Neurobehavioral functioning and breastfeeding behavior in the newborn

Effects of different doses of synthetic oxytocin on neonatal instinctive behaviors and breastfeeding

Synthetic oxytocin is the current domestic first-line agent of induced labor and labor augmentation, and its potential effects on neonatal neurobehavioral development is currently attracting increased attention. To explore the effect of different doses of synthetic oxytocin on neonatal instinctive breastfeeding behavior and breastfeeding by observing neonatal behaviors during skin-to-skin contact with mothers after delivery. Observations and comparisons of neonatal instinctive behaviors were conducted by using Widström's 9 Stages method. According to the total dosage of oxytocin administered during labor, participants were divided into a low dose group (≤ 2.5 U) of 39 pairs, a medium dose group (> 2.5 U) of 38 pairs, a high dose group (> 7.5 U) of 38 pairs and a control group (no synthetic oxytocin use) of 39 pairs. The occurrence time of newborns' instinctive movements and the duration of each behavior stage for the four groups were also analyzed. The number of exclusive breastfeeding sessions within 3 days after birth and the rate of exclusive breastfeeding at 3 months were collected and compared. There were significant differences among the four groups in the occurrence time of raising head or turning head (p = 0.004), eating hands (p = 0.011), moving body (p = 0.001), locating areola (p < 0.001), licking nipples (p = 0.002), containing nipple (p = 0.001), sucking (p < 0.001). There were significant differences among the four groups in the duration of activity (p = 0.004), clawing (p = 0.001), familiarization (p = 0.001), and sucking (p < 0.001). There was also a significant difference in the number of exclusive breastfeeding sessions of 24 h (p = 0.011), 48 h (p < 0.001), 72 h (p = 0.001) after birth among the four groups, but there was no statistical difference in the rate of exclusive breastfeeding at 3 months after birth. The intrapartum administration of synthetic oxytocin was associated with the expression of neonatal instinctive breastfeeding. With increases in drug dose, the effect of breast seeking activity and breast attachment was more significant, and the association of synthetic oxytocin on sucking and breastfeeding was dose-dependent.

Newborns' early attuning to hand-to-mouth coordinated actions

Already inside the womb, fetuses frequently bring their hands to the mouth, anticipating hand‐to‐mouth contact by opening the mouth. Here, we explored whether 2‐day‐old newborns discriminate between hand actions directed towards different targets of the face—that is, a thumb that reaches the mouth and a thumb that reaches the chin. Newborns looked longer towards the thumb‐to‐mouth compared to the thumb‐to‐chin action only in the presence, and not absence, of anticipatory mouth opening movements, preceding the thumb arrival. Overall, our results show that newborns are sensitive to hand‐to‐face coordinated actions, being capable to discriminate between body‐related actions directed towards different targets of the face, but only when a salient visual cue that anticipates the target of the action is present. The role of newborns’ sensorimotor experience with hand‐to‐mouth gestures in driving this capacity is discussed.

Breastfeeding skills of full-term newborns and associated factors in a low-and-middle-income setting

BACKGROUND

Normative information on the breastfeeding of term newborns may guide clinicians in early identification of breastfeeding difficulties and oro-pharyngeal dysphagia (OPD), and may support optimal breastfeeding practices.

OBJECTIVE

To describe breastfeeding skills of term newborn infants in a South African hospital, a lower-middle-income setting, and investigate associations between infants' feeding and other factors.

METHOD

One breastfeeding session of each of the 71 healthy newborn full-term infants (mean chronological age=1.9 days; mean gestation=39.1 weeks) was evaluated using the Preterm Infant Breastfeeding Behavior Scale (PIBBS), suitable for use with term newborns.

RESULTS

All participants were exclusively breastfed. Thirteen participants (18%) were HIV-exposed. There was no significant difference in the findings of the PIBBS between HIV-exposed and unexposed participants. Most newborns had obvious rooting, latched deeply onto the nipple and some of the areola, had repeated long sucking bursts (mean length=16.82 sucks/burst), and swallowed repeatedly. Most participants were in either the drowsy or quiet-alert state, which are optimal behavioural states for breastfeeding. One to two-hourly on-demand feeds was significantly associated with mothers who had normal births and did not use galactogogues to promote lactation.

CONCLUSION

Results may be used for early identification of OPD in newborns. The findings may be useful to primary care clinicians.

