Pregnancy and birth are filled with many unpredictable features, whether this be your first go at the rodeo or 5th.
Pain experienced during labor is also unpredictable. Pain may be manageable without medication, or it may become severe and exhausting.
If you find yourself calling the United States your home, then you are among the majority if you opt for epidural pain relief during labor.
Ladies in the U.S. have fewer options for labor pain management than our counterparts in other industrialized nations (such as the UK and Canada). It is uncertain if the excessive use of epidural analgesia is a true preference in the US or if it is simply chosen because of the lack of other presented options.[*]
Interesting, none-the-less….
What is certain is that epidural use is nearly always an elective procedure. Although it can be a useful tool in supporting a laboring mother, the use of epidural medication expands the chance for complications, this does not occur in drastic numbers. Each family has their own comfort level with side effects and risk – what one family may consider safe, another may become uncomfortable. (you can learn more about risks associated with epidural use here and here)
Everyday, devoted and loving soon-to-be mothers opt for epidural anesthesia pain relief during the birth of their babies.
I was among them, choosing an epidural with my first daughter because I thought it would help with pain and allow me to have a more enjoyable experience. In actuality, I experienced agonizing break-through pain and a cascade of interventions that I wasn’t anticipating (urinary catheterization, artificial rupture of membranes, internal fetal monitoring, use of synthetic oxytocin).
Was my disillusionment with epidural anesthesia in the minority?
Higher Pain Recall Among Those Opting for Epidural Analgesia
A remarkable finding from a longitudinal study (2009 BJOG) regarding women’s memory of labor pain found that mothers who opted for epidural analgesia reported higher pain scores at all time points versus those who went without.[*]
Another study (2006 JPOG) substantiates the above findings and also goes to on to provide data that women who received epidural analgesia not only had higher recollection of intense pain at two months and one year but also had greater difficulty forgetting pain 10 months later.[*]
If a mother chooses an epidural in most part to experience a labor that is less painful then one without anesthesia the data above can be sobering.
Research also suggests that pain experienced during labor is not entirely a negative experience, with more then 1 out of 4 women (28%) assessing pain as more of a positive than a negative – suggesting that coping with pain is a rewarding experience for some women.[*]
Lower Satisfaction Among Those Opting for Epidural Analgesia
Although women and care providers may assume that effective pharmaceutical pain relief during labor will ensure a more positive birth experience, there is mounting evidence that the opposite is true.
Several studies have shown that women who use no labor medication are the most satisfied with their labor and birth (times being assessed at time of birth, six weeks and one year after birth).[*][*][*][*][*][*]
Also worth noting, women who cope with labor using non-medical alternatives such as water birth, massage, positioning, focusing and breathing done with the support of another person report more satisfied than with standard pain relief given during childbirth.[*]
Natural techniques utilize a woman’s own strengths and places her in control of her own body. They also have been assessed to improve obstetric outcomes compared to pharmaceutical relief.[*][*]
Interestingly, the influence of pain relief on satisfaction is not as powerful as the attitudes and behaviors of the mother and caregivers involved. Consider a 2002 study published in the American Journal of Obstetrics & Gynecology which concludes four factors that appear to override pain experienced in labor:[*][*]
1. Personal expectations
2. Amount of support from caregiver
3. Quality of caregiver-patient relationship
4. Mother’s involvement in decision making
This reaffirms the main key to satisfaction and managing labor pain effectively, is to ready yourself in advance – arranging continuous support, accurately understanding pain control options (and the interventions involved) and having an active role in the decision making process.[*][*]
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As much as some might like to discount natural childbirth as a progressive trend among a small number of women, research affirms that women who opt for epidural anesthesia experience more pain, have a more difficult time forgetting the pain, and experience less satisfaction overall.
Women do not decline an epidural simply to “win a medal” – instead information on different types of pain relief are assessed and balanced against other goals such as walking, pushing effectively, or minimizing maternal/neonatal side effects and/or risks.
How much of an effect an epidural medication can have on a newborn or mother is not easily predetermined and can vary based on dosage/mix of pharmaceutical drug combination, the length of labor, and each individual.[*]
Opting for an epidural anesthesia is one method (among many) that can aid in relief of pain and discomfort during the labor process. This type of pain relief requires a mother to give some control to the hospital staff. It does involve risk and additional intervention.
