MAYD to Birth: At Your Doorstep

Promoting gentle, empowering mother journies…

3 sisters – 1 sister-in-law

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It was 5:45am and I should have been sleeping. Instead, I was sitting on a bedroom floor with a large container of coffee that was having a hard time keeping up with my level of fatigue. It was still dark outside, but light was creeping out to the east and I knew that dawn was approaching – I knew the light would wake me up even more than the coffee would be able to do.

The room was humid, damp from the birthing pool the laboring mother was resting in. This labor was not her first, but it was surprising all of us by being one of her more challenging births so far as she rolled from contraction to contraction long after she expected to be done. It broke my heart more than it usually would to see her having to work so hard for this baby because this wasn’t the first journey she and I have been on together.

Our journey started even before she and I had actually met. Several years ago a woman, S, who was pregnant with her second child came into my office to interview me as her potential midwife. I was lucky – the interview went well and she hired me….and this was how I was introduced to her entire family – three sisters and one sister-in-law.

S introduced me to her sister-in-law M who was also pregnant. M was present when S birthed her baby….and a few months later, S was present with her little baby in arms when M birthed her baby – her first homebirth!

Before long I got a call from M’s sister, pregnant with her first baby…followed quickly by a third sister who was also pregnant with her first baby. The deep love I felt for M and S quickly spilled over to these two first time mothers as they grew their babies together. Each of those sisters, facing their own unique journeys and challenges, had beautiful homebirths of their first babies earlier this very same year! That made 3 sisters and 1 sister-in-law that I had seen through their birthing time!

Before the two first-time mommies had their babies, it was announced that M was expecting AGAIN…and I was asked to again be her midwife. The honor of being chosen to be someone’s midwife is something I have a hard time putting into words – but to be asked back MULTIPLIES the joy, the prayers, the honor. And finally it was S’s turn to announce she was expecting another baby – again trusting me to be her midwife.

Having already experienced FOUR of these ladies births, I had grown close to their mother (the grandmother) and she and I have developed a very special bond.

So here I sit, in this bedroom I’d been in years prior, watching her work with contractions once more. My eyes closed in prayer, I open them to see that the room is lightening up with the dawn. I glanced around the room at who was in there – the grandma sitting on a chair in the corner, the matriarch of this family; the laboring mother’s 3 sisters (one of whom is already showing the cutest little baby belly once again) sat around the pool supporting her; her doula, whom I have seen through two babies and carried the latest baby in a wrap snuggly holding him to her chest; my student/assistant who took time off last year when she gave birth to her own baby with me assisting as her midwife; the laboring mother in her birthing pool holding hands with her husband who watched with mixed expression of incredible excitement mixed with a very real pain of seeing her struggle this time.

My eyes went from woman…to woman….to woman….and I realized that if I included myself, this room contained 7 homebirth mothers – and I had been present for every single one of their births at least once! Without counting myself, I had seen 7 babies come from these women – another would arrive in a couple of hours, and still another in a few months.

My breath got stuck in my chest and wet tears filled my eyes – that was their gift to me. To have such an important role in an entire family like that, to be trusted to not just provide medical safety, but to take good CARE of them and their babies with respect and love…

I am humbled. I don’t feel worthy…it’s an enormous blessing they gave to me. I feel it, I appreciate it, and in that warm room filling with golden light I realized that this was a moment I would likely not be able to experience in quite the same way ever again in my lifetime.

A baby boy was born into the water and was lifted up by his daddy’s waiting hands and handed to his mother’s waiting arms. The room was joyous – and tears flowed down my cheeks faster than I could wipe them away. How do I tell them how much they mean to me? How can I make them understand how they’ve made me feel?

I accept that I can’t – and I don’t have to. Their journeys weren’t about me and I understand that. But even though it’s their experience, I was invited along to experience it with them – a ride that is exhilarating and challenging and triumphant and AMAZING! Thank you seems absurdly inadequate, but it’s all I can offer them.

Thank you.

Comparative Lactation Lab: Dispatches from the Field

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Usually Mammals Suck… Milk! showcases recent scholarly publications from throughout lactation biology, usually emphasizing the evolutionary perspective. However, those journal articles, so meticulous, brief, and jargony, often obscure the months and years scientists spend doing the science
 
“Science has it ALL!” -Principal Skinner

 

Well, 2013 has been a really exciting year around the Comparative Lactation Lab and I am going to take a moment to high five my colleagues and the cool stuff everyone is doing.
This summer, 3rd  year graduate student Laura Klein conducted pilot research for her dissertation. She investigates the types and levels of immune molecules in breast milk from women who live in different disease ecologies. During summer 2012, she collected milk samples and interviewed women at the Mogielica Human Ecology Study Site in rural Poland established by Professor Grazyna Jasienska. Most families in this area live on small-scale farms or help relatives plant and harvest, so this is a great location to look at milk immunofactors that may be important for protecting infants who will be exposed to a variety of farm animals and soil microbes. The area also has one of the highest fertility rates in Poland, which is helpful for researchers looking for moms and babies!

