Tienchin Ho

Elective Repeat Cesarean Sections

A New England Journal of Medicine article this month discusses outcomes for babies born by elective repeat cesarean section. Here is a link to a New York Times article about the study.

In this study, data on 19 university hospitals was taken from the Eunice Kennedy Shriver National Institute of Child Health and Human Development cesarean registry. The investigators looked at 28,867 patients with prior cesarean sections who had repeat cesarean sections. Patients who had cesareans before 37 weeks were excluded from the study. Those who were in labor or already had spontaneous rupture of membranes were also excluded.

Then, for each case, the investigators determined the reasons for the cesarean section. Only cesareans without a medical reason were considered elective.

Some of the reasons they found were:
multiple gestations
non vertex presentation
major malformations
maternal medical problems such as heart disease or HIV
prior uternie incision that was not low transverse
non-reassuring fetal heart tracing or fetal testing
suspected macrosomia (abnormally large baby)
placenta previa or abruption

There were 13,258 elective repeat cesarean sections done after 36 weeks (46% of all repeat cesarean sections).

Distribution of elective repeat cesarean sections by gestational age:
37 weeks          834 pts     6.3% of all elective cesareans
38 weeks        3909         29.5%
39 weeks        6512         49.1%
40 weeks        1385         10.4%
41 weeks          505           3.8%
>= 42 weeks     113           0.9%

Then the investigators tracked the babies' outcomes.

They looked for:
death
breathing problems
hypoglycemia
severe newborn infection
seizures
hypoxis ischemic encephalopathy
CPR
signs of severe stress
admission to the neonatal ICU
hospitalization for 5 days or more

They found that babies born by elective repeat cesarean section before 39 weeks were at higher risk for having these problems.

babies born at:
37 weeks    15.3% had problems       had 2.1 times the risk of problems compared to 39 weeks
38                11.0%                                1.5
39                 8.0%                                 ----     
40                 7.3%                                 0.9
41               11.3%                                 1.4
>=42           19.5%                                 2.5

The researchers concluded from their study two things.

First, that elective repeat cesarean sections before 39 weeks is common (one-third of all repeat elective cesarean sections).

Second, earlier cesareans have an increased risk of neonatal complications.

So, what does all this mean to a pregnant woman trying to make decisions?
If there are no medical problems, this study suggests that she can minimize the risk of problems with baby by scheduling the cesarean section after reaching 39 weeks.

In real life, however, there are two situations I can think of that make it difficult to apply this study. First, if a woman really wants an elective repeat cesarean section, how does she know she isn't going to go into labor before 39 weeks? There would be pressure to have a cesarean section sooner rather than later to make sure she was really going to get an elective repeat cesarean section. This is the sort of decision that may seem easy for those of us who are not pregnant but can be excruciating for women who are.

Second, this study was based on trained reviewers looking at medical records. Unrecorded conversations between providers and patients may include soft indications. For example, if I tell a mother that baby feels big, I haven't officially diagnosed macrosomia on the record, but I implied it to the mother. This may be the final straw for a woman to decide on an early repeat cesarean. In this study, her case would still be considered an elective repeat cesarean section. The woman, however, may feel her cesarean is medically indicated. She may feel it is better to have the cesarean earlier than 39 weeks to avoid having a big baby. This study suggests that by doing this, the baby will be at increased risk for complications. Given the known inaccuracies of predicting birth weight, I think using the possibility of a big baby as a medical indication for cesarean section before 39 weeks is problematic but more common than suggested by this study.

The Newborn Hearing Test

Partial or complete hearing loss delays or prevents language, cognitive, and social-emotional development. Groups such as the National Association of the Deaf advocate testing before three months of age and starting family-centered intervention by six months of age. Without automatic testing, the average child with hearing loss is not discovered until over two years old. Parent and physician observation do not usually detect hearing loss even if profound.

To find infants with hearing loss sooner, California requires hospitals with intermediate or intensive care nurseries to offer testing before a baby goes home. Usually the test is done with the infant asleep in the nursery separate from the parents. Testing can also be done as an outpatient at a hospital or a physician’s office. Testing requires informed consent. Insurance companies may or may not cover newborn hearing tests. There are no good studies that show that testing every infant leads to better long term outcomes.

Two types of testing are available, otoacoustic emissions (OAEs) and auditory brainstem response (ABR). OAEs use the sounds that are reflected back from the ear to check for problems with the structures of the ear such as the eardrum, the ear canal, and the hair cells. A small probe placed in the ear records sounds from the ear over time. OAE testing can be done with the infant in your lap or nursing as long as baby is not vocalizing.  The equipment for OAEs testing is much less expensive than that for ABR testing.