The decision, rightfully, rests for each woman to make. In due course, researching the procedure and talking others who have may be able to offer different perspectives could help a mother decide on what is right for them.
As the data suggests, most women who choose unmedicated birth (and prepare for it) find the pain intense but manageable and they are happier with their experience afterwards.
Ultimately, what can be said, each woman should use the insight into herself to be the best guideposts in directing her toward a positive decision regarding pain relief during labor.
"You gain strength, courage and confidence by every experience
in which you really stop and look fear in the face."
This post will kick off a series that will be providing information on each disease and vaccine that is currently on the CDC’s recommended national immunization schedule.I hope this information is able to help those attempting to decide on an alternative vaccine schedule (whether that is a delay, select or decline one). Please leave a comment if you have any questions.
The information below is gathered from sources included PubMed, the CDC, the Mayo Clinic, and package inserts published from the vaccine manufacturer. (See below for a full list)
The Disease
Hepatitis B is irritation and swelling (aka: inflammation) of the liver due to the infection of the hepatitis B virus (HBV).
Hepatitis B infection is spread through contact with the blood or body fluids of someone who already has a hepatitis B infection.
Some common ways HBV is spread is through:
·Blood transfusions (which is not common in the US)
·Direct contact with blood in health care settings
·Sexual contact with an infected person
·Tattoos with unclean needles or instruments
·Shared needles during drug use
The highest concentrations of the hepatisis B virus is in blood with lower titers being found in other fluids, such as saliva. No transmission of HBV has been found via tears, urine, sweat, or stools.
It is improtant to note that the hepatitis B virus can be passed to an infant during childbirth if the mother is infected. Due to this higher risk, pregnant women are tested for hepatitis B during their prenatal care. If you are not infected with hepatitis B while pregnant, you may want to consider delaying or declining this vaccine.
If mother positive for HBsAg and HBeAg
70%-90% of infants infected
90% of infected infants become chronically infected
If positive for HBsAg only
10% of infants infected
90% of infected infants become chronically infected
Symptoms
The majority of people infected with HBV experience no symptoms but if symptoms do appear they commonly consist of yellowing of the skin and eyes, fatigue, nausea, dark urine and abdominal pain.
If your body is healthy it will be able to fight off the hepatitis B infection, any symptoms will diminish over a period of weeks to months.
In some cases, a person’s body lacks the ability to completely get rid of the infection. This is what is called chronic hepatitis B.
Chronic hepatitis B occurs in less than 5% of adults. However, chronic infection occurs in almost all newborns that become infected (about 50% in children). Again, due to this higher risk, pregnant women are tested for hepatitis B during their prenatal care.
Interestingly, the majority of people who have chronic hepatitis B infection have no symptoms -although, damage to the liver may be occuring gradually over time. Another reason to be careful who you have sex with and to say no to drugs.
Treatment
Regular hepatitis B infection needs no treatment other then plenty of rest, fluids, and eating healthy foods. Hepatisis B is removed from the body after 2 - 3 weeks with the liver returning normal function within 4 - 6 months.
Antiviral medication (peginterferon) is utilized for patients with chronic hepatitis B. Althought there is no cure for hepatitis B, the majority of adults infected with HBV recover fully, even when they have severe symptoms.
Hepatitis B is fatal in approximately 1% of cases.
The Vaccine
Some background: Hepatitis B vaccines have been available in the US since 1981. Interestingly, the impact of vaccines on hepatitis has been less than ideal and this can be attributed to a few reasons.
For a decade after the introduction of the HBV vaccine in 1981, vaccination was targeted to only persons in high risk groups (heterosexuals with contact with infected persons or multiple partners, injection-drug users, and men who have sex with men). These high risk groups are difficult to include in a national vaccine program for many various reasons.
To alleviate this, in 1991 a new strategy to eliminate HBV was adopted. It included routine vaccination of all newborns and children – even though this group was the least likely to aquire infection it was most cost effective and simplest of solutions.
The ACIP in conjunction with the CDC recommends that all infants be vaccinated with three doses of hepatitis B vaccine beginning at 12 hours of age with the last dose given before 18 months of age.
