Parental factors that impact the ecology of human mammary development, milk secretion, and milk composition-a report from "Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN)" Working Group 1.

The goal of Working Group 1 in the Breastmilk Ecology: Genesis of Infant Nutrition (BEGIN) Project was to outline factors influencing biological processes governing human milk secretion and to evaluate our current knowledge of these processes. Many factors regulate mammary gland development in utero, during puberty, in pregnancy, through secretory activation, and at weaning. These factors include breast anatomy, breast vasculature, diet, and the lactating parent's hormonal milieu including estrogen, progesterone, placental lactogen, cortisol, prolactin, and growth hormone. We examine the effects of time of day and postpartum interval on milk secretion, along with the role and mechanisms of lactating parent-infant interactions on milk secretion and bonding, with particular attention to the actions of oxytocin on the mammary gland and the pleasure systems in the brain. We then consider the potential effects of clinical conditions including infection, pre-eclampsia, preterm birth, cardiovascular health, inflammatory states, mastitis, and particularly, gestational diabetes and obesity. Although we know a great deal about the transporter systems by which zinc and calcium pass from the blood stream into milk, the interactions and cellular localization of transporters that carry substrates such as glucose, amino acids, copper, and the many other trace metals present in human milk across plasma and intracellular membranes require more research. We pose the question of how cultured mammary alveolar cells and animal models can help answer lingering questions about the mechanisms and regulation of human milk secretion. We raise questions about the role of the lactating parent and the infant microbiome and the immune system during breast development, secretion of immune molecules into milk, and protection of the breast from pathogens. Finally, we consider the effect of medications, recreational and illicit drugs, pesticides, and endocrine-disrupting chemicals on milk secretion and composition, emphasizing that this area needs much more research attention.

Use of External Uterine Electromyography Across Stage I Labor.

INTRODUCTION: Highly sensitive, external uterine electromyography (EMG) measures myometrial electrical activity and is noninvasive compared with the clinical intrauterine pressure catheter. Most experimental studies have measured EMG in 30-minute epochs, limiting the utility of this instrumentation in intrapartum clinical practice. To test proof of concept, surface uterine EMG contraction activity was continuously collected throughout the first stage of labor from healthy women at term gestation with (n = 3) and without (n = 1) epidural or combined spinal-epidural analgesia for a maximal length of 11 hours and 24 minutes. METHODS: EMG activity was recorded concurrently with tocodynamometer (toco) signals, using a pair of electrodes on the left and right sides of the maternal umbilicus with grounds attached to both hips of the reclining woman in labor. The preamplifier cutoff frequency settings were appropriate to monitor smooth muscle contraction in labor, with the analog high-pass filter set at 0.05 Hz and the low-pass filter at 1.50 Hz. Signals were sampled at 100 Hz, transmitted to a computer, and visualized by Chart 4.2 software. EMG data from epochs at baseline, during the pre-epidural fluid bolus and at the 60-minute post-epidural test dose, and at 3, 5, 6, and 8 cm dilatation were analyzed for burst power spectrum peak frequency (Hz), burst power spectrum amplitude (mV2 ), and burst duration (seconds). RESULTS: Uterine EMG contractile bursts were preceded and followed by a stable baseline and coincided with toco contractions. Movement artifacts were negligible, and large movement artifacts were easily distinguishable. The EMG bursts and toco contractions remained clearly identifiable, even when one woman without epidural analgesia stood beside the bed laboring for approximately 10 minutes. Burst spectral components fell within the expected 0.34-to-1.00 Hz range for term labor. DISCUSSION: High-quality data demonstrate that EMG instrumentation effectively and accurately measures uterine contraction parameters across the first stage of term labor.

Intrauterine contraction parameters at baseline and following epidural and combined spinal-epidural analgesia: A repeated measures comparison.

