All Scientific Studies are NOT Created Equal

suggestion box
Hash Milhan
November 6, 2013. Marta Wegorzewska, PhD candidate, in collaboration with Dr. Seth Bokser, MD. Edited by Dr. Darya Rose, PhD.

All Scientific Studies Are NOT Created Equal

If a scientific study claims eating garlic daily during pregnancy shortens labor, should pregnant women start eating garlic every day?

It depends on the type of scientific study. All studies are not created equal. Some studies prove, and others suggest.

Studies that suggest may be right, but they may also be wrong. For example, Facebook suggests people we may know. Some of them we do know and request their friendship. Some of the suggestions are wrong, and we ignore them.

Which studies prove and which suggest?

Studies that Prove

The best study would ask, “Does garlic shorten labor?”

To answer this question, women would be asked to volunteer for the study. They would have just found out they are pregnant so they could eat garlic throughout nine months of pregnancy (prospective).

Hundreds to thousands of women would be involved in the study to ensure any observations are not due to chance. The women would be randomly split into two groups (randomized). The due dates for the two groups would be similar. One group would eat garlic throughout pregnancy and the other would not (control).

The number of hours the women are in labor would be recorded. To prevent unintentional bias, the individual recording the time would not know whether the woman ate garlic or not. He would be “blinded” to that information.

Women who require a drug to speed labor would be excluded from the study.  Excluding these cases ensures the effect on labor is from the garlic and not from the drug (confounding factor).

This type of study is called a prospective randomized control study.

The strength of this type of study is that it proves if one factor (garlic) causes another (shorter labor). If the number of hours of labor is shorter for women who ate garlic during pregnancy compared to those that didn’t, the study proved garlic shortens labor!

Why aren’t all studies designed as a prospective randomized control study?

Imagine if scientists wondered if women who are obese during pregnancy give birth to sick babies.

A prospective randomized control study would ask women to voluntarily become obese during pregnancy to see if their babies would be born sick. No woman would volunteer for this study! It would be unethical to conduct a study that would potentially harm mom and baby.

Studies that Suggest

Other studies would provide clues.

A case control study would look at already sick babies. This study would compare the weight of pregnant women delivering sick babies to women delivering healthy babies.

A cohort study would look at already obese pregnant women. The health of their babies would be compared to the health of babies of non-obese women.

These studies would not prove that obesity causes sick babies. They would suggest that being obese during pregnancy may be associated with (linked to) sick babies.

Case control and cohort studies suggest instead of prove because they have limitations. They cannot eliminate other factors that may contribute to sick babies. For example, maybe obese pregnant women eat more fast food because they are struggling financially, working longer hours and are more stressed. Stress may be another factor that could impact a baby’s health. A prospective randomized control study would avoid this problem by randomly splitting women into groups. Stress would affect both groups equally and cancel out. Any differences seen between the groups would be due to obesity.

That being said, are you going to start eating garlic every day?

If a prospective randomized control study proved garlic causes shorter labor, I would try to eat garlic even if I hated it.

If a case control or cohort study suggested garlic is linked to shorter labor, I might eat garlic if I didn’t mind it, but I wouldn’t view garlic as a guarantee my labor would be shorter. If I hated garlic, I would ignore this suggestion.

This work is funded in part by the Graduate Student Internships for Career Exploration (GSICE) program at UCSF

Four Steps to Trusting Pregnancy Information on the Internet

October 30, 2013. Marta Wegorzewska, PhD candidate, in collaboration with Dr. Seth Bokser, MD. Edited by Dr. Darya Rose, PhD.

Blue screen
Till Westermayer

Stacy became concerned about a report on a scientific study linking father’s age and his child’s risk of autism while watching the news with her husband. She’d never heard this before.

Stacy is 3 months pregnant and her husband is 48 years old. Will her child have autism? This question lingers in her mind into the next day.

Stacy turns to Google. Her first search, “autism and father’s age”, pulls up an overwhelming number of hits. She starts at the top and works her way down until the contradictory information about the study frustrates her.

What should Stacy believe?