Babies born from infected mothers will be given the hepatitis B immune globulin (HBIG) in addition to the vaccine at birth. Also worth noting, preterm infants or babies weighing less then 2,000 grams (4.5 lbs) should not receive the vaccine until 1 month or hospital discharge (except those born to infected moms).
There are two manufacturers in the US that produce the hepatitis B vaccine, Merck (Recombivax HB) and GlaxoSmithKline Pharmaceuticals (Engerix-B). These vaccines can be utilized in both adult and populations. These vaccines can also be used interchangeably, except for the two-dose schedule for adolescents (11 -15yrs - only Merck vaccine is approved for this schedule).
The hepatitis B vaccine is a recombinant vaccine. This means that a section of DNA from one species is inserted into the DNA of another (aka transgenic species). Another recombinant vaccine on the market today is the HPV vaccine.
This hepatitis recombinant vaccine is produced by inserting the surface protein of a hepatitis virus into common baker’s yeast. Yeast cells then produce HBsAg, which is collected and then purified. Recombinant vaccines are safer then most since infection of the virus cannot result from use of this vaccine since no infectious viral DNA is produced. The vaccine HBsAg is adsorbed into an aluminum hydroxide adjuvant (250 mcg Engerix-B and 500 mcg Recombivax HB).
Immunogenicity and Vaccine Efficacy
After three doses of the hepatitis B vaccine, it is estimated that approximately 90% of healthy adults and 95% of children develop an adequate antibody response. It is understood that an age-specific decline has been seen in immunity. According to the CDC, the studies that have been done on efficacy indicate that immunologic memory remains intact for 20 years among healthy vaccinated populations.
A note to those that may decide to delay this vaccine, the highest titers are achieved when the last two doses of the vaccine are spaced at least 4 months apart which makes this spacing preferable.
Quick info on some other options:
The Comvax vaccine is a hepatitis B vaccine in combination with Haemophilus influenzae type b (Hib) vaccine developed by Merck. Each dose of Comvax contains 225 mcg of aluminum with not more than 0.0004% (w/v) residual formaldehyde.
GlaxoSmithKline’s Pediarix vaccine was approved in 2002 and was the first 5-component (pentavalent) combination vaccine licensed in the US. Pediarix contains DtaP:(Infanrix), hepatitis B (Engerix-B), and inactivated polio vaccine. Pediarix contains the highest level of aluminum adjuvant at a level of 850 mcg. Each dose also contains ≤100 mcg of residual formaldehyde and ≤100 mcg of polysorbate 80 (Tween 80).
Pediarix cannot be used for the first dose at birth since the minimum age for dosage is 6 weeks. Pediarix is commonly utilized for the first three doses of the DTaP and IPV series, which are usually given at about 2, 4, and 6 months of age.
For those of you who might delay, Pediarix is approved for use through 6 years of age. So a child who is on a delay schedule can still receive Pediarix as long as it is to a child younger than 7 years of age.
A schedule for adolescents (11 or 12 years of age) is two doses separated by no less than 4 weeks, and a third dose 4 to 6 months after the second dose –the Engerix-B or Recombivax HB vaccine can be administered at this age.
Precautions to Vaccination with HBV
Children with moderate illness should not be vaccinated until their condition improves.
However, it is noted specifcally that a minor illness, such as an upper respiratory infection, is not a contraindication to vaccination. (If you ask me, I would wait until my child is healthy to vaccinate – but that’s just my two cents)
Studies of the safety of hepatitis B vaccine in pregnant women have not been performed and it is not known whether the vaccine will effect breastmilk.
Adverse Reactions
The most common adverse reaction following hepatitis B vaccine is pain at the site of injection. Fatigue, headache, and irritability have also been reported in up to 20% of children after vaccation. Fever can also occur and was seen in approximately 6% of children in the safety studies performed by the manufacturers.
Hepatitis B vaccine has been noted to cause or exacerbate multiple sclerosis. A 2004 retrospective study in a British population found a slight increase in risk of MS among hepatitis B vaccine recipients (study was published in Neurology-click here to review).
