Why is induction recommended over age 35?

What is induction?

Induction is using medical means to start a labor that hasn’t started on its own. (Learn more about methods of medical induction.)

Induction may be recommended if: the baby is not growing well or thriving in utero, the parent has an illness that is worsening (such as diabetes or hypertension), the baby is overdue, or the bag of water broke and labor hasn’t started on its own. There is also a category called elective induction, which is being induced for non-medical reasons, such as wanting to control the timing of the birth or being tired of being pregnant.

As with all medical interventions, induction has benefits and risks. If there is a clear medical indication that delivering the baby sooner rather than later would have more benefits than the risks of induction, then induction is recommended.

How Common is Induction

Induction rates rose steadily from 1990 to 2010 ((source for chart), then somewhat plateaued, following some active campaigns to reduce elective induction, such as AWHONN’s “Don’t Rush Me – Go the Full 40” about the physiologic benefits of full-term pregnancy, and an editorial in American Family Physician about stopping elective induction before 39 weeks to reduce unintended harms to babies not yet ready for birth.

In 2014, ACOG’s recommendation was to induce at 41 weeks.

That changed after the results of the ARRIVE trial were published in 2018. The ARRIVE trial was considered a high quality randomized controlled clinical study (although ACNM did caution against over-generalizing the results, this article addresses methodology concerns, and this infographic addresses how the results might not apply to all people.)

The results of that trial (and other trials) were that elective induction decreased the risk of cesarean. (Rates were 18.6% in the induction group versus 22.2% in those assigned to the wait for labor to begin group.) The induction group was also less likely to have gestational hypertension / preeclampsia (9% vs 14%).

ACOG (the American College of Obstetrics and Gynecology) issued guidance in response, and a joint statement from ACOG and SMFM (Society for Maternal Fetal Medicine) said ““ACOG and SMFM have … determined that it is reasonable for obstetric care providers to offer an induction of labor to … Women who are planning their first delivery, are healthy and have no medical or obstetrical complications… who are 39 weeks pregnant and had an ultrasound performed early in the pregnancy to confirm dating.”

In other words, elective induction at 39 weeks is back on the table as an option after 2018. In 2016, 24.5% of US births were induced. In 2021, 32% were.

There was not universal agreement with this recommendation: WHO says there’s insufficient evidence to recommend elective induction before 41 weeks and NICE says induction should be offered at 41 weeks. SOGC (Society of Obstetricians and Gynaecologists of Canada) said we shouldn’t recommend induction just to reduce cesarean risk, ACNM (American College of Nurse Midwives) said there are benefits of spontaneous labor and risks of induction and other effective ways to reduce the risk of cesarean (e.g. doulas, midwifery care, movement during labor)

Is induction recommended for parents over age 35?

In a 2022 consensus statement on Pregnancy after Age 35, ACOG made a more explicit move to recommend induction for older moms: “We recommend proceeding with delivery in well-dated pregnancies at 39 0/7–39 6/7 weeks of gestation for individuals with anticipated delivery at age 40 years or older due to increasing rates of neonatal morbidity and stillbirth beyond this gestational age.” A randomized trial of induction at 39 weeks for women over 35 also indicated no increased risk of cesarean and no short-term adverse effects on mothers or babies.

Stillbirth Risk

How high is the risk of stillbirth for mothers over age 35? How much higher is it if the pregnancy continues past 39 weeks?

This chart (source) compares the risk of stillbirth per 10,000 pregnancies during each week of pregnancy for pregnant people under age 35 vs. for people 35 years or older. It is clear that the risk does increase each week, and that it is much higher after age 35.

Weeks	<35 yrs	>35 years
39	3.9	5.0
40	6.8	10.0
41	8.5	15.4
42	28.2	32.5

[Note: if you’re a pregnant person reading this, I know that numbers like this can be frightening. Take a deep breath, and flip the numbers: even a rate like 32.5 per 10,000 means that 9,967 out of 10,000 will NOT have a stillbirth in week 42.]

Benefits and Risks of Induction

So, the research cited above indicates that inducing at week 39 may reduce the risk of stillbirth, possibly reduce the risk of cesarean, and can reduce the chance of hypertension or diabetes worsening.

What else does the research show us about the risks and benefits of induction? A Cochrane review, which mostly looked at induction at 41 weeks vs. continuing to the 42nd week, showed:

• fewer perinatal deaths / stillbirths
• better Apgar scores at birth, and fewer NICU admissions
• little to no difference for: perineal tears, postpartum hemorrhage, breastfeeding at discharge

But, induction is not innocuous. What are the risks or tradeoffs of induction?

