Relaxation Techniques

Sometimes, the best way to understand something is to see it! Here is a short video demonstrating some great positions to use in labor. All of these promote relaxation and proper alignment.

Watch the You Tube video below.

Lydia Rhodes and Kate Scott, certified nurse-midwives at the Olson Center for Women's Health demonstrate a few relaxation techniques and positions for mothers during labor.

http://youtu.be/s1daFjsKH1M

Premature rupture of membranes

Premature rupture of membranes (PROM) refers to the bag of waters breaking prior to the onset of labor. Usually labor starts soon after, most often within the first 24 hours- though not always. In my class I provide a copy of a study that shows no higher risk of infection/complication in 12 hours or 72 hours of managed labor after PROM.

I came across this very thorough look of studies related to PROM.  LOTS of information to read through, but worth it to educate yourself in how you would handle this situation should it happen to you.

Premature Rupture of Membranes at Term

Belly Tales

Answers to common objections to delayed cord clamping

Most Bradley students include in their birth plan that they desire delayed cord clamping. Sometimes they are met with objections from their birth team. Here is an article, siting recent research, that pediatrician Mark Sloan, MD wrote refuting common objections.

Unclamped cord over the course of 15 minutes

Please click on the title to read the full article.

Common Objections to Delayed Cord Clamping – What’s The Evidence Say?

November 13th, 2012 by Sharon Muza

Goto commentsLeave a comment

by Mark Sloan M.D.

Today’s guest post is written by Dr. Mark Sloan, pediatrician and author of Birth Day: A Pediatrician Explores the Science, the History and the Wonder of Childbirth.  Dr. Sloan shares information and current research on delayed cord clamping after birth, in a helpful Q&A style format that consumers and professionals can use to discuss this important topic.

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photo credit pattiramos.com

Many maternity care providers continue to clamp the umbilical cord immediately after an uncomplicated vaginal birth, even though the significant neonatal benefits of delayed cord clamping (usually defined as 2 to 3 minutes after birth) are now well known.

In some cases this continued practice is due to a misunderstanding of placental physiology in the first few minutes after birth. In others, human nature plays a role: We are often reluctant to change the way we were taught to do things, even in the face of clear evidence that contradicts that teaching.

Though there is no strong scientific support for immediate cord clamping (ICC), entrenched medical habits can be glacially slow in changing. Here are some often-heard objections to delayed cord clamping (DCC), and how an advocate for delayed clamping might respond to them:

Little-to-no evidence for the use of a saline lock during an un-medicated labor

Read the full article for more information to help you make an informed decision about having a hep-lock. The article sites other research. I encourage you to read the article in it's entirety, but here is a part (for you cliff note readers)

Evidence for the Saline Lock during Labor

http://evidencebasedbirth.com/the-saline-lock-during-labor/

Benefits of having a saline lock:

• If you change your mind and decide you want an epidural, most anesthesiologists want you to have a fluid bolus prior to the epidural and you will become “more high risk” with an epidural and need the IV
• There is an overall 2.9% risk for post-partum hemorrhage (the risk is much less if you have a vaginal delivery and no risk factors), in which case an IV will need to be inserted for fluids, Pitocin (which can also be given in a muscle injection), and (very rarely) blood products
• If you do get really thirsty or tired and can’t hold anything down, you can be given IV fluids for a bit of a boost
• If you do decide you want a saline lock, Dr. Shannon recommends, “Get it placed earlier in labor when you are more comfortable, as you may desire or need IV medications later on (such as for nausea, pain, or hemorrhage) when placing an IV may be more difficult (of course, Pitocin can be given by muscle injection if necessary for post-partum hemorrhage).

Risks of having a saline lock:

• It hurts to have the IV placed, and some women find it uncomfortable and distracting during their labor
• It may cause bruising or small amount of bleeding at the IV site
• The vein can become inflamed (phlebitis) which can cause redness and pain (risk = 7-10%) (Rickard et al. 2010)
• If the IV is used for medication or fluids, these may leak out of the vein and into the tissues, also known as extravasation (risk = 30-33%) (Rickard et al., 2010)
• Infection at the IV site resulting in a severe bloodstream infection (risk = 0.1%) (Maki et al. 2006)
• Having a saline lock might make it easier for your doctor or nurse to initiate unnecessary interventions, like IV fluids or Pitocin for augmentation
• The saline lock could be viewed as a symbol that the woman is “sick” and a “patient” instead of a healthy woman giving birth, and this symbol may have consequences for the woman’s mindset for giving birth– and may also adversely affect caregivers’ attitudes towards the laboring woman  (Newton et al., 1988)

In the end, I think it comes down to this. There is little-to-no evidence for the use of a saline lock during an un-medicated labor. However, there are risks and benefits to having the saline lock. The ultimate decision for whether or not to have a saline lock should come from you. If you want one and feel safer or more comfortable by having a saline lock just in case it is needed for medications or IV fluids, then that is your right to make that choice. If you have reviewed the risks and benefits and feel that you do not want a saline lock, then that is your right to make that choice. You are a consumer, and you have educated yourself on the risks and benefits, and you do have a say in this matter!