Mogielica Human Ecology Study Site
This summer, she worked closer to home, recruiting an urban sample of Boston-area moms to come into “the Milk Study” here at Harvard University. While the study objectives and methods are the same in both locations, recruiting over the past two summers has been quite different. In Poland, Laura and her field assistants hiked over the mountains between farms, going door-to-door to recruit mothers. In Boston, while she did distribute flyers at playgrounds, she primarily recruited online through social media networks with the help of active parenting groups. Over the next few months, Laura will take the milk samples she’s collected in Poland and Boston into the lab to start analyzing their nutritional and immunological composition.
Importantly, we thank the Nursing Mother’s Council, the Somerville and Arlington Parents listserv, Boston Garden Moms, the Cambridge Birth Center, Isis Parenting, The Diaper Lab, the Birth and Beyond Center in Jamaica Plain, and the many participants who have shared information about our study with their friends! This research has been funded by a Department of Human Evolutionary Biology Summer Research Grant and a Harvard GSAS Graduate Society Summer Research Fellowship.

 

 
Laura Klein in Poland with Kiddo
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Cary Allen-Blevins, a 2nd year graduate student, spent the summer of 2013in Zanzibar! She was there conducting a pilot research for a project launched by Professor Richard Wrangham on paedomorphic traits and extended suckling behaviors in Zanzibar red colobus (Procolobus kirkii). Zanzibar red colobus females have been reported to habitually nurse sub-adult and adult males. Cary spent 10 weeks in Zanzibar with fellow Human Evolutionary Biology student Jenny Wong, collecting fecal samples and conducting focal observations. They studied two social groups of colobus, for a total of 66 individuals. Once back in the lab (samples did make it through customs with only a raised eyebrow and “Now, why are you travelling with monkey poop?”), Cary will determine relatedness using DNA extracted from fecal samples. 
Funding for Cary’s research was provided by a Harvard Graduate Student Council Summer Research Grant, Harvard Human Evolutionary Biology Summer Research Grant, and the Nacey Maggioncalda Grant for Doctoral Students.

 

  
Cary Allen-Blevins in Zanzibar with Red Colobus Monkey (and poop)
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Post-Doc Amy Skibiel. In one year she set the bar very high for all future post-docs. Between applying for jobs, writing grants & manuscripts, and joining me for the to explore logistics, methods, and feasibility of a Meerkat Milk Study at the Kalahari Meerkat Project, she managed to ran nutritional and hormonal assays on hundreds of rhesus macaque milk samples (in duplicate!). As of August 15 she is now Faculty at Auburn University in the Department of Biological Sciences. She also just published a kickass meta-analysis of mammalian milks (topic of future blogpost!).

  
Dr. Amy Skibiel in the Lab and the Kalahari
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We also welcome Claire Stingley, starting her PhD program *this week* in the Comparative Lactation Lab. She comes from the Anthropology Dept at University of Pennsylvania where she worked with Prof. Claudia Valeggia- she already has experience conducting milk research with the Toba people of Argentina.  She also did a stint developing her benchwork skills with Thom McDade at the Laboratory for Human Biology Researchat Northwestern University. She plans to study physiology and life-history trade-offs in women and infants, especially in the context of demographic and ecological transitions.

 
Claire Stingley in Argentina
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As for me… let’s see… the typical ridonkulous workload of all tenure-track professors: wrote papers & grants, gave talks & posters at professional meetings, taught classes, mentored students, advised honors theses, reviewed papers, book proposals, & grant proposals, investigated logistics of meerkat milk study, exposed dangers in our field, blogged, SPLASH!ed, Mammal March Madness, milked monkeys, and reached the end of the 3-year longitudinal study of rhesus macaque lactation (many papers to follow).

 
Katie Hinde and Meerkats
And next week Prof. Brooke Scelza, Anthropology Dept at UCLA and I are going to NAMIBIA to recruit Himba women into a milk study! Oh Yeah!

Dr. Brooke Scelza and Himba Women
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Lab Alumni: Kickin’ Ass & Taking Names!
Although its so hard to say goodbye to yesterday, previous lab members are doing amazingly awesome things now:
Alison Foster begins an MA and credential in Early Childhood Special Education at Mills College in Fall 2013. At the Mills College Children’s School, a laboratory school with a constructivist educational philosophy, Alison will learn to work in early intervention and school settings with children, usually 5 and younger, who are developing atypically.
 Alison Foster with NOT A MAMMAL!
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Chase Nuñez is in Kakamega, Kenya managing the long-term Blue Monkey field project of Prof. Marina Cords, Department of Ecology, Evolution and Environmental Biology, Columbia University. This research on Cercopithecus mitis life-history and behavioral ecology has been ongoing for 34 years!  Chase is especially interested in the intersection of physiology and behavior within a life-history context, has awesome R skills, and is working on manuscript from his time in the Comparative Lactation Lab.

 Chase Nuñez & Blue Monkey Mother-Infant Dyad
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Danielle Rendina earned an MA in Social Sciences at the University of Chicago investigating postnatal social factors influencing individual and sex differences in cognition and anxiety in the lab of Prof. Sian L. Beilock. This fall she joins Dr. Chris Coe’s lab at the Harlow Center for Biological Psychology at the University of Wisconsin Madison. 
 Danielle Rendina, Being Awesome
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Michelle Wechsler worked at the San Diego Zoo Institute for Conservation Research in Dr. Lance Miller’s Behavioral Biology Lab. She performed hormonal assays and conducted behavioral observations of lions, cheetahs and okapis. Michelle now splits her time between investigating communication, emotion, and cognition in bottlenose dolphins with Drs. Brenda McCowan and Eliza Bliss-Moreau and monogamous pair bonds in titi monkeys in Dr. Karen Bales’ Lab for Comparative Neurobiology of Monogamy.
 
Michelle Wechsler, Also Being Awesome
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I am super fortunate in getting to work with such a fantastic set of colleagues and students. And shout outs to the HEB students Charlotte Lane and Jorie Sullivan who, while not directly studying milk, wrote Honors Theses in 2013. High five everyone! 