• Medicalization: An induced birth is inherently more medicalized than waiting for labor to begin spontaneously – continuous fetal monitoring is required, IV fluids are common – these two factors can also reduce the birthing parent’s ability to move around and use natural coping techniques. Plus they may not be allowed to eat solid foods. ACNM summarizes this as “Based on US practices, induction may not be a desirable option for those persons who prioritize a… low-intervention birth experience.”
• Not waiting for baby to trigger labor: In the final weeks of pregnancy, babies are gaining immunities, gaining weight, increasing their brain development and maturing their lungs. When the baby’s lungs are mature, that triggers hormones that trigger labor. If we induce labor before that happens, there is a chance that baby is not as ready for birth as they would be if labor started spontaneously. At 39 weeks, many babies are totally ready to go, but not all.
• Longer labor / hospital stay: In late pregnancy, prostaglandins cause the cervix to ripen and thin. If we jumpstart labor, the body may not have made these preparations for labor. So, with an induction, it can take a while to get labor started. It might take 12 – 24 hours, or longer if cervical ripening is needed. If an induction takes too long, cesarean may be recommended.
• Changes to the hormonal dance of labor. Typically, in late pregnancy, the uterus becomes more sensitive to the oxytocin hormone which causes labor contractions. During labor, as the cervix stretches, pain receptors in your brain release endorphins, a natural painkiller more effective than morphine. When labor is induced with Pitocin (synthetic oxytocin), your body does not produce as much natural oxytocin and does not produce as much endorphins, so you miss out on that natural pain relief. (Learn more about the hormonal differences.)
• More Pain? I have not been able to find any research comparing average pain levels in an induced labor versus a spontaneous labor. (Nor much on maternal satisfaction, although it seems to me that both of these things are important factors that we should be researching.) Anecdotally, many people seem to experience more pain in an induced labor. That may be partially due to the fact that a natural labor builds intensity gradually, allowing you to adapt and find coping techniques thar work for you. With a Pitocin induced labor you jump straight into long, strong contractions. (3 – 4 contractions in ten minutes, each lasting 40 – 60 seconds.)
• Induction can cause variations in the baby’s heart rate, which can lead to additional interventions.

Questions to Ask

If your care provider has offered induction at 39 weeks, here are some questions you can ask yourself or them to decide if it’s right for you:

• Are there other ways to reduce risk of stillbirth or monitor for other problems with my baby?
  • Learn about fetal movement tracking – paying attention to your baby’s kicks can reassure you that all is well.
  • Ask about tests to monitor baby’s well-being, such as the non-stress test, biophysical profile
• Are there other ways to reduce the chance of cesarean birth? There are: having continuous labor support (especially from a doula), upright positions and movement during labor and birth, choosing a midwife rather than an OB as your care provider and waiting until 6 cm dilation before being admitted to the hospital are just a few. (Learn more.)
• Are there non-medical ways to get labor started? Possibly sexual intercourse, definitely breast / nipple stimulation, possibly acupuncture, herbs, or castor oil. If the need to start labor is urgent, your care provider may tell you these aren’t effective enough. But, if you have some time, they may say these are options you could try.
• How likely is induction to be successful? If you’re almost ready to go into labor on your own, induction will be faster and more effective than if you’re not. So, learn about the Bishop score which measures ripening and effacement of the cervix and ask your caregiver what your score is. Starting Pitocin only when you have a Bishop score of 4 increases the chance of cesarean. Waiting for your cervix to get ready naturally, or using cervical ripening methods to get your Bishop score up to 8 or higher (if it’s your first baby, 6 or higher if you’ve given birth before) will increase the chance of a successful induction. (Learn more about this and other factors here.)

How to have the best possible induction?

If you do decide that induction is the best answer for you, here’s how to increase your satisfaction:

• Ask your care provider what method(s) will be used, and learn more about them.
• Be prepared for a long process. Pack some entertainment options and plenty of patience. Consider having an extra support person so they can swap off or take breaks.
• Eat before your induction begins, as you may not be able to eat after it begins.
• Create an environment that is as calm and soothing as possible: perhaps dim light, music playing, favorite items to wear or look at or hold.
• Try to be as mobile as possible (this helps baby rotate and descend which helps labor to progress.) For example, try sitting on a birth ball or in a rocking chair rather than lying in bed.

Learn more about interventions in maternity care and making informed choices in episode 8 of the Transition to Parenthood Podcast, or by reading Pregnancy, Childbirth, and the Newborn: The Complete Guide.

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Free Illustrations for Birth Professionals

Years ago, I created LOTS of simple line drawings for use in birth education materials. I’m putting them here for anyone who wants to use them for any perinatal education or birth support purpose, whether that’s for class handouts, PowerPoints, to show to a client over a video call, or whatever. Everything on this page is free for you to use, no need to credit me as the source. For any of them, just right click on it, and choose copy or save as.