Delayed Cord clamping : ACOG review

Number 543, December 2012

Committee on Obstetric PracticeThis Committee Opinion was developed by the Committee on Obstetric Practice with the assistance of the American Academy of Pediatrics. The American Academy of Pediatrics endorses this document. This information should not be construed as dictating an exclusive course of treatment or procedure to be followed.

PDF Format

Timing of Umbilical Cord Clamping After Birth

ABSTRACT: The optimal timing for clamping the umbilical cord after birth has been a subject of controversy and debate. Although many randomized controlled trials in term and preterm infants have evaluated the benefits of delayed umbilical cord clamping versus immediate umbilical cord clamping, the ideal timing for cord clamping has yet to be established. Several systematic reviews have suggested that clamping the umbilical cord in all births should be delayed for at least 30–60 seconds, with the infant maintained at or below the level of the placenta because of the associated neonatal benefits, including increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and lower frequency of iron deficiency anemia in term infants. Evidence exists to support delayed umbilical cord clamping in preterm infants, when feasible. The single most important clinical benefit for preterm infants is the possibility for a nearly 50% reduction in intraventricular hemorrhage. However, currently, evidence is insufficient to confirm or refute the potential for benefits from delayed umbilical cord clamping in term infants, especially in settings with rich resources.

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Before the mid 1950s, the term “early clamping” was defined as umbilical cord clamping within 1 minute of birth, and “late clamping,” as umbilical cord clamping more than 5 minutes after birth. In a series of studies of blood volume changes after birth carried out by investigators in Sweden, the United States, and Canada, it was reported that in healthy term infants, more than 90% of blood volume was achieved within the first few breaths the infant took after birth (1). Because of these findings and the lack of specific recommendations regarding the optimal timing, the interval between birth and umbilical cord clamping began to be shortened. In most cases, umbilical cord clamping is performed within 15–20 seconds after birth, with the infant maintained at or below the level of the placenta. Although many randomized controlled trials of term and preterm infants have evaluated the benefits of immediate umbilical cord clamping versus delayed umbilical cord clamping (generally defined as umbilical cord clamping performed 30–60 seconds after birth) (2–26), the ideal timing for umbilical cord clamping has yet to be established and continues to be a subject of controversy and debate (21, 27–29).

Concerns exist regarding universally adopting delayed umbilical cord clamping. Delay in umbilical cord clamping may jeopardize timely resuscitation efforts, if needed, especially in preterm infants. However, because the placenta continues to perform gas exchange after delivery, sick and preterm infants are likely to benefit most from additional blood volume derived from a delay in umbilical cord clamping. Another concern has been raised that delay in umbilical cord clamping increases the potential for excessive placental transfusion, which can lead to neonatal polycythemia, especially in the presence of risk factors for fetal polycythemia, such as maternal diabetes, severe intrauterine growth restriction, and high altitude. Additionally, delayed umbilical cord clamping (with the infant placed at or below the level of the placenta) may be technically difficult in some circumstances. Another issue is that delayed umbilical cord clamping might interfere with attempts to collect cord blood for banking. However, the routine practice of umbilical cord clamping should not be altered for the collection of umbilical cord blood for banking (30).

Delayed Cord clamping

In Bradley classes you will learn that delayed cord clamping is beneficial for the baby. Delaying the cord clamping allows for the baby to get the proper blood volume and additional iron. The link below is a scientific study of the benefits of the delayed cord clamping (in this case only 45 seconds!) for premature infants, delivered by cesarean. Not only was it found safe, but beneficial.

A randomised controlled trial of delayed cord clamping in very low birth weight preterm infants

European Journal of Pediatrics

September 2000, Volume 159, Issue 10, pp 775-777

If you don't want to buy and read the entire study:
Conclusion Delayed cord clamping of 45 s is feasible and safe in preterm infants below 33 weeks of gestation. It is possible to perform the procedure at caesarean section deliveries and it should be performed whenever possible. It reduces the need for packed red cell transfusions during the first 6 weeks of life.

