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Risks and Benefits of Fetal Monitoring During Births by Horatio Daub MD, MPH

In a recent article in the August 1, 2020 edition of American Family Physician which is a peer reviewed and editorially independent journal of the American Academy of Family Physicians, there is an interesting study discussing “Intrapartum Fetal Monitoring.” It explains that continuous electronic fetal monitoring (CEFM) was developed to screen for evidence of fetal distress including hypoxic ischemic encephalopathy or fetal acidosis (compromised brain function due to inadequate circulation and oxygen delivery to the brain), cerebral palsy (which
is most likely caused by factors prior to birth), and impending fetal death during labor. Because of the low frequency of occurrence of these events during labor, CEFM has a false positive rate of 99%. In other words, lkg99% of the time when the monitoring shows a pathologic pattern, it is not indicative of an immediate danger for the fetus.

CEFM leads to increased rates of cesarean delivery

The widespread use of CEFM has led to increased rates of cesarean and other operative deliveries without any significant improvements in outcomes for the newborns. CEFM is a very blunt tool for detecting fetal distress. CEFM is falsely positive for fetal acidosis 67% of the time and when actually present, has a low sensitivity of 57% of correctly detecting fetal acidosis. When fetal acidosis is not present, there is a low specificity of CEFM with only 69% of the time showing a negative or normal result. Further complicating this is difficulty interpreting the CEFM tracing with agreement between experts on interpretations of the CEFM tracings only half of the time.

Structured Intermittent Auscultation (SIA)

Structured intermittent auscultation is preferred for women without risk factors as detailed below. ‘The main antepartum factors indicating high risk labor and the need for CEFM include any condition in which placental insufficiency is suspected such as intrauterine fetal growth restriction, known fetal anomalies, maternal preeclampsia/gestational hypertension or maternal type 1 diabetes mellitus. Intrapartum factors indicating high-risk labor and requiring CEFM include presence of meconium, presence of tachysystole (overactive uterine
contractions), signs or symptoms of intrauterine infection, unexplained vaginal bleeding, or use
of oxytocin or other uterine stimulants for labor induction or augmentation.

If one of the following is detected during SIA for a low-risk patient switching to CEFM is recommended to assess the National Institute of Health and Human Development category and to determine necessary clinical management: irregular fetal heart rate, fetal tachycardia (<160bpm for >10 minutes), fetal bradycardia (<110bpm for >100 minutes) or recurrent decelerations following contractions (<50% of contractions) or prolonged decelerations (>2 minutes but <10 minutes).

Risks of CEFM

The main risks of CEFM are increases in cesarean and operative vaginal delivery rates without improvements in fetal outcomes. Along with the increases on operative deliveries also come costs of longer hospital stays and higher risks of complications such as infections, bleeding, and bladder injury, etc. Another important consideration is that the ability of the laboring woman to move around and walk or assume a position that facilitates her delivery and labor is very restricted, making a normal natural labor and delivery almost impossible to achieve.

Barriers to Implementing SIA

Not all birthing facilities offer the option of SIA because of barriers in nursing staffing and education and physician oversight. Most organizations, including the American College of Obstetricians and Gynecologists (ACOG) and the American College of Nurse Midwives (ACNM) recommend instituting SIA with the onset of the active phase of labor. However, there are differing ways of defining active labor. The two most commonly used are 4 cm of cervical
dilatation and 6 cm of cervical dilatation but regular uterine contractions which are strong and frequent (<5 contractions in a 10 minute period averaged over 30 minutes) without uterine stimulants is also important for active natural labor. Be sure to ask your birthing facility if the option of SIA is available.

Choosing Wisely Campaign: Advice for birthing women

A recommendation from the Choosing Wisely Campaign is to not automatically initiate CEFM during labor for women without risk factors, and consider SIA first. Another very important recommendation from the Choosing Wisely Campaign is: Don’t separate mothers and their newborns at birth unless medically absolutely necessary. Instead, help the mother to place her newborn in skin-to-skin contact immediately after birth and encourage ongoing skin-to-skin contact and always keeping the newborn in her room during the hospitalization after the birth.

Breastfeeding within a half an hour after birth is optimal both for the mother and infant’s health along with exclusive breast feeding for the first 6 months of life after which appropriate complementary foods should be introduced, and the infant should continue to breastfeed for one to 2 years or longer as desired. Worldwide, the lives of an estimated 1.5 million children less than the age of five would be saved annually if all children were fed according to this standard.