As of March 2012, there has been a total of over 66,000 hepatitis B vaccine-related adverse events reported to the federal Vaccine Adverse Events Reporting System (VAERS),
Search for Vaccine Reactions
NVIC hosts MedAlerts, which is a VAERS database search engine. MedAlerts examines symptoms, reactions, vaccines, dates, places, and more.
Reporting a Vaccine Reaction
Reporting vaccine reactions to VAERS is the law. If your doctor will not report a reaction, you have the right to report a suspected vaccine reaction to VAERS. Here is the website to report a reaction: http://vaers.hhs.gov/esub/index
Whenever you make a health care decision for yourself or your child, especially one that involves a pharmaceutical product such as a vaccine, you should consider obtaining information from many different sources as well as consulting your health care professional.
Becoming an informed health care consumer is important and will empower you to ask doctors important questions and ultimately help you to take control of your health choices.
If your doctor is not supportive of your informed health choices, consider consulting another doctor who will work with you as a partner helping you make important health care decisions for yourself or your child(ren).
Information presented on this post can be reviewed in depth from the following sources:
For me, being a first time mother, I never knew that there were routine hospital procedures that influenced the welfare of my child AND that I had the authority to manipulate them.
My advice to a new mama is to learn about what to expect in the hospital beforehand.
There are several routine practices that should can be considered for you to declined, delayed or modify.
Since your number one priority is to the welfare of your child, take the time review the information available on the procedures used in hospital maternity wards – surprisingly, most are not evidence-based practices, instead they are in place due to the ease and convenience of the staff or because that is what has been done in the past.
Cord Clamping
Clamping the cord within 30 to 60 seconds after birth is one of three steps in an "active management" approach to the third stage of labor in hospitals.
The reason for this routine medical procedure is because immediately following birth the new mother is most vulnerable to excessive blood loss.[1]
However, The Cochrane Library (a publication of The Cochrane Collaboration, an international organization that evaluates medical research-systematic reviews draw evidence-based conclusions about medical practice after considering both the content and quality of existing medical trials on a topic) found that in terms of the amount of bleeding, delayed clamping did not reduce the mother's risk of bleeding.[2]
In fact, there are many benefits of delaying this procedure until the newborn’s umbilical cord has stopped pulsating. The benefits of waiting are well documented and many parents are not aware of the large impact this particular routine procedure can have on their new baby.
One benefit that has recently received a lot of attention is the effect of iron levels in a newborn. The amount of iron in the blood at birth influences health, particularly an infant's risk for anemia in the first months of life.
This is especially relevant when considering that iron deficiency is the primary cause of anemia which can lead to central nervous system effects and cognitive impairment. In addition, delayed cord clamping can increase the rate of transfer of hematopoietic stem cells to the newborn, which may play a role in the prevention of certain blood disorders and immune conditions.[3]
Please consider telling your partner to watch and be vocal about what you wish when giving birth. Delaying clamping of the cord is an easy one to watch for and your hospital should be able to abide by your request.
Vitamin K Injection
The injection of vitamin K to every newborn infant was a practice that began in the 1950’s. The injection is used to artifically alter the naturally occurring level of vitamin k in the baby and to promote blood clotting.
To account for a rare liver disease (called Hemorrhagic Disease) that occurs approximately about 5 out of 100,000 births – the answer the CDC has come up with to tackle this rare bleeding trauma is to inject all infants with not double the amount…not 10 times or not even 100 times ….but rather 20,000 times the newborn level of vitamin k.
If you opt out of the vitamin K injection, the baby will gradually raise their levels after birth by breastfeeding (colostrum is extremely high in vitamin k).
You can also consider giving vitamin k drops orally (liquid vitamin K9) which is a significantly lower dose then the 20,000x level of the injectable vitamin k. If you consider this - I would contact the pediatrician to determine how this will be administered and how to attain it.
-Women on anticonvulsant drugs during pregnancy (for epilepsy)
-Babies that had premature clamping or cutting of their umbilical cord (this deprives the baby of up to 40% of their blood volume which includes platelets which aid in clotting) - another reason to delay cord clamping!