The effect of labor medications on normal newborn behavior in the first hour after birth: A prospective cohort study

BACKGROUND

Skin-to-skin contact after birth between mother and baby has immediate and long-term advantages. Widström's 9 Stages of Newborn Behavior offer an opportunity to evaluate a baby in the natural, expected and optimal habitat. Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin (synOT), have been studied in relation to neonatal outcomes with conflicting results.

AIMS

Determine the effects of common intrapartum medications on the instinctive behavior of healthy newborns during the first hour after birth through a prospective cohort study.

STUDY DESIGN

Video record newly-born term infants during the first hour after birth while in skin-to-skin contact with mother. Code and analyze videos using Widström's 9 Stages; compare with the labor medications mothers received.

SUBJECTS

Convenience sample of sixty-three low-income mothers self-selected to labor with or without intrapartum analgesia.

OUTCOME MEASURES

Duration of time infants spend in each of Widström's 9 Stages for four cohorts: 1) exposed to no synOT or epidural fentanyl during labor, 2) exposed to fentanyl (but not synOT), 3) exposed synOT (but not fentanyl), 4) exposed to both fentanyl and synOT.

RESULTS

A strong inverse correlation was found between intrapartum exposure to fentanyl and synOT and the normal behavior of an infant, as measured by time in each Stage.

CONCLUSIONS

Intrapartum exposure to the drugs fentanyl and synOT is associated with altered newborn infant behavior, including suckling, while in skin-to-skin contact with mother during the first hour after birth. Widström's 9 Stages offer an opportunity to analyze newborn behavior whilst in the optimal habitat of the infant.

A priori choice of neuraxial labour analgesia and breastfeeding initiation success: a community-based cohort study in an Italian baby-friendly hospital

OBJECTIVE

To investigate whether the nature of the decision about receiving neuraxial labour analgesia is associated with breastfeeding initiation success (BIS), defined as exclusive breastfeeding until discharge associated with postnatal weight loss <7% at 60 hours from birth.

DESIGN

Single-centre community-based cohort study.

SETTING

An Italian baby-friendly hospital, from 1 July 2011 to 22 September 2015.

PARTICIPANTS

Inclusion criteria: women vaginally delivering singleton cephalic newborns and willing to breastfeed.

EXCLUSION CRITERIA

women who delivered in uterus-dead fetuses, were single or requested but did not receive neuraxial analgesia. Overall, 775 out of the 3628 enrolled women received neuraxial analgesia.

RESULTS

Compared with women who tried to cope with labour pain, those who decided a priori to receive neuraxial analgesia had less BIS (planned vaginal birth: 2121/3421 (62.0%), vs 102/207 (49.3%; p<0.001; risk difference (RD), 12.7%); actual vaginal birth: 1924/2994 (64.3%), vs 93/189 (49.2%; p<0.001; RD, 15.1%)). Multivariable analyses with antelabour-only confounders confirmed both associations (planned vaginal birth: relative risk (RR), 0.65; 95% CI, 0.48 to 0.87; actual vaginal birth: RR, 0.59; 95% CI, 0.43 to 0.80). Although women who requested analgesia as a last resort had less BIS than did those successfully coping with labour pain in the bivariable analyses (planned vaginal birth: 1804/2853 (63.2%), vs 317/568 (55.8%; p=0.001; RD, 7.4%); actual vaginal birth: 1665/2546 (65.4%), vs 259/448 (57.8%; p=0.002; RD, 7.6%)), multivariable analyses with either antelabour-only or peripartum confounders did not confirm these associations (planned vaginal birth: RR, 0.99; 95% CI, 0.80 to 1.23; actual vaginal birth: RR, 0.90; 95% CI, 0.69 to 1.16).

CONCLUSIONS

Compared with trying to cope with labour pain, a priori choice of neuraxial analgesia is negatively associated with BIS. Conversely, compared with having successfully coped with pain, requesting neuraxial analgesia as a last resort is not negatively associated with BIS.

Breastfeeding and swallowing in a neonate with mild hypoxic-ischaemic encephalopathy

BACKGROUND

Specific breastfeeding and swallowing characteristics in neonates with hypoxic-ischaemic encephalopathy (HIE) have not yet been well described in the literature. Considering the relatively high incidence of HIE in resource-poor settings, speech-language therapists should be cognisant of the feeding difficulties in this population during breastfeeding.

OBJECTIVE

To systematically describe the breastfeeding and swallowing of a single case of a neonate diagnosed with mild HIE from admission to discharge.