OBJECTIVE: The effects of epidural and combined spinal-epidural analgesia on uterine contraction parameters are unclear, although as many as 80% of laboring women use neuraxial analgesia. We explored the effects of epidural and combined spinal-epidural analgesia on all uterine contraction parameters using a retrospective analysis of selected parturients, who required Intrauterine Pressure Catheter (IUPC) instrumentation for clinical management. Additionally, we analyzed the effects of parity, Pitocin dose, and mode of neuraxial anesthesia, i.e. epidural verses combined spinal-epidural on uterine contractility. DESIGN: Using a retrospective within and between repeated measure design we compared uterine contraction parameters at 4 time points (epochs): (1) baseline, (2) pre-epidural fluid bolus, (3) immediate and (4) secondary post-epidural/combined spinal-epidural analgesia to detect differences in contractility over time comparing two types of epidural interventions. METHODS: Eighteen healthy parturients at term gestation were admitted to the labor unit for induction, augmentation, or spontaneous labor. Contraction parameters including frequency, duration, peak intensity, resting intensity and duration, and Montevideo Units (MVUs) were collected using fetal monitor strip data with intrauterine pressure catheter (IUPC) instrumentation. FINDINGS: Parametric and non-parametric tests showed no significant differences within or between the two Epidural intervention groups for frequency, duration, peak intensity, resting intensity and duration, and MVUs at all epochs at the .05 alpha level. Compared with Nulliparous women, multiparous women had significantly lower contraction intensity and longer contraction duration. Based on multilevel modeling (MLM), neither Pitocin dose nor type of epidural intervention revealed significant differences on any contraction parameters. CONCLUSIONS: When parity, other demographic variables and Pitocin dose were statistically controlled, no uterine contraction parameter changed from baseline through 90 min following either epidural or combined spinal-epidural analgesia. Obstetrical care providers should consider the preciseness their contraction monitoring instrumentation and their clinical management preferences as well parity as before prescribing Pitocin after neuraxial analgesia intervention.

Uterine Contraction Parameters Before and During the Pre-Epidural Fluid Bolus: A Pilot Study.

BACKGROUND: The first stage of labor is significantly longer with epidural analgesia use, implying an alteration in uterine contractility. Although the pre-epidural fluid bolus is used with every epidural and affects as many as 80% of laboring women, its effects on uterine contraction parameters are unknown. DESIGN: Using a retrospective descriptive repeated measures design, we compared uterine contraction parameters including frequency, duration, peak intensity, resting tone, and Montevideo units at baseline and during the intravascular pre-epidural fluid bolus (Bolus) epochs for healthy laboring women at term gestation undergoing augmentation or induction. METHOD: Contraction parameters were compared using data from fetal monitor strips with intrauterine pressure catheter instrumentation. RESULTS: No significant differences were found between epochs for women receiving constant Pitocin dosages (n = 10) using Wilcoxon signed rank tests at .05 α level, but all parameters trended in the direction of improved contractility except frequency, which was unchanged. CONCLUSIONS: These pilot study findings do not support the proposal that the pre-epidural fluid bolus is a contributor to decreased uterine contractility in any parameter. It is possible that the bolus improved myometrial perfusion and metabolic function in the contracting and resting states in less hydrated women.

Culture, bathing and hydrotherapy in labor: An exploratory descriptive pilot study.

OBJECTIVE: Though bathing (hydrotherapy) is widely used during labor to decrease anxiety and pain and to promote relaxation, the influence of cultural beliefs about bathing by parturients is virtually unknown. This pilot study explored pregnant women's experiences of bathing, bathing in labor, and cultural beliefs about bathing. DESIGN: An exploratory, descriptive design. SETTING: Low risk obstetrical clinics. PARTICIPANTS: Healthy Hispanic, Black, White, American-Indian and Asian women (N = 41) at >37 weeks gestation. METHODS: During a routine prenatal visit women responded to a brief openended questionnaire on the use of bathing. Data was captured using a modified ethnographic method involving observation and note taking with thematic analysis and quantification of percent response rates. FINDINGS: Forty-six percent (N = 41) of women used bathing for purposes other than hygiene but only 4.9% (N = 41) of these women bathed during a previous labor. The women described bathing as relaxing, easing, calming, and efficacious for relief of menstrual cramps and labor contractions. Ten percent of women reported cultural beliefs about bathing. CONCLUSIONS: Women who bathe, report relief of anxiety, menstrual and labor pain and promotion of mental and physical relaxation. The findings do not support the view that bathing is associated with identifiable cultural beliefs; rather, they suggest that bathing is a self-care measure used by women. This practice is likely transmitted from generation to generation by female elders through the oral tradition. Assumptions that race or ethnicity precludes the use of bathing may be faulty. Cautionary instructions should be given to pregnant women who are <37 completed weeks of gestation, to avoid bathing for relief of cramping or contractions and to seek immediate health care evaluation. Study of culturally intact groups may uncover additional themes related to bathing in labor and as a self-care measure for dysmenorrhea.