Birth plans

A great article of why birth plans DO matter and what to include for a natural, Bradley birth:

Writing a Bradley Method Birth Plan  original source
By CAITLINHTP | April 4th, 2012 at 9:50 pm

When you say the term “birth plan,” there are two general reactions: 1) “That’s a really good idea.  If you are sure you do or do not want certain things under certain circumstances, it’s helpful to write it out so your midwife, nurse, and doctor are aware,” and 2) “Birth plans are pointless. You can’t plan birth.  Just go with the flow.”  Since I’m writing a birth plan, I’m obviously in camp #1, but I can understand what those in camp #2 mean when they say you can’t plan birth.  It’s a natural process, things don’t evolve according to a chart, and sometimes, emergencies happen. 

That being said… This is my body and my baby.  I have a right to make informed medical choices.  And, quite frankly, I need to write a birth plan because the statistics regarding what commonly occurs in a hospital are not in line with my personal preferences regarding childbirth.  For example, in 2004, the episiotomy rate was 24.5% (an episiotomy is a surgical incision of the perineum).  I would rather use midwifery techniques to prevent tearing (massage, warm compress) or tear naturally than get an episiotomy (here’s why).  I want to be 100% sure that my midwife, nurses, and doctor are aware that I do not want an episiotomy preformed unless it is a true emergency.

I feel the need to preface the rest of this post by saying that my opinions about my ideal birth are just that… My opinions on my ideal birth. I’m not trying to preach about what other women should do or judge other choices.  Personally, I have always found it interesting to read about what women decide to do and why, even if they do something I would not choose for myself, so that is why I am sharing.

As I sit down to write my birth plan, I’m trying to integrate as much as the Bradley Method as possible.  I am waiting to write a complete summary post on the Bradley Method (probably post-baby), but I really love it so far and would recommend it to any expecting momma, even if you want an epidural, because the 12-week program gives you and your partner so much confidence regarding birth.  Bradley Method teaches natural childbirth techniques, and 90% of Bradley women who have a vaginal birth do it without medication – a pretty good success rate!

The #1 rule of the Bradley Method is not to go to the hospital too soon.  Basically, the later you arrive, the less chance of medical intervention (such as pain medication and drugs to speed contractions; remember, Bradley mommas are trying to avoid these things).  We are taught a variety of physical and emotional signposts to know when we should ideally go to the hospital.  Under normal circumstances, I’ll be laboring at home for as long as I can stand it and is safe – I really don’t want the Husband delivering the baby in our bedroom – and then my birth plan will kick in.

I’m not ready to share my final birth plan quite yet (if you’re interested in reading the draft, feel free to shoot me an email at caitlinjboyle at gmail.com), but here are some highlights.  Note that all of these items have been approved by my midwife; I can’t say that every doctor, midwife, nurse, or hospital would allow these things, but mine do.  Most of these items are in line with Bradley Method teachings, which is why I’m including them:

• Caitlin plans to have a medication-free labor. Please do not offer her an epidural. She does not want any drugs to speed along labor (i.e. Pitocin). If there is an issue, and you believe these medications are necessary, please discuss it with Kristien.
• Caitlin would like to labor out of bed and would like to be encouraged to try different laboring positions.  She may want to deliver out of bed.
• If water has not broken by the time Caitlin arrives, water should be allowed to break naturally. Breaking water should be discussed with Kristien first.
• Kristien would like to announce the gender of the baby to Caitlin.  Please do not spoil the surprise!
• Please do not clamp or cut cord immediately.  Wait at least three minutes prior to clamping or cutting.  (Side note: here’s why.)
• Please allow the placenta to come out naturally (no pulling or Pitocin injections, please).  We will be signing a medical release so we can take the placenta home. (Here’s why.)
• Baby should be placed on Caitlin’s stomach or chest immediately for a minimum of two hours of skin-to-skin contact.

I imagine that, at this point, many of you are thinking, “Dude, if you don’t want them to do anything to do, why aren’t you delivering at home or in a birthing center?”  Good question!  Ultimately, I truly understand that although I can write a birth plan, I cannot plan birth, and scary things do happen.  For me, the best place to be in that scenario is in the hospital with doctors and nurses who can help.  If there is a true medical emergency, I will trust these people to make the appropriate choices for me – screw the birth plan.

Another remark that I commonly hear about birth plans is that the birth doesn’t really matter that much.  All that matters is that the baby comes out, healthy and safe.  While I do think the ‘bottom line’ is true, I do believe that the birth matters, not only in regards to the physical health of my baby, but also for my emotional health.  The birth process does matter to me.  It doesn’t have to be perfect; it doesn’t have to follow my exact birth plan.  But I know this will be a transformative moment in my life, and I want the space around that moment to be one of positivity.  Leaving the hospital with our little boy or girl will be the most amazing thing in the entire world.  But if I can walk out those doors feeling protected, respected, happy, and healthy… then that’s just icing on top of the cake.

