Fetal Lungs Provide a Signal Initiating Labor

This isn't new information (the press release below was published in 2004), but it seems to be relatively unheard of among mothers and childbirth educators. It has significant implications and should greatly influence families' decisions about inducing labor or electing to deliver a baby via cesarean section. If the mother has not gone into labor, the baby most likely has not given the signal that he's ready!

A protein released from the lungs of a developing mouse fetus initiates a cascade of chemical events leading to the mother's initiation of labor, researchers at UT Southwestern Medical Center at Dallas have found.

The research, which has implications for humans, marks the first time a link between a specific fetal lung protein and labor has been identified, said Dr. Carole Mendelson, professor of biochemistry and obstetrics and gynecology and senior author of the study. The paper appears in an upcoming issue of the Proceedings of the National Academy of Sciences and is currently available online.

The initiation of term labor is carefully timed to begin only after the embryo is sufficiently mature to survive outside the womb. Previous studies suggested that the signal for labor in humans may arise from the fetus, but the nature of the signal and actual mechanism was unclear, Dr. Mendelson said.

In their study, UT Southwestern researchers found evidence that a substance secreted by the lungs of a developing fetus contains the key signal that initiates labor. The substance, called surfactant, is essential for normal breathing outside the womb.

"We found that a protein within lung surfactant serves as a hormone of labor that signals to the mother's uterus when the fetal lungs are sufficiently mature to withstand the critical transition to air breathing," Dr. Mendelson said.

"No one really understands what causes normal or preterm labor. There may be several chemical pathways that lead to labor, but we think that this surfactant protein, which is also produced by the fetal lung in humans, may be the first hormonal signal for labor," said Dr. Mendelson, who is co-director of the North Texas March of Dimes Birth Defects Center at UT Southwestern.

In humans the signaling protein, called surfactant protein A, or SP-A, also helps immune cells, called macrophages, fight off infections in the lungs of children and adults by gobbling up bacteria, viruses and fungi that infiltrate the lung airway.

"Women who go into preterm labor frequently have an infection of the membranes that surround the fetus, and the number of macrophages in the wall of the uterus increases with the initiation of preterm labor. When women go into labor at term, they also have an increase in macrophages in the uterus," Dr. Mendelson said.

This led the researchers to investigate whether there was a connection between what happens during normal labor at term and in infected mothers who go into early labor.

"This also raised the question: If bacterial infection can cause increased macrophage infiltration of the uterus in preterm labor, what is the signal for the enhanced macrophage migration to the uterus at term?" Dr. Mendelson said.

In mice, the developing fetal lung starts producing SP-A at 17 days gestation; full-term delivery occurs at 19 days. The developing human fetus starts producing SP-A in increasing amounts after 30 to 32 weeks of a 40-week normal gestation, at which time the baby's lungs are essentially developed. As the fetus "breathes" amniotic fluid in the womb, the protein is released into the fluid.

"The SP-A protein binds to macrophages in the amniotic fluid, macrophages that come from the fetus itself," said Dr. Jennifer Condon, a postdoctoral researcher in biochemistry and the study's lead author.

The macrophages, "activated" by the protein, make their way through the amniotic fluid to the wall of the uterus. Once embedded there, they produce a chemical that stimulates an inflammatory response in the uterus, ultimately leading to labor.

http://www.utsouthwestern.edu/utsw/cda/dept37389/files/158762.html

Canadian Research Suggests Maternal IV Fluids Linked to Newborns' Weight Loss

BioMed press release.

A newborn baby's weight loss is often used to determine how well a baby is breastfeeding, and concern about a baby which loses too much weight may result in supplementing breastfeeding with formula. However, many women receive IV fluids during labor, and new research published in BMC's open access journal International Breastfeeding Journal shows that some of a newborn's initial weight loss may be due to the infant regulating its hydration and not related to a lack of breast milk.

A group of Canadian researchers looked at relationships among the IV fluids a mother received during labor (or prior to her caesarean section), neonatal output (measured by diaper weight), and newborn weight loss. They found that during the first 24 hours following birth there was a positive association both between the IV fluids given to mothers before birth and neonatal output, and between the neonatal output and newborn weight loss. At 60 hours post birth, the time of the average lowest weight, there was a positive relationship between maternal IV fluids and newborn weight loss.

"Nurses, midwives, lactation consultants, and doctors have long wondered why some babies lose substantially more weight than others even though all babies get small amounts to eat in the beginning," said principal investigator Prof Joy Noel-Weiss from the School of Nursing at the University of Ottawa's Faculty of Health Sciences. "It appears neonates exposed to increased fluids before birth might be born overhydrated, requiring the baby to regulate his or her fluid levels during the first 24 hours after birth."