Influence of maternal exercise on fetal heart response during labor and delivery.

OBJECTIVES: The purpose of this study was to determine if prenatal exercise alters the maternal and fetal heart responses during labor and delivery. We hypothesized that fetuses of exercising mothers would exhibit a lower baseline heart rate (HR), increased HR variability (HRV), and no differences in fetal heart accelerations and decelerations. DESIGN: This study employed a cross-sectional design. METHODS: The Modifiable Physical Activity Questionnaire was used for group classification. Exercising women were those participating in 30 minutes of moderate-to-vigorous exercise at least 3×/week throughout the entire pregnancy. Women achieving a lower dose of exercise were classified as non-exercisers. Cardiotocography recordings during the first hour of labor and delivery assessed fetal baseline HR, HRV, accelerations, decelerations, and contractions. ANCOVA analyses were performed to assess group differences in these outcomes and were adjusted for maternal body mass index. RESULTS: Thirty-one women were included in the analyses. No group mean differences were found for maternal and fetal characteristics, except for maternal age (EX: mean (SD) 28.5 (±4.6y) vs NON-EX: 24.1 (±1.2y)). After controlling for body mass index, no statistical differences in maternal HR response (ß = 3.9, SE = 5.0, 95%CI -6.4-14.2) or fetal HR response (ß = 3.9, SE = 2.5, 95%CI -1.2-9.11), accelerations and decelerations (ß= -0.03, SE = 0.4, 95%CI -0.9-0.8; ß= -0.10, SE = 0.4, 95%CI -0.8-0.9, respectively), or HRV (ß = 0.6, SE = 1.7, 95%CI -2.8-4.0) were observed. CONCLUSIONS: Based on the findings of this study, we found no evidence that maternal exercise during pregnancy was associated with maternal or fetal HR response during labor and delivery. These data suggest maternal exercise may not elicit positive or negative effects on maternal and fetal cardiovascular responses to the physiological stress of labor and delivery.

Adaptation of Maternal-Fetal Physiology to Exercise in Pregnancy: The Basis of Guidelines for Physical Activity in Pregnancy.

Only 50 years ago obstetric care providers and women had many concerns regarding whether exercise during pregnancy created a harmful competition for substrate resources between the fetus and the mother. Animal and human research in the past 50 years, which includes acute and chronic aerobic exercise during pregnancy, has a reassuring margin of safety throughout gestation in women. Maternal physiology adapts to pregnancy changes involving the cardiorespiratory and glucometabolic alterations. Due to these changes, pregnant women have slight differences in response to acute exercise sessions. Chronic exposure to aerobic exercise before and during pregnancy is associated with numerous maternal and neonatal adaptations which may have short- and long-term benefits to maternal and child health. On the basis of the consistent evidence of safety of exercise during pregnancy, multiple nations and health care organizations, including the American College of Obstetrics and Gynecology, recommend moderate exercise for 20 to 30 minutes most days of the week. Despite the 15 to 20 years since the first recommendations were made, only 10% to 15% of pregnant women meet this recommendation. It seems there may be 2 foci for failure to achieve these exercise recommendations: patient specific and culturally driven and/or obstetric provider not recommending regular exercise due to lack of knowledge or motivation. This article addresses the provider knowledge by a review of the normal (at rest) physiologic adaptation to pregnancy. Then, we provide a detailed description of the type and intensity of controlled experiments that document the safety of exercise during pregnancy. The short- and long-term benefits are reviewed, including the safety in moderate-risk women.

Role of Mediators in Reducing Antepartum Depressive Symptoms in Rural Low-Income Women Receiving a Culturally Tailored Cognitive Behavioral Intervention.

Although cognitive behavioral interventions (CBIs) have demonstrated effectiveness for reducing depressive symptoms in the general population, the mechanism for reducing antepartum depressive symptoms (APDS) in rural low-income and minority women is unknown. This study tested the hypothesis that reducing stress and negative thinking, enhancing self-esteem, and increasing social-support will mediate the effect of a CBI on reducing APDS in rural low-income and minority women. Our findings show that CBI may work through reducing stress and negative thinking and enhancing self-esteem, but not social support. The findings also suggest that mental health care providers should emphasize these activities to reduce antepartum depressive symptoms.

Activity in Pregnancy for Patients with a History of Preterm Birth.