Science is a language most of us are not familiar with, and it can be confusing. Scientists spend years going to school to learn it.

If you are not a scientist and want answers to questions about your pregnancy, how do you know what to believe if you do not know the scientific language?

The good news is you don’t have to change careers to get answers to your questions. Google will pull up lots of information for you. And the information can be translated into words that you understand.

The bad news is, the Internet is full of opinionated people who want to be heard. You have to decide if you can trust what you read. How do you know that you are getting the facts?

The following steps will help you better identify accurate information on the Internet:

1. Get to know your author. Would you change your eating habits because a stranger on the bus told you to? Probably not, unless you found out that she was a dietitian. If you cannot determine if your author was trained in science (holds a MD, PhD, and/or masters) or has years of experience (works for an organization that specializes on your topic of interest), you may want to hold off on taking her advice.

2. Learn about the other side of the story. If your author only presents one side of the story, chances are there is another side she is not telling you about. You may see more articles on the Internet about one side than the other. Quantity of articles does not equate with quality of the information. One side may have an advantage in grabbing readers’ attention. It may be inherently more dramatic or presented in such a way that intentionally plays on your fears. Spend time learning about the other side of the story.

3. Look for references. Accurate information comes from scientific studies. You will know if what you are reading is supported by science if your author tells you where this information came from. Sometimes the author will talk about a specific study directly in the article or list it at the end of the article. Do a quick scan for the references or you may find yourself believing an opinion that may not be true.

4. Make decisions with your provider. Do not change anything about your pregnancy because of what you read on the Internet. Talk to your provider first about what you learned. Scientific studies have limitations. Science takes years and multiple studies to find the truth. These studies are like the pieces of a puzzle. Many pieces are required to have a clear picture. Talk to your provider about what you learned and together decide if scientists have a clear enough picture of their findings to affect you today.

You do not have to enroll in years of school to get accurate information related to your pregnancy questions. By following steps 1-4, you will be able to:

1. Eliminate scientifically inaccurate information from your reading list.
2. Have an informed conversation with your provider to discuss if it is safe for you to change your behavior based on what you read.

Which of the questions above are the hardest for you to answer as you scan the Internet for answers?

This work is funded in part by the Graduate Student Internships for Career Exploration (GSICE) program at UCSF

Extra Cord Blood: It Does a Baby Body Good?

October 21, 2013. Marta Wegorzewska, PhD candidate, in collaboration with Dr. Seth Bokser, MD. Edited by Dr. Seth Bokser, MD; Dr. Angie Jelin, MD; Dr. Yao Sun, MD; Dr. Tracey McLean, MD.

The crowning of the Jacob’s head sparks excitement and anticipation. Family members are there to support the mother and celebrate the arrival of the newborn. The obstetrician announces the baby is coming and coaches the mother through every last contraction, encouraging her through the final stage of labor. The next minute, the first minute of the newborn’s life, happens fast. The umbilical cord (cord) is clamped in two places and cut between the clamps. Jacob’s cries come instantly and the entire room breathes a sigh of relief. He is cleaned and wrapped in towels for warmth. The healthy boy is placed on mother’s chest for some bonding time. Meanwhile, the mother continues to be cared for by a team of physicians and nurses who aid in the delivery of the placenta.

Until recently, cord clamping was routinely done in less than a minute1 in an effort to deliver the baby and limit blood loss. During pregnancy, blood circulates between the placenta and the fetus via the cord. Clamping leaves excess fetal blood in the placenta. Rich in stem cells, some parents elect to donate or privately bank some of the blood left in the placenta for potential future use. Otherwise, this blood gets discarded.

