Mothering Magazine Ask The Experts Michel Odent

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	ask the experts michel odent

Michel Odent, MD
Labor and Birth, Waterbirth

Risks with induction

I am pregnant with my third child and am struggling with the decision to have a natural birth, as I did with the first two, or instead opt for general anesthesia and have a c-section. This radical question is because I had my first child with no medical interventions in a hospital, where the doctor was attending to paperwork, and not to my delivery. As a result, I sustained a tear that went anterior from the vagina along the clitoris and dissected 60% of my labia away from my body. I had five surgeries attempting to correct the chronically painful 'torn labia' issue before getting pregnant with my second child. My second was born in a birth center, in a waterbirth with attention to my perineum to prevent further trauma. I had scar tissue from the surgeries and only sustained a small tear, requiring no stitch for healing.

Since the birth of my second child, I had two more surgeries to correct the still-problematic detached labia, and ultimately had my labia removed. I sustained, as a result of the removal and complications from the stitches, a very sensitive/painful scar. After all these procedures and four years of grief and pain, part of me is ready to just 'check out' of this third delivery via a c-section (though only if I can do so through general, and not spinal/epidural, anesthesia). My labors in and of themselves were not 'bad,' and were very manageable in general, but I am facing a mental brick wall regarding this scar, and deep fear of a horrible birth experience. Any suggestions?

Of course, you are the only one who can decide, because what you feel is not directly related to what others can see with their eyes. If you opt to give birth by cesarean, it should be ideally an 'elective in-labor cesarean.' If you are already in labor when the operation is performed, it is a guarantee that your baby has given a signal that its lungs are ready to breathe as efficiently as possible. Keep in mind that the baby participates in the initiation of labor. Furthermore, the hormones that both of you start releasing during labor will make the maturation of your baby's lungs more complete. In other words, a cesarean before the labor starts is a risk factor for breathing problems during the days following birth. From a bacteriological perspective, it is important, in the case of a cesarean, that the baby is immediately in contact with its mother's skin and then, if possible, in the arms of a familiar person, such as the baby's father. The mother, the father (who is more often than not a familiar person) and the newborn baby are supposed to share the antibodies called IgG (those that cross the placenta). It is important that the first germs that will colonize the baby's body are familiar, therefore friendly. They will protect the baby against unfamiliar, and therefore potentially dangerous, germs.

If you opt for a birth by the vaginal route, I can just mention what I have understood after half a century of experience. The best way to avoid serious perineal damage is to create the conditions for an authentic 'fetus ejection reflex.' This means that the baby is born after a very short series of irresistible contractions without any room for voluntary movements. In this case the mother, who is 'on another planet,' is able to find a complex posture perfectly adapted to the particular case. It is usually an asymmetrical bending forward posture. Very few people can understand what a fetus ejection reflex is because it is more often than not transformed into a second stage of labor with voluntary movements. It does not occur if there are several persons around. It does not occur if there is a birth attendant who behaves like a guide, or a 'coach,' or a support person. It does not occur if somebody wants to 'take care of the perineum.' It does not occur in the presence of the baby's father. The best situation I know for a fetus ejection reflex is nobody around, but an experienced, low-profile, motherly, and silent midwife... a midwife able to remain silent even when the mother-to-be says silly words, such as, for example, "kill me," "let me die," etc... a midwife who will just make sure that the baby will not fall down on the floor.

Can someone with HPV, but no warts, have a homebirth?

Human papillomavirus (HPV) infection is extremely common. It does not influence the way women give birth.

What are the risks associated with a vaginal birth after an abdominal myomectomy? I am in my first pregnancy and my doctor is suggesting a c-section as the safest method. Is it possible to attempt a vaginal birth and how significant are the risks?

It is difficult to answer your questions because there are many types of myomectomies (surgical removal of fibroids) according to the location of the fibroid(s). If the docotr is suggesting a c-section to prevent a possible uterine rupture, it is probably because the fibroid was 'intramural' (inside the wall of the utereus). If the fibroid was 'subserous' (outside the wall of the utereus) or 'pedunculated' (connected to the utereus by a stalk), you should not hesitate to try to give birth vaginally. You need a detailed report of the operation.