ABR uses electrodes similar to those used for brain EEGs and cardiac EKGs. These stickers send information back to a computer that monitors brain activity in response to sounds. To have a normal ABR result, the outer ear structures, the auditory nerve, and the auditory pathways in the brain must all function. ABR testing requires baby to be very still.

Here is one home birth mother's point of view on newborn hearing tests.

In Fresno you can get outpatient hearing tests at these locations:

Community Regional Medical Center
Newborn Audiology
Tammy Vawter
2823 Fresno St, 3rd Floor
Fresno CA 93721
(559) 459-2807

Children’s Hospital of Central California
Audiology Services
(559) 353-6801

Valley Pediatric Medical Group
7130 N Sharon #101
Fresno CA 93720
(559) 436-8606

Central California Ear, Nose, and Throat Medical Group
1351 E Spruce Ave Suite 100
Fresno CA 93720
(559) 432-3303

Exercise During Pregnancy

Read any information on pregnancy and childbirth and you will find a section on the benefits of exercise. ACOG has a practice guideline for exercising during pregnancy that suggests 30 minutes a day.

Most of the advice is pretty obvious.

• Avoid activities where you might fall or get injured, such as contact sports or ski jumping.
• Choose familiar activities.
• Don't involve movements that are jarring or sudden.
• Use common sense.

Low impact activities like swimming or walking are obvious choices. There are also certain conditions which are contraindications to exercise, such as an incompetent cervix or placenta previa (covering the cervical opening).

Some things researchers worry about exercising during pregnancy:

Overheating
Any cause of higher temperatures such as a fever or sauna use is associated with increased risk for having fetal central nervous system problems. So, it is a good idea to keep cool and hydrated during exercise.

Decreased oxygen flow to baby
During exercise, working muscles are using more oxygen than at rest. Faster breathing and heart rate work to meet this increased demand. At the same time, blood flow may be shunted away from the uterus and placenta to the working muscles. Heavy exercise, resulting in heart rate over 80% of maximal heart rate, may be associated with decreased fetal movement.

Women who are later found to have intrauterine growth restriction (IUGR, abnormally small baby) due to placental problems have decreased blood flow during heavy exercise. It is unknown whether these changes in uterine blood flow make any difference to the fetus in the long run.

Fortunately, most women are able to judge whether they are exercising lightly or heavily. So, paying attention to how you feel during exercise is important. Don't overdo it.

Some potentially beneficial things about exercising during pregnancy:

Improved muscle tone, flexibility, posture, and mood
Exercise during pregnancy keeps body and mind healthy. Staying flexible and fit helps the work of labor and childbirth. The postpartum period is draining physically and emotionally; so, optimize both while you can.

Provides insight into the mind-body connection
Physical and emotional health are intertwined. Learning your personal coping methods to stress can help prepare you for the demands of labor. Physical activity reinforces body awareness and mindfulness. The practice of yoga has a special emphasis on the mind-body connection.

Controversial benefits of exercising during pregnancy:

Lowers maternal blood pressure - may prevent and treat pre-eclampsia
Some researchers are concerned that exercise in predisposed women can worsen pre-eclampsia or intrauterine growth restriction. In fact some may recommend bedrest as treatment.

SeonAe Yeo PhD, RN from the University of Michigan has been involved in women's health research since 1995. Her recent work compares stretching exercises to walking for 30 to 40 minutes about three to four times a week. She found that stretching exercises may decrease the risk of developing pre-eclampsia in women with a sedentary lifestyle who have had pre-eclampsia before.

Improves maternal sugar regulation - may prevent and treat gestational diabetes
A small study comparing bicycle exercise to insulin treatment for gestational diabetes showed that both treatments result in similar blood sugar levels and the number of newborns with low blood sugar levels.

Improves maternal posture - may optimize baby's position
Some positions are more difficult for baby to come out than others. The ideal position for birthing is vertex position (head down) and occiput anterior (baby facing back). Some midwives actively help to move baby into this position. Even if your baby is already in good position, maintaining good posture may help to reduce some of the aches and pains.

Resources:

Gail Tully CPM
Online resource developed by a midwife in Minneapolis for defining your baby’s position and recommendations for optimizing it.

Perfect Balance Yoga
5091 N Fresno St Ste 133
Fresno 93710
(559) 222-6212
Conveniently located at Shaw and Fresno streets. Provides a supportive atmosphere where women can share childbirth experiences and an awareness for a variety of childbirth options in addition to the practice of yoga.