In an effort to provide Jacob with the very best start possible, we are now asking the question, Should cord clamping be delayed past 1 minute (“delayed clamping”) to allow for the transfer of up to an additional 30% of fetal blood from placenta to the baby at the time of delivery?2

The placenta: a sac of blood

A dramatic transformation occurs in a baby’s first minutes outside the womb. For nine months, the growing fetus is dependent on the placenta for its source of oxygen and nutrients. Blood from the mom and fetus fills the placenta in separate compartments that come into very close contact without physically mixing. Maternal blood brings in oxygen and nutrients (including iron) to the placenta, while fetal blood brings in blood lacking in oxygen and nutrients. An exchange occurs in the placenta, allowing the fetus to transfer waste to the mother and receive oxygen and nutrients from the mother.  Once separated from the placenta, the baby learns to use his lungs to breathe and ingest breast milk or formula for nutrients.

Pages from cord clamping articleV5What happens to all the blood in the placenta when the cord is cut? If the cord is clamped and cut immediately after labor, the fetal blood that traveled to the placenta during pregnancy (Figure 1, red spaces) gets trapped in the placenta (Figure 1, circle). A small amount of it moves from the placenta to the baby (Figure 1, smiley face) in the time that it takes physicians to prepare the cord for cutting (estimated at 15 seconds). The longer physicians wait to clamp the cord, more blood can travel from the placenta to the baby.2 Scientist found that waiting longer than a minute could provide the baby with an additional 30% more blood.2

What does this mean for a baby born weighting 3kg (about 6.6 pounds)?

A 3kg baby has about a cup of blood circulating at the time of birth.2 If the cord gets clamped within 15 seconds, almost half a cup of blood is retained in the placenta.2 Waiting a minute can provide the baby with an additional quarter of a cup of blood.2

Going back in time: lessons from our predecessors

Early cord clamping was not always the norm. Our predecessors were proponents of delayed cord clamping. In 1801, Erasmus Darwin warned, ‘Another thing very injurious to the child, is the tying and cutting of the navel string too soon; which should always be left till the child has not only repeatedly breathed but till all pulsation in the cord ceases. As otherwise the child is much weaker than it ought to be’.3 How did early cord clamping become common practice in modern medicine?

Babies who struggle to take their first breath are clamped early to prioritize resuscitation. Early clamping also evolved out of the practice of active management of the third stage of labor to assist with delivery of the placenta and reduce maternal blood loss. This final stage of labor is the time from the delivery of the baby to the delivery of the placenta.4 Pitocin is given to induce contractions that constrict the blood vessels feeding the placenta and aid in its delivery.5 Active management shortens the duration of the third stage of labor and significantly decreases postpartum hemorrhage (maternal blood loss) following birth.6 Postpartum hemorrhage occurs in approximately 4 percent of vaginal deliveries and is responsible for 25 percent of all maternal childbirth-related deaths.7 Early cord clamping is commonly practiced to decrease the time of the third stage of labor and maternal blood loss. However, in 2008, a Cochrane review reported that studies show no increase in postpartum hemorrhage in women after delayed cord clamping.8 Is it time to reconsider our predecessors’ warnings in case where both mother and baby are healthy?

Today, research provides evidence for the health benefits associated with delayed cord clamping that Darwin hinted at in the 1800s.4 The benefits of delayed cord clamping for babies born early (premature) have already been recognized and implemented in clinical practice.9 Now, scientists and physicians are exploring the possibility that term babies may also benefit from delayed cord clamping. A Cochrane review published July 2013 announced that “delayed clamping of the umbilical cord in healthy term infants appears to be warranted”.10 They found that babies with later clamping weighed more and were less likely to be iron-deficient three to six months after birth compared to term babies who had early cord clamping.10

Pumping iron: the importance of iron in infant development

Iron is crucial during the first six months of life when the baby is undergoing rapid growth. During this period, the baby is receiving its nutrients from breast milk. Although not rich in iron,11 the baby absorbs a large percentage of the iron in breast milk12 but also depends on the stores of iron he received from the mother (through the placenta) during pregnancy. It has been estimated that delayed cord clamping can provide the baby with an additional three months of iron that is stored for use during the early months of life until the baby starts eating iron rich food.12 In certain scenarios, this extra iron may be critical if the baby did not have the opportunity to build up his iron stores during pregnancy and is at risk of iron deficiency. This baby may have been born prematurely or to a mother who was iron deficient.13 However, healthy term babies born to healthy moms may also require extra iron. The extra iron from delayed cord clamping has shown to reduce risk of anemia soon after delivery and months later.14

