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Monthly Archives: September 2016

PROM AT TERM… Some Evidence

index-14PROM AT TERM… Some Evidence  

written by Jackie Levine

 

Many define PROM as any release of waters before labor has actually begun…. whether at 32 or 42 weeks. There are recommendations about the management of PROM, but there’ is no definitive proclamation from the CDC or anywhere else  about what one “must” do to a woman after a certain number of hours have gone by without some contrax, especially at “term”.  The statistics about PROM pretty much don’t change….around the world the same % of women will go into labor and will birth  after 12-24 hours,  the same % after 48 hours, then 72 hours, etc, with the same low per centage of mothers and babies sustaining infection. 

It seems that the whole establishment is not convinced about exactly how to handle PROM, and the studies continue. You can find  ACOG practice bulletins on this at least since 2000.  The studies don’t all study things the same way….yes to pelvic exams?  No exams?  Expectant management with testing for fever or other signs of infection?  When and how?  Many mothers are really in early early labor, water breaks but there are no discernible contrax, yet the cervix is slowly slowly beginning to change.  Do these women as qualify as PROM and should they be put in the 24-hour queue? Or should they br  “classified” as being in labor, however early, which takes the “P” out of PROM…

The latest info on this is from the Cochrane, 2014. Here’s the “Background” and the “Conclusion”, followed by the citation.  This information may help mothers-to-be to make the  decision about whether to be treated according to routine, cookie-cutter care  that her OB applies to all clients with PROM at term, or to make sure that  a truly genuine  assessment of her  and her baby’s individual, actual health status is made.

BACKGROUND:

Prelabor rupture of the membranes (PROM) at or near term (defined in this review as 36 weeks’ gestation or beyond) increases the risk of infection for the woman and her baby. The routine use of antibiotics for women at the time of term PROM may reduce this risk. However, due to increasing problems with bacterial resistance and the risk of maternal anaphylaxis with antibiotic use, it is important to assess the evidence addressing risks and benefits in order to ensure judicious use of antibiotics. This review was undertaken to assess the balance of risks and benefits to the mother and infant of antibiotic prophylaxis for PROM at or near term.

AUTHORS’ CONCLUSIONS:

This updated review demonstrates no convincing evidence of benefit for mothers or neonates from the routine use of antibiotics for PROM at or near term. We are unable to adequately assess the risk of short- and long-term harms from the use of antibiotics due to the unavailability of data. Given the unmeasured potential adverse effects of antibiotic use, the potential for the development of resistant organisms, and the low risk of maternal infection in the control group, the routine use of antibiotics for PROM at or near term in the absence of confirmed maternal infection should be avoided.

Cochrane Database Syst Rev. 2014 Oct 29;10:CD001807. doi: 10.1002/14651858.CD001807.pub2.Antibiotics for prelabour rupture of membranes at or near term.Wojcieszek AM1Stock OMFlenady V.

Here’s another concise recent piece of information: JUNE 18, 2015/BCAYLEY Summary: For women with pre-labor rupture of membranes occurring after 36 weeks’ gestation (who do not have a confirmed infection), use of antibiotics does not appear to reduce the risks of endometritis, early-onset neonatal sepsis, maternal infectious morbidity, stillbirth, or neonatal mortality; but use of antibiotics in this situation may be associated with increased rates of cesarean delivery and maternal length of stay in hospital, and potentially could be associated with adverse medication side effects from antibiotic use and the potential for the development of resistant organisms. (In other words, avoiding antibiotic use for prelabor rupture of membranes after 36 weeks’ gestation unless there is a confirmed maternal infection, may be associated with lower risks adverse antibiotic effects, lower rates of cesarean delivery, and shorter maternal stay in hospital; without increasing the risks of any neonatal or maternal morbidity or mortality.)

http://www.ncbi.nlm.nih.gov/m/pubmed/25352443/

 

 

Thank you, Jackie! You know I, Triad Birth Doula, always enjoy sharing your articles.
Interesting thing…in my experience here in NC, I have only had antibiotics offered once for PROM, which mother refused much to the doctor’s distress.
I have had a couple of mothers become sick after 24+ hours and were then given antibiotics as soon as fever appeared. But no wonder with all of the vaginal exams, catheter and internal monitor due to pitocin & epidural.
I have a theory about avoiding PROM….
Around here, and with my clients, I feel that a sudden drop of barometric pressure is all too often the culprit of PROM. So I suggest that when we know this type of weather is going to occur, drink extra water and if safe get in bath tub. If not safe (lightening) lie down so at least gravity is taken out of the picture.
Some may laugh at me but I believe in this.

 

 

 

Active Management of Third Stage of Labor & Birth

managing-the-3rd-stage-of-labor-drrhodora-cruzbulacan-ob-g-14-728

Jacqueline Levine, Childbirth Educator/Lactation Consultant, has taken a hard look at the Third Stage of Labor and Birth.
If this stage is “managed” or not may have an impact on your breastfeeding.
Take a look at what this long time professional has to say…..

Prophylactic pit is just  part of that package of “Active Management of Thirds  Stage of Labor” (AMTSL) and there’s  a really great analysis of that concept  and its consequences  in “Optimal Care in Childbirth” Romano and Goer’s  great book.  They contend, and studies agree,  that the medical model of birth…induction and pit to augment labor and other protocols…are modifiable causes of PPH (Post Partum Hemorrhage),  and all woman do not just bleed to death after birthing their babies.   

We know that docs think that medical intervention is always the answer to a problem… never the cause.   I quote from the Goer/Romano book “…research fails to provide ANY evidence that universal application of AMTSL   results in clinically important improvements in maternal outcomes in developed countries, while documenting that it introduces harms”  (p379).     

 In 2010, Cochrane reviewers raised many issues about the trade-offs between the benefits and harms of managing third stage, including worries about prophylactic pit for all women regardless of their risk profile. The key phrase for looking at PPH is, I think, “developed” countries.   99% of deaths due to hemorrhage are in undeveloped and developing countries (says the WHO) , and pit has had  great success in the prevention and treatment of PPH in low-resource countries.

 But here in the US and  in other  high-resource settings, AMTSL “ conferred no benefit other than a small absolute reduction in transfusion rates, but findings show that transfusion rates are not an objective measure”, (Goer/Romano p379), because of the biases found in decisions about  the administration of transfusion and the lack of standardization as to when to treat.   Here, where we have the best medical resources (badly used and badly distributed, no doubt), a pit shot for every woman is overkill, unnecessary for the healthy mother, takes the place of her own highest-ever levels of natural oxytocin, upsets the beneficent cocktail of post birth hormones  the high levels  that nature provides for the most successful and joyous first minutes and hours with her newborn.  

During a c-section,  the mother may lose as much as 1000ml of blood, and that’s not enough to make docs call for a transfusion, but the standard for vaginal birth is only 500ml, and one wonders how they can tell how much blood loss there really is, when much of what a woman loses may be absorbed in the chux pads under and around her.

The Cochrane  says” Women should be given information on the benefits and harms of both methods to support informed choice. Given the concerns about early cord clamping and the potential adverse effects of some uterotonics, it is critical now to look at the individual components of third-stage management.”

Active versus expectant management for women in the third stage of labour. Cochrane Database Syst Rev. 2011; 11:CD007412 (ISSN: 1469-493X) Begley CM ; Gyte GM ; Devane D ; McGuire W ; Weeks A
School of Nursing and Midwifery, Trinity College Dublin, 24, D’Olier Street, Dublin, Ireland, Dublin 2.