Resources on Hazards in Pregnancy

substancesDuring pregnancy, some women worry a lot about the potential harms they might expose their developing baby to – medications, smoking, environmental pollutants, workplace hazards and more. Others feel like they’re continuously bombarded with messages that ‘nothing is safe’ and ‘you can’t do / eat/ drink anything you want to do / eat / drink because you’re pregnant.’

If parents look in the popular media, they see a wide range of information: some accurate and research-based but hard to read, some easy to read but not so accurate. It helps to have good resources to point expectant parents to. These are in order from the ones that I think are most broad / helpful to parents to those which are less broad or less helpful.

The Mother to Baby website from OTIS (Organization of Teratology Information Specialists) has a large collection of fact sheets on specific hazards that are research-based and consumer friendly (though not for a low reading level). Topics include medications, herbal products, infectious diseases, illicit substances, and maternal medical conditions. http://www.mothertobaby.org/otis-fact-sheets-s13037

The March of Dimes http://www.marchofdimes.org/pregnancy/staying-safe.aspx is a very consumer friendly site with good summaries on lots of topics.

Center for Disease Control (CDC). Lots of helpful information and links on infectious diseases, medication, workplace hazards, and more. http://www.cdc.gov/pregnancy

LactMed – Drugs and Lactation Database. For info on medications and breastfeeding. “Information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided.” http://toxnet.nlm.nih.gov/newtoxnet/lactmed.htm

FDA information for Expectant and New Parents. Info on food safety, breast pumps, ultrasounds, and more. http://www.fda.gov/ForConsumers/ByAudience/ForWomen/WomensHealthTopics/ucm117976.htm

The Environmental Working Group offers Consumer Guides on choosing healthier (for humans and the planet) products: pesticides in produce, cleaning products, cosmetics, genetically engineered foods, and lots more. http://www.ewg.org/consumer-guides

MotherRisk. The website includes a few fact sheets, plus links to research studies on medications, herbs, and infectious diseases. For Canadians, they offer phone hotlines for questions about medications exposures, nausea and vomiting in pregnancy, exercise in pregnancy, and HIV and pregnancy. http://www.motherisk.org/prof/index.jsp

Reproductive Health in the Workplace has info about workplace exposures and breastfeeding and on how not to take your workplace hazards home with you. http://www.cdc.gov/niosh/topics/repro/pregnancy.html

OSHA (Occupational Safety and Health Administration) Standards related to reproductive hazards in the workplace: https://www.osha.gov/SLTC/reproductivehazards/standards.html

The Environmental Protection Agency (EPA) lists hotlines consumers can call with questions on particular hazardous substances: http://www2.epa.gov/home/epa-hotlines

Safety and International Travel: http://wwwnc.cdc.gov/travel

How Expectant Parents Can Help

Part of the reason there is limited information on the safety of substances during pregnancy is because of limited research on pregnant women. Expectant parents can volunteer to be in a pregnancy registry. These studies just collect information from pregnancy parents who take medications and vaccines, and collect information on the baby. Outcomes are compared to those of parents who did not take that medication during pregnancy.

Participating parents are NOT taking experimental drugs or anything they wouldn’t otherwise take!! These registries are an opportunity for parents who are already taking medication or need to take a medication to share their experience with researchers. It might especially appeal to parents who are frustrated at how little information is available to them about their meds. This helps them help others moving forward.

Participating would typically involve a few phone calls (or possibly even online surveys): one or two during pregnancy, and one after the birth. I

Learn more here: http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm251314.htm and here: http://www.pregnancystudies.org/participate-in-a-study/participate-in-a-study/

If you are a professional who would like to encourage your clients to participate in registries, there are outreach materials (brochures, etc.) available here: http://www.fda.gov/ScienceResearch/SpecialTopics/WomensHealthResearch/ucm256789.htm

photo credit: G. J. Charlet III via photopin cc

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Talking about Prenatal Mood Disorders in Birth classes

pregnancydepressionMost childbirth educators are covering postpartum depression in their classes. Some are also covering other postpartum mood disorders such as anxiety and obsessive compulsive disorder which are quite common. (Depression affects 10 – 20% of new moms, Anxiety or panic disorder affects ~10% and OCD affects 3 – 5%). And hopefully they’re also pointing out that a person can experience multiple disorders at once – for example, she can have depression AND anxiety.

A few educators are remembering to include partners – about 5% of new dads have a postpartum mood disorder.

But I wonder how many of us are talking about mood disorders in pregnancy?

Incidence of Mood Disorders in Pregnancy

Of women who experience depression after birth, a third say it started during pregnancy. (Source) Sometimes, depression is missed because symptoms can be mistaken for the fatigue or appetite disturbances associated with pregnancy. Estimates of incidence of depression in pregnancy range:

Rates determined by structured interview have ranged from 2 to 21% and up to 38% for women of low SES. Estimates derived from self-report questionnaires have ranged from 8 to 31% and 20 to 51%, respectively. Source.

Almost one third of women with manic depression (aka Bipolar disorder) report onset during pregnancy. OCD often begins in pregnancy (pre-existing OCD is usually exacerbated by pregnancy). Interestingly, pre-existing anxiety / panic disorder  may actually decrease in pregnancy due to hormonal effects. Source

How do we talk about this in childbirth classes?