METHOD

A case study of a 2-day old neonate with mild HIE in a neonatal intensive care unit at an urban teaching hospital, is presented. Data were prospectively collected during four sessions in a 12-day period until the participant's discharge. Feeding and swallowing were assessed clinically, as well as instrumentally using a video-fluoroscopic swallow study.

RESULTS

After parenteral feeding, nasogastric tube feeding commenced. Breastfeeding was introduced on Day 6, as it was considered a safe option, and revealed problematic rooting, shallow latching, short sucking bursts, infrequent swallowing, and a drowsy state of arousal, with coughing and choking. No penetration or aspiration was identified instrumentally. After 13 days, the neonate was breastfeeding safely.

CONCLUSION

Although the pharyngeal stage of swallowing was intact, symptoms of oral stage dysphagia were revealed using a combination of clinical and instrumental measures. Breastfeeding difficulties were identified, exacerbated by poor state regulation, which lead to prolonged hospitalisation. The case study highlights the unexpected long duration of feeding difficulties in an infant with mild HIE and indicates further research.

Labor Epidural Analgesia and Breastfeeding: A Systematic Review

Despite widespread use of epidural analgesia during labor, no consensus has been reached among obstetric and anesthesia providers regarding its effects on breastfeeding. The purpose of this review was to examine the relationship between labor epidural analgesia and breastfeeding in the immediate postpartum period. PubMed, Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature were searched for articles published in 1990 or thereafter, using the search term breastfeeding combined with epidural, labor epidural analgesia, labor analgesia, or epidural analgesia Of 117 articles, 23 described empirical studies specific to labor epidural analgesia and measured a breastfeeding outcome. Results were conflicting: 12 studies showed negative associations between epidural analgesia and breastfeeding success, 10 studies showed no effect, and 1 study showed a positive association. Most studies were observational. Of 3 randomized controlled studies, randomization methods were inadequate in 2 and not evaluable in 1. Other limitations were related to small sample size or inadequate study power; variation and lack of information regarding type and dosage of analgesia or use of other intrapartum interventions; differences in timing, definition, and method of assessing breastfeeding success; or failure to consider factors such as mothers' intention to breastfeed, social support, siblings, or the mother's need to return to work or school. It is also unclear to what extent results are mediated through effects on infant neurobehavior, maternal fever, oxytocin release, duration of labor, and need for instrumental delivery. Clinician awareness of factors affecting breastfeeding can help identify women at risk for breastfeeding difficulties in order to target support and resources effectively.

The Association Between Common Labor Drugs and Suckling When Skin-to-Skin During the First Hour After Birth

BACKGROUND

Intrapartum drugs, including fentanyl administered via epidural and synthetic oxytocin, have been previously studied in relation to neonatal outcomes, especially breastfeeding, with conflicting results. We examined the normal neonatal behavior of suckling within the first hour after a vaginal birth while in skin-to-skin contact with mother in relation to these commonly used drugs. Suckling in the first hour after birth has been shown in other studies to increase desirable breastfeeding outcomes.

METHOD

Prospective comparative design. Sixty-three low-risk mothers self-selected to labor with intrapartum analgesia/anesthesia or not. Video recordings of infants during the first hour after birth while being held skin-to-skin with their mother were coded and analyzed to ascertain whether or not they achieved Stage 8 (suckling) of Widström's 9 Stages of newborn behavior during the first hour after birth.

RESULTS

A strong inverse correlation was found between the amount and duration of exposure to epidural fentanyl and the amount of synthetic oxytocin against the likelihood of achieving suckling during the first hour after a vaginal birth.

CONCLUSIONS

Results suggest that intrapartum exposure to the drugs fentanyl and synthetic oxytocin significantly decreased the likelihood of the baby suckling while skin-to-skin with its mother during the first hour after birth.

Effective suckling in relation to naked maternal-infant body contact in the first hour of life: an observation study

BACKGROUND

Best practice guidelines to promote breastfeeding suggest that (i) mothers hold their babies in naked body contact immediately after birth, (ii) babies remain undisturbed for at least one hour and (iii) breastfeeding assistance be offered during this period. Few studies have closely observed the implementation of these guidelines in practice. We sought to evaluate these practices on suckling achievement within the first hour after birth.

METHODS

Observations of seventy-eight mother-baby dyads recorded newborn feeding behaviours, the help received by mothers and birthing room practices each minute, for sixty minutes.