Positions for Labor

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Maternity Care

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Complications

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Breastfeeding

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Breastmilk Expression

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Babywearing

Rebozo Techniques

Choices in Maternity Care

We’ll talk about all the choices you make in your maternity care, from choosing a care provider and birthplace and developing a birth plan to what happens if unexpected complications arise and you have to make choices about interventions you were hoping to avoid. [A transcript of the episode is available at https://transitiontoparenthood.wordpress.com/for-parents/options-for-maternity-care/choices-in-maternity-care/]

Birth and Baby’s First Hour

This episode covers second stage labor – the birth of a baby, third stage – the delivery of the placenta, and the first hour of baby’s life. Addresses when to push, how to push, and positions to aid labor progress. Talks about “the Golden Hour” of bonding with a new baby. [A full transcription of this episode is available at: https://transitiontoparenthood.wordpress.com/for-parents/labor-and-birth/birth-and-babys-first-hour/]

Pregnancy and Disability

Someone recently asked me to share my perspectives on how perinatal professionals can provide sensitive, supportive care for people with disabilities. Here are some initial thoughts on that question.

First, a caveat to any advice I offer below: I can only speak to my own experience. The needs of each person are unique and depend on such things as:

• What is the disability?
• How long have they had it and how experienced are they at working around it?
• What is their self-image / identity – if they think of themselves as “disabled” they are likely to have more worries about the perinatal period than someone who doesn’t see their disability as a primary part of their identity or life experience

My experience: I had bone cancer when I was 15 years old, and had my leg amputated above the knee. I wore an artificial leg for a few years, but discovered I can move around faster and easier on crutches than with an artificial leg. I don’t really think of myself as “handicapped” because there’s little I can’t do. I can’t “run” very fast. But, I can ski, swim, roller-blade, ice skate, and ride a tandem bike. I can carry things while walking on crutches, take care of all my household chores, drive, work full-time, and so on.

When I became pregnant with my first, I’d already been an amputee for 11 years, so I was very used to making the physical adaptations I needed to make. So, throughout my pregnancy, I never questioned my ability to handle pregnancy, birth, and caring for a baby. I didn’t know all the exact details of how I would adapt everything, but I had complete confidence I would figure it out. And I did… I’ve now birthed and cared for 3 children – I don’t actually find it that difficult.  (OK, honestly, we all find parenting difficult! I’m just saying that having one leg did not make it particularly more challenging.)

My care providers vs. others:  During my pregnancies, I don’t remember my disability being a big issue for anyone. My care providers never implied that there would be anything especially challenging about my case, which I appreciated.

But that’s not always the case. Once a public health nurse called and asked me to doula for someone delivering at Valley. I told her I didn’t travel that far. But then she told me why she’d called me specifically. The client was a double amputee who used a wheelchair. She had been told that she would need to deliver by cesarean because she was an amputee. I was dumbfounded! It’s not like you need legs to have a vaginal birth. I ended up not assisting that mother because of timing, but I did meet with her and talk to her about her options, and she did end up planning and having a vaginal birth.

What care providers can do:

• First and foremost: Assume she is capable of pregnancy, birth and baby care. (You may be one of the few who treat her this way.)
• If you see accommodations that you think could be made, ask her if she would like your help brainstorming how to handle something. If she’s had her handicap for more than a few months, she probably knows a great deal more about her needs than you do. Respect that.
  • For example, I happened to have a dad who was an arm amputee attend a newborn care class I was teaching. I approached him on break, and said “I am wondering if you have any specific questions that are unique to your situation. I don’t know anything about having one arm, but I know a lot about baby care, so if you have things you’re wondering about, maybe you and I can put our knowledge and experience together and brainstorm some kind of solution together.”
  • Once when I attended a prenatal yoga class, the instructor approached me before class, and said “let me know if there’s anything I can do to help you with the exercises.” I told her: “I can usually do a better job than you can of figuring out how to adapt things, but it helps me to know what my goals are. So, when you teach a position, if you can tell me whether the goal is to stretch my hamstring, or stretch my calf muscles, or strengthen my glutes or whatever, that helps me adapt the exercise in a way that reaches that goal.”
• Don’t “other” someone.  Don’t do things that imply that they are a weird aberration from a normal human being. Examples from my experience:
  • When a caregiver is going to a pelvic exam on me, they always pull out both stirrups as per their usual habit. I like it if they then calmly put one away instead of getting all flustered and awkward when they realize that I don’t have a foot to put in the right side stirrup.
  • When a nurse opened a package of non-slippy socks, I liked that she calmly set one aside on the table, saying “here’s an extra for later”
  • If you make a “mistake”, calmly apologize and move on. Don’t make a big deal of it.
  • If someone gushes over me like “wow! You’re so brave to take this on. If I were handicapped, I would be too afraid to try this,” they may think that’s supportive, but it’s easy for that to come off as “something’s wrong with you. You’re less capable of parenting than other people are.”
• Be sensitive about their “appliances”. Their wheelchair, hearing aids, glasses – whatever – should be treated with the same respect with which you treat their body.
  • My crutches may seem like inanimate objects to you, but they are an essential part of my independence and mobility. It is VERY important to me that no one take my crutches and move them across the room without my permission. Although I can hop short distances, I can feel “trapped” in place the second my crutches are out of my reach, which can be anxiety inducing.
  • I also wear glasses as I am very near-sighted. I need to know where they are at all times, because when I don’t have them on, I can’t find them! And I feel mentally competent with my glasses on, and severely limited without them.
• A person with a disability also often has a long history with health care providers and medical institutions. Her experiences may be positive, negative, or a very complex mix.
  • If you sense any defensiveness or animosity toward you, or if she “over-reacts” to a situation, realize there may be a very good reason for her reaction.
  • Respect that she may have some expertise that a non-disabled layperson might not have. For example, I can tell you that I’ve had many I.V’s in my life, and been told by many health care providers that my veins are tiny and tend to roll, and it’s hard to get an I.V. into me. If a patient tells you something like that, respect that. I appreciate when care providers have said “Oh, thanks for letting me know. I’m actually going to ask X to come in and start this I.V. because she’s a wizard at finding a vein.”
  • Ask her: “I’m guessing you’ve had some experience with medical care – tell me what kinds of things you find most helpful or let me know if what I’m doing is not helpful.”
• Don’t assume that their handicap defines them. Although the fact that I have one leg is certainly the first thing people notice about me, it is only a very small part of all the things that I am.
  • Someone once asked me: “Wouldn’t you have loved to take a childbirth class that was specifically aimed at people with disabilities and that could really focus on your unique needs?” I answered “not really.” Not that I have anything against the idea, but it also didn’t feel like something I needed. When I was pregnant for the first time, my disability was old news. I didn’t need peer support with it. Becoming a parent for the first time was new… I needed support from other expectant parents. Whether they had a disability like me, or liked Broadway musicals like I do, or enjoy Indian food like I do didn’t matter. The key was that they were other first-time parents like me.
  • If there are support services in the community that are unique to specific populations, learn about them! When you have a client that fits that demographic, let them know the resource is out there. But also tell them about all the other support services that might be a good match for them. Don’t assume you know which are the best match. Let them choose the support services that they feel best meet their needs.

 

Medical Mindset Tool

When making choices about medical care, are you a maximalist or a minimalist? A maximalist may use lots of tools to prevent and treat problems. A minimalist may try to use as few tools as possible, letting things run their natural course. What kinds of medical tools do you use? Natural remedies and self-help techniques or medicine and technology? A maximalist naturalist might prepare for birth by attending prenatal yoga, drinking raspberry leaf tea, and frequent love-making to get her oxytocin flowing. A minimalist technologist might choose a hospital birth with an OB, but ask for as few interventions as possible.

Helping your students or clients understand their medical mindset may help them in choosing care providers and birth places, and may also help them explain their decision making in labor to their partners and care givers. There are a few tools you can use to learn more and help your clients to understand this idea.

Jerome Groopman has written a book on Your Medical Mind: How to Decide What is Right for You. (He also wrote How Doctors Think and some other great books.) You can read an article which summarizes it here: http://news.harvard.edu/gazette/story/2012/02/%E2%80%98your-medical-mind%E2%80%99-explored/ or watch a video here that presents the idea to medical professionals: http://practicalbioethics.tv/2012/06/11/jerome-groopman-pamela-hartzband/when-experts-disagree.html

Kim James and Laurie Levy discuss this in their childbirth classes and with doula clients. They designed a worksheet you can find here: http://kimjames.net/Data/Sites/3/groopmanspectrumsforlamaze2012landscape9.24.12.pdf

I liked their idea, but found the worksheet complicated and a little dense on information for my client population, so I made a simplified version of the worksheet. Click here for the PDF. If I were using this in a class, I might give one copy to the pregnant parent, and one to the support person to fill out separately, then compare and discuss.

[Added on 7/28/15: a 2-page version of the handout that looks at more factors that affect decision-making. Find it here.]

Seeding and Feeding a Baby’s Microbiome

What is the microbiome?

The collection of bacteria, viruses, fungi, and other organisms that live in and on the body. We have about 10 trillion human cells in our bodies, and about 100 trillion microbes. We have evolved in tandem with this microbiome for thousands of years. The balance of microbiomes varies throughout our body, and the bacteria found in our mouths is different than on our skin, which is different than in our intestines.

Why does the microbiome matter?

• A balance of microbes leads to optimal health. An imbalance can lead to disease. For example, a vaginal yeast infection may occur when the healthy bacteria are reduced by antibiotics, allowing yeast to overgrow.
• Good bacteria can aid digestion, provide vitamins (K and B12), regulate the bowels, stimulate the development of the immune system, and protect against infection.
• An overgrowth of harmful bacteria can lead to infectious disease.
• Disruption of the gut microbiota has been linked to inflammatory bowel disease, diabetes, obesity, allergies, asthma, and some cancers.
• Many studies have shown that the presence of absence of specific microbes can cause life-long changes in immunity.