I see multiple places we could address this:

1) when talking about discomforts of pregnancy and the physical changes of pregnancy, you could also address emotional changes and challenges

2) when discussing self-care in pregnancy, could include emotional self care and talk about mood disorders there

3) when talking about postpartum mood disorders.

I find it works well for me to cover it when talking about postpartum mood disorders.When I’m almost done with that topic I say “Although you may hear a lot of talk these days about postpartum mood disorders, we know that they begin in pregnancy for a third of the women who experience them. If you were just listening to my description of symptoms and thinking ‘I feel that way now’, then you may be experiencing a prenatal mood disorder. All the resources for support and techniques for self care I just talked about can also help with pregnancy mood disorders. I would encourage you to reach out for support now – the sooner someone gets support, the sooner they start feeling better. If you have concerns or questions, you can talk to me after class or by email.”

So, it works well for me to cover it near the end of the series when I’m talking postpartum. But, I could also make an argument that it would be better to cover it as early in the series as possible so that parents who are experiencing it get support as early as possible.

When do you (could you) cover it in your classes?

For more resources on perinatal mood disorders, see http://ppmdsupport.com/index.html
photo credit: Maria & Michal P. via photopin cc

Screening for Gestational Diabetes

In this post, I compare guidelines for testing for gestational diabetes. 4 – 9 % of pregnant people have gestational diabetes. Women with GDM are at a higher risk for gestational hypertension and cesarean. Their babies are at higher risk of macrosomia (being > 9.9 pounds), hypoglycemia, jaundice, cesarean delivery, and shoulder dystocia.

Types of Tests Used

GCT = A glucose challenge test is a screening test, where an expectant parent drinks 50 g of a sugary beverage (or eats a prescribed sugary snack such as white toast with honey), and then one hour later blood is drawn to test her blood glucose levels. If they are high (above the threshold listed below), she will then have a GTT.

GTT = A glucose tolerance test is a diagnostic test. After fasting for 8 hours, a woman drinks either 75 g or 100 g of a sugary beverage, and then has her blood drawn at 1 hour, 2 hours, and 3 hours. If her blood glucose levels are high, then gestational diabetes is diagnosed.

Who is at risk (aka categories of risk):

High risk: Risk factors that increase a woman’s risk for developing GDM include obesity (BMI >30), increased maternal age (>35), history of GDM, family history of diabetes, and belonging to an ethnic group with increased risk for type 2 diabetes. [NICE defines high risk as BMI > 30, previous baby over 9.9 pounds, previous GDM, first-degree relative with diabetes, South Asian, black Caribbean, Middle Eastern. PCOS.]

Average risk: not high risk, not low risk.

Low risk: under 25 years, normal BMI before pregnancy, member of ethnic group with low prevalence of GDM, no known diabetes in first degree relatives

When to test:

ADA says screen high risk women as early as possible, and re-test at 24- 28 weeks if first screen was negative. Screen average risk women at 24- 28 weeks. For low risk asymptomatic women, no screening required.

ACOG: Screen all women at 24 – 28 weeks

CDA: Screen all women at 24 – 28 weeks (Optional: Screen higher risk women earlier and again at 24 – 28)

NICE: Do a GTT at 16–18 weeks if prior GDM; at 24–28 weeks if risk factors

USPSTF says there is not sufficient evidence for screening before 24 weeks. Should screen after 24 weeks.

How to test:

ADA – 1 step: 75 g fasting GTT may be cost-effective for high risk patients or populations. Or 2 step: 50 g GCT. Then, if indicated, 100 g GTT

ACOG: 2 step –-50 g GCT, then fasting 100 GTT

CDA: Preferred 2 step – 50 g GCT, then if indicated 75 g GTT. Alternate 1 step: 75 g GTT

NICE: 75 g GTT (but only test if there are risk factors)

On GCT results, what threshold indicates need for GTT diagnostic testing?

ADA / ACOG / CDA: If <140 mg/dl, no further testing is indicated. If > 140, then GTT should be done. ACOG says 135 should be threshold in women at high risk for GDM.

If the threshold was set at 130, then you would catch 90% of cases of GDM, vs. the 80% of cases you catch when setting threshold at 140. However, at 130, there would be many more false positives – women diagnosed and treated for GDM who did not have it. [Note: None of these guidelines share what the false positive rate is.]

On GTT results, what threshold indicates a diagnosis of gestational diabetes?

Fasting 1 hour 2 hour
ADA/CDA 1 step 75 g GTT ≥ 92 mg/dl (5.1 mmol/L) ≥ 180 (10) ≥ 153 (8.5)
ADA / ACOG 2 step 100 g GTT ≥ 95 mg/dl ≥ 180 ≥ 140
CDA 75 g GTT ≥ 95 (5.3) ≥ 190 (10.6) ≥ 153 (9.0)
NICE 75 g GTT ≥ 126 (7.0) ≥ 140 (7.8)

Can an expectant parent do anything to decrease her risk of a false positive result?

About 15 – 20% of expectant parents test positive on GCT. Only 4 – 9% are diagnosed with GDM after a GTT. (Doing only the one-step GTT increases the rate of diagnosis, which likely means there are more false positives with the one step than with the two step method.)

To reduce false positives on a GCT. Eat healthy, non-sugary meals in the days before the test. Be well-rested and relaxed on the day of the test. Eat a small, healthy non-sugary meal one hour before test, then walk around to let your body metabolize it. In the hour between drinking the glucose and having blood taken, do not drink tea, coffee, soda, etc.; eat sugary food, or smoke cigarettes.