I would love to have a waterbirth, but there are not many people in our area who do them. Do you have any advice on how to pick a good midwife for a waterbirth? I am 28, healthy, and in great shape. Is there anything I need to do to prepare for our little arrival's waterbirth?

Your midwife does not need any special training. She does not need any previous experience of the use of birthing pools. She just needs to be aware of a small number of recommendations. All these recommendations are based on the fact that immersion in water at the temperature of the body tends to make the contractions more effective during a limited length of time, which is in the region of an hour or two. The first practical recommendation is to give a great importance to the time when the laboring woman enters the pool. If she is patient enough to wait until the middle of the dilation, if she does not feel observed or guided, and if the room is dark enough, there is a high probability that she will reach complete dilation in an hour or two, even for a first baby. The second recommendation is to avoid planning a birth under water. In general it is better when a pregnant woman has no precise pre-conceived script of what the birth of her baby will be. When a woman has planned a birth under water she may be the prisoner of her project; she is tempted to stay in the bath while the contractions are getting weaker, with the risk of a long second stage followed by difficulties for the delivery of the placenta. There are no such risks when a birth under water follows a short series of irresistible contractions before the mother feels the need to get out of the bath. A birth under water can happen. It should not be the primary objective. The primary objective is to reduce the need for drugs.

Of course you need a deep enough birthing pool, so that your body can be completely immersed. Today it is easy to rent such birthing pools. You also need a way to check that the temperature of the water is never above the temperature of the body (37 degrees Celsius). A too hot bath is dangerous for the baby. It is better if your husband, or partner, has to prepare the bath while you are already in hard labor. Remember that a century ago the secret for an easy home birth was to make the husband busy: he was spending hours and hours boiling water. Are we rediscovering the value of old rituals?

Dr. Odent, it is an honor. I am in the USA, studying to become a midwife and noticed a peculiar quote in my Anatomy & Physiology textbook. It states that "The pain of human childbirth, compared to the relative ease with which other mammals give birth, is an evolutionary product of two factors: the unusually large brain and head of the human infant, and the narrowing of the pelvic outlet, which adapted hominids to bipedal locomotion." (Kenneth S. Saladin, Third Edition). Do you agree with this statement, or is this merely an assumption made due to the high levels of intervention and passivity of the woman during childbirth? Thank you for your time; I truly respect all that you havedone.

We cannot deny that human beings must overcome several handicaps in the period surrounding birth. The main handicap is not mentioned in your textbooks. It is the huge development in our species of that part of the brain called the neocortex. The neocortex is not basically different from what we might call the brain of the intellect. The point is that during the birth process (and during any sort of sexual experience), if there are inhibitions, they come from the powerful neocortex.

Nature found a solution to overcome this human handicap. The maternal neocortex is supposed to be at rest, so that primitive brain structures supporting our survival instincts can more easily release the necessary hormones. That is why women who give birth by themselves, with their own hormones, tend to cut themselves off from our world, to forget what they read or what they have been taught; they dare to do what a civilized woman would never dare to do in her daily social life (daring to scream, to swear, to be impolite, etc.); they can find themselves in the most unexpected, bizarre, primitive, often quadrupedal postures; I heard women saying afterwards: 'I was on another planet'. When a labouring woman is 'on another planet', this means that the activity of her neocortex is reduced. This reduction of the activity of the neocortex is an essential aspect of birth physiology among humans.

This aspect of human birth physiology implies that laboring women need to be protected against any sort of neocortical stimulation. This helps us to understand the importance of quiet (since language is a powerful stimulant of the neocortex) and of a dim light. It explains also the importance of privacy (when we feel observed our neocortex is stimulated) and the need to feel secure (when we perceive a possible danger we must be attentive and alert). Because the most important aspect of birth physiology is not understood in our cultures, there is no reference in your textbooks to the handicap related to a highly developed neocortex.