RESULTS

Duration of naked body contact between mothers and their newborn babies varied widely from 1 to 60 minutes, as did commencement of suckling (range = 10 to 60 minutes). Naked maternal-infant body contact immediately after birth, uninterrupted for at least thirty minutes did not predict effective suckling within the first hour of birth. Newborns were four times more likely to sustain deep rhythmical suckling when their chin made contact with their mother's breast as they approached the nipple (OR 3.8; CI 1.03 - 14) and if their mothers had given birth previously (OR 6.7; CI 1.35 - 33). Infants who had any naso-oropharyngeal suctioning administered at birth were six times less likely to suckle effectively (OR .176; CI .04 - .9).

CONCLUSION

Effective suckling within the first hour of life was associated with a collection of practices including infants positioned so their chin can instinctively nudge the underside of their mother's breast as they approach to grasp the nipple and attach to suckle. The best type of assistance provided in the birthing room that enables newborns to sustain an effective latch was paying attention to newborn feeding behaviours and not administering naso-oropharyngeal suction routinely.

The development of sucking patterns in preterm, small-for-gestational age infants

OBJECTIVE

To determine whether the development of sucking patterns in small-for-gestational age (SGA) preterm infants differs from appropriate-for-gestational age (AGA) preterm infants.

STUDY DESIGN

We assessed sucking patterns in 15 SGA and 34 AGA preterms (gestational age<or=36 weeks) longitudinally from 34 to 50 weeks postmenstrual age (PMA) using the Neonatal Oral-Motor Assessment Scale (NOMAS). At each measurement, we scored sucking as normal, dysfunctional, or disorganized. We examined the development of their sucking patterns in relation to clinical characteristics.

RESULTS

SGA preterms developed a normal sucking pattern later than did AGA preterms (median, 50 versus 44 weeks PMA, P=.002). At term-equivalent age, none of the SGA and 38% of the AGA preterms showed normal sucking (P<.05); at 48 to 50 weeks PMA this was 54% and 81%, respectively (P=.064). Abnormal sucking including "incoordination" and dysfunctional sucking were more prevalent in SGA preterms than in AGA preterms (median, 11% versus 0% per infant, P<.05). A higher gestational age and z-score for birth weight were predictive of normal sucking at 50 weeks PMA.

CONCLUSIONS

SGA preterms developed a normal sucking pattern later than AGA preterms. Many AGA preterms also developed a normal mature sucking pattern only after they had reached term age.

Neonatal neurobehavioral organization after exposure to maternal epidural analgesia in labor

OBJECTIVE

To explore relationships between maternal epidural analgesia and two measures of neurobehavioral organization in infants at the initial feeding 1 hour after birth.

DESIGN

Prospective comparative design.

SETTING

Inner-city community hospital, Chicago, Illinois.

PARTICIPANTS

Convenience sample of 52 low-risk, mainly Black and Latino, mother/infant dyads.

METHODS

Mothers self-selected to labor with epidural or no labor pain medication. Neonatal neurobehavioral organization was measured in term infants at the initial feeding 1 hour after birth. A nutritive sucking apparatus generated data on total number of sucks and sucking pressure. Video recordings of infants (before and after the initial feeding) were coded for behavioral states, with analysis on frequency of alertness.

RESULTS

Total number of sucks and sucking pressure were not related to epidural exposure, although an epidural drug dosage effect on total number of sucks was evident when gender was a factor. Unmedicated girls demonstrated more sucks than girls in the high-dosage epidural group (p=.027). Overall, girls exhibited stronger sucking pressure than boys (p=.042). Frequency of alertness was not related to epidural exposure, although longer labor was related to greater alertness (p=.003), and Latino infants were more alert than Black infants (p=.002).

CONCLUSIONS

Results suggest attenuated neonatal nutritive sucking organization in girls after exposure to high maternal epidural dosages. In comparison to boys, girls may have enhanced neurobehavioral organization at birth. Race/ethnicity and alertness may have spurious associations in which hidden factors drive the relationship.

Cup versus bottle feeding for hospitalized late preterm infants in Egypt: a quasi-experimental study

Background

Although previous studies have demonstrated beneficial breastfeeding outcomes when cup feeding rather than bottle feeding was used for feeding preterm infants, cup feeding has not been implemented in Egypt. The aim of the current study was to examine the effect of using cup feeding as an exclusive method of feeding preterm infants during hospitalization on breastfeeding outcomes after discharge.