The potential and reality of stem cells today

Fetal blood is rich in stem cells. These cells are desired for their potential to develop into any mature cell. For example, a stem cell can become a heart cell, a brain cell or a liver cell, depending on the biological signals that direct its growth pattern. In the fetus, stem cells can be found in the blood. Once isolated, scientists can theoretically push these cells to develop into various desired cell type with the potential to treat disease. While the application of these cells in the clinic is still preliminary, scientists and physicians are starting to harness the power of these cells to treat cancers and various disorders of the blood, immune system, and metabolism.reviewed in 15

For the baby, development does not cease at birth. The brain undergoes significant growth for years after birth that manifests into an ability to move around, communicate and understand the surrounding social environment. Part of this growth is the commitment of stem cells to various cells of the brain that will carry out these functions. Does the baby need the extra stem cells that are trapped in the placenta with early cord clamping? The theory is that these cells have the potential to impact the developmental of the brain and other organs. Because of this potential, we wonder if having more of them could be better for the baby. Some also argue that premature babies might especially benefit from greater numbers of stem cells since their nine month developmental process was cut short. The reality is, we just do not know. No evidence is available at this time that shows that the stem cells gained during delayed cord clamping are 1) needed since the baby has a lot of stem cells already and 2) will have an impact on the babies immediate and long-term health. Currently, we think that stem cells have the potential to benefit health but we do not have the evidence to show that is the case.

The counter argument: “Too much, Too soon”

In light of no formal guidelines for the timing of cord clamping in term infants, some practitioners cut the cord out of fear of overloading the baby with extra blood. Too much blood increases risks for polycythemia,16 a condition where the baby has too many red blood cells. An increase in red blood cells causes the blood to get thicker, the flow of blood slows and blood clots may form. However, the Cochrane review reports no differences in polycythemia in babies what had early versus late cord clamping among five trials that reported data on polycythemia.10

Some studies have shown that babies of delayed cord clamping have higher risk of developing jaundice compared to babies of early cord clamping.10 Too much blood can lead to jaundice,17 a condition that results in yellowing of the skin because of excess amounts of newborn bilirubin. Bilirubin is a yellow pigment that is released during the normal breakdown of red blood cells. Normally cleared by the liver, a newborn’s still-developing liver may not be able to efficiently clear the bilirubin. While jaundice is common in newborn and benign when blood levels of bilirubin are low, high levels of bilirubin can affect brain cells and cause permanent damage—a condition called “kernicterus.”18 Exposure of the newborn to specific wavelengths of light in a process called phototherapy is an effective treatment for jaundice but it often prolongs the time that the neonate must spend in the hospital.19 The authors of the Cochrane review conclude that “delayed cord clamping is likely to be beneficial as long as access to treatment for jaundice requiring phototherapy is available”.10

Should you delay cord clamping for your baby?

 When it comes to cord clamping, every baby will be different. Delayed cord clamping may or may not be beneficial for your baby. We know there are benefits for some preterm and term babies. We also know some babies will have to spend more time in the hospital to undergo phototherapy after delayed cord clamping. To help you decide if delayed cord clamping should be part of your birth plan, discuss cord clamping and what you know and do not know with your obstetric and pediatric providers.

It is also important to remember that birth plans may not always go as planned. Complications may occur during delivery that could make delayed cord clamping dangerous. If you decide on delayed cord clamping, be open-minded about early cord clamping if the baby needs to be attended to immediately. Delaying that care may put the baby at risk.

This work is funded in part by the Graduate Student Internships for Career Exploration (GSICE) program at UCSF. 