It is commonplace, on the other hand, to focus on the mechanical difficulties of the birth of Homo Sapiens. In fact, these difficulties are also related to brain development. Today Homo Sapiens is classified as a chimpanzee with an enormous brain. At term, the smaller diameter of the baby's head (which is not exactly a sphere) is roughly the same as the larger diameter of the mother's pelvis (which is not exactly a cone). The evolutionary process adopted a combination of solutions in order to reach the limits of what is possible.

The first solution was to make pregnancy as short as possible, so that, in a sense, the human baby is born prematurely. Furthermore we have realized recently that the pregnant mother can, to a certain extent, adapt the size of the fetus to her own size by modulating the blood flow and the availability of nutrients to the fetus. That is why small surrogate mothers carrying donor embryos from much larger genetic parents give birth to smaller babies than might have been anticipated.

From a mechanical point of view, the baby's head must be as flexed as possible, so that the smaller diameter is presenting itself before spiralling down to get out of the maternal pelvis. The birth of humans is a complex asymmetrical phenomenon, the maternal pelvis being widest transversally at the entrance and widest longitudinally at the exit. A process of 'moulding' can slightly reshape the baby's skull if necessary.

When mentioning the mechanical particularities of human birth, one cannot help referring to and comparing ourselves with our close relatives the chimpanzees. The head of a baby chimpanzee at term occupies a significantly smaller space in the maternal pelvis, and the vulva of the mother is perfectly centered, so that the descent of the baby's head is as symmetrical and as direct as possible. It seems that since we separated from the other chimpanzees, and all along the evolution of the hominid species, there has been a conflict between moving upright on two feet and, at the same time, a tendency towards a larger and larger brain. The brain of the modern Homo is four times bigger than the brain of our famous ancestor Lucy. There is a conflict in our species because the pelvis adapted to the upright posture must be narrow to allow the legs to be close together under the spine, which facilitates transfer of forces from legs to spine when running. An upright posture is the prerequisite for brain development. We can carry heavy weights on our head when we are upright. Mammals walking on all fours cannot do the same. That is apparently why the process of evolution found other solutions than an enlarged female pelvis in order to make the birth of the 'big-brained ape' possible: the faster our ancestors could run, the more likely they were to survive.

Nature found several other solutions to overcome the mechanical difficulties. One of them is that when the neocortical control is reduced, the laboring woman can spontaneously—instinctively—find postures that are usually complex, asymmetrical, and adapted to the different phases of the process of rotation. Another solution is the capacity human mothers have to give birth thanks to a powerful 'fetus ejection reflex', that is to say a series of irresistible contractions without any room for voluntary movements... on the condition that the neocortex is at rest.

We must add that Nature found solutions to compensate the physiological pain of labour. One of them is an appropriate release of natural morphines. Another one is the reduced activity of the new brain, so that the painful stimuli are not processed and imprinted in the upper parts of the nervous system, and so that the memory is depressed.

We cannot deny the human handicaps in the period surrounding birth. The point is to understand the many solutions the evolutionary process found to overcome a great diversity of difficulties. Understanding these solutions is the prerequisite to rediscover the basic needs of laboring women. It is a difficult task after thousands of years of culturally controlled childbirth and a recent proliferation of theories that have mislead most schools of "natural childbirth." What a responsibility for the generation of midwives you belong to!

Conventional pregnancy magazines are full of ads and articles on banking cord blood. Is this just a profit-driven trend or is there value to it?

