Friday, May 16, 2008

Everything you ever wanted to know about your amniotic sac (and then some)

Everything you ever wanted to know about your amniotic sac (and then some)

I wrote this for the pregnant community today, but prasava said that I could share it here, as well. It's really geared towards women who have a more mainstream approach to their pregnancies (ie. follow a standard medical model of care), who may not know that amniotomy has risks involved or that having their waters break without starting labor doesn't automatically mean induction.

The topic of ruptured membranes, particularly having a "fore bag" of waters that breaks while an inner layers remains intact, has been brought up in several recent posts. I thought you might find this interested and helpful as you approach the end of your pregnancies.

Your baby isn't enclosed in a simple, single membranous layer. The "bag of waters" (amniotic sac) surrounding him/her/them is comprised of two layers: the chorion and the amnion. Other membranes have also surrounded your baby at different points in his/her development, and have helped with the development of the placenta and the umbilical cord.

The amnion is the innermost of the embryonic or fetal membranes, the sac in which the embryo is suspended. Early in the pregnancy, this membrane is in close contact with the developing embryo, but expands and moves away into a protective bubble as amniotic fluid production increases. This is your "inner bag" or "hind bag" of waters, the sac in which the baby is directly contained. When one is talking about the amniotic sac, this is what one is normally thinking of. For the sake of rupture of membranes, this is the one that really "counts" as having had your water break.

The chorion is the tougher outer membrane enclosing the embryo. It contributes to the development of the placenta. The chorionic villi (what is sampled in a CVS procedure) emerge from the chorion, invade the endometrium, and allow transfer of nutrients from maternal blood to fetal blood.

Identical twins may share a chorion or both a chorion AND an amnion, while fraternal twins each have their own chorion and amnion. In about 70% of identical twins, the twins will share a chorion (monochorionic), though some may also share an amnion (monoamniotic). Twins can share a placenta without being monoamniotic. The rare phenomenon known as twin-to-twin transfusion can sometimes occur in monoamniotic twins with a shared placenta, where twins receive an unequal amount of nutrition through the placenta.

Some women may actually have a true double bag of waters (two chorions and two amnions). This is uncommon and in some cases may be the result of a twin pregnancy where one twin was reabsorbed very early in the pregnancy, leaving one empty sac and one healthy developing baby.

The chorion and amnion are in contact with each other by the end of the pregnancy, often fused together so that when one breaks, so does the other, but they also can have a thin layer of amniotic fluid in between them. Many of you may have heard about women's bags of water "springing a leak" and then "resealing" -- in many of these cases, the chorion has developed a slight tear, allowing a minimal amount of fluid to escape. As the torn portions of membranes come into contact with each other again, however, they overlap and stick together, much like plastic wrap/cling film does when doubled over on itself. This is one reason why you will often see the more naturally-minded among us encouraging you not to rush to the hospital immediately, but wait to see if the fluid leakage stops.

This is one reason why women may experience a breaking of waters, sometimes one that seems pretty significant in its amount, only to be told by a doctor or nurse at the hospital that their waters are intact OR that only one layer has broken. I experienced this first hand, so I know the frustration of rushing to the hospital (as your care provider has told you) only to discover that you went much earlier than you needed to. Sometimes you will simply be sent home, but your care provider may also present the option of amniotomy (artificial rupture of membranes or AROM) to fully break your waters, especially if you are having contractions. Amniotomy has many disadvantages* and some advantages, and is a medical intervention you should research for yourself before the situation arises, to decide under what circumstances you would/would not feel comfortable having the procedure performed.