Midwifery Practice During Birth: rites of passage and rites of protection

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Finally I have completed my Phd! It took me six years – the last two mostly writing… and writing… and rewriting. Entire chapters did not make the final ‘cut’. There is so much more I wanted to say (and did) about authoritative knowledge and the ritual nature of midwifery practice. Hopefully I will share this work another way in the future.

My aim was to contribute to an understanding of birth, and midwifery practice, grounded in women’s experience. I believe we need to develop (reclaim?) our own birth knowledge in order to shift the current medical paradigm that is failing women.

The Phd journey has been a rite of passage itself, and I pushed myself to my edge and beyond. I thought about giving up at times, and felt self-doubt about my ability (I left high school with no qualifications and a baby in my belly). I accepted my fears and kept going one step at a time. In the process, I learned not only about my topic, research, and writing; but also about myself.

The abstract is posted below, and you can download the full thesis here. I’d welcome comments, questions and discussion about the research.

Big THANKS to the participants – mothers and midwives – who generously shared their birth stories.

Abstract

This study explored midwifery practice during birth. In particular, the experiences, actions and interactions between midwives and women during uncomplicated, normal births.

Most of the existing literature focuses on outcomes associated with individual practices; and there is a lack of research evidence supporting many of the common midwifery practices carried out during birth. There is also limited research exploring midwives’ experiences and perceptions of their practice during birth; although it seems that the context of midwifery practice, and cultural norms influence practice. Studies exploring women’s experience of birth have identified an altered state of consciousness, and issues of control as key factors. However, there has been very little research specifically examining women’s experience of midwifery practice during birth. This study sought to explore the experience of midwifery practice from both the perspective of the midwife and the woman.

The study is a narrative inquiry, and a feminist approach was taken throughout the research process. Birth stories were gathered from mothers and midwives during in-depth interviews. The participants had either experienced or attended an uncomplicated vaginal birth, and were encouraged to share their story of this experience. Narratives were created from the interview transcripts and analysed to identify common themes. An explanatory framework ‘rites of passage’ was then applied to further illuminate the narrative of midwifery practice during birth.

The findings are presented in three chapters. The first focuses on the mothers’ experiences of birth as a rite of passage. This chapter provides the foundation for the following chapters that present midwifery practice during birth. Midwives enacted ‘rites of passage’ during birth that tended the boundaries of aloneness, and nurtured self-trust and inner wisdom. Midwives also enacted ‘rites of protection’ which contradicted rites of passage, but tended the needs of the institution. Tensions arose between these two types of rites, and conflicting cultural values were transmitted and reflected through their performance.

Findings are discussed in relation to the literature, and the thesis concludes with recommendations for midwifery practice, midwifery education, and further research. Recommendations centre on a model of midwifery practice as ‘ritual companionship’ as the basis for developing midwifery practices that are aligned with women’s experience of birth.

Conceptual map of findings

We Speak the Same Language

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By Michal Klau-Stevens

I love public speaking, and I didn’t want to mess this speech up.  I was asked to be the closing speaker for the 2nd Annual Birth Activist Retreat, and I decided to speak about the leadership concepts I’ve been integrating into our work at BirthNetwork National.  They come from the book, “Forces for Good: Six Practices of High-Impact Nonprofits” by Leslie R. Crutchfield and Heather McLeod Grant.  My talk was about “Adopting the Network Mind-Set.”

I think the concepts are mind-expanding and game-changing in terms of recognizing the potential that exists within our own network and with the Birth Community as a whole.  The problem is that talking about these academic tools to people who have not read the book tends to sound too theoretical or outside the scope of the current vision to hold people’s interest.  I’ve tried to present the material to our chapter leaders through conference calls, but it’s hard to quickly and clearly demonstrate the potential of these big ideas with people who are unfamiliar with the concepts.  The few who have engaged with the material get benefit from it, but many just choose not to engage.

Also, apparently reading a book these days is a pretty major thing.

Not wanting to be a flop as a public speaker, and feeling very strongly about the content of the speech yet also having experienced resistance to it already, I was VERY NERVOUS about giving this presentation.  However, as the weekend progressed, every speaker mentioned at least one point of information that I planned to speak about.  I found that the network mind-set is already being thought about by many in attendance, and that we just needed to connect that it is part of a larger framework of best practices that have already been studied and can be conscientiously applied. 

Suzanne Arms spoke about “cultural creatives,” who are integrating information in new ways.  Dawn Thompson, Cristen Pascucci, Barbara Rivera, and Adeola Adeseun all spoke about finding the center where many organizations have unity, even while great amounts of diversity coexist.  Social media experts Kate Donahue, Gina Crosley-Corcoran, and Jen McLellan spoke about how powerful it is to share the work of others and how it amplifies the work they personally do.  Sherry Payne addressed the weakness in the network when it comes to racial diversity, and the consequences of institutionalized racism and a lack of cultural sensitivity.  David Paxon spoke about the power of government and the role it is playing in our larger network as the new healthcare laws take effect.  Rebecca Dekker taught us about horizontal violence – the tendency to attack each other instead of working to change the oppressive environment surrounding us.  And, Karen Brody reminded us about the need to “step into our worth and claim our value;” that as birth workers and as organizations, we tend to struggle monetarily but “business” is not a dirty word, and the potential for abundance is right in front of us.      