Women who are supposed to give birth to the baby and to deliver the placenta without any drug should be reluctant to bank cord blood. When the physiological processes are not disturbed, human mothers have the capacity to reach a very high peak of the hormone oxytocin soon after the birth. This peak of oxytocin is vital, first because it is necessary for a safe delivery of the placenta without any blood loss, and also because oxytocin is undoubtedly the main hormone of love. This release of oxytocin is possible (in a warm place) if the mother, who is still 'on another planet', is not distracted at all and has nothing else to do than to feel the contact with the baby's skin, to look at the baby's eyes, and to smell the baby. Imagine a mother who has just given birth and who has forgotten the rest of the world while discovering her newborn baby. Then a practitioner arrives with clamps and scissors to collect a sufficient amount of blood from the cord. What a dangerous distraction! The risk is a difficult and bloody delivery of the placenta. Furthermore the baby will be deprived of a certain amount of precious blood. Well-informed women would not take such risks, while the odds that the average baby without risk factors will ever use his banked cord blood are negligible.

It is another matter in the case of medicalized births (cesarean-section, drip of pitocin, or drugs injected routinely to deliver the placenta). In such cases, the cord is clamped anyway soon after the birth of the baby. Then the risks are mostly financial. The point is that until now there has been little experience with transplanting self-donated cells (stem cells from bone marrow are currently given by relatives or strangers). Some experts have hypothesized that an ill baby who receives his or her own stem cells during a transplant would be at risk of repeating the same disease. Long-term studies are needed. Meanwhile we must be cautious.

My planned natural birth turned out to be very traumatic. I had severe abruptio placente. I was 24, I don't smoke or have any of the risk factors for it, I was very healthy, I ate right and was not overweight. It happened while in the early stages of labor at home and things didn't seem right to me. My husband rushed me to the hospital. I was in severe pain and only 4 cm dilated, my baby's heart rate was at 70, I was hemorrhaging. They rushed me to perform an emergency c-section. My daughters had to be intubated for a short time and spent a few days in the NICU. I thought I could never be thankful for such medical intervention, but I am for it saved our lives. My daughter is two now and we are thinking about having another child. I have not found much information on what happened to me. Is it because they aren't sure why it happens? Is it likely to happen again? Should I still try for a natural birth? How can I find out more information on it?

Abruptio placentae means that the placenta separated from the uterus before the birth of the baby. It can happen before the labor starts or during labor. The separation may be complete or partial. In your case it was probably a quasi-complete separation. Your daughter was rescued thanks to an emergency c-section. Abruptio placentae is an important chapter of the program of 'first aid in obstetrics' we include in our information sessions for doulas. We understand why your doctors could not give you much information on what happened to you. More often than not it is impossible to find a cause for such an accident. It is noticeable that a previous abruption placentae is not usually mentioned as a significant risk factor for the advent of a similar accident at the end of the following pregnancies. The conclusion is that when you give birth to your second baby, you'll be in the usual situation of a mother trying to give birth vaginally after a previous c-section. This means first that labor induction will be an absolute contraindication. Because you cannot extinguish in your memory the dramatic complication you previously had, you'll probably prefer to labor in a hospital. The point is to find a hospital where they accept your project of a trial of labor and at the same time where they understand the meaning of the word privacy.

Is taking castor oil for inducing labor okay for both the unborn child and mother?

Castor oil is one of the most unpleasant ways to induce labor. It makes the mother nauseous and it often causes diarrhea. Furthermore its safety has not been evaluated by large randomized controlled studies. I personally know about several cases of fetus distress during labor obviously related to the use of castor oil. I use this opportunity to mention that women often ask me about 'natural' methods of labor induction. My answer is that there are no natural methods of induction. If a method is effective, it means that it is not natural, because it has preceded the signals given by the baby. We understand today that the fetus participates in the initiation of labor by sending messages that mean: 'I am ready'. (For example the mature baby's lungs can release in the amniotic fluid factors that play a role in birth physiology). Whatever the method, an induced labor is usually longer and more difficult (therefore more dangerous) than a labor that started spontaneously. Instead of being impatient and taking castor oil, it would be wiser to rely on ultrasound scans in order to check that the amount of amniotic fluid is still normal. This is the best way to reassure the health professionals. Today we routinely offer mothers-to-be a great number of useless scans. We must realize that the most useful ones are those done 'on demand' when the pregnancy is longer than usual.