Remember that breaking waters (in a full term pregnancy) doesn't have to put you on a clock. There is no hard and fast rule regarding at which point the risk of infection increases, but the best way to avoid infection is simply not to insert anything into the vagina. If your water breaks, but contractions don't start right away, you might consider avoiding internal exams to check for dilation. Internal exams can introduce new bacteria/viruses into the vagina or push pre-existing bacteria/viruses further into the vagina. You always have a right to decline an internal exam, an induction, or any other procedure. If your labor has not started after a certain period of time after your waters have broken, ask your care provider about alternatives to induction, such as IV or oral antibiotics, or periodic monitoring of your health and your baby's. Your baby won't run out of amniotic fluid; it is constantly replenishing! The pockets of amniotic fluid can be measured via ultrasound; even for those of you who prefer to limit or avoid ultrasounds during pregnancy, this may be a preferable alternative to induction for those of you with care providers pushing for interventions.

I hope this hasn't been too boring and has answered some of your questions about the amniotic sac. I'm by no means a medical professional, but as an unassisted homebirther, I have made it my goal to learn as much about how my body works as possible, and to answer the many lingering questions I had about the many interventions performed (both with and without my consent) during my first birth (which was in a hospital).

*Amniotomy may also contribute to malpositioning of the baby, a disadvantage not listed in the link above.

Lilah Monger - - AAMI Student Midwife #1769

New Student Advisor, Mentor Program Director, and Reading Room Coordinator

Thursday, May 01, 2008

Guest Post : Judgment, Fear, and Focus

Laureen is the technical editor and online community advocate for and at Sun Microsystems, a freelance editor for Hunt Press, and a contributor to several peer-reviewed group blogs. She's a blogger, a podcaster, a website manager, and an enthusiastic geek enabler. She's the mother of two gorgeous children, and the wife of a man who understands her birth passion. She's had one iatrogenic unnecesarean, and one triumphant HBAC.

Judgment, Fear, and Focus

For only having two children, I have pretty much the range of birth experience; my first was a planned birth center birth turned hospital transfer with epidural turned cesarean. So there's the complete spectrum of medicalized birth. (At the time I was planning it, I thought my birth center birth was non-medicalized. I learned the hard way about medical midwifery.) My cesarean was brilliant, as these things go. The doctor was near retirement, had a 40% cesarean rate in his private practice, and knew what he was doing. I was too ignorant to even ask for things, but upon examination of my medical records, I got a Cadillac of a cesarean. Sheer dumb luck, that was. But despite that, due to hospital protocols, my baby spent the first four hours of his life with strangers; four hours we'll never get back.

For my second birth, I had an unassisted pregnancy, followed by a home birth with a midwife.

The move from home to hospital for birth in our culture involved a paradigm shift, whereby medical professionals convinced women that they were incompetent to birth without assistance, despite millennia of successful field testing to the contrary. The move to reclaim women's power by bringing birth back under their control is involving another paradigm shift, and that's going to be uncomfortable, and it's going to upset people. I think it matters that I know all kinds of women who've gone from hospital births to home births, but only two who've gone the other way, even if the home birthers ended up transferring ultimately. Because of my own experience, I am strongly biased towards home birth, and I admit that up front. On the other hand, because of the experiences of women I know personally, I would rather gnaw off my own arm than deny women the right to choose to birth in a hospital.

One of the things that really bothers me about the comment-foo on Rixa's blog is the complete abandonment of logic. Instead of classical logic, symbolic logic, the construction of actual arguments based on fact, we saw logical fallacies. Use of fallacy in argument invalidates the whole thing, in addition to bringing the entire discussion down to blows in short order. This does nothing to contribute to the betterment of women and babies; it sets us against each other for no purpose whatsoever. The thing about a good, solid, well-constructed argument is that invariably, both sides of the issue learn something and see further into their opponent's mindset. Everyone is bettered, perspective is gained, and we're that much closer to being a unified force...unified behind the true betterment of the situation here for mothers and babies.

I'd like to address a few of the real arguments brought up in the course of the commentary on Rixa's post...