This post was checked by the following science articles:

1. Philip A, and Saigal S. When Should We Clamp the Umbilical Cord? NeoReviews. 2004; 5(4): e142 -e154.
2. Yao AC, Moinian M, Lind J. Distribution of blood between infant and placenta after birth. Lancet. 1969;2871-873.
3. Darwin E. Zoonomia. Volume III. Dublin: B Dugdale, 1801
4. Norwitz ER, Robinson JN, Repke JT. Labor and delivery. In: Gabbe SG, Niebyl JR, Simpson JL. Obstetrics: normal and problem pregnancies. 4th ed. New York: Churchill Livingstone, 2002:364.
5. Elbourne DR, Prendiville WJ, Carroli G, Wood J, McDonald S. Prophylactic use of oxytocin in the third stage of labour. Cochrane Database Syst Rev. 2001.
6. WJ, Elbourne D, McDonald S. Active versus expectant management in the third stage of labour [update]. Cochrane Database Syst Rev. 2000;(3):CD000007.
7. Abouzaher C. Antepartum and postpartum haemorrhage. In: Murray CJ, Lopez AD, eds. Health dimensions of sex and reproduction: the global burden of sexually transmitted diseases, HIV, maternal conditions, perinatal disorders, and congenital anomalies. Boston: Harvard University Press, 1998:172–4.
8. McDonald, S.J. and P. Middleton. Effect of timing of umbilical cord clamping of term infants on maternal and neonatal outcomes. Cochrane Database Syst Rev. (2): CD004074. 2008.
9. Rabe H, Diaz-Rossello JL, Duley L, Dowswell T. Effect of timing of umbilical cord clamping and other strategies to influence placental transfusion at preterm birth on maternal and infant outcomes. Cochrane Database Syst Rev. 2012; 15 (8):CD003248.
10. 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 Syst Rev.2013; 11(7):CD004074.
11. Trumbo P, Yates AA, Schlicker S, Poos M. Dietary Reference Intakes for vitamin A, vitamin K, arsenic, boron, chromium, copper, iodine, iron, manganese, molybdenum, nickel, silicon, vanadium, and zinc. J Am Diet Assoc. 2001; 101(3):294-301.
12. Saarinen, U. M., Siimes, M. A. & Dallman, P. R. (1977) Iron absorption in infants: high bioavailability of breast milk iron as indicated by the extrinsic tag method of iron absorption and by the concentration of serum ferritin. J. Pediatr. 91:36-39.
13. Chaparro, C.M. Timing of umbilical cord clamping: effect on iron endowment of the newborn and later iron status. Nutr Rev. 69 Suppl 1: p. S30-6. 2011.
14. Hutton EK, Hassan ES. Late versus early clamping of the umbilical cord in full-term neonates: Systematic review and meta-analysis of controlled trials. JAMA. 2007;297:1241–1252.
15. Tolosa JN, Park DH, Eve DJ, Klasko SK, Borlongan CV, Sanberg PR. Mankind’s first natural stem cell transplant. J Cell Mol Med. 2010;14(3):488-95.
16. Austin T, Bridges N, Markiewicz M, Abrahamson E, Abrahamson E. Severe neonatal polycythaemia after third stage of labour underwater. Lancet. 1997;3501445.
17. Blackburn S. Hyperbilirubinemia and neonatal jaundice. Neonatal Netw. 1995;1415-25.
18. Barateiro A, Miron VE, Santos SD, Relvas JB, Fernandes A, Ffrench-Constant C, Brites D. Unconjugated bilirubin restricts oligodendrocyte differentiation and axonal myelination. Mol Neurobiol. 2013;47(2):632-44.
19. American Academy of Pediatrics Subcommittee on Hyperbilirubinemia. Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation. Pediatrics. 2004;114(1):297.

Improving the Pitocin Conversation: One Question at a Time

July 12, 2013. Marta Wegorzewska, PhD candidate, in collaboration with Dr. Seth Bokser, MD. Edited by Dr. Tracey McLean, MD*.