Prof Noel-Weiss added, "We should reconsider the practice of using birth weight as the baseline when calculating newborn weight loss in the first few days following birth. For mothers and their breastfed babies, accurate assessment of weight loss is important. Although more research is needed, based on our findings, we would recommend using weight measured at 24 hours post birth as a baseline."

Alongside this article, the researchers have provided a standardized method for clinicians to collect and analyze data about newborn weight loss in their own maternity site, in the hope that this protocol will help them to make informed decisions when assessing newborn weight changes.

1. An observational study of associations among maternal fluids during parturition, neonatal output, and breastfed newborn weight loss. Joy Noel-Weiss, A Kirsten Woodend, Wendy E. Peterson, William Gibb and Dianne L Groll. International Breastfeeding Journal (in press)

2. Iatrogenic newborn weight loss: knowledge translation using a study protocol for your maternity setting . Joy Noel-Weiss, A Kirsten Woodend and Dianne L Groll. International Breastfeeding Journal (in press)

Ob/Gyn Ministers to "Unclean Women" in the Name of Jesus

Dr. Catherine Hamlin, 87, has saved countless Ethiopian women's lives through her work repairing fistulas. Most don't know that she labors out of love for Jesus.

Read the story at: http://blog.christianitytoday.com/women/2011/03/mother_teresa_of_our_age_talks.html

Addis Ababa Fistula Hospital is not a mission hospital or affiliated with a particular denomination, but the Hamlins’ faith defines it. The staff begins the day with a prayer meeting, and recordings of Scripture readings and messages are available in at least 25 languages for the women to listen to on headphones as they recover. Many patients have become Christians.

As the second fistula hospital in the world (the first ran in New York from 1855 to 1928 whenVVFs became obsolete in the U.S.), Addis Ababa depends on donations to provide free surgery and care for these women. Organizations give financial support to run the hospital and provide each woman with a new dress, a bus ticket home, and, if they would like one, a Bible. Hamlin Fistula International also raised money to launch five regional hospitals in Ethiopia that serve 3,000 patients a year and hopes to treat 4,000 annually. In order to prevent VVFs, another project involves training midwives to serve in rural areas and supporting them in their work.

Cytotec Is Dangerous, No Matter What Your Doctor Told You...

There has been renewed conversation about Cytotec in my local doula community recently because a doula was concerned that this was what a doctor had prescribed for her client. A few doulas commented that their clients had experienced medically-induced labor with Cytotec and had good outcomes. But we must remember that a few happy endings are not evidence that the practice is safe.



This article by Marsden Wagner in a 2001 issue of Midwifery Today covers the major points...

Induction with Cytotec should never be attempted anywhere, most especially in out-of-hospital settings. Incredibly, the American College of Obstetricians and Gynecologists (ACOG) recently approved Cytotec induction: 1) in spite of lack of FDA approval; 2) in spite of a letter to doctors earlier this year from Searle (which manufactures Cytotec) imploring doctors not to use it for induction; 3) in spite of lack of approval from the Cochrane Library (the best scientific opinion); and 4) in spite of the fact that it is not approved nor used for induction in any country in Western Europe.

Recent articles in prestigious medical journals such as The Lancet have questioned the validity of standards of practice from professional organizations like ACOG, because their goal of protecting the health of women through using scientific evidence to guide members toward best practices too often conflicts with their other role as a trade union representing the interest of their members. As a result of this "trade union" role, ACOG recommendations are too often compromised by the needs of the obstetricians. A classic example of putting the doctors' needs ahead of the families' needs is the ACOG recommendation not to permit videotaping by families of a hospital birth.

So ACOG quotes studies of Cytotec induction, none of which have a sufficient number of research subjects, and consequently, none of the studies quoted have sufficient statistical power to detect small but potentially important risks such as uterine hyperstimulation and uterine rupture. Furthermore, because published studies of Cytotec induction have such wide methodological variability, meta-analysis is impossible and the published attempts at such meta-analysis are seriously flawed. But Cytotec is a godsend for busy obstetricians, as its use allows them to schedule the woman's labor at a convenient time and speeds up the labor, resulting in a return to "daylight obstetrics"-pharmacological induction of labor has increased from 10 percent to 20 percent in the past decade in the United States. So with their members' needs in mind, ACOG plows ahead, ignoring the best scientific evidence as well as the recommendations of the best scientific bodies, of government agencies not only in the United States but in every country in Western Europe, and of the pharmaceutical company. Instead, ACOG uses weak, inadequate evidence to approve Cytotec induction. Midwives should stay as far away as possible from such vigilante obstetrics-obstetricians taking matters into their own hands while ignoring the recommendations of the real judges.

article from Midwifery Today, Issue 57, Spring 2001, page 44

by Marsden Wagner MD, MSPH

Cover photo of Jessie and Hans © 2000 by Caroline E. Brown, DEd, MS, RNC.

http://www.midwiferytoday.com/articles/midwivescytotec.asp

Cesarean vs. VBAC: A Dramatic Difference

This is a video excerpt from the homemade film called "The Journey to Homebirth," made by Alexandra Orchard. We watched this film at the VBAC workshop I attended recently and I found it to be a really poignant story. She ends the film with a powerful letter that she wrote to her doctor, explaining why she is choosing to leave his care and have her third baby at home.