How does a baby’s microbiome develop?

• During pregnancy
  • In the past, the womb was believed to be a sterile environment. However, microbes are found in the placenta, amniotic fluid, and in meconium. (The waste that accumulates in the fetal bowels.)
  • Maternal fecal microbes have been found in the uterine environment, leading to hypotheses that microbes from throughout the body are transferred through the bloodstream. And from there into the placenta, then the umbilical cord and the amniotic fluid.
  • Placental microbes are similar to the microbes in the mother’s mouth – especially types of bacteria that aid in the metabolism of food.
  • Healthy bacteria may benefit baby. For example, if the mother lived or worked on a farm, that might protect against allergies and asthma.
  • Others worry that unhealthy bacteria may affect baby. For example, obese women tend to have abnormal gut microbiota. This may be transferred to the baby.
  • Maternal diet affects the baby. E. coli bacteria (an unhealthy bacteria) was less common amongst babies whose mothers ate primarily organic foods.
• At birth
  • During a vaginal birth, a baby is exposed to the microbes in mother’s vagina. In the third trimester, these are especially high in lactobacilli, which help the baby to digest milk.
  • When a baby is placed skin-to-skin on a parent, they are exposed to the parent’s skin microbiome. The baby’s skin, mouth, and digestive tract are “seeded” by whatever and whomever they first have contact with.
• Through feeding
  • Breastmilk exposes the baby to more microbes. Several are gut microbes that influence digestion.
  • Breastmilk contains sugars (oligosaccharides) which are not digestible by babies, and whose role appears to be to nourish / feed a healthy microbiome in baby’s gut. These are also referred to as prebiotics. By helping healthy bacteria to grow, there is less room for unhealthy bacteria.
  • When solid food is introduced, the microbiome begins to evolve to a more adult-like combination of microbes.
• Through the environment
  • As baby is held by various people, their microbiomes influence it.
  • As the baby starts to explore his world, crawling on the floor, playing outdoors, petting animals, and putting everything in his mouth, his microbiome shifts and evolves, becoming quite diverse by age 3. The “hygiene hypothesis” states that babies who are exposed to more symbiotic organisms have lower risks of asthma and allergies, and stronger immune systems.

What can interfere with the establishment of a healthy microbiome?

• During pregnancy and labor
  • Antibiotics given to mom can affect the mix of microbes in the placenta, amniotic fluid and vagina. This disrupted microbiome is inherited by the baby.
• At birth
  • Babies born by cesarean, and thus not exposed to vaginal bacteria, are at increased risk of asthma, allergies, obesity, diabetes, and celiac disease. Studies comparing the microbiomes of vaginally born babies with those born via cesarean have shown differences in their gut bacteria as much as seven years after delivery. (Salminen)
  • After cesarean birth, instead of skin-to-skin contact with the parents, the baby’s first exposures are to hospital bacteria and the bacteria of hospital staff. (Babies in NICU were found to be colonized by bacteria from the health care staff, from medical equipment, and from the counter-tops in the NICU. – Brooks)
• Newborn care
  • After any birth, if baby is wrapped in a blanket, and placed on a clothed parent, rather than skin-to-skin, the transfer of skin microbes is not complete.
  • Early baths remove / reduce protective vernix, vaginal microbiome, and baby’s own newly seeded skin microbiome. Those are replaced by hospital microbes.
  • If baby is given antibiotics, it reduces microbial diversity, and the number of both harmful and helpful bacteria. The impact lasts over 8 weeks. The longer the duration of antibiotics, the harder it is for the microbiome to recover. Early use of antibiotics, or prolonged use, can have long-term side effects, increasing risk of obesity or inflammatory bowel disease in later life.
• Feeding
  • Formula-fed babies (even those who just had short-term formula feeding in the first few days) had increased harmful bacteria and decreased helpful bacteria.

What can parents and health care providers do to foster a healthy microbiome?