Two women arrive to the hospital ready for the moment they have been preparing for months. Each woman has a plan for what she wants. One woman goes into labor so quickly there is no time for an epidural. Aware of her low threshold for pain, she never imagined delivering without pain medication. Yet, a healthy and happy Emily is born. Across the hall, 10 hours of painful labor results in little progress. An exhausted and frightened mother, who hoped to deliver without any medical intervention, wants options. Physicians have to make a difficult decision: wait longer or intervene. 12 hours into her slow progressing labor, physicians and mother decide to augment the delivery of the baby with a drug called Pitocin, a synthetic form of the natural hormone Oxytocin. Mother and baby are carefully monitored. Pitocin triggers contractions and a relieved mother starts to progress in labor. Baby Jacob is ready to be born. Suddenly, the doctors notice that Jacob’s heartbeat is slowing. Maybe they waited too long or maybe the contractions were too strong. The removal of Pitocin does not change Jacob’s state and doctors make the decision to perform a Cesarean Section (C-Section). Moments later, a happy and healthy Jacob is welcomed into the world.

When it comes to childbirth, every woman is different. Every experience is unique. Every delivery poses challenges for the mother, the baby, physicians and nurses. And every plan gets modified. Yet, the goal is the same: healthy mother, healthy baby. Mothers, fathers, family members, physicians and the public are questioning how this goal is being accomplished. Over 20% of deliveries are induced and Pitocin is the most common method used for labor induction 1. In this piece, we will explore the science behind labor and reveal what we know and are still learning about Pitocin.

Safety first: can Pitocin harm the baby?

Critics question the overuse and misuse of Pitocin. The documentary, The Business of Being Born, was released in 2008 to bring awareness to the safety concerns of critics 2. Today, Pitocin continues to be accused of being dangerous to mother and fetus. On May 7, 2013, new research on Pitocin was presented at the Annual Clinical Meeting of the American College of Obstetricians and Gynecologists (ACOG). The researchers claim to reveal, for the first time, adverse effects of Pitocin use on newborns. The Internet was quick to condemn Pitocin using little scientific data to base its claims. In fact, this study has yet to undergo a peer review process; a process put in place to determine the accuracy and quality of the data. Once the work led by Primary Investigator Michael Tsimis, MD, becomes published and available for the community to evaluate, only then will it be appropriate to judge the effect of Pitocin on the baby. Meanwhile, an already published study found no adverse affects on newborns after using a low dose of Pitocin but is limited by the small cohort of patients that were considered 3. Historically, research on Pitocin has been plagued by small sample sizes leading to questionable conclusions. There exists a consensus over the need for better data to learn more about Pitocin safety.

The recent findings discussed at the conference of ACOG on Pitocin shows that the concerns and questions surrounding Pitocin safety are not being ignored. In the press release put out by ACOG, Dr. Tsimis was quoted saying, “However, we don’t want to discourage the use of Pitocin, but simply want a more systematic and conscientious approach to the indications for its use.” Pitocin’s potential for effectiveness and safety should not be discouraged. But physicians and patients alike should demand better research with sound data to help define the parameters that make Pitocin safe.

Oxytocin and Pitocin: identical or fraternal twins?

Pitocin is made to mimic the natural occurring hormone Oxytocin that is produced throughout pregnancy and induces contractions at the time of labor. Despite the difference in their origin, Pitocin and Oxytocin are identical twins that look exactly alike 4. Pitocin is a synthesized drug that is a perfect replica of the natural hormone Oxytocin.

The rules of chemistry dictate that structure and function go hand in hand. If two chemicals look identical, they should act alike. But we all know that despite their appearance, identical twins have different personalities. Oxytocin and Pitocin are no exception. But not because chemistry got it all-wrong. In fact, Pitocin has the potential to function exactly like Oxytocin because they are structurally identical. However, replicating the naturally released concentrations of Oxytocin has proven a challenging feat. Various concentrations have been tried. Higher dosages of Pitocin compared to lower doses have been shown to cause stronger contractions in women being induced while resulting in fewer C-sections 5. While it is unclear if higher doses cause harm to the fetus, there is a lack of consensus about the optimal oxytocin dosage that should be used to ensure efficacy and safety 5,6. This lack of consensus comes from a difficulty in replicating the natural behavior of Oxytocin that is released from the brain in pulses and is eliminated from the circulation at a rapid speed 7. Better insight into the physiology of labor and behavior of Pitocin will help determine the optimal use of Pitocin to induce labor.