Sources

ACOG http://www.medscape.com/viewarticle/808409 2013

ADA, American Diabetes Association, 2003 http://care.diabetesjournals.org/content/26/suppl_1/s103.full

CDA: Canadian Diabetes Association, 2013 http://guidelines.diabetes.ca/fullguidelines/Chapter36

NICE: http://care.diabetesjournals.org/content/33/1/34.full.pdf+html

USPSTF 2014 http://www.uspreventiveservicestaskforce.org/uspstf/uspsgdm.htm

Update on Transgender Families

I’m working now on an update of Pregnancy, Childbirth, and the Newborn: The Complete Guide. It was originally not intended to be a full revision – it was just intended to be a limited update on new trends in maternity care, current statistics, and updated medical guidelines. But, I wanted to add in something to acknowledge parents who identify as men and are pregnant, and other expectant families who are genderqueer, gender non-binary, and so on. It started as inserting a few paragraphs on the topic, but I’m now also working to make more of the language in the book gender-neutral. It will not be fully gender-neutral, nor will it fully reflect the experience of these parents, because that level of change is simply beyond the scope of what I can do at this time with our publisher’s deadlines days away. But, I’m glad we’re making baby steps, and hope I don’t make too many mis-steps along the way.

In this process, people have kindly shared resources with me. I will share them here for reference by other birth professionals. If I mis-state anything here, feel free to comment – but be nice, OK? I’m still learning…

Understanding Gender Identity

First, if you know your knowledge of transgender issues is limited, a great place to begin is “Guide to Being a Trans Ally” on straightforequality.org. It’s long, but well worth the read. For example, it defines sex, sexual orientation, gender, gender identity and gender expression, and all the ways terms are used. It also talks about how all these things can be a spectrum. (A side note: If you think biological sex is totally binary, not a spectrum, you’ll find this a fascinating post about in-utero development of sexual characteristics.)

For example, I am a cisgender woman, because I was assigned female at birth, and I identify as female, and my gender expression is female though not exactly “extremely feminine” (you’ll never see me in high heels or makeup!)

A transgender man is someone who was assigned female at birth because of their biological sex characteristics, but internally identifies as male. Some transgender men are not “out of the closet” and don’t disclose their transgender status in their public life – they think of themselves as male and may ask those close to them to refer to them as male, but their gender expression in public is female or sometimes androgynous. Some transgender men express themselves as male – they dress in “male” clothing, may use mannerisms and speech patterns associated with men, and may have a male name but may disclose their history and transgender status. Some express themselves as completely male – as the Guide says, they “just want to be seen as their gender-affirmed selves (sometimes referred to as being stealth or private)” In your practice, you may have encountered these men as partners to a female-identified expectant mother.

Estimates on what percentage of the popular is gender variant range widely. The Williams Institute says 0.3% of Americans are transgender. The Transgender Law and Policy Institute says 2 – 5% of the population experience some gender dysphoria (an emotional / mental health condition that arises when someone’s gender expression and how other people refer to them and react to them does not align with their internal sense of who they are.)

It is very likely that younger people are more likely to identify as transgender than older people. When asked whether they identify as lesbian, gay, bi or transgender, 1.9% of those over 65 say yes, but 6.4% of those 18 – 29 do. (Source) This is likely not due to a change in actual incidence of homosexual orientation or transgender identity but more on social attitudes that make it more acceptable to acknowledge those feelings. This will mean that in the future, you will be more likely to knowingly encounter gender variant families than you were in the past.

Transgender people in America experience very high rates of harassment, discrimination, and assault. They have high rates of homelessness, unemployment, and lack of health insurance. (see http://www.transgenderlaw.org/resources/transfactsheet.pdf and Gender Not Listed Here.)

Transgender Men and Pregnancy

A pregnant father would be someone who was assigned female at birth (and has a uterus, ovaries, and so on) but his internal sense of gender identity is male. There are also people across the gender spectrum who carry and birth babies.

Some of those expectant parents will have an outward gender expression that is obvious to birth professionals, and they may also have a conversation with the professional about their gender identity, preferred pronouns, and preferred terms (e.g. father vs. mother). Other transgender people might not reveal their gender identity to their caregivers, and may be cautious in how they dress and present themselves when coming for appointments. However, this may increase their gender dysphoria. Dysphoria is often intense during pregnancy, but having your caregiver use ‘she’, ‘her’, ‘mother’ and other gendered terms frequently can increase that.

When birth professionals encounter clients who express themselves as gender variant, we  need to know how to treat them with respect and honor their identity. And, because we will also quite possibly encounter other gender non-conforming people without knowing it, we should work on adapting our language at all times to welcome them in. And that includes language on websites and advertising where potential clients may look before coming in to determine whether they would be welcomed by your practice.