Always be suspicious of motive when someone tries to make you do something that makes a lot of money for them

Maternity "care" is critical to the profitability of a hospital, and the more this can be managed, the more profit a hospital makes. The cesarean rate in the US is at levels so high (31.1% in 2006) that the World Health Organization considers it to be a "crisis." Scheduled cesareans are the epitome of optimally profitable managed birth. UnitedHealthcare sends maternity patients a brochure in late second trimester, offering them the option of a scheduled 39-week cesarean.

My cesarean, NICU stay, and hospital stay netted the hospital nearly $27,000, the anesthesiologists nearly $11,000, and a heap of other people other monies, and cost my insurance company a bundle.

My home birth cost my insurance company $3,000. Period.

So who stands to make money off my choice of birth? Hmm...

"You should be grateful you have a healthy baby/All that matters is a healthy baby"

Well, yeah, of course. But that's so not the whole story. Read Gretchen Humphries' brilliant essay "You Should Be Grateful."

There is room in this world for good experiences for both.

"Birth is about the baby, not the mother"

This letter, published in the ICAN eNews a little while back, says it all.

I am a lawyer who went to a top ten law school and then to a top tier firm. I used to be very mainstream in my views. I thought women who chose to give birth at home were reckless. When I got pregnant and was given the option of having a c-section, I readily agreed. I never went into labor and my c-section went flawlessly. I researched it, so I expected that my arms would be tied down, that I would likely shake from the anesthesia, and that I would not be able to hold my baby. That was ok, because I was ready for it. I handled the drugs well and, as a result, actually remember the first 24 hours. My recovery was uncomplicated.

My daughter, however, got the worst of it--which isn't even really that bad considering other stories I've heard. She was so sleepy and zoned out from the drugs that we had to put ice on her bare skin to wake her up enough to feed. She developed jaundice as a result of not eating enough. Because she couldn't feed properly (because she was so drugged), my milk never came in properly--which was a problem since it turned out she was allergic to all of the formulas they had. Given her allergies, breast milk would have really helped. She kept losing weight. She was diagnosed with failure to thrive. It was a very scary time, because we thought she might die.

On a long term basis, because she never came through the birth canal, her gut didn't get colonized with the right bacteria. That translates into the gut and immune system dysfunction she has today and the medicine that we give our 3.5 year old 5 to 6 times a day. She is also on a severely restricted diet--no wheat/gluten, dairy/casein, soy, citrus, etc. Bacteriologists say that the first germs that the baby is exposed to will set the tone for the baby's life. Those germs really need to come from the vagina.

The c-section went well for me, personally. I was very, very lucky as you will see from other stories you read. It did NOT go well for my daughter. I am now pregnant with a second child and plan to do all I can to deliver vaginally. A c-section still seems like an easy choice sometimes. Indeed, if I were giving birth to a tumor, not a baby, I might be inclined to do it, in spite of the crazy risks. But I will not put this baby at risk.

I'm a litigator and I love evidence. Crazily enough, the evidence is strongly in favor of vaginal birth. I believe that the cavalier attitude of OBs toward this major surgery is a result of a combination of factors (preference for control, fear of malpractice, higher payment, surgery is more "fun," lack of education on natural birth as opposed to how to manage an impending crisis, etc.). But carefully look at the evidence first, before you make up your mind. The evidence really does speak for itself and I'll let someone else who is better versed in the evidence point you in the right direction.

And with cesarean delivery, the baby itself is more likely to die. The US has the second worst newborn death rate in the developed world, despite the fact that we spend more money on "medical care."

How is it that we forgot that babies and mothers are a dyad? You can't truly separate the well-being of the mother from the well-being of the baby, not even with a scalpel. Go ahead; tell me that a mother who lives and a baby who dies, or a baby who lives and a mother who dies, deserve to be a separate statistic. I don't know a mother or a child in either circumstance who doesn't have a little bit of them die too, even if the statistics don't neatly account for it.

"But women used to die in childbirth!"