From fetus to baby: how is labor triggered?

For 80% of women, nine months of pregnancy ends with the natural delivery of a healthy baby 1. Uterine contractions increase in frequency and intensity resulting in a dilated cervix ready to allow passage of the baby through the birth canal. The amount of time it takes for the baby to be born from the start of labor (contractions begin) varies among women. For 20% of women, labor either does not begin or it stalls (cervical dilation does not progress despite contractions) 1. This great diversity in scenarios at the time of delivery begs the question: what triggers labor?

During pregnancy, Oxytocin is made in the brain and is released into the blood stream. The blood stream is a means of transportation. Ultimately, Oxytocin settles on one of the numerous oxytocin-binding receptors in the uterus. The interaction between oxytocin and its receptor causes contractions to begin. During labor, the sensitivity of the uterus to Oxytocin increases because the number of receptors available to interact with Oxytocin increases significantly 8. However, what signals the start of labor that results in this physiological change in the uterus is unknown. Maybe a mature fetus is able to communicate to the mother that its time to live outside the womb. A fetal lung protein released during the onset of labor has been proposed to trigger labor 9. Maybe the maternal immune system plays an active role in inducing labor. Immune cells that function to protect us during times of sickness are found in the uterus at the time of labor and may play a role in its onset 10. The lack of understanding of how labor is triggered makes it very difficult for physicians to predict when labor will happen and when it won’t. Which makes for difficult decision-making.

To wait or not to wait, that is the question!

Physicians assess risks and benefits when deciding to wait or intervene during labor. Sometimes patience ultimately leads to natural vaginal delivery and reduces unnecessary cesarean deliveries that pose a risk to maternal health 11. But waiting can also be problematic. Waiting too long leads to larger babies that are more difficult for the mother to deliver, in turn increasing the chances of C-section 12. The placenta, which functions to supply the fetus with nutrients and oxygen from the mother’s circulation, starts to age and become less efficient resulting in fetal malnutrition and deprivation of oxygen 13. Although low overall, the risk of fetal death increases with gestational age 14,15. Physicians face a challenging decision and must consider maternal and fetal health when determining if intervention outweighs the risk of waiting 16.

Answering questions with quality research

The implementation of a standardized protocol and careful monitoring of mother and baby during Pitocin administration was born out of research that aimed to address the concerns over Pitocin safety 17. These concerns are encouraging better quality scientific studies in obstetric care.

Scientists and physicians are improving the quality of the research needed to answer the question: does Pitocin harm the newborn? Often Pitocin is given to augment labor that stalls after many hours. In the previous section, we learned that prolonged labor has potential risks for the newborn. Therefore, a conclusion that Pitocin harms the baby without acknowledging that prolonged labor may also have an effect on the baby is questionable. Comparing prolonged, Pitocin-augmented labor to quick, Pitocin-free labor does not rule out if the effect on newborn health came from the many more hours of labor or from Pitocin. To address concerns over Pitocin safety, future studies need to ensure that the effect of prolonged labor does not confound data on Pitocin’s effect on newborn health. Scientists and physicians need to compare Pitocin-augmented mothers to mothers who had long labor but were not given Pitocin. Although challenging due to how rare the latter scenario is, it is the most accurate comparison for defining Pitocin’s effect on newborn health.

Understanding what triggers normal labor and how these triggers fail in some women will also help ensure Pitocin safety but providing better indicators for Pitocin use. Until science figures out why some women require medical intervention, expectant parents should discuss their plan with their healthcare providers to prepare for a delivery that may not go according to that plan. Education of, and communication among, providers and their patients will encourage appropriate use of Pitocin while ensuring the careful monitoring of mother and baby when Pitocin becomes the agreed-upon, best option for helping achieve a safe delivery of a healthy baby.

*Conflict of interest: The authors have declared that no conflict of interest exists.