Can artificially rupturing the membranes contribute to fetal distress? I know that it can speed up labour, and that shorter labors can be less distressing, but my daughter's heartbeat dropped considerably not long after my doctor broke my water.

We cannot be sure that, in your particular case, there was a cause and effect relationship between the artificial rupture of the membranes during labor and the changes in your daughter's heartbeat. However it is well understood that, after a rupture of the membranes and therefore after an acceleration of labor at a time chosen by the doctor (or the midwife!), the baby's head is suddenly subject to greater pressure during contractions and the cord is more likely to become compressed. The baby must protect herself by releasing in particular the hormone ?noradrenaline?, which tends to slow down the heartbeat. The best way to prevent the common temptation of breaking the bag of water is to avoid assessing the progress of labor with vaginal exams. This is easier when the laboring woman has complete privacy and does not feel guided. In this case an experienced birth attendant can more often than not follow the progress of labor thanks to the noise the mother-to-be is doing, the way she is breathing, and the complex postures her body can find spontaneously.

Regarding waterbirth, I have two questions: 1. Is there a point at which it is too early to get in the pool? 2. Is it really possible to get so relaxed that labour can stop? I wouldn't say I was relaxed - just removed from the present and in a deep state of concentration.

1. Entering the bath too early is the most common misuse of the birthing pool. Originally we introduced the concept of birthing pool in a French hospital in order to replace drugs when the first stage is long, difficult, very painful, and when the dilation of the cervix is already well advanced. It is essential to understand that immersion in water at body temperature makes the contractions more effective during a limited period of time, which is in the region of an hour and a half. Helping the laboring women to be patient and to avoid entering the bath too early is a new aspect of the art of midwifery. However, in some cases, a bath can be useful to stop the contractions of a painful pre-labor, and therefore to make the difference between labor and pre-labor.

2. When a woman is so relaxed that apparently labor stops, it means that it was not labor, but pre-labor. In general the release of adrenaline (which induces the opposite of a state of relaxation) inhibits the release of oxytocin (the hormone necessary for effective uterine contractions).

How would you define "normal" birth?

The term 'normal' is useless when applied to birth. In 'normal' there is a cultural connotation. A birth can be considered normal in Rome, but not in Santa Fe. It is only in retrospect that a birth can be qualified 'normal' (the same about 'natural'). What we need today is to qualify an attitude. That is why I suggested the concept of 'biodynamic attitude in childbirth'. A biodynamic attitude (in farming, in childbirth, etc.) is based on a good understanding of the physiological processes. In other words it means: working with the laws of Nature.

Can you explain why waterbirth might be better than using the "traditional" route, i.e. drugs?

All drugs given to a woman in labor may have side effects for the mother and for the baby. When we introduced the concept of birthing pools in a French hospital in the 1970s, our primary objective was to reduce the need for pain killers and drips of pitocin. When a labor is long, difficult and abnormally painful, it usually means that the mother-to-be is not in the right hormonal balance.

It means in particular that the pituitary oxytocin is not being released in an effective way, more often than not because the level of stress hormones is too high. Immersion in water at the temperature of the body is a way to reduce the level of stress hormones and therefore to facilitate the release of oxytocin, the main hormone that makes uterine contractions during labor effective.

Since the 1970s we learnt that obstetric medications may also have long term side effects. Visit our data base www.birthworks.org/primalhealth and click, for example, on the key word 'drug addiction'. You'll find a series of studies suggesting that when the mother has used certain drugs when in labor, her child is - statistically speaking - more at risk than others to become drug addicted later on in life. It is probably not by chance that, in the US, the age of 'twilight sleep' was followed by the 'drug culture' generation. Furthermore we learnt recently that the complex cocktail of hormones released by laboring women is a cocktail of 'love hormones'. All pharmacological substitutes block the release of the natural hormones and don't have the same behavioral effects: they are not hormones of love. So the questions must be raised in terms of civilization.