I saw the ideas supporting the network mind-set being organically put into action throughout the weekend.  It was exciting and affirming to hear and see these concepts being brought to life right in front of my eyes as leaders of organizations and birth activists from around the country shared ideas, tools, and resources.  And, at one point we saw a huge learning opportunity for network growth as the interests of individuals overtook the well-being of the greater community during a heated discussion about cultural sensitivity relating to religious circumcision.  Even that experience allowed for a pathway for attendees to actually experience the challenges and benefits of adopting the network mind-set.

When my time came to speak, I felt confident that the words and PowerPoint visuals I was sharing about “Growing the Pie,”  “Sharing Knowledge,” “Developing Leadership,” and “Working in Coalitions,” were simply highlighting concepts we had lived during the weekend as we experienced “Adopting the Network Mind-Set.” We have many skills that we are putting to use and we are already engaged in building and strengthening our network. With the work we had done over the course of the weekend, adding the conceptual framework and common language was easy, because we had participated hands-on with the activity at the retreat.  I realized that I didn’t have to be nervous because I was with my “tribe” of birth activists, and we speak the same language.

I think each chapter of BirthNetwork National can have a similar experience integrating the six practices in “Forces for Good” while doing the work of building the network.  In many ways we already walk the walk and talk the same talk.  Now, our challenge in growing and advancing our movement is to refine our vocabulary.  I’m working on figuring out a way to do that which doesn’t involve reading a book.     

Michal Klau-Stevens is the President of BirthNetwork National

Amniotic Fluid Volume: too much, too little, or who knows?

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This post is in response to readers asking me to cover the topic of induction for low amniotic fluid volume (AFV). Most of the content is available in textbooks, in particular Coad and Dunstall 2011 and Beall and Ross (2011), and I have provided references/links for research where I have stepped outside the textbook sources. I use the word ‘may’ quite a bit in this post because little is known about AFV, therefore a lot of the available information is theoretical. In fact, this post probably raises more questions than answers! Also note that I am focussing on AFV at term.

Amniotic fluid volume regulation

Amniotic fluid is in a constant state of circulation. In the second half of pregnancy the main sources of fluid production are from the baby:

  • urine (700mls per day)
  • lung secretions (350ml/day)

And the main sources of fluid clearance are:

  • the baby swallowing fluid and passing it back into mother’s blood stream
  • direct flow across the amnion (placental membrane) into placental blood vessels

The balancing act required to maintain a healthy AFV may be influenced by hormones (prolactin and prostaglandins), osmotic and hydrostatic forces, and the baby. Maternal hydration is also associated with AFV (Patrielli et al. 2012). From day to day there is little change in AFV, however volume decreases towards term. This is normal. Perhaps this reduction reflects reduced lung secretions as the baby nears term?

The amniotic sac and fluid play an important role during pregnancy and birth – you can read more about that in an earlier post.

Abnormalities in AFV occur when there is an imbalance between fluid production and clearance. Too much fluid is called ‘polyhydramnios’ and too little fluid is called ‘oligohydramnios’. However, measurement and thresholds of normal/abnormal are not clear.

Accurate Measurement?

Here is the first problem… there is no accurate method for measuring AFV. The two ultrasound tests aimed at assessing AFV are:

  • Amniotic Fluid Index: four ‘pockets’ of fluid are measured by ultrasound and added up resulting in an Amniotic Fluid Index (AFI) eg. AFI = 10cm.
  • Maximum Pool: The ‘single deepest vertical pocket’ of fluid is identified by ultrasound and measured in centimetres.

Neither of these methods are supported by research (that I can find). However, studies comparing the two conclude that the ‘maximum pool’ measurement is the ‘better choice’ (Nebhan & Abdelmoula 2008Magann et al. 2011). The reasoning for this is interesting… AFI increases the detection of oligohydramnios resulting in increased rates of induction without improving outcomes for babies. So the best method is the one that does not detect the ‘problem’ you are looking for?

Measurement of AFV by AFI or ‘maximum pool’ is part of the Biophysical Profile assessment which aims to identifying babies with inadequate oxygenation via the placenta. However, it is unclear whether there is any benefit to this test. Indeed, an umbilical artery doppler test may provide a better assessment of placental function, and therefore how well oxygenated the baby is (Alfirevic, Stampalija & Gyte 2010) – which is what everyone is worried about.

There is of course the old fashioned method of assessment, also not well researched. Abdominal palpation is usually carried out during antenatal visits. In addition to working out what position the baby is in, a midwife assesses the amniotic fluid volume. When you have palpated lots of pregnant bellies, ‘real’ polyhydramnios and oligohydramnios are usually pretty obvious. Mothers are also experts regarding their own body/baby and notice differences themselves – particularly if they have been pregnant before and can compare pregnancies. What you may find:

  • Oligohydramnios: baby is very easy to feel – in some cases you can see limbs; the uterus is smaller than expected; the mother may notice reduced movements.
  • Polyhydramnios: baby is difficult to palpate and floats away as you apply pressure; the uterus is bigger than expected; the baby’s heart rate may sound muffled; the mother may notice breathlessness, vulval varicosities, oedema and gastric problems.

When you are working as a midwife in a continuity of care situation you get familiar with the individual woman’s bump over time, and it is easier to notice changes. Measuring (with a tape measure) is often used to assess uterine growth – particularly when care is spread between a number of practitioners. Whilst measuring can assist with identifying polyhydramnios, it is unreliable in identifying oligohydramnios (Freire et al. 2013).