References:
1. “Intrapartum Fetal Monitoring,” American Family Physician American Family Physician,
2020;102(3):158-167
2. For more information on the Choosing Wisely Campaign, see
http://www.choosingwisely.org. For Primary care see
https://www.aafp.org/afp/recommendations/search.htm

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Yes! Type 2 Diabetes is Reversible!

 

BirthWorks is a comprehensive program that works to improve birth and health for the whole person. We address many issues that help keep a woman in the perinatal period healthy so she has a better chances of growing  a healthy baby, having a transformative birth,  and being of sound mind, body, and spirit during the early years of parenting. Here, we are addressing the national/global concerns of obesity and Type 2 diabetes brought on by a diet high in fats and highly processed foods that bear little resemblance to the whole foods that they came from.  This is adversely impacting the health of both mother and babies and the process of birth today.

Obesity and Type 2 Diabetes have become major health issues in the USA and most countries around the world.  They are a large health cost to the global population and are also contributing to complications for pregnant and birthing women.  We used to think that once a person has Type 2 Diabetes, he/she has it for life.  The good news is that the latest research shows this is not necessarily true.  Type 2 Diabetes can be reversed with a lifestyle program of eating a whole foods plant based diet, regular exercise, and managing stress.  It can also prevent development of diabetes in the many people who have prediabetes or have had gestational diabetes.

Normally, the pancreas secretes insulin which allows us to store and use glucose (sugar) from the food we eat.  In type 2 diabetes, the problem starts when our cells become resistant to the insulin and do not allow glucose to be transported into the cells of muscle, liver, brain, and other organs for energy, metabolism, storage, and overall function.

Exciting new research!  Decrease your fat intake.

Research has now shown that the main culprit is the fats that are deposited in the cells of muscle, liver, and other vital organs which  interfere with the transport of glucose into the cells.  Like a lock and key mechanism, insulin attaching to the receptors on the outside of the cell, acts as a key to facilitate the glucose coming from the blood into the cell.

When fats are deposited into cells, they inhibit the effect of insulin which is to facilitate the uptake of glucose from the blood into the cell.  Inside the cell, glucose is used to produce energy and carry out  other functions of the cell depending on the organ or tissue that these cells are within.

If there is an inadequate supply of glucose in the cell, there will not be enough energy or power for the cell and organ that the cell is a part of, to do its job.  If the cell is in a muscle, it will not be able to move or contract the muscle it is a part of.  If the cell is in the brain and does not get enough glucose, you have impaired cerebral function and can eventually go into a coma.

The solution is to start with the root cause of the disease which is to prevent or remove fat buildup in cells  Where are the fats coming from?  They are coming from a variety of sources and include any added fats or oils to your foods.  Examples are salad dressings containing fat, saturated fats in baked goods, pastries and butter and margarines in recipes, fats added to foods or foods cooked in fat such as French fries and chicken nuggets, and especially any deep fat fried foods.  To avoid oils, I saute my vegetables in water or vegetable stock and it works just fine!

The most effective way to improve or reverse your diabetes, is to decide now to begin eating a Whole Foods Plant Based Diet.  All a person with prediabetes or Type 2 Diabetes has to do, is to eat only whole plant foods that are minimally processed and avoid all fats and oils which are mostly highly processed.  You can get all the fats that you need by eating whole foods such as corn, seeds and nuts (especially flax seed meal and chia seeds), instead of processed corn oil, sunflower oil, olive oil, etc. Since the body is always trying to heal itself, you will be surprised how quickly you will see results.

However, if you are on medications, especially insulin for diabetes, work closely with your doctor to adjust medicines according to what your blood sugars are running and also blood pressure meds to keep your blood pressure and blood sugar from going too low from these lifestyle changes in combination with medications.  Also speak to your doctor about supplementing with Vitamin B-12 and Vitamin D to prevent deficiencies of these vitamins on a plant-based diet.

Here is a picture of a lunch served at the recent conference I attended in Washington DC called the ICNM (International Committee of Nutritional Medicine).  Start now eating more fruits, vegetables, grains and nuts being sure you have a rainbow plate of many colors.  It is delicious and you will begin feeling healthier and having more energy.  If pregnant, your baby will also be having the best start in life.