-Women who had a vacuum extractor assisted birth (this often causes bruising and internal bleeding) – another reason to try for a natural birth
-Women/newborn on antibiotics
The administration of any injection into the blood stream of a newborn carries risk, particularly of infection…especially in an environment that contains the most hazardous germs.
I imagine there is a very delicate, complex relationship between blood clotting levels and a newborn’s cell growth. To go all ‘willy-nilly’ (sorry no other term applies here) and inject a synthetic vitamin in the blood stream (20,000 times higher then normal, a level chosen with no rhyme or reason) to alter something we don’t fully understand seem a tad bit reckless.
Erythromycin Eye Ointment
Erythromy-what?
Erythromycin is an antibiotic ointment applied to a newborns eyes just minutes after birth.
The administration of erythromycin is on the grounds of preventing blindness from exposure to maternal gonorrhea.
Yes – if you have gonorrhea, then you might want to consider keeping this procedure in place – if not, pass on it.
Please note that it is common practice to screen mothers for STDs during their prenatal care so if you don’t have an STD
I’m not sure why it would make sense on administering it.
Again, the administration of this groundless routine intervention is waive-able, but could include a fine of $5.00 in most states (however, in New York it is much more difficult to decline).
If you are considering administering “just in case” - is there risk?
The antibiotics in the ointment enter the bloodstream through the eye – the potential for diaper rash, thrush, and digestive problems are all present when this happens.
The bottom line-is it necessary and effective?
According to the several medical studies listed below (and in more detail here), that answer is no:
Bell TA, Grayston JT, Krohn MA, Kronmal RA. Randomized trial of silver nitrate, erythromycin, and no eye prophylaxis for the prevention of conjunctivitis among newborns not at risk for gonococcal ophthalmitis. Pediatrics 1993 Dec;92(6):755-60.
Chen JY. Prophylaxis of ophthalmia neonatorum: comparison of silver nitrate, tetracycline, erythromycin and no prophylaxis. Pediatr Infect Dis J 1992 Dec;11(12):1026-30.
Black-Payne C, Bocchini JA Jr, Cedotal C. Failure of erythromycin ointment for postnatal ocular prophylaxis of chlamydial conjunctivitis. 14: Pediatr Infect Dis J 1989 Aug;8(8):491-5.
Krohn MA, Hillier SL, Bell TA, Kronmal RA, Grayston JT.The bacterial etiology of conjunctivitis in early infancy.5: Am J Epidemiol 1993 Sep 1;138(5):326-32.
Being that this is a sensitive issue – I will not discuss this subject in detail or my personal views on the matter.
I will ask that if you are expecting son, please carefully assess the information available. This is definitely a procedure that the hospital will honor in declining, in fact, the rate of circumcision is declining because evidence-based knowledge is mounting.
If you are unsure, consider viewing a circumcision video to understand what your son will experience. (note-I did NOT view this video, I can’t handle stuff like that).
The majority of these surgeries in America are done without any anesthetic.Some will utilize a topical cream which takes nearly 45 minutes to numb the skin, yet these creams have not been studied in newborns.
Please be diligent in this decision, many faiths that commonly recommend circumcision have large followings that support keeping sons whole. Please take time to learn more then what is offered in a brochure at your OBGYN.
Hepatitis B
To begin with, hepatitis is a viral disease associated with sexual contact, blood transfusions, re-use of contaminated needles and vertical transmission (mother to child).
Prevelance of Hep B
The virus has the ability to cause an infection of the liver that can have long-lasting effects.For infants – this disease can be exceptionally serious and this is found when the mother is positive for the hepatitis.
Now in countries that have a much better infant mortality rate, such as Sweden and The Netherlands, medical professionals only administer the vaccine to mothers who test positive for the disease, not all newborns.
It’s also important to note that it has been recommended that the routine vaccination of all newborns for Hepatitis B is performed only in areas where the carrier prevalence is greater then 2% - this does not include the United States![*]
You might say that the vaccine is safe, so why not be extra sure? However, do you know how many safety studies have been performed on the Hepatitis B vaccine for newborns?
None.
You may want to consider delaying this vaccine until your next pediatric visit (2 months) or declining it until the risk is more prominent. Click here to learn more about hepatitis B and the vaccine used.