Birthing pools will seriously compete with drips of pitocin plus epidurals on the day when a simple fact will be widely divulged. It is that immersion in water at the temperature of the body tends to the make the uterine contractions more effective for a limited period, which is in the region of an hour and a half. This implies that a new aspect of the art of midwifery will be to help women to be patient enough not to enter the bath too soon, ideally not before the middle of the dilation of the cervix. It also implies that a birth under water should not be the goal and should not be planned, although it is a possibility. When the mother-to-be is the prisoner of her project, she may be tempted not to listen to her body and to stay in the birthing pool at a time when the contractions are already becoming weaker and less effective.

What are the risks/benefits to letting your baby have a shot of vitamin K after birth?

Today there are many reasons to de-dramatize the topic and to reassure at the same time the parents who are inclined to refuse the shot and also those who prefer to do it.

To the parents who refuse the injection, we can say that they don't take a great risk, since the chances of their breastfed baby having a hemorrhagic disease related to vitamin K deficiency is in the region of one in 15,000. It is even probable that the risks are still lower if the birth and the initiation of lactation were undisturbed. My view is that vitamin K deficiency of breastfed babies is probably no more physiological than the weight loss in newborn babies. After thousands of years of culturally controlled childbirth and lactation, we usually underestimate the amount of 'colostral milk', and therefore of vitamin K, a human baby has been programmed to consume during the first days following birth.

A well-constructed Japanese study showed that babies who consume 350 ml of breast milk in the first three days following birth are protected against vitamin K deficiency. Let us also remember that vitamin K deficiency is unheard of among formula fed babies.

Some parents who accepted the injection might feel guilty or anxious afterwards when hearing about two British studies suggesting that vitamin K injected at birth (not vitamin K given orally) is a risk factor for cancer in childhood. These parents must be reassured as well because the British findings have not been confirmed by other studies, particularly a huge authoritative Swedish study involving more than one million children. However one cannot hide the fact that the routine injection of 1 mg of vitamin K at birth is always associated with the injection of 10 mg propylene glycol and 5 mg phenol, the effects of which are unknown.

Would you advise a home birth or water birth when attempting a VBAC?

In an ideal world, we should not contrast home birth and hospital birth. When an effective communication has been established between the home birth midwife and the obstetrical team, it should be possible to combine what the privacy of the home can offer and what the hospital facilities can offer. If a laboring woman feels secure in her own "nest", if an experienced, motherly and silent midwife is available, and if the first stage is easy and straightforward, it may be risky to change the environment in hard labor: a transfer to hospital can induce inhibitions. On the other hand, if the first stage is slow, difficult and very painful, it is probably better to change the environment and to go to the hospital. The point is not to be the prisoner of a project. Such strategies are valid for almost all births, but still more when attempting a VBAC.

When I introduced the concept of hospital birthing pools in the 1970s, our first objective was to reduce the need for drugs when the labor was long and difficult. Originally, we used it in particular in the case of a woman attempting a VBAC, if the contractions were becoming less effective around 5 centimeters. At that phase of labor, immersion in water at the temperature of the body is usually a way to reach complete dilation within an hour or two. Once more, it is important not to be the prisoner of a project, such as the project of giving birth under water. Many women feel the need to get out of the pool for the very last contractions.

What are the risks associated with routine ultrasound for low-risk pregnancies?

In general the most authoritative studies of the long term effects of being exposed to ultrasound during fetal life are reassuring. A Swedish study, for example, involved 19 prenatal care clinics and more than 4000 children.(1) After randomization (after drawing lots) only the pregnant women belonging to the 'screening group' were offered a scan at 15 weeks. After follow-up of the children, no statistically significant differences in body weight or height at 1, 4, 7 years of age between exposed and unexposed children were found. There were no differences either in terms of impaired vision or hearing during childhood.