Here is the second problem… there is currently no agreement about what constitutes ‘high’ or ‘low’ levels of AFV. Megann et al. (2011) conclude that: ‘high and low levels [of amniotic fluid] have yet to be established in the literature and are difficult to directly link to adverse pregnancy outcomes.’ So we are busy finding measurements that we don’t really understand the implications of?

Most of the time there is no known cause for the ‘high’ or ‘low’ volume of fluid, and there is are complications caused by it. However, there are some factors worth considering if you are labelled with oligohydramnios or polyhydramnios.

Oligoydramnios - too little

The definition of oligohydramnios is usually less than 500mls of fluid; <2cm maximum pool; or AFI <5. Around 3-5% of pregnant women are diagnosed as having too little fluid. Because of the complexities of measurement and the diagnosis of oligohydramnios, I have differentiated between what I believe are two types:

Physiological oligohydramnios

Most cases of ‘oligohydramnios’ are an outcome of 2 factors:

  1. The normal physiological changes that occur to AFV as term approaches (see chart above) and/or the ‘normal’ level for the individual mother/baby is comparatively low to the general ‘norm’.
  2. Women having routine scans for ‘post-dates’ which then identifies this normal ‘low’ AFV.

There is a lack of evidence supporting induction for oligohydramnios in ‘low risk’ pregnancies ie. when there is nothing else ‘abnormal’ going on with mother or baby (Quiñones et al 2012). Driggers et al. (2004) concluded that: “evidence is accumulating that in the presence of an appropriate-for-gestational age fetus, with reassuring fetal well-being and the absence of maternal disease, oligohydramnios is not associated with an increased incidence of adverse perinatal outcome.’’

A recent review of the literature (Rossi & Prefumo 2013) found that in term or post-term pregnancies oligohydramnios (with an otherwise healthy pregnancy/baby) was not associated with poor outcomes. However, it was associated with increased risk of obstetric interventions… probably because the diagnosis leads to intervention.

Pathological oligohydramnios

Pathological oligohydramnios is generally a consequence of reduced urine output (baby) which may indicate a redirection of blood flow away from the kidneys to the vital organs in response to reduced oxygenation. This usually occurs alongside pregnancy complications such as pre-eclampsia. In this case the low fluid volume indicates inadequate placental circulation to the baby. These babies often have significantly low AFV (easily identified by palpation), and are also growth restricted i.e. small and with limited glycogen supplies.

Management?

Induction of labour is the usual management for oligohydramnios (regardless of type), and I have never been able to understand this… There is concern that the baby has inadequate placental circulation and poor reserves for the birth process. So, the answer is to start a procedure that is associated with reducing placental circulation and causing hypoxia and fetal distress. In addition, if the baby is post-dates he may have already passed meconium, and/or will if he becomes hypoxic due to the induction process. Oligohydramnios = less fluid to dilute the meconium = increased risk of meconium aspiration. I may be crazy but these babies – particularly those with pathological oligohydramnios and growth restriction – seem the least likely candidates for getting through an induction unscathed. In clinical practice I saw the inevitable fetal distress and rush to theatre resulting from this management over and over again. If the baby really is in danger – perhaps a physiological birth or a c-section are the two most logical approaches? Anecdotally, I have noticed that women with pathological oligohydramnios and growth restricted babies tend to have very spaced out contractions during a non-induced labour. Is this the body protecting the baby by altering the contraction pattern to maximise placental circulation?

Polyhydramnios – too much

The definition of polyhydramnios is usually around 2000mls of fluid; >8cm maximum pool; or AFI >25cm. Around 1-3% of pregnant women are diagnosed with having too much amniotic fluid. In 60% of cases there is no known cause, but factors that increase fluid volume include:

  • The baby producing too much urine
  • Decreased fetal swallowing (baby)
  • Increased water transfer across the placenta by the mother

These factors may be influenced by the general well being of mother and baby ie. may occur if there are complications present such as diabetes, rhesus isoimmunisation, congential abnormalities, etc. But, usually no complication is present.

Complications associated with polyhydramnios

  • Preterm birth – as the uterus become over stretched with fluid.
  • ‘Unstable’ position of the baby – the baby can float about into helpful and not so helpful positions.
  • Cord presentation or prolapse – because the baby is floating about the cord can get between his head and the cervix.
  • Placental abruption – may occur with a sudden change in fluid volume and therefore size of uterus/placental site.

Management?

Tests may be suggested to see if a cause can be identified (although nothing can be done at this point). Induction of labour with a ’controlled’ artificial rupture of membranes may be suggested to manage the risk of an unstable lie and/or cord prolapse. This involves breaking the waters whilst holding the baby in place… and with quick access to theatre as the procedure can result in a cord prolapse. Alternatively, the woman may choose to wait until labour begins, and assess her baby’s position once contractions have started. Either way – the risk is the woman’s therefore she must be the person to decide which risks are best for her – induction or waiting.

In Summary

  • The exact mechanisms involved in regulating AFV are still unknown.
  • AFV reduces significantly after 37 weeks – this is normal.
  • There are no accurate methods of measuring amniotic fluid.
  • There is no agreement about what measurements indicate ‘high’ or ‘low’ AFV.
  • The intervention used to manage polyhydramnios or oligohydramnios ie. induction also carries risks which need to be taken into consideration.

So, as you can see this topic creates more questions than answers which is why I previously avoided it!

Further Resources

Science & Sensibility – What is the evidence for induction for low amniotic fluid in a healthy pregnancy?

