differences either in terms of impaired vision or hearing during childhood.

However there are studies suggesting that exposure to ultrasound during fetal life is not completely neutral. This is the case of a large Australian study. It appeared, after analyzing thousands of cases, that frequent exposure to ultrasound tends to restrict fetal growth.(2) Such results confirmed the results of studies with pregnant monkeys scanned with doses used in human medicine.(3) This is also the case of several Scandinavian studies showing that exposure to ultrasound tends to slightly modify the proportion of right-handed and 'non right-handed' children.(4,5)  Since exposure to ultrasound during fetal life is not completely neutral, the selective use of scans should be preferred to routine scans. There are reasons to be cautious but, in the scientific context of 2003, one cannot refer to documented real complications.

-1- Kieler H, et al. Routine ultrasound screening in pregnancy and the children's subsequent growth, vision and hearing. British Journal of obstetrics and gynaecology. 1997; 104: 1267-72.
-2- Newnham JP, et al. Effects of frequent ultrasound during pregnancy: a randomised controlled trial. Lancet 1993; 342: 887-91.
-3- Tarantal AF, Hendrickx AG. Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque. Teratology 1989; 39 (2): 137-47.
-4- Savelsen KA, et al. Routine ultrasound in utero and subsequent handedness and neurological development. BMJ 1993; 307: 159-64.
-5- Kieler H. Routine ultrasound screening in pregnancy and the children's subsequent handedness. Early Human Development 1998; 50: 233-45.
Source: http://www.waysofthewisewoman.com/dr-michel-odent-notes-obgyn-studies.html

The World's Most Famous Obstetrician

Michel is a French obstetrician who developed the maternity unit at Pithiviers Hospital in France in the 1960s and '70s. He is the world's famous obstetrician who introduced the concept of birthing pools and home-like birthing rooms in the 1960s and 1970s. Michel also founded the Primal Health Research Center in London which focuses on the long-term consequences of early experiences. I met him at the MidwiferyToday Conference in 2000 in Philadelphia, PA where he spoke about the importance of oxytocin and early bonding between mother and baby. Michel talks about the importance  of early bonding because early experience, literally those first hours, can have a great impact on the person a baby becomes.

 

His approach has been featured in eminent medical journals, and in TV documentaries such as the BBC film Birth Reborn. After his hospital career he practiced homebirth. As a researcher, he founded the Primal Health Research Center in London (UK), which focuses upon the long-term consequences of early experiences. An overview of the Primal Health Research data bank ( www.birthworks.org/primalhealth) clearly indicates that health is shaped during the primal period (from conception until the first birthday). It also suggests that the way we are born has long-term consequences in terms of sociability, aggressiveness or, otherwise speaking, capacity to love.

His other research interests are non-specific, long-term effects on health of early multiple vaccinations. Author of 55 articles indexed in PubMed, Odent has published 11 books in 21 languages. In his books he developed the art of turning traditional questions around: "how to develop good health", instead of "how to prevent disease", or "how the capacity to love develops", instead of "how to prevent violence". "The Scientification of Love" and "The Farmer and the Obstetrician" raise urgent questions about the future of our civilizations. Dr. Odent's essays on the primal orgins of health and disease are of unique importance in the field of prenatal and perinatal psychology and health, and give substance to an urgent new branch of studies affecting all future families.

For as long as we can remember, childbirth was predominately a woman's business. We all  recognize that many women find the presence of a midwife helpful in birth, and I hope that midwives will continue to be available. Odent also claims that “Everywhere in the world there has been a tendency to dramatically alter the original role of the birth attendant, to deny the birthing woman’s need for privacy and to socialize childbirth. More often than not, the midwife has become an agent of the cultural milieu, transmitting its specific beliefs and rituals.

Michel Odent suggests a labouring woman not enter a warm bath until the onset of hard labour.  Then one can expect she will dilate quickly, say 1-1 ½ hours for a first baby. The contractions are less intense, less painful and more efficient in warm water.  Water is an obvious easy way to dramatically reduce adrenaline and it is a well-established fact that low adrenalin makes the first stage of labour easier and faster.   

He goes on to say that there comes a time when mothers in water feel the contractions are not working efficiently any longer; then when she gets out of the pool and experiences the cooler atmosphere the baby is born after a few huge contractions.  Odent tells us that the adrenalin rush caused by the change of temperature creates a fetus ejection reflex.  To know more about this man visit www.wombecology.com.