Maj Alison Baum. R3, Nellis FMR

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1 Maj Alison Baum R3, Nellis FMR

2 What are some of your thoughts about birth plans?

3 xf04

4 Labor: Pain management wishes Doulas Episiotomy Intermittent fetal monitoring Postpartum: Delayed cord clamping Cord blood banking Placental encapsulation Vitamin K/ baby meds

5 Uterine contractions T10-L1 nerve roots May be felt as low back pain Descent Stretching of pelvic floor/ perineum

6 Increased perception of pain: first delivery, h/o dysmenorrhea, fear of pain Decreased pain: childbirth prep classes, pregnancy complications, plans to breastfeed, high SES, older age

7 Epidurals control pain more effectively than opioids, alternative methods Opioids cross placenta postnatal resp depression Hypothermia Decreased suckling ability Anim-Somuah M, Smyth RMD, Jones L. Cochrane 2011.

8 Risks of epidurals Assisted/operative vaginal birth RR 1.42 Maternal hypotension RR Urinary retention RR C/S for fetal distress RR 1.43 No risk of increase in overall C/S rate Anim-Somuah M, Smyth RMD, Jones L. Cochrane 2011.

9 Hypnobirthing/ Bradley method Cochrane review: decreased need for analgesia, RR 0.53, 95% CI 0.36 to 0.79 Acupuncture Cochrane: decreased need for pain relief RR % CI Randomized, patient blinded, placebo controlled trial: significantly less pharm use, shorter labor time Smith CA et al. Cochrane 2006 Borup L et al. Birth Mar 2009

10 A female support person, especially a childbirth educator, other than the woman s partner or medical team DONA.org: a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period

11 Cochrane Review: Decreased use of analgesia RR 0.90 ( ) Decreased operative births/increased SVD Increased satisfaction Best: not hospital staff or friend when epidural not available When spouse not allowed Hodnett et al. Cochrane 2012.

12 ACOG recommends against routine episiotomy Risk of extension of incision 3 rd and 4 th degree tears Possible risks Future tears Sexual dysfunction Increased pain ACOG Practice Bulletin Eason E. et al Obstet Gynecol

13 Cardiotocography vs. intermittent monitoring Perinatal death RR 0.85 ( ) Neonatal seizures RR 0.50 ( ) Cerebral palsy RR 1.74 ( ) Cesarean section RR 1.66 ( ) Operative vaginal RR 1.16 ( ) Alfirevic Z et al. Cochrane 2006.

14 ACOG recommendation: High risk pregnancies toco Low risk- toco or intermittent

15 Perceived benefits: Decreased postpartum hemorrhage Higher hemoglobin in infant True benefits Higher birthweight Higher infant hemoglobin Increased iron reserves at 6 mo Cochrane 2013.

16 No change in PPH rates Risks Increased risk of jaundice requiring phototherapy Conclusion: Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available. McDonald SJ et al. Cochrane 2013.

17 Conditions treated Options Privately held UCB banking Publicly held UCB for autologous use

18 Privately held UCB Costs: $1500-$2000 upfront, $ /year Expected benefits Not used to treat leukemia in general 1 Cannot be used for inborn errors of metabolism Less than 10 case reports of autologous transplant 2 Chances about 1 in 2700 or lower 3 1. Rowley JD. Nat Med 1998;4: Petrini C. J Blood Med Umbilical Cord Blood Banking, ACOG Committee Opinion, 2012

19 Public banking: Requires screening for infectious diseases Free No guarantee blood will be available for later use Requires extra effort if not offered at MTF Generally must be screened by 34 weeks gestation

20 Definition Maternal Non-maternal Claims of benefits Energy levels Decreased postpartum depression Increased milk supply

21 Literature limited to anthro studies Risks: Improper handling Blood borne pathogen transmission

22 Examine reason for objection Vitamin K Prevents Vitamin K deficient bleeding 3 types: early (0-24 hours) classic (2-14 days) and late (2-12 weeks)

23 Tennessee outbreak

24

25 Common items in birthplans Evidence Explored patient s perspective

26 McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7. Anim-Somuah M, Smyth RMD, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12. ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Obstet Gynecol. 2006;107(4):957. Rowley JD. Backtracking leukemia to birth. Nat Med 1998 Feb; 4(2): Petrini C. Umbilical cord blood banking: from personal donation to international public registries to global bioeconomy. J Blood Med Jun 18;5: Umbilical Cord Blood Banking, ACOG Committee Opinion, 2012 Preventing perineal trauma during childbirth: a systematic review. Eason E, Labrecque M, Wells G, Feldman P. Obstet Gynecol. 2000;95(3):464. Maizes V, Low Dog T. Integrative Women s Health. Oxford University Press, Borup L et al. Acupuncture as pain relief during delivery: a randomized controlled trial. Birth 2009 Mar 36 (1) Smith CA et al. Complementary and alternative therapies for pain management in labour. Cochrane Database Syst Rev 2006 Oct 18;(4):CD Warren M. Notes from the Field: Late Vitamin K Deficiency Bleeding in Infants Whose Parents Declined Vitamin K Prophylaxis Tennessee, CDC Notes from the Field.

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Priya Rajan, MD Northwestern University September 13, 2013

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