Early Life Conditions Influence Milk Production

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Maternal nutritional conditions during pregnancy are known to have substantially affect infant development. This was most clearly demonstrated by research into the outcomes of infants from the Dutch Hunger Winter of 1944. Because determination and differentiation of cell lines occur during embryonic development, nutritional conditions and other environmental insults early during pregnancy can substantially alter offspring phenotype, including behavior and general health. For example, the Hunger Winter produced different results depending on whether the mother’s nutrition was most interrupted during the first, second, or third trimester, or during lactation. 
 photo from Dutch Resistance Museum
Since then, systematic research into fetal programming and developmental origins of health and disease (DoHAD) has identified that early life nutritional conditions affect numerous physiological systems and organ structures, putting individuals at later risk for kidney, liver, heart, pancreatic, neurobiological, endocrine, and reproductive dysfunction (Schug et al., 2012).
Simply put, our early life experiences leave their mark.
Factors within the mother and the environment beyond nutrition affect offspring development because of constraints and trade-offs. Life history theory, an area within evolutionary biology, is predicated on the fact that organisms have limited energy and resources that must be allocated toward several biological “imperatives”- maintenance, development, and reproduction (Stearns, 1992). Maintenance is basically keeping your body alive — such as thermoregulation and immune responses. Growing (i.e., adding mass) and development (i.e., skeletal ossification) also require energy and resources. And producing that most valuable currency of natural selection – BABIES — does not come cheap.
Because you can only spend, or burn, a calorie once, individuals face trade-offs among maintenance, growth, and reproduction. Under famine conditions children don’t grow very well and they can’t always “catch-up” – for example in terms of height, they are permanently stunted (Gørgensa et al., 2012). Female Olympic athletes often have reduced fertility due to altered ovarian function (DeSouza et al., 2010). Basically the body says “Why cycle if body fat reserves are too low to sustain pregnancy or lactation?” And once pregnant and lactating, females face trade-offs between the kid they are investing in now vs. the kids that they will have later- aka current and future reproduction. Allocating too much energy to the current offspring can deplete body reserves, extend maternal recovery, and delay subsequent conceptions.
In this day and age of pregnancy planning and the demographic transition to smaller families, delaying subsequent reproduction is a often the goal. But our physiology has been shaped by a mammalian life history very different than our modern world. 
 Liverpool Library Family History Archives
Natural selection favors adaptations that allow females to maximize their lifetime reproductive success — the total number of offspring produced over their reproductive careers.  Underlying mechanisms in female reproductive physiology are seemingly sensitive to nutritional intake and body condition, and through these mechanisms fertility, pregnancy, and lactation are regulated and resources allocated to the developing offspring.
In some mammalian species, females can produce more offspring over their lifetime if they can sustain overlapping pregnancy and lactation. This is actually a characteristic feature of some marsupials (Tyndale-Biscoe and Renfree, 1987). For example the tammar wallaby, close relative of the kangaroo, can be pregnant, have a tiny pouch joey attached to the nipple continuously and a larger joey that still consumes milk.

photo by Thorsten Milse
Fun fact: the different mammary glands produce different milk composition fine-tuned to the developmental states of the two differently-aged joeys (Trott et al. 2002, Nicholas et al. 2012).

 Fig. 2. Lactation in the tammar wallaby. Nicholas et al. 2012.

While simultaneous pregnancy and lactation can increase reproductive output, it also sets the stage for competition for maternal resources between milk synthesis for the infant and nutrient transfer via the placenta for the fetus. 
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Enter the awesomest* lactation biology animal model: 
The Dairy Cow
*Yeah I know it should be ‘most awesome’ but I prefer to use ‘awesomest.’
In December 2012, González-Recio and colleagues reported that overlapping pregnancy and lactation had consequences for the fetus that manifested in adulthood. They used a sample of >40,000 Holsteins, and admirably controlled for other genetic and environmental factors.  Cows that were gestated by a mom who was also lactating produced significantly less milk and died at younger ages! 
Of course, just like when signing a contract, it’s important to read the fine print. These cows produced ~52 kg less milk per lactation, but since the average production per annum for a Holstein is on average ~10,000 kg of milk, translated that is ~0.005% less milk. They also died only 16 days earlier than cows that were gestated by a mom who was not lactating. 
However, these  effects, while relatively modest, demonstrate that early embryonic and fetal development *IS* sensitive to any reductions in resource allocation. Moreover, from a biological perspective, we would expect this effect to be greater in wild-living mammals that aren’t fed or provided with any veterinary care like domesticated dairy cows.
Lascaux cave art of Bos primigenius
the wild predecessor of domesticated cattle. 
Along similar lines, Soberon and colleagues showed that among calves reared on milk replacer, trade-offs between maintenance and growth reduced milk yield in adulthood (2012). Standard rations of milk replacer were provided to calves, but calves born during the winter had to burn more calories to stay warm- thermoregulation is energetically costly. Less energy was available for growth and these calves grew more slowly. Calves that grew better had better milk production in adulthood. For every additional kilogram gained per day resulted in 850-1100 kg more milk on their first lactation. This was directly linked to the amount of milk replacer the calves got above their maintenance needs. Thermoregulation wasn’t the only maintenance cost some calves had to pay. Getting sick in early life also impacted future production — calves that received antibiotics went on to produce ~500 kg less milk on their first lactation. Immune response, like staying warm, isn’t free, and those costs- diverting energy from growth and development reduced future ability to synthesize milk.
The precise underlying mechanisms by which mammary gland function is impacted by early life trade-offs (either by the dam or the calf) are not yet clear. However, the effects are likely through epigenetic modification of gene expression. Important questions remain about the length of critical windows in which developing organisms are sensitive to environmental influences and the possibility for reversing or mediating early life programming. Until we better understand the proximate pathways, these phenomenological results still provide valuable insights. Dairy scientists may be able to further improve milk production by shaping animal husbandry practices to optimize early life development. And most importantly, these results illustrate the value of theoretical and evolutionary perspectives for understanding lactation biology (Hinde and German 2012).