Health Care Experiences of Transgender People

Many transgender people have a history of bad encounters with health care providers: As many as one-fourth of gender variant people avoid health care services due to concerns about discrimination and harassment. (Source)  “FTM youth said they frequently encountered verbal abuse and condescension from frontline health care staff such as receptionists: ‘I can’t even make it through the front door without staff staring at me, laughing at me, or whispering about my gender presentation.’ In the FTM youth group, all participants agreed that they did not feel safe receiving health care.” (Source) “One FTM youth found experiences with gynecological care especially upsetting:’There is a lack of sensitivity… The doctor was not sensitive to the fact that I experience myself as male and that this experience was overwhelming for me.’ Said one FTM adult,“I think for me it is respect and a willingness to respect your pronoun.I found that to be a huge problem.As somebody that hasn’t done any body alterations,it’s hard for people to switch pronouns and accept the pronoun [that I prefer].” (Source)

This page http://transequality.org/Issues/health.html offers brief, but helpful, recommendations for trans* people about accessing effective health care in general, and things they should consider, and talk to a supportive caregiver about.

Health Professionals Advancing LGBT Equality (previously known as the Gay & Lesbian Medical Association) has an excellent resource for health care providers on Guidelines for Care of LGBT Patients. It talks about how LGBT clients might “scan” a practice to see how friendly it is: they might look for gender-neutral language (pregnant parent, partner, and so on – not mother and father), non-discrimination statements, gender-neutral restroom signs, pride flags, intake forms that ask for relationship status not marital status, offer a check box for transgender, a line for preferred pronoun, and so on. Check it out for ideas that might apply to your practice.

Birth Professionals and Gender Variant Families

The Science and Sensibility blog hosted a post by Simon Adriane Ellis on Working with Gender Variant (Transgendered) Families which is an excellent summary for birth professionals (OB’s, midwives, doulas, childbirth educators, and so on) about how to work with gender variant people successfully. Some tips are:

  • Offer accommodations such as one-on-one classes, appointments at the beginning or end of the day, if you need to refer to another provider, you call ahead to provide the patient’s background.
  • Plan to offer additional emotional support – they may feel very isolated and may be struggling with gender dysphoria. [Note: Ellis also co-authored a journal article titled “Conception, Pregnancy, and Birth Experiences of Male and Gender Variant Gestational Parents: It’s How We Could Have a Family” which explores this parenting experience and says the over-arching theme was loneliness.]
  • Use sensitive language. It’s important to ask them what name, pronoun, and parenting term they would like to be addressed by.
  • “Don’t let your curiosity get the best of you” – it may be tempting to ask the whole history of their gender identity… only ask what you need to know to care for them
  • I think a really important sentence from the article is “The urge to refer clients/patients to “someone who has more experience” is strong; often, it is grounded in sincere concern for the client’s well-being. But the truth is: with very few exceptions, there is no one with more experience.”

ACNM has a position statement on Transgender/Transsexual/Gender Variant Health Care which includes some pointers to additional research.

Inclusive Language in Childbirth Classes

I attended an in-service by Kristin Kali, from Maia Midwifery on how language matters for LGBT students in childbirth classes. Here are some of my takeaway notes from that:

  • Using very gendered language like “mom” and “dad” can be very alienating for many families: single parents, gay or lesbian couples, surrogates, donor fathers, polyamorous families where there will be more than two parents, or a transgendered dad who is carrying the baby.
  • On intros, could ask “who is in this baby’s family?” Or “who will support you in birth and in the early weeks as a parent?” “Who is in your family? You and your child? You and a partner and child? Uncles and aunties?”
  • In class, refer to pregnant parent rather than “mom”, people in labor rather than “women in labor”, the uterus rather than “her uterus”, parents instead of “mothers.”
  • Don’t wait till you have someone in class who you know is transgender before you adapt your language. It’s hard to remember it in that one class! Consider just changing your language  long-term for ALL classes to be as inclusive as possible so that it flows naturally when you do have that parent.

Resources for Finding Supportive Caregivers

Here are some directories that may aid a gender variant expectant parent in finding a caregiver:

Updates on Cesarean Birth

As we update Pregnancy, Childbirth and the Newborn, I will post here about major updates in each section since our 2010 edition. Here’s what’s new in thoughts about cesarean.

Key resources to be aware of

Barber, et al. Indications Contributing to the Increasing Cesarean Delivery Rate. OBGYN VOL. 118, NO. 1, JULY 2011. Reviews records of over 32,000 births at Yale-New Haven hospital between 2003 and 2009, when the cesarean rate increased from 26% to 36.5%. Factors that contributed the most to the increase were, in order:

  • An increase in the diagnosis of nonreassuring fetal heart rates and failure to progress in labor. [Note: These are somewhat subjective diagnoses. It is possible that the rates of problems did not change much, but that caregivers began to lower the threshold at which they would decide cesarean was indicated.]
  • Multiple gestation. The rate of twins increased slightly, but it also became more common to do a cesarean for multiples rather than attempting a vaginal delivery.
  • Suspected macrosomia. Although more cesareans were done because it was thought the baby was too big, the actual size of babies delivered did not increase.
  • Preeclampsia. The average age of mothers has increased, and more women are obese prior to pregnancy, and this has led to an increase in gestational hypertension. Also, caregivers are becoming more likely to use cesarean rather than induction for women with preeclampsia.
  • Maternal request. A very small (less than 1%), but increasing, percentage of women requested a cesarean.

A 2011 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US summarizes current trends. Some of the data from this article figured strongly in the ACOG / SMFM statement discussed below.

