Birth Plans: Evidence–Based Recommendations

Maj Alison Baum

R3, Nellis FMR

Examine your prejudices

What are some of your thoughts about birth plans?

Video

http://www.youtube.com/watch?v=HH62v0cxf04

Components of Birth Plans

Labor: Pain management wishes Doulas Episiotomy Intermittent fetal monitoring

Postpartum: Delayed cord clamping Cord blood banking Placental encapsulation Vitamin K/ baby meds

Labor Pain- Physical

Uterine contractions T10-L1 nerve roots May be felt as low back pain

Descent Stretching of pelvic floor/ perineum

Labor Pain- Emotional

Increased perception of pain: first delivery, h/o dysmenorrhea, fear of pain

Decreased pain: childbirth prep classes, pregnancy complications, plans to breastfeed, high SES, older age

Pain control

Epidurals control pain more effectively than opioids, alternative methods

Opioids cross placenta postnatal resp depression Hypothermia Decreased suckling ability

Anim-Somuah M, Smyth RMD, Jones L. Cochrane 2011.

Pain control

Risks of epidurals Assisted/operative vaginal birth RR 1.42 Maternal hypotension RR 18.23 Urinary retention RR 17.05 C/S for fetal distress RR 1.43▪ No risk of increase in overall C/S rate

Anim-Somuah M, Smyth RMD, Jones L. Cochrane 2011.

Alternative pain management

Hypnobirthing/ Bradley method Cochrane review: decreased need for

analgesia, RR 0.53, 95% CI 0.36 to 0.79 Acupuncture

Cochrane: decreased need for pain relief RR 0.7 95% CI 0.49-1.00

Randomized, patient blinded, placebo controlled trial: significantly less pharm use, shorter labor time

Smith CA et al. Cochrane 2006Borup L et al. Birth Mar 2009

Doulas

A female support person, especially a childbirth educator, other than the woman’s partner or medical team DONA.org: a trained and experienced

professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period

Doulas

Cochrane Review: Decreased use of analgesia RR 0.90

(0.84-0.96) Decreased operative births/increased

SVD Increased satisfaction

Best: not hospital staff or friend when epidural not available When spouse not “allowed”Hodnett et al. Cochrane 2012.

Routine episiotomy

ACOG recommends against routine episiotomy

Risk of extension of incision 3rd and 4th degree tears

Possible risks Future tears Sexual dysfunction Increased pain

ACOG Practice Bulletin 2006.Eason E. et al Obstet Gynecol. 2000.

Intermittent fetal monitoring

Cardiotocography vs. intermittent monitoring Perinatal death RR 0.85 (0.59-1.23) Neonatal seizures RR 0.50 (0.31-0.80) Cerebral palsy RR 1.74 (0.97-3.11) Cesarean section RR 1.66 (1.30-2.13) Operative vaginal RR 1.16 (1.01-1.32)

Alfirevic Z et al. Cochrane 2006.

Intermittent fetal monitoring

ACOG recommendation:

High risk pregnancies – toco

Low risk- toco or intermittent

Delayed Cord Clamping

Perceived benefits: Decreased postpartum hemorrhage Higher hemoglobin in infant

True benefits Higher birthweight Higher infant hemoglobin Increased iron reserves at 6 mo

Cochrane 2013.

Delayed Cord Clamping

No change in PPH rates

Risks Increased risk of jaundice requiring

phototherapy

Conclusion: “Delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available.”

McDonald SJ et al. Cochrane 2013.

Cord Blood Banking

Conditions treated

Options Privately held UCB banking Publicly held UCB for autologous use

Cord Blood Banking

Privately held UCB Costs: $1500-$2000 upfront,

$100-200/year Expected benefits▪ Not used to treat leukemia in general 1

▪ Cannot be used for inborn errors of metabolism▪ Less than 10 case reports of autologous

transplant 2

▪ Chances about 1 in 2700 or lower 3

1. Rowley JD. Nat Med 1998;4:150–1.2. Petrini C. J Blood Med 2014.3. Umbilical Cord Blood Banking, ACOG Committee Opinion, 2012

Cord Blood Banking

Public banking: Requires screening for infectious

diseases Free No guarantee blood will be available for

later use Requires extra effort if not offered at

MTF Generally must be screened by 34

weeks’ gestation

Placentophagy

Definition Maternal Non-maternal

Claims of benefits Energy levels Decreased postpartum depression Increased milk supply

Placentophagy

Literature limited to anthro studies

Risks: Improper handling Blood borne pathogen

transmission

Baby meds (Vitamin K)

Examine reason for objection

Vitamin K Prevents Vitamin K deficient bleeding 3 types: early (0-24 hours) classic (2-14

days) and late (2-12 weeks)

Vitamin K

Tennessee outbreak

Conclusion

Common items in birthplans Evidence Explored patient’s perspective

Works Cited

McDonald SJ, Middleton P, Dowswell T, Morris PS. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database of Systematic Reviews 2013, Issue 7.

Anim-Somuah M, Smyth RMD, Jones L. Epidural versus non-epidural or no analgesia in labour. Cochrane Database of Systematic Reviews 2011, Issue 12.

ACOG Practice Bulletin. Episiotomy. Clinical Management Guidelines for Obstetrician-Gynecologists. Obstet Gynecol. 2006;107(4):957.

Rowley JD. Backtracking leukemia to birth. Nat Med 1998 Feb; 4(2): 150-1. Petrini C. Umbilical cord blood banking: from personal donation to international public

registries to global bioeconomy. J Blood Med. 2014 Jun 18;5:87-97. Umbilical Cord Blood Banking, ACOG Committee Opinion, 2012 Preventing perineal trauma during childbirth: a systematic review. Eason E, Labrecque M,

Wells G, Feldman P. Obstet Gynecol. 2000;95(3):464. Maizes V, Low Dog T. Integrative Women’s Health. Oxford University Press, 2010. Borup L et al. Acupuncture as pain relief during delivery: a randomized controlled trial.

Birth 2009 Mar 36 (1) 5-12. Smith CA et al. Complementary and alternative therapies for pain management in labour.

Cochrane Database Syst Rev 2006 Oct 18;(4):CD003521. Warren M. Notes from the Field: Late Vitamin K Deficiency Bleeding in Infants Whose

Parents Declined Vitamin K Prophylaxis — Tennessee, 2013. CDC Notes from the Field.

Questions?