This post is checked by the following science articles:
1) Martin A, Hamilton B, Ventura S, Osterman M, Wilson E, Matthews TJ. Births: Final data for 2010. Natl Vital Stat Rep. 2012;61(1):1.
2) The Business of Being Born. Dir. Abby Epstein. Perf. Mary Helen Ayres, Julia Barnett Tracy, Sylvie Blaustein. New Line, 2008. Film.
3) Bugg G, Siddiqui F, Thornton J. Oxytocin versus no treatment or delayed treatment for slow progress in the first stage of spontaneous labour. Editorial Group: Cochrane Pregnancy and Childbirth Group Published Online: 6 JUL 2011.
4) Stewart R and Slezak R. Synthetic and Natural Oxytocin: Comparison of their effects in initiating labor. Obstetrics and Gynecology. 1958; 11(3):295.
5) Wei SQ, Luo ZC, Qi HP, Xu H, Fraser WD. High-dose vs low-dose oxytocin for labor augmentation: a systematic review. Am J Obstet Gynecol. 2010 Oct;203(4):296-304.
6) Alfirevic Z, Kelly AJ, Dowswell T. Intravenous oxytocin alone for cervical ripening and induction of labour. Cochrane Database Syst Rev. 2009.
7) Meyer C, Freund MM, GuerneY, Richard P. Relationship between oxytocin release and amplitude of oxytocin cell neurosecretory bursts during suckling in the rat. J Endocrinol 114: 263–270, 1987.
8) Kimura T, Tanizawa O, Mori K, Brownstein MJ, Okayama H. Structure and expression of a human oxytocin receptor. Nature 356: 526–529, 1992.
9) Condon JC, Jeyasuria P, Faust JM, Mendelson CR. Surfactant protein secreted by the maturing mouse fetal lung acts as a hormone that signals the initiation of parturition. Proc Natl Acad Sci U S A. 2004 Apr 6;101(14):4978-83.
10) Gomez-Lopez N, Vega-Sanchez R, Castillo-Castrejon M, Romero R, Cubeiro-Arreola K, Vadillo-Ortega F. Evidence for a role for the adaptive immune response in human term parturition. Am J Reprod Immunol. 2013 Mar;69(3):212-30.
11) Dana E.M. Henry, Yvonne W. Cheng, Brian L. Shaffer, Anjali J. Kaimal, Katherine Bianco, Aaron B. Caughey. Perinatal Outcomes in the Setting of Active Phase Labor Arrest. Obstet Gynecol. 2008 Nov; 112(5): 1109–1115.
12) Najafian M, Cheraghi M. Occurrence of FetalMacrosomia Rate and ItsMaternal and Neonatal Complications: A 5-Year Cohort Study. ISRN Obstet Gynecol. 2012;2012:353791.
13) Vorherr H . Placental insufficiency in relation to postterm pregnancy and fetal postmaturity. Evaluation of fetoplacental function; management of the postterm gravida. Am J Obstet Gynecol. 1975;123(1):67.
14) Bruckner TA, Cheng YW, Caughey AB. Increased neonatal mortality among normal-weight births beyond 41 weeks of gestation in California. Am J Obstet Gynecol. 2008;199(4):421.e1.
15) Yudkin PL, Wood L, Redman CW. Risk of unexplained stillbirth at different gestational ages. Lancet. 1987 May 23;1(8543):1192-4.
16) ACOG Practice Bulletin No. 107: Induction of labor. ACOG Committee on Practice Bulletins –Obstetrics. Obstet Gynecol. 2009;114(2 Pt 1):386.
17) Optimizing Protocols in Obstetrics. Oxytocin for Induction. ACOG.

The Dark Truth about Migraine Treatments

Meet Jane. Most days she is like any other 37-year-old professional woman. Busy with her career and 8-year-old, she is always running off to some important meeting or soccer game. Some days, however, she is a migraine sufferer. She is among the 17% of women who suffer from migraines each year 1.  She suffers the typical symptoms: severe throbbing headache, nausea and vomiting, intolerance to light and sound, and pain. These symptoms stop Jane from living her life for the 24 hours she is a migraine sufferer. These debilitating migraine symptoms affect a surprising number of Americans 2. How do they deal with it?

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