First Bath
Although it might seem somewhat logical to wash a baby immediately after birth, there are significant drawbacks that you might not have otherwise considered.
Firstly – if you decline or delay washing your newborn in the hospital, you might find more resistance then any other routine produce listed here. You will be met with the counter, “It is hospital policy” – this may very well be true but it does not mean you are required to abide by the policy, you have every right to decide what or what not procedures or performed on your child. [4]
If you alter the routine schedule of bathing, the hospital staff may insist on wearing gloves to handle your child – which is fine by me – this is because the medical thought is that your child will be posing a hazard to the staff.
Consider this-who is posing more of a hazard to who?
Newborns have a valid risk of nosocomial infection (infection that is caused by hospital staff) especially with MRSA strains. Bacteria have adhesive pili on their surface to attach to skin – the vernix that is rubbed into the baby’s skin and is allowed to stay on the newborn significantly inhibits growth of bacteria, as well as being antimicrobial in nature (similar to breast milk).[5][6][7]
A baby is born with exceptionally senstitive skin. Vernix can be rubbed into the skin and is highly effective at deterring the growth of common pathogens found in the hospital: as group B Strep, K pneumoniae, L. monocytogenes, C. albicans and E coli.[7]
The Department of Health (in conjunction with the World Heath Association) sets forth protocol for newborns: specifically in the section addressing the 0-3 minutes after the baby is born which states - Immediately dry the baby but “do not wipe off vernix” and “wait at least six hours to wash the baby”. [8]
Personally, I would wait longer – I would wait to wash my baby at home. Commercial products used in hospitals are harsh and can be harmful on neonatal skin. You could bring your own baby wash and ask the nurse if you could give your baby it’s first bath. I think that would be ideal if you choose not to wait until you get home.
Remember, there are no evidence-based guidelines relating to newborn skin care in hospitals and postnatally, vernix exhibits antioxidant, skin cleansing, temperature-regulating and antibacterial properties.[9][10]
Conclusion
Remember, you have every right to choose what will be performed on your baby.
Cautiously take into account what care options you have. If you have questions about a procedure for your baby-speak up and ask.
You are the number one advocate and the only voice your child has. Your responsibly is to him or her, not out-dated hospital policies.
[2]McDonald SJ, Middleton P. "Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes (Review)." Cochrane Database of Systematic Reviews 2008, Issue 2.
[3]Gina Eichenbaum-Pikser & Joanna Zasloff. Delayed Clamping of Umbilical Cord: A Review With Implications for Practice: Benefits of Delayed Cord Clamping. J Midwifery Womens Health. 5(4):321326.2009 http://www.medscape.com/viewarticle/708616_3
[4]Andreas Matussek, Jan Taipalensuu, Ing-Marie Einemo, Malena Tiefenthal, Sture Löfgren. Transmission of Staphylococcus aureus from maternity unit staff members to newborns disclosed through spa typing. American Journal of Infection Control. Vol 35, Issue 2. Mar 2007 http://www.sciencedirect.com/science/article/pii/S0196655306011898
[5]Annika Nelson, Kjell Hultenby, Éva Hell, Hilde M Riedel, Hjalmar Brismar, Jan-Ingmar Flock, Joachim Lundahl, Christian G Giske and Giovanna Marchin. Staphylococcus epidermidis isolated from newborn infants express pilus-like structures and are inhibited by the cathelicidin-derived antimicrobial peptide LL37.Pediatric Research. 25 Mar 2009 http://www.nature.com/pr/journal/v66/n2/abs/pr2009183a.html
[6]Dao M. Nguyen, Elizabeth Bancroft, Laurene Mascola,Ramon Guevara, Lori Yasuda. Risk Factors for Neonatal Methicillin‐Resistant Staphylococcus aureus Infection in a Well Infant Nursery. Infection Control and Hospital Epidemiology. Vol 28;No4. Apr 2007 http://www.jstor.org/stable/10.1086/513122
[7]Akinbi, H. T., Narendran, V., Pass, A. K., Markart, P., & Hoath, S. B.Host defense proteins in vernix caseosa and amniotic fluid. American Journal of Obstetrics and Gynecology, 191(6), 2090–2096. 2004 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1595247/
