|July 30, 2008|
Volume 10, Issue 16
|Midwifery Today E-News|
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In This Week’s Issue:
Quote of the Week
"Act as if what you do makes a difference. It does."
— William James
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The Art of Midwifery
HIV is found in blood, semen, vaginal fluids and breast milk. The virus is also found in the fluids from the penis that precede ejaculation. STIs like gonorrhea, chlamydia and non-gonococcal urethritis can increase the amount of HIV in a man's semen. The level of virus in vaginal fluids is highest just before menstruation because the high hormone levels increase HIV production from the cells in the vagina and cervix. If a woman has bacterial vaginosis, gonorrhea, chlamydia or ulcerated lesions of herpes simplex or syphilis, she also will have more HIV in her vaginal fluids or coming from the ulcers. Women who are newly infected or have more advanced HIV disease (both with high viral loads) are more likely to transmit HIV. Tears, saliva, sweat, blister fluid, urine and feces all have only very small amounts of HIV and are unlikely to be infectious. Antiretroviral treatment (ARV) does decrease the virus in semen and vaginal fluids but does not eliminate the virus altogether; a person on Highly Active Antiretroviral Therapy (HAART) is still able to transmit the virus.
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Research to Remember
Both temperament of baby and interaction with parents can predict behavior problems later in life, according to a study of 1863 children. That study, which followed them from infancy to age 13, found that those children whose parents read to them, talked to them and took them out of the house were less likely to have serious behavioral problems. It also found that kids that were fussy and moody, or exhibited unpredictable behavior, were more likely to have problem behaviors "such as lying, bullying or disobeying parents" later in life, as well.
— Medline Plus, www.nlm.nih.gov/medlineplus/news/fullstory_66528.html. Accessed 7 Jul 2008.
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Antiretrovirals in Pregnancy
A woman [with HIV] should make decisions about use of antiretrovirals (ARVs) during pregnancy after she has discussed with her health care provider the known and unknown benefits and risks. HIV-positive pregnant women are offered ARVs for two purposes. First, Highly Active Antiretroviral Therapy (HAART) should be offered for the treatment of her HIV disease using the same criteria as if she were not pregnant (CD4 count below 350, presence of AIDS-defining illness, etc.). Of course, the potential impact of the drugs on the baby (as a fetus and, long-term, as a child and adult) is an additional consideration.
Second, she will be offered HAART as part of a three-part regimen to reduce the risk of transmitting the virus to her baby, even if she is not in need of it for her own health. Discussion should include the effectiveness of ARVs in reducing transmission of the virus to the baby and what is known and not known about effects of the drugs on the baby. There is currently a lack of data on long-term side effects in babies exposed during pregnancy for any of the available ARVs. AZT, the first ARV given to pregnant women, was first administered in 1992. A pregnant woman must understand that no treatment can absolutely guarantee that her baby will not contract HIV, but with the three-part regimen, including HAART, the risk is very low—less than 1%.
A few drugs should not be used in pregnancy or should be used with care. Efavirenz should not be used in the first trimester, as birth defects (cleft palate, anencephaly and other neural tube defects) have been seen in monkeys and in babies with first-trimester exposure. Use after the first trimester can be considered if other drugs are not available. D4T and ddI should not be used together in pregnancy, as they increase the risk of lactic acidosis.
Nevirapine (NVP) should be used with caution in pregnant women. Because of increased risk of liver toxicity in women who start NVP with CD4 cell counts above 250, they should be monitored closely for liver toxicity in the first 18 weeks. Women who are already on NVP and tolerate it well can continue it, on becoming pregnant, without increased risk of liver problems.
One small study reports increased incidence of pre-eclampsia in women taking ARVs in pregnancy. While this association is not definitive, HIV-positive pregnant women need the same careful assessment for pre-eclampsia that we provide for all pregnant women. Pregnant women on protease inhibitors (PIs) need more frequent glucose monitoring until it is clear whether the increased risk of hyperglycemia with PIs also means an increased risk for gestational diabetes.
Recommended drugs during pregnancy are: Nucleoside reverse transcriptase inhibitors (NRTIs) zidovudine and lamivudine, the non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) nevirapine, and the PIs nelfinavir and saquinavir soft gel tablet boosted with ritonavir.
An HIV-infected pregnant woman who has not taken ARVs previously and has a viral load above 1000 copies/ml should be offered a three-part regimen for preventing mother to child transmission (PMTCT) (1) HAART, including AZT as one of the three drugs, (2) AZT intravenously during labor, and (3) AZT syrup for the newborn for six weeks. She may consider delaying the initiation of therapy until second trimester. If her CD4 count is below 350, she should consider continuing HAART postpartum. For women with CD4 counts above 350, it is recommended that HAART be stopped appropriately after birth.
There are some special considerations for an HIV-positive woman who is on HAART when she becomes pregnant. In general, she should be counseled about the known and unknown risks to her baby of exposure to the specific drugs she is taking and be advised to continue her regimen. A change of drugs may be suggested for some women. AZT, the most well studied drug in pregnancy, should be part of her regimen, if possible. If she is taking efavirenz, the only ARV documented to date to be associated with an increased risk of birth defects, it should be changed. Any woman who has taken EFV during the first trimester should have careful counseling about the possible birth defects and a targeted anatomical ultrasound in second trimester. AZT should be offered as above to the mother in labor and to the baby for PMTCT.