Cesarean vs. VBAC: A Dramatic Difference from Alexandra Orchard on Vimeo.

Alexandra Orchard also started a support network called www.empoweredmomma.net.

"Our country has the best medical technology available in the world, yet we are 20th in the world for infant mortality. I am all for women’s choice in childbirth, however it is incredibly one-sided. Women can choose a cesarean for no medical reason, but I could not find one doctor in my area willing to give me the chance of a natural childbirth after two cesareans. One nurse laid it out perfectly for me: "no doctor is willing to risk their career on you", she said, and I knew she was right. But my baby and I deserved more. I knew I would be in better hands with my midwife who knew my baby so well and wouldn’t be pushing my body or my mind with time limits, instruments, or any other stresses. I felt very strongly that my chance of having a successful vaginal birth would be significantly compromised in a hospital setting. I gave birth to my daughter at home because it was right for us... We were made to do this. We don’t need to be “rescued” from this important, though sometimes difficult journey. We need to be in control and we need to be given the freedom and time to let our bodies and our babies do what needs to be done in peace. We need to be surrounded by people who will be patient with our bodies, our babies, and our progress in a natural labor. More importantly, we need to be surrounded by people who believe in us."

Homebirth in the media

This TODAY Show report - portraying homebirth as a particularly risky option - is taking a lot of flack: http://today.msnbc.msn.com/id/26184891/vp/32795933#32795933

It doesn't address the sad reality that sometimes babies die, even in births at the hospital. There is no way to completely prevent infant mortality, but homebirths do result in fewer infant deaths than hospital births. Like the video points out, that is in part because homebirths are low-risk births. But all the more reason to choose homebirth if your pregnancy isn't high risk!

Here are two stories about homebirth on USA Today. These provide the positive coverage to balance out the negative stuff from the aforementioned video!

Study Shows Home Birth with Midwife as Safe as Hospital Birth
by Amanda Gardner
http://www.usatoday.com/news/health/2009-09-03-midwife-home-birth_N.htm?obref=obinsite

Home Births Get a Bump, Over Obstetricians' Objections
by Rita Rubin
http://www.usatoday.com/news/health/2009-09-13-home-births_n.htm

Laboring Without the Labor Bed: It's a Good Thing

This press release from the University of Toronto details a pilot study that removed the standard hospital bed as a focal point of labor. In the redesigned "ambient" room, instead of the typical hospital room, women didn't spend as much time in the bed. And the result was that they labored better and had a better perception of their labor experience.

Here's the story:

A University of Toronto pilot study that re-conceptualized the hospital labour room by removing the standard, clinical bed and adding relaxation-promoting equipment had a 28 per cent drop in infusions of artificial oxytocin, a powerful drug used to advance slow labours. The study, called PLACE (Pregnant and Labouring in an Ambient Clinical Environment) was published in the current edition of the journal Birth.

In addition, more than 65 percent of the labouring women in the ambient room, compared to 13 per cent in the standard labour room, reported they spent less than half their hospital labour in the standard labour bed.

Led by Dr. Ellen Hodnett, Bloomberg Faculty of Nursing professor and Heather M. Reisman Chair in Perinatal Nursing Research at the University of Toronto, PLACE included 62 women at two Toronto teaching hospitals.

Hodnett devised a set of simple, but radical modifications to the standard hospital labour room, with the intention of surrounding the women and their caregivers with specific types of auditory, visual and tactile stimuli.

"The removal of the standard hospital bed sent a message that this was not the only place a woman could labour," says Hodnett. A portable, double-sized mattress with several large, comfortable cushions was set up in the corner of the ambient room. Fluorescent lighting was dimmed, and DVDs of ocean beaches, waterfalls and other soothing vistas were projected onto a wall. A wide variety of music was also made available.

"The intent was to allow the women the ability to move about freely during their labour, to permit close contact with their support people, and to promote feelings of calm and confidence," says Hodnett.

Reaction to the ambient room was overwhelmingly positive, as respondents were pleased to have options for mobility and for helping to cope with their labour. They also indicated they received greater one-on-one attention and support from their nurses.

"This study raises questions about the assumptions underlying the design of the typical hospital labour room," says Hodnett. "The birth environment seems to affect the behaviour of everyone in it – the laboring women as well as those who provide care for her.
Hodnett hopes to further this study with a larger, randomized controlled trial.