ACOG Committee Opinion on Cesarean Delivery on Maternal Request, 2013. They estimate 2.5% of all U.S. births are elective cesareans without medical indication. Their summary recommendation was: ” in the absence of maternal or fetal indications for cesarean delivery, a plan for vaginal delivery is safe and appropriate and should be recommended to patients. In cases in which cesarean delivery on maternal request is planned, delivery should not be performed before a gestational age of 39 weeks. Cesarean delivery on maternal request should not be motivated by the unavailability of effective pain management. Cesarean delivery on maternal request particularly is not recommended for women desiring several children, given that the risks of placenta previa, placenta accreta, and gravid hysterectomy increase with each cesarean delivery.”

Consensus statement from ACOG and Society for Maternal-Fetal Medicine. Safe Prevention of the Primary Cesarean Delivery. 2014. This statement has the potential of a huge impact on maternity care practices and should be read by all childbirth educators and other birth professionals. From the abstract, with my emphasis added: “The rapid increase in cesarean birth rates from 1996 to 2011 without clear evidence of concomitant decreases in maternal or neonatal morbidity or mortality raises significant concern that cesarean delivery is overused. Variation in the rates of nulliparous, term, singleton, vertex cesarean births also indicates that clinical practice patterns affect the number of cesarean births performed. The most common indications for primary cesarean delivery include, in order of frequency, labor dystocia, abnormal or indeterminate (formerly, nonreassuring) fetal heart rate tracing, fetal malpresentation, multiple gestation, and suspected fetal macrosomia. Safe reduction of the rate of primary cesarean deliveries will require different approaches for each of these, as well as other, indications. For example, it may be necessary to revisit the definition of labor dystocia because recent data show that contemporary labor progresses at a rate substantially slower than what was historically taught. Additionally, improved and standardized fetal heart rate interpretation and management may have an effect. Increasing women’s access to nonmedical interventions during labor, such as continuous labor and delivery support, also has been shown to reduce cesarean birth rates. External cephalic version for breech presentation and a trial of labor for women with twin gestations when the first twin is in cephalic presentation are other of several examples of interventions that can contribute to the safe lowering of the primary cesarean delivery rate.

Read a response to this statement on Lamaze’s blog, Science and Sensibility. And Penny Simkin’s presentation on the statement and its implications. Or my reflections on it.

What does this all mean?

It can take a long time for practice recommendations to become wide-spread practice in the “real world” of obstetrics. They will likely be adopted more quickly in university teaching hospitals in major urban areas than in rural hospitals.

I think these are the messages we give our students about cesarean:

For a parent who has not had a previous cesarean, your chance of having a cesarean with this birth is about 23%. It is much higher if you are carrying twins (47%), if you are older, obese (44% at BMI of 35+), or if your labor is induced (about twice as likely). Rates vary greatly by hospital, so it’s good to research your options.

If you are carrying multiples, and the first baby is head-down when it is time for the birth, vaginal birth is better than cesarean.

If your baby is breech at 35 weeks, try chiropractic, acupuncture / moxibustion and other techniques to turn baby. Ask for a version at week 37.

If a care provider tells you your baby is looking big, and recommends an ultrasound in late pregnancy to assess size, or recommends induction / cesarean to treat: know that a) late-term ultrasounds are not a precise way to measure size, b) macrosomia is not considered a reason for induction, and c) macrosomia should only be considered an indication for cesarean if baby is believed to be at least 5000 grams (11 pounds) in a woman without diabetes, and at least 4500 grams (9 pounds, 14.7 ounces) in a woman with diabetes.

The most common reasons for cesarean are repeat cesareans, failure to progress in labor and concerns about baby’s heart rate that arise during labor.

For most women with prior cesareans, VBAC is a safe option and should be pursued.

Failure to progress in labor. See my post on what should be considered prolonged labor. Also, talk to your clients about all the ways that we promote labor progress.

For baby’s heart rate: If there are concerns, ask how concerning it is – does it warrant immediate intervention, or is it possible to try other things. Some options are: changing mom’s position, IV fluids or oxygen for mom, amnioinfusion for baby, turning down Pitocin, letting narcotics wear off, giving tocolytics to gentle the contractions. She can also request that they use fetal scalp stimulation to check baby’s response.

 

 

 

 

Prolonged Labor: New definitions

A 2010 journal article by Zhang, et al for the Consortium on Safe Labor, titled Contemporary Cesarean Delivery Practice in the US, and a 2014 consensus statement from ACOG and Society for Maternal Fetal Medicine argue for a re-definition of what should be considered prolonged labor, and when intervention should happen.Here is a brief summary:

Phase Definition Friedman / standard practice Consortium on Safe Labor / ACOG & SMFM
Latent When mother perceives regular contractions Prolonged if over 20 hr in nullips, and 14 in multips A prolonged latent phase (e.g. over 20 hours) is not an indication for cesarean. If it is not treated, women may stop contracting or may eventually reach active labor. If treated with AROM and Pitocin, most will enter active labor.
Active When rate of dilation significantly increases. Protracted = slow. Arrest = progress has stopped. Protracted if < 1.2 cm/hr for nullips and < 1.5 for multips. Typical dilation ranged from .5 cm/hr to .7 for nullips, and from .5 to 1.3 for multips. From 4-6 cm, dilation is slower than historically described. After 6 cm, progress speeds up. Protracted labor should not be diagnosed before 6 cm. After 6 cm, protracted labor is not an indication for cesarean as long as there is progress, even if it’s slow.
Arrest if no change in 2 hours (after 4 cm and with adequate contractions) Cesarean for arrest should only be for women who are beyond 6 cm with ruptured membranes who fail to progress despite 4 hours of adequate uterine activity or, for those with inadequate contractions, at least 6 hours on Pitocin.
Second Stage When cervix is fully dilated through delivery. (Note: some researchers argue we should define it as when the mother develops the urge to push) Typical practice has been to limit nullips to three hours, and multips to two, even with epidural. (ACOG) Parity, delayed pushing, use of epidural analgesia, mom’s BMI, birth weight, and OP position affect length of pushing. (e.g. pushing is one hour longer on average with epidural). No absolute maximum length of pushing has been defined. Arrest should not be diagnosed until after 3 hours pushing for a nullip, and 2 for multip – longer if she has an epidural or diagnosed malposition. In case of prolonged second stage or arrest of descent, vacuum, forceps, and manual rotation of the fetus should be considered prior to cesarean.