Methods

A quasi-experimental design, with the control group studied first, was used to examine the effect of cup feeding for preterm infants on breastfeeding outcomes after discharge. Sixty preterm infants (mean gestational age was 35.13 weeks and mean birth weight was 2150 grams) were recruited during Neonatal Intensive Care Unit (NICU) stay. Control group infants (n = 30) received only bottle feedings during hospitalization and the experimental group (n = 30) received only cup feedings during hospitalization. Both groups were followed up after discharge for six weeks to evaluate infant's breastfeeding behavior and mother's breastfeeding practices. Data were analyzed using descriptive statistics and repeated measures ANOVA for testing the differences between the cup feeding and bottle feeding groups over six weeks after discharge.

Results

Cup fed infants demonstrated significantly more mature breastfeeding behaviors when compared to bottle fed infants (p < 0.01) over six weeks, and had a significantly higher proportion of breast feedings one week after discharge (p = 0.03).

Conclusion

Cup fed infants were more exclusively breast fed one week after discharge, supporting the Baby Friendly Hospital Initiative recommendations for using cup feeding and avoiding bottle feeding when providing supplementation for preterm infants. The current study provides initial evidence for the implementation of cup feeding as a method of supplementation for late preterm infants during hospitalization.

Trial Registration

Clinical Trial NCT00756587.

Assessing midwives' breastfeeding knowledge: properties of the Newborn Feeding Ability questionnaire and Breastfeeding Initiation Practices scale

BACKGROUND

There are few reliable and valid tools to assess lactation and infant feeding knowledge and practices. This study tested the psychometric properties of two new scales, the Newborn Feeding Ability (NFA) questionnaire and Breastfeeding Initiation Practices (BIP) scale to assess midwives' breastfeeding knowledge and practices specific to breastfeeding initiation.

METHODS

A national postal survey of Australian midwives (n = 3500) was conducted in October 2001. Reliability was determined through Cronbach's alpha coefficient and stability determined by a test-retest. Content validity was established through a critical review of literature and review by an expert panel. Construct validity was informed by an exploratory factor analysis and principle component analysis with varimax rotation. Correlations between NFA and BKQ knowledge subscale scores and BIP and BKQ practice subscale scores assessed criterion validity. A multiple hierarchical regression analysis determined predictive validity of the NFA and BIP.

RESULTS

A response rate of 31.6% (n = 1107) was achieved. Adequate internal consistency was established for both instruments. Five factors on the NFA questionnaire were congruent with knowledge about effects of skin-to-skin contact, physiological stability, newborn innate abilities, work practices and effective breastfeeding. The BIP revealed three factors related to observing pre-feeding behavior, mother/baby care and attachment and positioning practices. Predictive validity of knowledge was moderate (r = 0.481, p < 0.01) and contributed to 31.5% of variance in reported practice. Midwives with high knowledge scores were more likely to report best practice when assisting mothers to initiate breastfeeding. Midwives with more personal breastfeeding experience scored higher on all scales.

CONCLUSION

The Newborn Feeding Ability questionnaire and the Breastfeeding Initiation Practices scale can contribute to practice development by assessing lactation and infant feeding knowledge and practice deficits. Individual learning needs can be identified, and effectiveness of education interventions evaluated using these tools. Further testing is required with other samples of midwives and health professionals involved in the promotion of breastfeeding.

Concept clarification of neonatal neurobehavioural organization

AIM

This paper is a report of a concept analysis of neonatal neurobehavioural organization for healthy full-term infants.

BACKGROUND

The neonatal period is an opportune time for researchers and clinicians to assess and intervene for optimal neurobehavioural organization. Yet there is inconsistency and lack of clarity in a scientifically grounded definition of neonatal neurobehavioural organization. Clarification of the concept will strengthen research findings that influence practice for optimal infant development.

METHOD

A concept analysis of the literature between 1939 and 2007 (n = 57) was conducted using Penrod and Hupcey's principle-based concept analysis and Morse's concept clarification.

FINDINGS

The concept analysis within and across multiple disciplines revealed: (1) a view of the concept as a holistic phenomenon with multiple dimensions; (2) no agreement on the ideal instrument to operationally define the concept; and (3) consistency in implied meaning, but great variability in terminology. Neonatal neurobehavioural organization was defined as the ability of the neonate to use goal-directed states of consciousness, in reciprocal interaction with the caregiving environment, to facilitate the emergence of differentiating, hierarchical, and coordinated neurobehavioural systems, with ever-increasing resiliency and capacity to learn from complex stimuli.

CONCLUSION

A clear conceptual definition will help the international community to communicate effectively within and between disciplines and to apply evidence-based research findings. It will encourage the development of valid and reliable instruments to capture the concept's multiple dimensions and direct attention to the infant's experience, which sculpts early neurobehavioural organization.