View Dr. Hodnett's study here: http://www3.interscience.wiley.com/cgi-bin/fulltext/122413904/HTMLSTART

Read Dr. Hodnett's bio here: http://bloomberg.nursing.utoronto.ca/staff/Faculty_Bios/Ellen_Hodnett.htm

Florida hospital creates suite for natural birth

I'm not sure how natural the births that happen in this hospital are, but here's a news report about their attempt to appeal to clients who want less intervention and more of a homey ambience...

http://www.happynews.com/news/792009/florida-hospital-promotes-natural-birth.htm

http://www.memorialmiramar.com/

Experiencing a Spiritual Cesarean

Tonight I attended a two-hour workshop led by Lanell Coultas on the topic of c-sections. She is an excellent teacher and she could really teach a 6-week course on this topic. But we didn't have that much time, so we spent most of the session role-playing and walking through what the mom and dad and baby might encounter during a c-section and how the doula could best support them.

A few people shared stories and Lanell offered suggestions. More than any of her suggestions, though, I am always most impressed by how Lanell remains so calm and sensitive and genuine. She empathizes so deeply and seems to get to the root of issues in a way that makes me want to sit at her feet and soak up all of her knowledge and wonderfulness. :)

So, don't get caught up in the to do's or not to do's and definitely don't take them as rules, but consider some of these ideas that Lanell offered:

- Don't avoid talking about cesarean birth with your client. Sometimes doulas and other fans of natural birth methods act like they might jinx a birth by even mentioning a c-section. But by neglecting to talk about the possibility or to consider how you might respond in such a situation, you do your client a great disservice. It is a good idea to let her know that a c-section is always a (distant) possibility and it might be a good idea to bring a CD to listen to in the operating room or comfy socks, in the event that she has to walk from L&D to the operating room. It doesn't mean she needs to spend time worrying about a c-section. But she can be a little more prepared, just in case.

- If your client is having a planned cesarean, encourage her and her partner to establish a common vision that they can reflect on during the moments throughout the birth when they are separated. This might include when the mom is getting her spinal anesthesia or when the dad goes to the nursery with the baby. If the mom and dad are sharing a common thought about their home or their baby or their dreams, they can feel connected despite the temporary physical separation. This is also a great way to help them go inward, and not get distracted by all the noise and hustle and bustle of the operating room.

- When the anesthesiologist gives the mom the bolus, she might shiver or shake quite a bit. You can support her by gently and firmly holding the pressure points in the arches of her feet. This can help her to feel grounded and should help relieve a little bit of the shaking.

- Slow down. Help the mom to focus on her vision, her dream, and not get flustered by all of the adrenaline in the room.

- If she is concerned about the c-section being anti-climactic compared to labor and vaginal delivery, give the mom some ways to experience this as a rite of passage. She can go inward and speak the words her baby needs to hear. She can imagine the surgery that is happening and how her baby is emerging into the world. She can focus on the doctor's hands and pray for him. Lanell told about a client who was meditating to focus all of her love for her baby into the doctor's hands so that the baby could feel his mother's love that first moment when the doctor touched him.

- Suggest that the dad take lots of pictures so that the mother can fill in all the blanks in her birthing experience. He can ask the anesthesiologist to take some pictures of the surgery and of the new family, too. :)

- Tissues with a few drops of essential oils are a good idea for both the dad and the doula. The scent of peppermint or lavender can remind you to slow down and experience the moment and can also combat the unpleasant smell as the doctor cauterizes the mother during surgery.

- Affirm the mother in her pain. Not having seen the procedure, the mother may feel guilty for not being more resilient or for needing pain medication. Remind her that she has just undergone major abdominal surgery and her body has lots of recovering to do. It's okay to use pain medication if she needs it.

In light of my recent thoughts about supporting dads, I also thought Lanell had some particularly good ideas about the dad's role in all of this. She said the dad can assume that his place is always with the baby. If he ever needs to step back, a doctor or nurse will tell him. But he can know that he has a clear and significant role as he accompanies the baby while the mother is stitched up and goes to recovery. Also, it is completely natural that he wants to protect his child and reunite his family. It's okay for him to be like a broken record, asking if he and the baby can see mom yet... When they are all together again, he can tell her about the surgery and about everything that happened in the nursey. His words will contribute significantly to how the mother processes the whole experience.


Anyway, there was so much more, but I don't want to get caught up in little details. Basically, Lanell challenged us to think about the fact that once c-sections become necessary, they really are just that - necessary. Whether it's because of the mother's feelings, the father's thoughts, the doctor's experience, circumstances beyond anyone's control, or whatever, once they have decided on a c-section, it is necessary. Because at that moment, it's the best way. She compared it to this vortex that everything is flying around in, to bring about this one result.
And in the end, a baby will be born. and it is still amazing!