In an induced labor, latent phase may go 24 hours or longer. It should not be considered a “failed induction” until Pitocin has been administered for at least 12 – 18 hours after AROM.

Breast Cancer Screening Guidelines

If you just want a brief summary of guidelines, look here. For all the details, read on!

Breast Cancer Screening

Over recent years, there have been significant changes in recommendations for how to screen for breast cancer, how often, what age to start at, and what age to stop screening. A significant influence on the debate has been the recommendations issued by the United States Preventive Services Task Force (USPSTF) in 2009, which are summarized in the chart below. (Read the full document here. Our Bodies Ourselves has a helpful detailed examination of them here.)

Here is a review of current thoughts.

Methods of screening:

  • Breast self-exam (BSE) – Looking in the mirror for changes, then using a standardized pattern to methodically check the breast for lumps or other changes. (Instructions here.) Past recommendations were for monthly BSE, but research hasn’t shown much benefit to this routine, so it is no longer specifically recommended. Instead, they recommend breast self-awareness – this simply means being familiar with your breasts, and having a sense of what is normal for you so you can tell if there are any changes.
  • Clinical breast exam (CBE) – A health care professional examines your breasts, first looking at them for any abnormalities in size or shape, then using hands to feel the breasts, checking for lumps. CDC says it does not reduce the risk of dying from breast cancer
  • Mammograms – An x-ray of the breast. See details here. 70% of women over 40 have mammograms. (NY Times, 2013) It is the most effective method for finding breast cancer (though it has limitations as discussed below) and is recommended for all women, although recommendations range on frequency and on age to begin screening (See below)
  • Magnetic Resonance Imaging (MRI) – magnets and radio waves create detailed, cross-sectional image of the breast. Details here. It is recommended only for high risk women, and only in conjunction with mammograms. (See below.)

Incidence of Breast Cancer

About 230,000 women are diagnosed with breast cancer each year in the United States. That’s 14% of all cancer diagnoses. The chance that a woman will have breast cancer at some point in her life is around 12%, or 1 in 8 chance. Approximately 90% of breast cancer patients survive at least 5 years beyond diagnosis. (SEER)

The risk of breast increases with age. For a 30 year old, the chance she’ll have it in the next ten years is just .44% (1 in 227). For a 70 year old, the chance is 3.82% (1 in 26.) (National Cancer Institute)

Benefits of breast cancer screening:

Breast self-awareness and CBE may detect some tumors. Mammograms can find malignant tumors that could not be detected by hand. Screening can help to detect breast cancers when they are small and more treatable, and before they spread to other parts of the body. A small tumor is easier to remove and less likely to result in mastectomy. Dr. Richard C. Wender, chief of cancer control for the American Cancer Society says mammography reduces the death rate by at least 15% for women in their 40s and at least 20% for older women.

Another way of viewing this is: For an individual woman in her 40s, the chance of dying of breast cancer in the next ten years is .35% if she doesn’t have annual mammograms and .3% if she does. For a woman in her 50s, annual mammograms lower her risk from .53% to .46%. (NY Times, 2013)

For some women, regular screenings can also reduce their anxiety about developing breast cancer. Everywhere women go, they see pink ribbons, and messages that build their fear of breast cancer and reassure them that “mammograms save lives.” So, the annual checkup soothes their fears. (Interestingly, women may be overly fearful of breast cancer. The actual risk of having breast cancer in your lifetime is 12 – 13%. 89% of women overestimate that, with an average estimate of 46%. Science Daily.)

Hazards of breast cancer screening:

  • False negatives: Mammograms may miss 20% of tumors (National Cancer Institute). False negatives are more common for younger women, because mammograms are less effective on younger women’s breasts, which have denser tissue. Digital mammograms may be more effective for women under 50.
  • False positives: the mammogram may find something that after further testing turns out to not be cancer. False positives are more common for younger women, women with a family history of breast cancer, and women who are taking estrogen.
  • Additional testing and procedures: 10% of mammograms lead to follow-up testing. 8 – 10% of those women will get biopsies. (org) “Research has shown that as many as 75% of post-mammogram biopsy results turn out to be benign (non-cancerous) lesions.” (OBOS) In addition to the risks and costs of these biopsies, they put a huge emotional strain on the women involved as they go through a great deal of fear and anxiety through the testing, biopsy, and waiting for results.
  • Over-diagnosis / Over-treatment: Screenings may find DCIS (ductal carcinoma in situ – a non-invasive tumor, which can evolve into cancer) or slow-growing cancers that would never have caused symptoms or threatened the woman’s life. If these are treated, then the woman may be unnecessarily exposed to the side effects of cancer treatment.
    • A recent Canadian study found 22% of the breast cancers detected by screening were over-diagnosed. “Put simply, this means that one in five cancers do not pose a deadly threat, yet these women may still undergo treatment, including surgery, chemotherapy and radiation.” (OBOS)
    • A review concluded that “for every 2,000 women screened annually over 10 years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, with therapies that themselves have life-threatening side effects.” (NY Times, 2013)
  • Cost: Although most private insurances and Medicare cover the majority of costs of mammogram, and thus individual consumers don’t pay much, the cost to society is high. About 38 million mammograms were performed in the US last year. (FDA) Average cost of a mammogram is $266. (Source.)