• During pregnancy:
  • A mother can increase exposure to diverse healthy bacteria. Taking probiotic supplements may improve gut diversity (for mom and baby), may reduce gestational diabetes, and may reduce risk of allergy and eczema for the baby. (Research cited in Collado) You can eat probiotic foods which introduce healthy bacteria, such as fermented foods and foods with live cultures. And you can eat prebiotics – foods with oligosaccharides which feed healthy bacteria – see the list at the end of this article. (Reed)
  • Minimize exposure to unhealthy bacteria, such as food-borne illnesses.
• During pregnancy and labor: Minimize exposure to antibiotics. If they are needed, consider consuming probiotics or prebiotics after the course of antibiotics is complete.
• If baby will be delivered by cesarean, a baby’s initial seeding is from hospital bacteria and skin microbes rather than vaginal microbes. You can expose the baby to vaginal bacteria by swabbing. Although swabbing does not colonize the baby as well as vaginal birth, it helps. (Swabbed babies had twice as much maternal bacteria as babies who were born by cesarean but not swabbed. Babies who were born vaginally had six times as much maternal bacteria.) Here’s the process:
  • Sample mom’s vagina: make sure the mother is HIV-negative, strep-B negative, and has an acid, lactobacillus-dominated vagina.
  • Place sterile gauze in the mother’s vagina. Incubate gauze for one hour. Remove prior to surgery.
  • After birth, wipe baby’s mouth, face and hands with the gauze.
  • Note: If the caregiver will not do this procedure, the mother and partner can do it themselves.
• After birth, baby should go straight onto the mother’s body, skin-to-skin. (Consider bringing a blanket from home to cover baby, rather than using a hospital blanket.)
• In the first hours, encourage people other than the parents to look but not touch.
• Wait 24 hours after birth to bathe the baby.
• Feed baby only breastmilk for as long as possible.
• If a breastfeeding mother develops mastitis or a yeast infection, ask a lactation consultant about treatment with lactobacillus probiotics.
• Giving probiotics to a baby can treat antibiotic-induced diarrhea, prevent eczema, reduce colic symptoms, and possibly reduce obesity in later life. (Studies cited in Arrieta and Collado.)
• Let your child explore their world, with plenty of time outdoors, digging in gardens, and exposure to animals, both pets and animals at petting zoos.
• Offer your child diverse foods, including: fermented foods and foods with live cultures (Yogurt, buttermilk, sour cream, kefir, sauerkraut and other fermented vegetables, tempeh, miso, soy sauce, kimchi, dosas and sourdough breads, kombucha, etc.) and prebiotic foods that are high in oligosaccharides (onions, garlic, legumes,  asparagus, starchy vegetables like sweet potatoes, squash, turnips, parsnips, beets, and plantains)

Note: While many of those recommendations are supported by scientific research, not all have been adequately researched.

Here is a 2 page handout of this information to share with clients.

Sources:

• Aagard, et al (2014). The placenta harbors a unique microbiome. Science Translational Medicine. http://www.ncbi.nlm.nih.gov/pubmed/24848255
• Arrieta, MC, et al. 2014. The intestinal microbiome in early life: health and disease. Front Immunol. Sep
• 5; 5:427. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4155789/
• Azad MB, et al. 2013. Gut microbiota of healthy Canadian infants: profiles by mode of delivery and infant diet at 4 months. CMAJ. Mar 19;185(5):385‐94. http://www.cmaj.ca/content/185/5/385.long
• Brooks B, et al. 2014. Microbes in the neonatal intensive care unit resemble those found in the gut of premature infants. Microbiome. Jan 28;2(1):1. http://www.ncbi.nlm.nih.gov/pubmed/?term=Microbes+in+the+neonatal+intensive+care+unit+resemble+those+found+in+the+gut+of+premature+infants
• Canadian Medical Association Journal. (2013, February 11). Infant gut microbiota influenced by cesarean section and breastfeeding practices; may impact long‐term health. ScienceDaily. sciencedaily.com/releases/2013/02/130211134842.htm
• Collado, et al. (2012) Microbial ecology and host-microbiota interactions during early life stages. Gut Microbes. 3(4): 352-365. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3463493/
• Dominguez‐Bello MG. 2014. Restoring the Newborn Microbiota. Poster presentation American Society for Microbiology, Boston. (http://commonhealth.wbur.org/2014/06/birth‐canal‐bacteria‐c‐section)
• Grens, K. (2014). The maternal microbiome. The Scientist Magazine. 28(8), 46‐46.
  http://www.the‐scientist.com/?articles.view/articleNo/40038/title/The‐Maternal‐Microbiome/
• Kesser, C. L.Ac. (2014) What to do if you need to take antibiotics. (blog post) http://chriskresser.com/what-to-do-if-you-need-to-take-antibiotics/
• Salminen, et al. (2004) Influence of mode of delivery on gut microbiota composition in seven year old children. Gut. 53: 1388 – 1389. http://gut.bmj.com/content/53/9/1388.2.long
• Reed, Rachel, and Johnson-Cash, Jessie. (2015) The Human Microbiome: considerations for pregnancy, birth and early mothering (blog post) http://midwifethinking.com/2014/01/15/the-human-microbiome-considerations-for-pregnancy-birth-and-early-mothering/
• Silgalliss, Mara. (2015) Type of Birth Alters Baby’s Bacteria. (blog post) http://lactobacto.com/2015/01/09/type-of-birth-alters-babys-bacteria/
• Simkin, P. (2015) Maternity Care And The Microbiome: How Birth Practices Dictate Future Health. Conference presentation. http://www.goldmidwifery.com/pdf/handouts/2015/PennySimkin.pdf

To learn more about practically any topic related to the perinatal period, check out Pregnancy, Childbirth, and the Newborn: The Complete Guide.