San Joaquin Valley Rehabilitation
Hospital & Outpatient Center
7173 N. Sharon
Fresno 93720
(559) 436-3600

• Aqua Moms is an aquatic exercise class for expecting and post pregnancy mothers. The pool is an indoor, warm-water, therapeutic pool (92 - 95 degrees). Mondays and Wednesdays from 5:30 to 6:30. $42 per month. Physician's medical clearance required.

• Mommy Fitness is a land based exercise program for mothers and babies (until they begin walking). It focuses on core stabilization and strengthening with the natural progressive resistance of your baby's body weight. Tuesdays and Thursdays from 5:30 - 6:30. $42 per month. Physician's medical clearance required. You will need to bring a yoga mat, stroller or sling.

Mommy Matters
1010 E Perrin Ave
Fresno 93720
(559) 433-0172

Fig Garden Yoga Studio
6045 N Palm Ave Ste A
Fresno 93704
(559) 222-5100

Coil Yoga
764 P St
Fresno 93721
(559)270-4709

Size Matters

The mother's size, the baby's size, even pelvic size and head size are common themes during pregnancy and childbirth. Here is a discussion about some familiar quotes.

“I shouldn’t gain too much weight during pregnancy.”

Our culture cultivates a fear of gaining weight. Body image concerns make the normal changes that occur during pregnancy scary. It is healthy and necessary to gain weight during pregnancy. Gaining weight during pregnancy does not equal getting fat. Although mothers weigh in at every prenatal visit, the quality of her diet, not her weight, determines the health of the pregnancy. Babies born too small are at risk for being premature, not being head-down, having umbilical cord prolapse, breathing problems, low blood sugar, and low body temperature.

“If I gain too much weight, my baby will be too big.”

Dietary restriction during pregnancy can impair fetal growth. Dietary supplementation with high protein, special amino acids, and other nutrients has not been proven to prevent impaired fetal growth. Fear of a big baby stems from the belief that this can lead to baby getting “stuck” during childbirth, cephalopelvic disproportion (CPD) or shoulder dystocia. Fortunately, these are not common and having a baby over 9 lbs does not condemn a mother to either one. Additionally, minimizing pregnancy weight gain does not prevent CPD or shoulder dystocia.

“My ultrasound shows that my baby is going to be too big for me to birth vaginally.”

Ultrasounds done late in pregnancy are not accurate in predicting birth weight, but do increase the rate of early hospital admissions and inductions without any benefit to baby.

“Special x-rays and pelvimetry can determine whether my pelvis is big enough to pass a baby.”

Neither x-ray nor clinical pelvimetry predict the adequacy of a woman’s pelvis during childbirth. Labor is the only reliable test.

“My baby is getting too big so I need to be induced.” Or “My baby is getting too big so I need to have a cesarean section.”

Inducing labor in women thought to have a “big” baby does not produce healthier babies or mothers. It does increase the likelihood of other interventions and cesarean sections. Planned cesarean section for women thought to have “big” babies does not produce healthier babies or mothers.

“If I don’t lose weight within the first 3 months after childbirth, I’ll be fat.”

In order to remodel her body and establish her milk supply, a woman should avoid intentional weight loss until at least three months postpartum. A growing infant needs calories, vitamins, protein and fats to grow healthy. Breast milk provides all of these best, and even in cases of severe calorie restriction breast milk maintains its nutrition for baby. A mother should ensure her diet is adequate to maintain her own health. Although mothers who breastfeed seem to lose more weight on average than those who do not, sometimes the weight loss happens after breastfeeding stops.

“So what should I eat?”

A healthy diet is healthy before, during and after pregnancy.

Resources:

• FDA report on mercury levels in fish
• Eat, Drink, and Be Healthy by Walter Willett - Harvard professor in nutrition and epidemiology involved in NHANES studies (National Health and Nutrition Examination Survey)
• La Leche League - guidelines for diet and weight management with breastfeeding

Avoid:
Trans fats
High fructose corn syrup
High-mercury containing fish
    (king mackerel, shark, swordfish, tilefish)

Minimize:
Chips                French fries
Soft drinks        Candy
Alcohol             Caffeine

Include:
Protein: eggs, dairy, meats, fish, nuts, nut butters
Essential oils: fish, nuts, nut butters and oils, olive oil
Salt to taste
B12 500mcg a day
folate 500mcg a day

No limit on:
Whole fruit (not canned, frozen ok)
Whole vegetables (not canned, frozen ok)
Whole grains
Beans
Nuts
Red raspberry leaf tea