Benefit-Risk Ratio depends on the Age and Risk Status of the Individual Woman

The chance of getting breast cancer increases as we get older. The median age of diagnosis is 61. The median age of death is 68. So, screening in your 60s is much more likely to be worth doing (i.e. more likely to find a cancer that will benefit from treatment) than screening at a younger age. The chance of a 20 year woman getting breast cancer in the next ten years is only about .06%. (NY Times, 2013) So, screening is your 20s is not worth doing. (Even talking about breast cancer and breast self-exams with teenagers may just create fear and anxiety without giving benefit.)

What’s the tipping point for starting screening where benefits of screening outweigh the risks? And, what’s talked about less: at what age is it no longer relevant to screen for breast cancer? Let’s start with the recommendations for older women and work down.

Over 75 years of age: Screening may detect breast cancer. But the breast cancers women tend to get at this age are slow-growing. The older woman is more likely to die of other conditions before breast cancer would kill her. Treating a cancer at this age would cause risks and complications and not significantly lengthen life span. USPSTF

Age 50 – 75: There is general consensus that the benefits of screening outweigh the concerns.

Under 50: This is where the controversy lies.

For women who do have breast cancer, mammography increases the chance that will be found early and treated. The USPSTF says screening this age group led to a 15 percent decrease in mortality. The chairman of the USPSTF says: “If I take 1000 women over age 40, over their lifetimes, 30 will die from breast cancer if we do no screening. If I screen every one of those women beginning at age 50 until she’s 74, we reduce the deaths from 30 to 23.” He says if we start the screening in their forties, we might increase that by one additional life saved. (i.e. 22 would die)

However, the rate of false positives and over-treatment are higher for younger women. “Starting mammograms at 40 would mean having exams every two years for an average of 34 years. Over a lifetime, a woman’s chances of needing a biopsy to prove she didn’t have breast cancer might be as high as 50 percent.” (OBOS)

“The Cancer Society says for every 1,000 women in their 40s screened for 10 years, 600 will be called back for a repeat mammogram for something suspicious, 350 will get biopsied and about five will end up with a diagnosis of breast cancer. And some women might get treated for a cancer that would never have caused a problem.” http://www.npr.org/templates/story/story.php?storyId=130437187

Most experts say that between 40 and 50, the decision whether or not to screen is best made through a shared decision-making process between a woman and her physician / caregiver where they evaluate her risk factors, discuss the benefits and risks of screening, and assess her personal feelings about the screening – would it reduce her anxiety or increase it? For women at higher risk of breast cancer (see below), caregivers are more likely to recommend screening in their 40s (or, rarely, even younger than 40) versus they may recommend waiting until your 50s if you are at low risk.

Screening Recommendations

Here is my comparison of major recommendations, from: The Susan Komen Foundation, American Cancer Society (ACS), American Congress of Obstetricians and Gynecologists (ACOG), and the United States Preventive Services Task Force (USPSTF).

recommendations

* Breast Self Awareness and BSE: What to Look For

Women should be familiar with their breasts and, on occasion, check their appearance in a mirror and/o touch them to see if there are any unexplained changes. Women should remember that breast changes occur with pregnancy, breastfeeding, aging, menopause, during menstrual cycles, and when taking birth control pills or other hormones. It is normal for breasts to feel a little lumpy.

The Komen Foundation and American Cancer Society recommend that if you see these changes, check with your care provider:

  • Development of a lump – a thick hard knot inside the breast or under the arm
  • Swelling, warmth, redness, or skin irritation
  • Change in the size or shape of the breast; nipple pulling inward
  • Dimpling or puckering of the skin
  • Nipple discharge (other than breastmilk) that starts suddenly

** Risk Assessment

MRI recommendations say that it should be done in addition to mammogram, not instead of, and should be done only for women at high risk: those whose lifetime risk of breast cancer is 20 – 25% or higher.

Here are some guidelines from ACS and Komen Society on what factors would be assessed to determine high risk: A known BRCA1 or BRCA2 gene mutation or a first degree relative with one. Strong family history of breast cancer at age 45 or younger. A personal history of invasive breast cancer, DCIS, LCIS, or atypical hyperplasia. Radiation therapy to the chest between 10 and 30 years of age, Li-Fraumeni, Cowden, or Bannayan-Riley-Ruvalcaba syndromes.

How have benefits, risks, and survival rates changed over the years?