Research Summary on Effectiveness of Non-Drug Coping Techniques

There have been several literature reviews of available research on the available non-pharmacological techniques for coping with labor pain. Each of these reviews acknowledges the limitations of the research that they compile: primarily the studies are small sample sizes, and are not properly randomized control trials. (Women are typically allowed to choose which coping techniques to use with their labor.) So, all conclusions come with the caveat that “more research is needed.”

This chart summarizes those reviews. (Note: the birth ball results are based on a single study rather than a review.) Pain coping techniques are compared to “usual care.”

The chart compares the following factors that might be desired outcomes coping measures: less pain intensity, less likelihood that the laboring mother will turn to pain medications (unless that was her goal), higher satisfaction with pain relief, shorter labor, higher chance of spontaneous vaginal delivery (vs. instrumental delivery or cesarean), and less use of Pitocin to augment a slow labor.

Source	Less pain?	Less pain meds?	More satisfaction	Shorter labor	Spontan. vaginal	Less pitocin
Acupressure	yes *
Acupuncture		yes				yes
Acupuncture	yes	yes *	yes *		yes *
Aromatherapy	NSD
Aromatherapy	NSD	NSD		NSD	NSD
Birth Ball	yes *			NSD
Continuous Support		yes	yes	yes	yes	yes
Epidural & Pain Meds	yes	N/A	yes	no	no	no
Hypnosis	yes *	NSD	NSD	yes *	NSD
Hypnosis		yes	yes		yes	yes
Immersion in Water		yes			NSD
Massage	yes
Music / audio	NSD	NSD			NSD
Positions & Movement		yes		yes	yes
Relaxation	yes		yes		yes
Sterile Water Inj.	yes				NSD
Sterile Water Inj.	yes				yes
TENS	yes *				NSD
Yoga	yes		yes	yes

* means limited data; NSD means there may have been a difference, but it wasn’t statistically significant

(Note: In a 2014 review by Chaillet, et al, these techniques were pooled into 3 categories, which helped to increase the statistical significance of the findings. Learn more. Also check out more articles about coping with labor pain.)

New Ways to Talk about Labor Pain V: Research on Effectiveness of 3 Mechanisms

In 2012, a new Cochrane review of pain management for women in labor was released. Although it had positive things to say about the non-pharmacological techniques, it also said that research into their efficacy was unclear due to limited evidence…

“WHAT WORKS: Evidence suggests that epidural, combined spinal epidural (CSE) and inhaled analgesia effectively manage pain in labour, but may give rise to adverse effects. … WHAT MAY WORK: There is some evidence to suggest that immersion in water, relaxation, acupuncture, massage and local anaesthetic nerve blocks or non-opioid drugs may improve management of labour pain, with few adverse effects.  Evidence was mainly limited to single trials. …INSUFFICIENT EVIDENCE: There is insufficient evidence to make judgements on whether or not hypnosis, biofeedback, sterile water injection, aromatherapy, TENS, or parenteral opioids are more effective than placebo… Most methods of non-pharmacological pain management are non-invasive and appear to be safe for mother and baby, however, their efficacy is unclear, due to limited high quality evidence.”

A 2014 review by Chaillet, et al (Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37. http://www.ncbi.nlm.nih.gov/pubmed/24761801) is a significant addition to the research about non-drug approaches.

Chaillet, et al pooled techniques into three categories. If you’ve read my posts from the past few days, you’ll be familiar with these concepts. Also, see the chart at the top of this post for more information.

• Gate Control mechanism = apply non-painful stimuli on the painful area. Methods included massage, bath, positions, walking, and birth ball. The theory is that this will block some of the intensity of the pain.
• Diffuse Noxious Inhibitory Control (counter-irritant) = create pain or discomfort anywhere on the body. Methods included acupressure, acupuncture, TENS, sterile water injections. The theory is that this discomfort causes the body to release endorphins which reduce pain intensity. (Birth combs also fit in this category although they were not included in the research.)
• Central Nervous System Control (cognitive/support techniques). Methods included  attention focus, education, relaxation, hypnosis, continuous labor support.

By pooling studies together, you get larger sample sizes which increases the statistical significance of the results. Note, all techniques were compared to “usual care” which might have ranged broadly depending on the preparation of the laboring family and the support they were given by caregivers. It is possible that some in the “usual care” groups were also using a variety of coping techniques. So, the true difference between people who use some coping techniques and those who use none may be even greater than these results indicate.