If an HIV-positive woman who has taken no ARVs during pregnancy presents in labor, she should be offered AZT intravenously during labor and AZT syrup for the baby for six weeks, for PMTCT. A more potent PMTCT regimen is to add a single oral dose of NVP for the mother in labor and for the baby at 48 hours to the above AZT regimen. The risk of MTCT can be reduced to about 7% by combining NVP and AZT. After birth, the mother should be evaluated for use of HAART for her own health.
HIV-infected mothers who have had no ARVs in pregnancy or labor should be offered six weeks of AZT for their newborns. Some providers may offer combinations of two to three ARVs for the newborn as post-exposure prophylaxis in this case, but this has not been well studied. Again, the mother should be evaluated for HAART for her own health.
Side effects from ARVs for pregnant women are the same as those for non-pregnant women. AZT can cause anemia in both the mother and baby, which will resolve when the drug is stopped.
Prenatal care providers should register pregnant women taking ARVs in the Antiretroviral Pregnancy Registry at the Centers for Disease Control (CDC). This registry is to collect observational data about potential birth defects and long-term side effects caused by or associated with these drugs. Babies who are exposed to ARVs during pregnancy should have careful pediatric follow-up for evaluation of possible long-term side effects.
— Nancy Miller
Products for Birth Professionals
Mortality rates for HIV-infected persons have become much closer to general mortality rates since the introduction of highly active antiretroviral therapy (HAART). In industrialized countries, persons infected sexually with HIV now appear to experience mortality rates similar to those of the general population in the first 5 years following infection, though a mortality excess remains as duration of HIV infection lengthens.
— Journal of the American Medical Association, 2 July 2008
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Question of the Week
Q: I have always checked my patients with a rim or anterior lip, allowed laboring down as much as possible and then made a two push attempt to reduce the lip. Is this wrong? I have been practicing labor and delivery nursing for 18 years. It was explained to me that this was not an acceptable practice and, although I had a fabulous outcome, I was severely reprimanded because administration could find nothing to support this practice. HELP! Any ideas on how to support myself?
— Deborah Belty, RN, MS in Maternal/Child
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Question of the Week Responses
Q: A lot of women these days seem to be getting their labor induced because they have oligohydramnios, or too little amniotic fluid. How is this determined? And how accurate is the test that is done to show that this "problem" exists? Is it a real problem? If so, what causes it?
A: Doctor: "You have too little water. The ultrasound shows oligohydramnios, which means decreased amniotic fluid. Your baby is in trouble! We'll induce labor and try to avoid a cesarean."
These are words pregnant women often hear from well-meaning obstetricians. The only problem is that the reason given for interfering with nature has no medical basis. Too little water or too much water are associated with problems in the newborn. That is true. But it is not possible at this time to accurately estimate whether there is too little or too much water until after the baby is born.
This is similar to the problem of estimating the fetus's weight. The estimated fetal weight is most accurate for average size babies and not as accurate for very small and for very big babies. Those of course, are the babies for which the estimate is needed.
A study in the November 1998 issue of Obstetrics & Gynecology, the journal of the American College of Obstetricians and Gynecologists (Obstet Gynecol 92:5: 823–27) looked at 1038 women who had their amniotic fluid measured by ultrasound near the end of pregnancy. The technician measures, in centimeters, the length of the pockets of amniotic fluid that are seen on the screen and then takes an average of the some of the pockets surrounding the fetus. The pockets surrounding the fetus depend on its position at the time of measurement. The conclusion of this study is that indexing amniotic fluid by measuring the pockets of amniotic fluid—Amniotic Fluid Index (AFI)—is "a poor screening test" to identify infants at risk. AFI is simply not sensitive or accurate enough to be used as a diagnostic tool. This is the only tool that is used to date. The study mentioned that scientists are trying to develop a tool that will be useful for diagnosis of fetuses at risk.
Unfortunately, sometimes women are told that they have too little water or too much water, without any ultrasound measurements, after the doctor palpates the uterus. Clearly, it is impossible to accurately assess that there is too much water or too little water by just feeling the abdomen.
— Judy Slome Cohain
Responses to any Question of the Week may be sent to E-News at any time. Write to email@example.com. Please indicate the topic of discussion *and the E-News issue number* in the subject line or in the message.
Think about It
This spring, I had a Master's student, Ragan Cohen, who wrote about why and how to prevent cesareans. Then she took it the next step and learned how to make a YouTube! She interviewed moms who had both vaginal and cesarean deliveries. Ragan would like the video to be used in the birth community—in your childbirth classes, clinics, classrooms, whatever. Here is everything you'd want to know in 5 minutes flat. Enjoy! http://www.youtube.com/watch?v=EZy0JPtubiQ
— Cynthia B. Flynn, CNM, PhD
Re: Midwifery Today E-News Issue 10:14
I opened my e-mail to find a wonderful article, "Safer Birth in a Barn" only to read down to see an article [Editor's note: This was a paid ad] from a midwife program in New Jersey that talks about inhouse physicians and anesthesia. Being a traditional midwife for twenty five plus years, I can see how programs like this can destroy the internal culture of the traditional midwife. That article adds a lot of food for thought.
It sounds like these hospital-based programs are just an extension of the industrial hospital complex, just another sales and marketing pitch to sell a failing health care system under the guidance of those in the ivory tower. Do they teach theraputic conversation and Medicare billing, too? In retrospect, we should all fit into an ICD-9 code. Is that the future of the midwife? I can only hope that those who enroll in these courses can read between the lines and maintain their integrity after they leave the program.
I do commend you for this open forum from each side of the barn yard fence.
— Nica Ford
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