It is difficult to compare studies of how women have fared over the past 25 years with how they will fare over the next 25 years. Here are some factors that have changed breast cancer survival rates:

  • Awareness: Decades ago, breast cancer was not often spoken of. Women might have had lumps or other breast changes that they did not report to a physician until too late. As our society has talked about it more and more, it has raised awareness of the issue, which makes it more likely that women with concerning changes will seek treatment sooner.
  • Incidence: Increased screening has increased the number of cancers found. (i.e. the percentage of women who will receive a breast cancer diagnosis in their lifetime)
  • Understanding of breast cancer: We used to believe that most or all breast cancer was aggressive and would spread throughout the body if not detected and treated early. We now know there are several types of cancer found in the breast (NY Times, 2013), some of which are very slow growing or non-invasive, and some will disappear on their own. (NY Times, 2014) Thus, some of those extra diagnoses mentioned in the previous bullet point are likely to be of cancers that would never have developed into anything clinically significant.
  • Treatment has improved: There has been a 25% reduction in deaths since 1990, but it’s likely that is due to treatment, not to detection. (NY Times, 2013), Reductions in mortality are “more likely explained by changes in risk factors and improved treatment than by screening mammography.” BMJ.

Fear of Cancer, and the Politics and Economics of Breast Cancer Screening

Beyond the medical research and current guidelines, there are interesting cultural issues related to this topic which affect recommendations and affect whether women follow those recommendations.

What was the political response to the USPSTF guidelines?

“Rather than engaging in discussion about how to maximize the benefits of screening while minimizing its harms, Republicans seized on the panel’s recommendations as an attempt at health care rationing. The Obama administration was accused of indifference to the lives of America’s mothers, daughters, sisters and wives. Secretary Kathleen Sebelius of the Department of Health and Human Services immediately backpedaled, issuing a statement that the administration’s policies on screening “remain unchanged.” (NY Times, 2013)

How Do Women Feel about Screening Starting at Age 40?

After the USPSTF released their recommendations in 2009, a USA Today survey found that 76% of women disagreed with the recommendations. 84% of women age 35 – 49 said they would get a mammogram before age 50. 76% of women believed the panel recommended fewer mammograms because of cost, even though the panel only looked at medical benefits and risks.

The survey also showed again that women overestimate their risk of breast cancer. Whereas a 40-year-old woman’s chance of getting breast cancer in the next decade is only 1.4%, 40% of women think the chance is 20 – 50%.

Prophylactic mastectomy

Of women who have been diagnosed with cancer in one breast, there has been a significant increase in those opting for a double mastectomy. One study says they chose this to prevent having to face a second cancer (98%) and to improve chance of survival (94%). Even among women diagnosed with DCIS (a risk factor for cancer), there was a 188% increase from 1998 – 2005 in women choosing double mastectomy.

For women with a genetic predisposition to cancer, removing both breasts does not necessarily improve survival rates, and they were generally aware of that when making the decision.

For women who do not have a genetic predisposition, the chance of a cancer in the other breast is only 2 – 4 %, but those women tended to believe that the chance was 10%. In another study they estimated it at 30%. So, they may be basing their decision to have a double mastectomy on a fear-based over-estimation of the risk.

(Data combined from these sources: http://www.oncologynurseadvisor.com/young-women-overestimate-cancer-risk-in-second-breast/article/315231/ and NY Times 2013.)

Breast Cancer Charities may benefit from fears of breast cancer

A Susan Komen Foundation ad campaign from 2011 said “The 5-year survival rate for breast cancer when caught early is 98 percent. When it’s not? 23 percent.” Dr. Steven Woloshin from Dartmouth says this implies “[mammography] has this huge effect, and you’d have to be really irresponsible or crazy to not be screened.” (Huffington Post) But, Woloshin says the statistics are deceptive: “a woman in her 50s who goes for regular mammograms for 10 years will only cut her chance of dying by a fraction of a percentage point — for every 10,000 women who are screened 7 deaths will be prevented.” (MedicineNet)

Gayle Sulik, a sociologist, credits Komen (and other charities) for raising awareness of the disease, transforming “victims” into “survivors” and distributing over $1 billion to research and support. But she says “the function of pink-ribbon culture — and Komen in particular — has become less about eradication of breast cancer than self-perpetuation: maintaining the visibility of the disease and keeping the funds rolling in.” The Komen Foundation does have some vested interest in keeping awareness of breast cancer high. (NY Times, 2013) In 2012, CNBC reported that Komen’s annual income was around $340 million, and that Komen’s founder and CEO received an annual salary of $684,000, which is about a quarter million dollars higher than what is typical for a charity of that size.

Does anyone else have a vested interest in annual mammograms?

“[An] editorial in BMJ, “Too Much Mammography notes that it is difficult to make changes around screening mammography practices “because governments, research funders, scientists, and medical practitioners may have vested interests in continuing activities that are well established.” (OBOS) For example, the American College of Radiology, a trade organization for professionals who conduct and interpret mammograms, objected to recommendations to do mammograms less frequently.

Reducing your Risk of Breast Cancer

Obviously, no matter what screening approach you choose, we’re all hoping the results come back negative! What are some things you can do to increase that chance?

  • The more months of total breastfeeding in your life, the lower your risk.
  • Limit alcohol. No more than one drink a day.
  • Control your weight. Obesity, especially after menopause, increases your risk.
  • Don’t smoke. Smoking especially increases the risk of premenopausal breast cancer.
  • Limit hormone therapy for menopause related concerns. If you use, try the lowest possible dose that relieves your symptoms, keep use short-term (less than 3 years).
  • Minimize exposure to radiation and environmental toxins.
  • Exercise regularly.