Citations

De Souza MJ, Toombs RJ, Scheid JL, O’Donnell E, West SL, Williams NI. 2010. High prevalence of subtle and severe menstrual disturbances in exercising women: confirmation using daily hormone measures. Hum Reprod. 25(2):491-503. doi: 10.1093/humrep/dep411

González-Recio O, Ugarte E, Bach A. 2012. Trans-generational effect of maternal lactation during pregnancy: a Holstein cow model. PLoS One. 2012;7(12):e51816. doi: 10.1371/journal.pone.0051816.

Gørgensa T, Mengb X, Vaithianathanc R. 2012. Stunting and selection effects of famine: A case study of the Great Chinese Famine. Journal of Development Economics. 97: 99-111

Hinde K, German JB. 2012 Food in an evolutionary context: insights from mother’s milk. J Sci Food Agric. 92(11):2219-23. doi: 10.1002/jsfa.5720.

Nicholas, K., Sharp, J., Watt, A., Wanyonyi, S., Crowley, T., Gillespie, M., & Lefevre, C. (2012). The tammar wallaby: A model system to examine domain-specific delivery of milk protein bioactives. In Seminars in Cell & Developmental Biology (Vol. 23, No. 5, pp. 547-556). Academic Press.

Schug TT, Erlebacher A, Leibowitz S, Ma L, Muglia LJ, Rando OJ, Rogers JM, Romero R, vom Saal FS, Wise DL. 2012. Fetal programming and environmental exposures: implications for prenatal care and preterm birth. Ann N Y Acad Sci. 1276:37-46. doi: 10.1111/nyas.12003.

Soberon F, Raffrenato E, Everett RW, Van Amburgh ME. 2012. Preweaning milk replacer intake and effects on long-term productivity of dairy calves. J Dairy Sci. 95(2):783-93. doi: 10.3168/jds.2011-4391.

Stearns, Stephen C., 1992. The Evolution of Life Histories. Oxford University Press, London

Trott, J. F., Simpson, K. J., Moyle, R. L., Hearn, C. M., Shaw, G., Nicholas, K. R., & Renfree, M. B. (2003). Maternal regulation of milk composition, milk production, and pouch young development during lactation in the tammar wallaby (Macropus eugenii). Biology of reproduction, 68(3), 929-936.

Tyndale-Biscoe H. Renfree M. 1987. Reproductive physiology of marsupials. Cambridge University Press