However there are studies suggesting that exposure to ultrasound during fetal life is not completely neutral. This is the case of a large Australian study. It appeared, after analyzing thousands of cases, that frequent exposure to ultrasound tends to restrict fetal growth.(2) Such results confirmed the results of studies with pregnant monkeys scanned with doses used in human medicine.(3) This is also the case of several Scandinavian studies showing that exposure to ultrasound tends to slightly modify the proportion of right-handed and 'non right-handed' children.(4,5)

Since exposure to ultrasound during fetal life is not completely neutral, the selective use of scans should be preferred to routine scans. There are reasons to be cautious but, in the scientific context of 2003, one cannot refer to documented real complications.

-1- Kieler H, et al. Routine ultrasound screening in pregnancy and the children's subsequent growth, vision and hearing. British Journal of obstetrics and gynaecology. 1997; 104: 1267-72.
-2- Newnham JP, et al. Effects of frequent ultrasound during pregnancy: a randomised controlled trial. Lancet 1993; 342: 887-91.
-3- Tarantal AF, Hendrickx AG. Evaluation of the bioeffects of prenatal ultrasound exposure in the cynomolgus macaque. Teratology 1989; 39 (2): 137-47.
-4- Savelsen KA, et al. Routine ultrasound in utero and subsequent handedness and neurological development. BMJ 1993; 307: 159-64.
-5- Kieler H. Routine ultrasound screening in pregnancy and the children's subsequent handedness. Early Human Development 1998; 50: 233-45.

I was told I have the strep b virus, I don't know if I had it with my 5 other children or not. I am planning on another home birth, as my others have all been, but my doctor says that 40% of babies can die or have damage from this at birth. My mid-wife says that's not accurate and that many woman carry strep b and are not even aware of it. Do I need to take antibiotics during labor, and will the baby need drops in it's eyes after delivery? I have never had either done to any of my 5 babies. If you could please give me advise or direct me to issues that would answer these questions, I would really appreciate it. I am 43 years old, this is my 6th delivery coming up app. 6-20-03.

It is exceptionally rare that a baby born at term with a normal birth weight dies from a B strep infection. Those who are more vulnerable are premature babies and small-for-date babies. Three studies published in authoritative medical journals suggest that the use of a vaginal spray of chlorhexidine is as effective as antibiotics. For mysterious reasons these studies are not well known. I include the abstract of the most recent one. It is better not to give eyes drops to the baby at birth and to rely on the results of an antibiogram (in the unlikely occurence of an eye infection).

Abstract: -1- Facchinetti F, Piccinini F, Mordini B,Volpe A J Matern Fetal Med 2002 Feb;11(2):84-8 Chlorhexidine vaginal flushings versus systemic ampicillin in the prevention of vertical transmission of neonatal group B streptococcus, at term.

OBJECTIVE: To investigate the efficacy of intrapartum vaginal flushings with chlorhexidine compared with ampicillin in preventing group B streptococcus transmission to neonates.

METHODS: This was a randomized controlled study, including singleton pregnancies delivering vaginally. Rupture of membranes, when present, must not have occurred more than 6 h previously. Women with any gestational complication, with a newborn previously affected by group B streptococcus sepsis or whose cervical dilatation was greater than 5 cm were excluded. A total of 244 group B streptococcus-colonized mothers at term (screened at 36-38 weeks) were randomized to receive either 140 ml chlorhexidine 0.2% by vaginal flushings every 6 h or ampicillin 2 g intravenously every 6 h until delivery. Neonatal swabs were taken at birth, at three different sites (nose, ear andgastric juice).

RESULTS: A total of 108 women were treated with ampicillin and 109 with chlorhexidine. Their ages and gestational weeks at delivery were similar in the two groups. Nulliparous women were equally distributed between the two groups (ampicillin, 87%; chlorhexidine, 89%). Clinical data such as birth weight (ampicillin, 3,365 +/- 390 g;chlorhexidine, 3,440 +/- 452 g), Apgar scores at 1 min (ampicillin, 8.4 +/- 0.9;chlorhexidine, 8.2 +/- 1.4) and at 5 min (ampicillin, 9.7 +/- 0.6; chlorhexidine,9.6 +/- 1.1) were similar for the two groups, as was the rate of neonatal group B streptococcus colonization (chlorhexidine, 15.6%; ampicillin, 12%). Escherichia coli, on the other hand, was significantly more prevalent in the ampicillin (7.4%) than in the chlorhexidine group (1.8%, p < 0.05).Six neonates were transferred to the neonatal intensive care unit, including two cases of early-onset sepsis (one in each group).