The results of this review were:

• Gate Control mechanism. Those who used these techniques had lower pain intensity (as predicted), were less likely to use epidural, and needed less Pitocin.
• Diffuse Noxious Inhibitory Control (counter-irritant). Those who used these techniques had lower pain intensity, were less likely to use epidural, and more satisfied with birth. (Two trials found women felt safer, more relaxed, and more in control.)
• Central Nervous System Control (cognitive/support techniques) Those who used these techniques were less likely to use epidural, Pitocin, less likely to need instrumental delivery or cesarean, and had a higher satisfaction with birth. The CNSC did not reduce the intensity of the pain so much as they reduced the unpleasantness of the pain. (See more on intensity and unpleasantness here.) So, although labor still hurt a lot, women felt better able to cope – more like they were working with labor pain.

The most effective technique overall was continuous labor support, such as that offered by a doula. The effectiveness of support was already demonstrated in a Cochrane review by Hodnett et al, (Hodnett E, Gates S, et al.. Continuous support for women during in childbirth. Cochrane Database Syst Rev. 2013. CD003766)

The best results in pain coping were from combining the labor support and education which reduce the unpleasantness of pain with gate control or DNIC techniques that reduce the intensity of the pain.

Recommended: be sure to also check out Henci Goer’s discussion of this study on Science and Sensibility.

New Ways to Talk about Labor Pain, IV: Bonapace Method

The Bonapace Method for reducing pain during childbirth can be used instead of, or in conjunction with, a traditional childbirth education class.

This method does not just teach pain coping techniques, but also teaches about the role of labor pain, how pain messages are transmitted in the body, and three mechanisms that help moderate the perception of pain. Those mechanisms are:

Cognitive structuring / central nervous system control (CNSC). Understanding labor pain and progression – what’s happening and why – enhances a sense of self-control. Focusing on something positive (like a self-affirmation) helps with labor pain.

Gate ControlTheory. Non-painful stimulation blocks part of the pain message transmitted by the spinal cord. Note: Bonapace interprets this differently than I have see elsewhere, saying specifically that it is pleasant sensation applied where the pain is located. The description on their website says “To activate this mechanism during childbirth, the fingers must be run lightly over the painful area, particularly during contractions.”

Diffuse Noxious Inhibitory Control (DNIC). (I call this counter-irritation) Creating a second pain elsewhere on the body (i.e. not where you’re already hurting). The brain wants to reduce the pain’s effect on the body as a whole, so releases endorphins to do so. But the sensations near the second pain are still felt because the body is assessing them. (So, under this theory, holding a birth comb tightly causes a release of endorphins which helps with the labor pain, but the user is still aware of the pressure points from the comb on their palm.) In the Bonapace method, sensitive points on the body (trigger areas) are massaged by the partner, causing pain.

In a journal article (“Evaluation of the Bonapace Method: a specific educational intervention to reduce pain during childbirth”, J Pain Res 6: 653-661 at http://www.dovepress.com/articles.php?article_id=14256), Bonapace et al, compare the results of a “traditional childbirth training program” (TCTP) with the Bonapace method. Study participants chose which class to take from these options.

The TCTP was a 4 week class, with a total of 8 hours of class time, started around the 23rd week of pregnancy. It covered A&P of childbirth, exercises, stages of labor, variations, pain meds and newborn care. Relaxation, visualization, massage, and labor positions were not taught. Only breathing techniques were practiced.

The Bonapace class was 4 weeks, 8 hours, starting in the 30th week. The entire program was dedicated to pain management and partner participation. It covered 1) CNSC through breathing, relaxation, and cognitive understanding of labor pain and endorphins, 2) Gate control – non-painful stimuli such as walking and light back massage between contractions, and 3) DNIC where the partner did painful massage of acupuncture triggers points in the lower back, hands, and buttocks.

39 women participated in the full study. In labor, every 15 minutes, participants were asked to rate their pain on two scales: intensity and unpleasantness. (If pain medications were given, they stopped assessing pain after the medication. If that participant had pain scores for two phases of labor, they were kept in the study, if not, they were dropped.

Those who had learned the Bonapace method had an average of 45% less pain intensity and 47% less unpleasantness than those who had received the “traditional” childbirth education. No difference was found in the use of pain medication.

The reduction in intensity of pain was consistent for nulliparous and multiparous parents. On the “unpleasant” ratings, there was a larger reduction in scores for nulliparous than multiparous. This is likely due to anxiety… a nulliparous woman with no birth experience and no training / childbirth preparation is likely to be anxious about labor pain (and, of course, anxiety increases pain). With the TCTP, her anxiety may have been somewhat reduced and thus her pain unpleasantness would be reduced, but with the Bonapace method, her anxiety and thus unpleasantness were much more reduced.

This study indicates that being given information about the physiology of pain, and plenty of education in clear, simple techniques to manage it, has a significant impact on pain intensity and pain coping.