Preterm birth remains a leading cause of neonatal morbidity and mortality throughout the world. Numerous risk factors for preterm birth have been identified, including non-Hispanic black race, a variety of social and behavioral factors, infections, and history of a prior preterm delivery. Of these, a history of prior spontaneous preterm birth is one of the strongest risk factors. Traditionally, women with a history of preterm birth or those deemed at high risk for preterm delivery have been placed on bed rest or a reduced activity regimen during their pregnancy. However, there is little evidence to support this recommendation. Recent research has suggested that regular physical activity and exercise during pregnancy is safe and does not increase the risk of preterm delivery. Therefore, physicians should encourage women with a history of preterm birth to exercise throughout pregnancy according to guidelines published by the American College of Obstetricians and Gynecologists as long as they are receiving regular prenatal care and their current health status permits exercise. However, there are no randomized controlled trials evaluating exercise prescription in women with a history of preterm birth, hence additional research is needed in this area.

Drugs in Breast Milk.

Most drugs appear in breast milk in very small and safe amounts. The obstetric care provider evaluates drug transfer most commonly in the peripartum period, postpartum hospitalization; and they are often consulted when the new mother has a subsequent need for drug therapy. The chapter provides the foundations for the safest decisions for the mother and her breastfed infant. The foundation of safe decisions is accomplished through a review of the physiology of lactation, the lactation pharmacology, and the specific pharmacology and infant safety of drugs common to everyday obstetric practice.

Performance of a Culturally Tailored Cognitive-Behavioral Intervention Integrated in a Public Health Setting to Reduce Risk of Antepartum Depression: A Randomized Controlled Trial.

INTRODUCTION: Cognitive-behavioral group interventions have been shown to improve depressive symptoms in adult populations. This article details the feasibility and efficacy of a 6-week, culturally tailored, cognitive-behavioral intervention offered to rural, minority, low-income women at risk for antepartum depression. METHODS: A total of 146 pregnant women were stratified by high risk for antepartum depression (Edinburgh Postnatal Depression Scale [EPDS] score of 10 or higher) or by low-moderate risk (EPDS score of 4-9) and randomized to a cognitive-behavioral intervention or treatment as usual. Differences in mean change of EPDS and Beck Depression Inventory (BDI)-II scores for low-moderate and high-risk women in the cognitive-behavioral intervention and treatment as usual for the full sample were assessed from baseline (T1), posttreatment (T2), and one-month follow-up (T3), and for African American women in the subsample. RESULTS: Both the cognitive-behavioral intervention and treatment-as-usual groups had significant reductions in the EPDS scores from T1 to T2 and T1 to T3. In women at high risk for depression (n = 62), there was no significant treatment effect from T1 to T2 or T3 for the EPDS. However, in low-moderate risk women, there was a significantly greater mean change in the BDI-II scores from significant decrease in the BDI-II scores from T1 to T2 (4.92 vs 0.59, P = .018) and T1 to T3 (5.67 vs 1.51, P = .04). Also, the cognitive-behavioral intervention significantly reduced EPDS scores for African American women at high risk (n = 43) from T1 to T2 (5.59 vs 2.18, P = .02) and from T1 to T3 (6.32 vs 3.14, P = .04). DISCUSSION: A cognitive-behavioral intervention integrated within prenatal clinics is feasible in this sample, although attrition rates were high. Compared to treatment as usual, the cognitive-behavioral intervention reduced depressive symptoms for African American women at high risk for antepartum depression and for the full sample of women at low-moderate risk for antepartum depression. These promising findings need to be replicated in a larger controlled clinical trial that incorporates methods to maintain greater participant engagement.

Cortisol as a biomarker of stress in term human labor: physiological and methodological issues.

Literature on the use of plasma cortisol to quantify psychophysiological stress in humans is extensive. However, in parturition at term gestation, the use of cortisol as a biomarker of stress is particularly complex. Plasma cortisol levels increase as labor progresses. This increase seems to be important for maintenance of maternal/fetal well-being and facilitation of normal labor progress. Unique physiological and methodological issues involved in the use of cortisol as a biomarker of stress in labor present challenges for researchers. This review examines these issues, suggests mixed methods and within-subject repeated measures designs, and offers recommendations for assay procedures for parturient sampling. Documentation of clinical interventions and delivery outcomes may elucidate relationships among psychophysiological stressors, cortisol, and normal labor progress. With attention to these methodological issues, analysis of plasma cortisol may lead to clinical interventions that support normal labor physiology.