This is Haiti

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On my third shift in the hospital, I worked with an American nurse-midwife named Cathy. I helped with a couple of deliveries as she labor-sat with a 9th timer who was almost complete. It was unusual that she wasn’t just spitting her baby out. Her contractions were short and far apart. We had her up and walking but she became a spectacle in the labor ward. She has gray hair and thus, many people, waiting in the hospital for other loved ones, started staring at her and following her around. They wanted to see how this “gran moun” (old lady) would deliver. We finally gave her a private space in the maternitéso that she wouldn’t be the object of such gawking. The labor (or non-labor) was going on for hours.
Finally, it was decided that her labor would be augmented with pitocin. I didn’t think that this was a bad idea, seeing that she was a hemorrhage risk and that the weak labor pattern would make that worse. Within an hour or so of receiving pitocin, she was screaming her baby out. Again, a little unusual. I would have expected a 9th timer to be an old-pro. Anyway, the baby came. But, it didn’t breath. There was meconium staining and the student midwife on staff was slow and clunky with her aspiration of the baby’s nose and mouth. As I saw that the baby was not breathing, I asked for the ambu bag and began the resuscitation. The baby was still unresponsive and apneic (not breathing). Within a minute, we had also begun chest compressions because the baby’s heart rate was low. Cathy did the first shift of chest compressions as I bagged the baby. I began the mantra of neonatal resuscitation. One and two and three and breath and one and two and three and breathe and…… Over and over. The baby, a little boy, was not responding. He most likely had meconium in his lungs and the, ultimately, quick delivery did not allow for enough squeeze to get it all out. Most people believe now that meconium aspiration is the result of an in utero distress. In the U.S., we deal with it often in the NICU and the babies live.
This little guy, though, was not going to have that advantage. We resuscitated him for 30 minutes, which is a long time for that kind of thing. He was finally breathing on his own, but he never took a full cry and he had the rhythmic agonal gasping of one who is desperately trying to receive air. Miss Genette offered that we could try to find a pediatric doctor to help. I thought that was a great idea and so I carried him out of the maternity ward and across the courtyard to the largely, ill-equipped pediatric unit. The baby boy was breathing on his own, but was still limp and unresponsive. Cathy and I would continued ventilating him with the ambu bag which seemed to be offering him more support. Miraculously, the doctor somehow came up with an oxygen machine. So, we put a nasal cannula on the baby and observed.
He definitely seemed to be doing better with the oxygen, but I still felt that this baby needed more care. Could we transfer him to Paul Farmer’s hospital 45 minutes away in Cange? The doctor agreed that this was a good idea and said that he would make the arrangements. I left the hospital about an hour and a half after this birth, having stayed with the baby the whole time. I felt that he was doing a little better. He had a little better muscle tone, but he still hadn’t cried and most of the time, his eyes were closed. He was receiving the oxygen and was now under the care of the pediatrician. I was adamant with them that this baby needed to be watched carefully until he was transferred to Cange. Miss Genette left the hospital 3 hours later and the baby still had not left yet.
The next morning, back at the hospital for another shift in Labor and Delivery, I asked about the baby. Miss Genette did not know, but we finally found another midwife who had the news. The baby had died on route to Cange.
I felt numb. This baby would have lived in the U.S. But this is Haiti, and the hospital does not have a NICU, does not have good suctioning equipment, does not have endless supplies of oxygen. I don’t even know if the baby had medical support on the drive. All I know is that a family member accompanied him.
I saw the mother in the postpartum ward and told her how sorry I was. She was resolute and quiet. I also knew she was about to pick herself up and go on with life. There is no time in Haiti to mourn the loss of a baby when you have 8 other hungry mouths to feed. Death is sorrowful and yet, not unexpected. The town of Hinche has at least 3 or 4 coffin shops where the wood workers display their hand-made boxes along with school benches and tables. We saw a coffin being carried down a dusty, dirt road by a procession of pall-bearers and community members. Out in the middle of nowhere, obviously they were headed to a burial spot. Death. This is Haiti.
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Women waiting for prenatal care at the mobile clinic
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At the orphanage, we have been playing and hugging and getting to know the girls even better than before. We have been staying at their orphanage, which is now separate from the boys. It is nice this way. The girls can maintain their own little world, not having to worry about their safety or the taunting that comes with the sexual tension of teenagers.  Of course there are the occasional sibling spats: hitting, crying, hurt feelings. But it doesn’t seem to last long and for the most part, the girls are happy and peaceful. I wonder sometimes about how to give them things in the most appropriate manner. We brought a volleyball net, 12 balls, knee pads, team T-shirts. That all went pretty smoothly. But then I also had my special gifts – earrings, necklaces, shirts, all “extras” from home that I knew would be appreciated by the girls. It is hard to give one girl something. There is a strong need and feel for equity and justice amongst Haitians. But, inevitably, there are the girls who become our favorites. My favorites this year were Joska and Marlande. They are both about 9 or 10 years old. Marlande is confident, beautiful, a strong singer during the evening prayers. She was affectionate and fun with me. When I gave her a special beaded bracelet, she gave me a big hug around my waist. She is easy with her love. Joska is more reserved although when pushed for a photo, she strikes the pose with ease. She is thinner than the other girls and Dina says the house mother told her that she has a medical condition. I do not know what it is. But, I enjoyed her easy smile and feisty spirit.
Joska
On the last day, we were cleaning up and I had a leftover baguette. There were a few girls sitting on the porch outside our room, so I offered it to them, saying that they had to share it. As soon as I gave it to them, a near riot ensued. Like a pack of wolves, they pulled and shouted and fought over the bread until a house mother broke in. This is Haiti and although I only heard it mentioned twice, I know the girls are hungry. They eat plain spaghetti in the morning, beans and rice at noon, and cream of wheat at night. Always the same, except for one day a week, when they get a chicken leg.
With the final clean-up, I swept the front porch and scooped the trash into the garbage bag that we had been using all week. One of the girls offered to bring the trash to the garbage area for me. I was happy for the help but also wondered in the back of mind if she was going to go through our trash.
Of the many things that I had brought to Haiti, one of them was a stack of this year’s baby cards. My plan was to cut up all the little faces and create a matching game for the girls. Place all the faces face down, and see if you can find two little baby faces that would match. As it turned out, the weeks were full and I just never got around to it. On the second to last day, I threw away half of the cards, and on the last day, I let go of the rest, realizing that I just wasn’t going to get to it and that it was going to be too hard to explain – cutting out the faces, matching them up, sharing the sets. Everything seems to need a lot of set up and organization around who is going to keep everything together so that pieces don’t get lost, games are kept in order. In the same vein, by the time we left Hinche, we only had 4 out of 12 volleyballs left – some had popped, some were hidden away by the girls for soccer, others I just don’t know.
Later in the morning, I was reminded that this is Haiti. The girls started popping up with the little baby cards in hand. They were fascinated by the photos and the names on the back. It was so funny to hear them pronouncing the American names – “Maxine Danger,” “Emeline.” They even wanted me to put the postcard up on their empty dormitory walls. I obliged, humbled. No matter how many hair ribbons and bubbles and Uno games that we give out, they will always feel a desperation for more. Even though they truly appear happy, I need to remind myself that they lack the foundational elements that a family provides. They have had to re-create their family life with 52 girls and 4 house-mothers. Believe me, it is far better than many. But, they will still fight over bread and pick through the trash. 
This is Haiti.

 



Twins: Solen and Solange

 
Birth is empowering!

Volleyball Camp and My new Goddaughter

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All is well here in Haiti! The girls are doing volleyball camp every morning. That means they start at 7am at the latest. Some girls are ready at 6! By 8:30am, it is getting too hot to play and everyone takes a morning nap. Tomorrow is our last day in Hinche so they will try to do a small tournament.

Leika is the daughter of Genette’s neice. She is my new god daughter. I will try to post a photo of her but Genette and her husband, Louinet, are here now and I must go. Mobile Clinic tomorrow, then off to Port Au Prince on Friday morning. I feel like we have been here for 3 months and yet Friday is coming up so quick. Will post again soon!

Birth is empowering!