CONCLUSIONS: In this carefully screened target population, intrapartum vaginal flushings with chlorhexidine in colonized mothers display the same efficacy as ampicillin in preventing vertical transmission of group B streptococcus. Moreover, the rate of neonatal E. colicolonization was reduced by chlorhexidine.

Previous references:
-2 - Burman LG,et al. Prevention of excess neonatal morbidity associated with group B streptococci. Lancet 1992; 340: 65-69
-3 - Taha TE, et al. Effect of cleansing the birth canal with antiseptic solution. BMJ 1997; 315: 216-20.

How serious are the consequences if meconium shows up in the amniotic fluid during labor? Is this necessarily a emergency?

When the meconium shows up in the amniotic fluid during labor, it means that the baby is releasing a hormone of the adrenaline family called noradrenaline. This hormone is released when the baby must adapt to a low supply in oxygen. The effect of a release of noradrenaline is to provide enough blood to vital organs having priority (such as brain, heart, and kidneys) by reducing the amount of blood going to organs that are not yet vital such as the bowels. That is how the green-brown tary sterile substance that fills the bowels is eliminated into the amniotic fluid.

In other words, meconium staining during labor does not mean fetal distress and is not necessarily an emergency. It means that a physiological system of protection of the fetus is at work. That is why it is always a particular case that should be interpreted according to the phase of labor, the progress of labor, the duration of pregnancy, the number of babies the mother had previously, the place of birth, etc. Let us mention that a tainted liquid during labor is almost the rule in the case of a breech presentation and is not usually related to the release of noradrenaline.

Amniotic fluid inhalation occurs in 2% to 5% of babies with tainted liquid. Among them, some will develop a meconium aspiration pneumonia and will go on mechanic ventilators. Very few of them will have residual health problems. The practice of suctioning the mouth and throat of the baby just before the delivery of the shoulders is now considered useless. The routine intubation and suction of the trachea just after birth in the case of meconium staining is also considered useless according to recent studies. It does not improve the outcome.

What might be some reasons that a woman would have low or high amniotic fluid levels in pregnancy? What effects can these levels have on the well-being of the baby? And what, if anything, can be done to increase her chances of having "normal" amniotic fluid levels?

When a woman has too low levels or too high levels of amniotic fluid, the point is not to wonder what can be done to modify the amount liquid surrounding the baby. The priority is to detect a possible cause for such a deviation from what is considered 'normal'. It is impossible, within a paragraph, to analyze all the possible causes for a polyhydramnios (more than 2 litres of liquid) or an oligohydramnios (less than 300 mL at term). I must underline that there is a common tendency to overdiagnose polyhydramnios. In other words, many women are wrongly told that there is too much liquid.

How often does ultrasound find something wrong that can be fixed before birth? I would like no ultrasound but still want to be safe.

Apart from discovering a gross abnormality that leads the doctor to offer a late abortion (and exceptionally a very risky intrauterine operation), ultrasound scans rarely find something wrong that can be fixed before birth. In the case of a pregnancy that started while a mother is still breastfeeding and has no menstruation, the scan can give an idea of when the baby had been conceived (this is not exactly something wrong that can be fixed!). When the baby is really overdue an ultrasound scan can demonstrate that there is still a normal amount of liquid. Such a scan can be effective to reassure the doctor and therefore to postpone and even to avoid labor induction.

An experienced practitioner does not usually need a routine scan to suspect a breech presentation at 37 weeks or after, or to suspect a real placenta praevia. It is well known that ultrasound scans are not accurate to evaluate the size of the baby in the womb. Anyway if the baby seems to be too small, the recommendation should be: "Eat well and be happy". Such recommendations can be given without the help of ultrasounds.

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