Mother-Infant Breastfeeding Progress Tool: a guide for education and support of the breastfeeding dyad

OBJECTIVE

To describe the development of the Mother-Infant Breastfeeding Progress Tool to be used at the bedside by nurses to guide ongoing support and education for the mother-baby dyad.

DESIGN

Cross-sectional study.

SETTING

Community hospital in a Midwestern city.

PARTICIPANTS

Sixty-two English-speaking mother-infant dyads.

METHODS

Three nurse raters (two per session) independently scored the eight characteristics on the Mother-Infant Breastfeeding Progress Tool during 81 breastfeeding sessions.

MAIN OUTCOME MEASURE

Percent agreement between raters and suggested modifications for the Mother-Infant Breastfeeding Progress Tool.

RESULTS

The results support the use of the tool as a checklist for assessment of the breastfeeding mother-infant dyad to guide education and support.

CONCLUSIONS

The interrater agreement was high for individual items of the Mother-Infant Breastfeeding Progress Tool. The Mother-Infant Breastfeeding Progress Tool is useful as a checklist for assessing maternal and infant breastfeeding progress, though additional research is needed to support the validity of the tool.

Breast-feeding: good starts, good outcomes

Meeting national breast-feeding objectives and mothers' personal breast-feeding goals depends on a number of factors, including the provision of current, consistent, and timely help with breast-feeding. Nurses are in a prime position to guide mothers during their hospital stay and provide community follow-up postdischarge. Mothers and infants need to acquire a set of breast-feeding skills prior to hospital discharge so that a mother goes home confident that she can adequately nourish her infant, initiate and maintain an abundant milk supply, avoid problems, and address them if they occur. This article describes strategies for optimizing breast-feeding during the first 48 hours and delineates what mothers need to know before they leave the hospital.

Time of perinatal immunization, thimerosal exposure and neurodevelopment at 6 months in breastfed infants

AIM

Brazilian newborns immunized with hepatitis-B (thimerosal containing vaccine, TCV) receive the first dose within 24 h if delivered in public hospitals, but at a later time if born in private hospitals. We compared neurodevelopment (ND) in infants born in a state hospital (immunized within 24 h) and in privately run hospitals (immunized 2-4 days postnatally).

METHODS

We used the Gesell Developmental Schedules in 82 healthy exclusively breastfed infants at 6 months to assess motor skills, language development, comprehension capacity and social skills.

RESULTS

Compared to the group immunized 2-4 days after hospital discharge, the group immunized within 24 h showed no significant difference in ND delays. Despite the variation in gestational age (range 36-42 weeks) and TCV-ethylmercury (EtHg) dose (5.7-11.3 microg Hg/kg b.w.) at birth, time of exposure to TCV showed no significant association with ND. Gesell Developmental Score was not significantly correlated with total parenteral EtHg/unit of body mass neither with the relative increase in hair-Hg (as an additional challenge to prenatal Hg exposure).

CONCLUSION

In breastfed infants, differences in early exposure to TCV-EtHg cannot portend clinical neurodevelopment delays at 6 months. We speculate that breastfeeding remains a significant strategy to improve central nervous system protection of infants facing early exposure challenges.

Care practice #4: no routine interventions

This updated edition of Care Practice Paper #4 presents the evidence for risks of routinely intervening in normal physiologic labor and birth. The authors review evidence related to the routine use of restrictions on oral intake, intravenous lines, continuous electronic fetal monitoring, artificial rupture of membranes, pharmacologic augmentation of labor, epidural analgesia, and episiotomy. Medical indications for each intervention are listed. Women are encouraged to avoid routine interventions in labor unless interventions are medically indicated.

Eating disorders and women's health: an update

Anorexia nervosa, bulimia nervosa, and eating disorders not otherwise specified have a significant impact on the health care and childbearing outcomes of the female population. Primary care contact for gynecologic care, childbearing, or infertility can serve as a critical entry point for the initial recognition of potentially devastating disorders that may result in permanent impairment and/or chronic debilitation. This review addresses the nature and prevalence of eating disorders and the management of pregnancy complicated by an active eating disorder or a history of an eating disorder. Genetic influences and intergenerational transmission of eating disorders are discussed. Finally, the increased risk for postpartum depression among women with a current or past eating disorder is examined. Factors critical to improving pregnancy outcome and reducing the risk for exacerbation or relapse in the postpartum period are identified.