Read the news; they're dying now. Ask the families of Tatia Oden French, Valerie Scythes, Melissa Farah, Caroline Wiren, how they feel about the safety of hospital birth. Ask Claudia Mejia. Ask Amber Marlowe. Ask Dennis Quaid how safe hospitals are for babies.

Disaster can strike anywhere. But the idea that hospitals are inherently safe is not valid, and demonstrably so. There is no choice you can make that's an automatic get-out-of-jail-free card. The reason most women default to hospital birth is because that choice is presented as being blameless. If something happens in the hospital, well, that's just bad luck, but if it happens at home, that's bad decision making, with the mother occupying the role of bad guy, all by herself. This is not fact, this is not logic; this is marketing spin.

On Judgment

I have been told that my cesarean was a personal failure. I have been told that having a midwife present for my second birth was a personal failure. I have seen fully-medicalized birthers rip midwifery advocates apart, both live and online. I have seen women spend an ungodly amount of energy and time shredding at each other.

For what? I deeply believe that women who choose hospital birth do so because they want the safest and best for their babies. I deeply believe the same thing of the home birth set. So why are we still attacking each other?

Fear. And Judgment.

In the final analysis, birthing carries risk. Living carries risk. There are no guarantees anywhere that if you make all the "right" choices, you and yours will be saved from tragedy. Lightning strikes, and all the planning and research and analysis in the world will not save you from that. It comes down, in the end, to supporting each other the best we possibly can, to making our choices from a place of confidence, not a place of fear. If you're birthing in a hospital, do so because that's what feels safest to you. If you're birthing unassisted at home, do so because it speaks to you and feels right to you. Fear has no place in any decision about birthing.

A friend of mine who just had what she calls her "victorious homebirth after two cesareans" says:

Since our life-changing home birth I've encountered so much more support than we imagined possible. I cannot believe how many friends and acquaintances have said, "I sure wish WE had seriously considered birthing our children at home." Obviously there is a slow shift being made in the birthing climate of America. But there are also many other comments we've heard like, "I'm glad it worked out for you," which I now see as such a pitiful way to view birth--like it's a matter of luck. But I know that's the reality for most people. If these critics knew the amount of time, prayer, and research we put into this decision and into the type of provider we selected, they might have to consider why EVERYONE doesn't invest that kind of time and prayer in their own birthing decisions. For us, the search was priceless and ultimately put us in far better control of our decisions. And beyond the stats and truths we uncovered during this journey, we discovered something far more valuable: faith. After asking for guidance, begging for deliverance, and recognizing our answer, I was overcome with a peace that I have to say I've never experienced after praying before--and as the preacher's daughter I've spent a good many years on my knees in prayer. It was amazing to simply ask and to find the undeniable peace we so desperately desired. So THIS is what answered prayer feels like. I understand that's not much of a factor in modern society, which makes me incredibly sad.

We've also had to endure a number of horrible birth stories where someone nearly died "even in a hospital birth" (the fetal and maternal monitors didn't discover there was a problem until it was too late). I'm never sure how to take this kind of response to the introduction of our new baby. If these tactics are in an effort to get me to debate the home vs. hospital issue, I'm not taking the bait. My decision isn't up for debate--especially with those who've invested little in the search for truth other than personal experience and hearsay. I can respect your birthing decision if you can respect mine.

Standing together, we can do so much more good for everyone, than we can by compartmentalizing each other and shredding on anyone who doesn't share our precise set of birth circumstances. Different does not have to equal wrong. But the way things are right now, fear is controlling the cards, and we need to put down our differences, and stand together for a set of choices in birth and baby care that puts the U.S. back up at least in the top 10, because when it all comes down...the choice between home and hospital is not the point. The point is that women and babies are dying in utterly unacceptable numbers, and they're dying because our social, medical, and economic systems are not supporting women.

And women are not supporting women either. So let's focus on what matters.
Posted by Rixa at 7:41 AM 20 comments Links to this post