The effects of hydrotherapy on anxiety, pain, neuroendocrine responses, and contraction dynamics during labor.

BACKGROUND: Hydrotherapy (immersion or bathing) is used worldwide to promote relaxation and decrease parturient anxiety and pain in labor, but the psychophysiological effects of this intervention remain obscure. DESIGN: A pretest-posttest design with repeated measures was used to examine the effects of hydrotherapy on maternal anxiety and pain, neuroendocrine responses, plasma volume shift (PVS), and uterine contractions (CXs) during labor. Correlations among variables were examined at three time points (preimmersion and twice during hydrotherapy). METHODS: Eleven term women (mean age 24.5 years) in spontaneous labor were immersed to the xiphoid in 37 degrees C water for 1 hr. Blood samples and measures of anxiety and pain were obtained under dry baseline conditions and repeated at 15 and 45 min of hydrotherapy. Uterine contractions were monitored telemetrically. RESULTS: Hydrotherapy was associated with decreases in anxiety, vasopressin (V), and oxytocin (O) levels at 15 and 45 min (all ps < .05). There were no significant differences between preimmersion and immersion pain or cortisol (C) levels. Pain decreased more for women with high baseline pain than for women with low baseline levels at 15 and 45 min. Cortisol levels decreased twice as much at 15 min of hydrotherapy for women with high baseline pain as for those with low baseline pain. beta-endorphin (betaE) levels increased at 15 min but did not differ between baseline and 45 min. During immersion, CX frequency decreased. A positive PVS at 15 min was correlated with contraction duration. CONCLUSIONS: Hydrotherapy during labor affects neuroendocrine responses that modify psychophysiological processes.

Pioneering a universal curriculum: a look at six disciplines involved in women's health care.

This paper describes a multidisciplinary project of curriculum development and implementation at one university. Universal learning concepts for six health care disciplines in women's health, including nurse-midwifery, are being piloted in an online classroom environment. This multidisciplinary team approach to education distributes the work load, invites experts to share resources, and avoids the duplication of resources across the university departments and schools. This project provides midwifery faculty the opportunity to introduce a new educational paradigm and model the midwifery approach to holistic health care.

Racial disparities in biopsychosocial factors and spontaneous preterm birth among rural low-income women.

In this descriptive prospective study, 269 African American, Hispanic, and Caucasian women from rural prenatal clinics were interviewed once between 16 and 28 weeks' gestation. Associations between biopsychosocial risk factors and preterm birth (PTB) were examined. African American women with spontaneous PTB were more likely to be older, and to have higher Bowman Gray Risk Index scores and hypertensive diseases of pregnancy than African American women who did not have a spontaneous PTB. There were significant differences in bacterial vaginosis, hypertensive diseases of pregnancy, smoking, social support from others, and self-esteem among the three racial groups. In the total sample after adjustment for sociodemographic and biopsychosocial factors, women with spontaneous PTB were three times more likely to be African American, to have oligohydramnios, hypertensive diseases of pregnancy, and had higher Bowman Gray Risk Index scores than the total sample of women without spontaneous PTB. Understanding the risks associated with spontaneous PTBs that are unique to African American women and why biopsychosocial risk factors vary by racial/ethnic group may lead to tailored interventions.

Prenatal smoking cessation among Black and White women in Eastern North Carolina.

PURPOSE: Limited information is available about Black:White disparities in prenatal smoking cessation, and the results of prior research are inconsistent. We analyzed smoking cessation and factors associated with cessation (attitudes, environment, and nicotine addiction) in a sample of pregnant Black and White women. METHODS: Women were interviewed at the first prenatal visit at two hospital-based clinics. RESULTS: Among former and current smokers, there were no significant differences in the percentage of former smokers between Black (46.8%) and White (43.3%) pregnant women, or in the percentage of "spontaneous quitters" (i.e., those who quit after learning that they were pregnant) for Blacks (36%) and Whites (28%). Both Black and White spontaneous quitters had evidence of occasional relapses to smoking. For Black and White women, smoking more than a pack a day prior to pregnancy was associated with smoking during pregnancy. DISCUSSION: Among current and former smokers, spontaneous cessation was about the same for Black and White women, and about two thirds of women who were smokers when they learned of the pregnancy continued to smoke during pregnancy. Nicotine addiction contributed to continued smoking.