One bloggers review of her Bradley birth experience

This blog is an attempt to be a place for my Bradley students to read articles I reference or find extra information. One of these days I will start writing my own articles about these things, but for now I'm so grateful others have already produced some great stuff!

I found this "Post Birth-Review of a Bradley Method classes". This mom answers questions about her experience and how the Bradley method helped her achieve the birth she wanted. Click the link above for the full article, but I wanted to highlight a few points she made.

http://www.healthytippingpoint.com
Some women have said to me, “I want a drug-free birth but if it gets really bad and I can’t handle it, I’ll just get the epidural.”  The women I know with that attitude ended up getting medication (I’m referring again, of course, only to women who had a choice, not ones who medically needed drugs).  The reason that I think this attitude doesn’t work as well as, “I will not get pain relief unless there is a serious medical reason to do so,” is that childbirth is REALLY FREAKING PAINFUL.  If you are open to drugs, you will probably get them during delivery.
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Lots and lots of readers expressed concerns over my birth plan, stating that I was too committed to a particular birth scenario and was destined to be disappointed.  While this objection to birth plans makes some sense, I’d argue that you must be committed to the idea of a drug-free birth to make it happen.  Did that mean that I was going to have a meltdown if I got pain relief?  Not at all!  During one of our Bradley classes, the instructor told us something that really stuck with me:  Even if you end up getting drugs to ease the pain or speed along contractions, the longer you ‘hold out,’ the longer the baby has had a drug-free birth experience.  
....

What was most helpful for me was knowing what my body was doing and why.  I would’ve FREAKED OUT during transition if I didn’t know what was happening and that it would end soon.  I visualized what was physically happening to my cervix and uterus and pictured the baby moving down.  And I was nervous in the weeks leading up to labor, but again, I felt very well-prepared thanks to Bradley.  I think preparation is key.

Evening Primrose Oil

This is a great article that brings up some good points on natural remedies. As a Bradley instructor, I teach the avoidance of drugs (social, prescription and over the counter) as well as being cautious with homeopathic and natural drugs. Homeopathic and natural drugs WORK, they can have side effects as well.

I've never recommended or used evening primrose oil, but the benefits are touted among natural birth supporters (as well as my own midwife!).

Read this article and be educated so you can make an informed decision before using natural  drugs

Original source:
drugs.http://vbacfacts.com/2012/11/13/evening-primrose-oil-dont-use-it-if-you-are-pregnant/

Evening primrose oil: “Don’t use it if you are pregnant?”

Note: After I published this article, it came to my attention that there was one other study on the oral use of EPO in pregnant woman.  You can read more about this second study in the comments section below.

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Many moms and midwives use evening primrose oil (EPO) for cervical ripening. So I was absolutely shocked at the complete lack of evidence on the effectiveness and safety of EPO use among pregnant women. There is one study that examined the oral use EPO and it’s ability to ripen the cervix during pregnancy. It concluded EPO didn’t work as we expected it to and further, women who took EPO were more likely to experience a whole host of complications. Shockingly, there are no studies on the vaginal use of EPO and it’s affect on ripening the cervix during pregnancy. In short, there is insufficient clinical evidence documenting the risks and benefits of EPO and without that information, should pregnant women take it?

The one study that examined cervical ripening via oral EPO

Paula Senner gives an excellent review of this single study in her Quantitative Research Proposal entitled, “Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women” (emphasis mine),

A study by Dove and Johnson (1999) investigated the use of evening primrose oil on the length of pregnancy and selected intrapartum outcomes at an American free-standing birth center in low-risk nulliparous women. More specifically, the study examined the effect of oral evening primrose oil on length of pregnancy, length of labor, incidence of postdates induction, incidence of prolonged rupture of membranes, occurrence of abnormal labor patterns, and cesarean delivery.

A two group retrospective quasiexperimental design was conducted on a sample drawn from the records of all nulliparous women at a free-standing birthing center over a seven year period from 1991 to 1998. All of the records were screened for accurate gestational age dating, cephalic presentation, low risk status and delivery between 38 and 42 weeks gestation. The study group consisted of 54 women who took oral evening primrose oil in their pregnancy (500 mg three times a day starting at 37 weeks gestation for the first week of treatment, followed by 500 mg once a day until labor ensued), and the control group was composed of 54 women who did not take anything. Antepartum and intrapartum records of all women were reviewed focusing on the above identified criteria.

Differences between measured variables of maternal age, Apgar score, birth weight, length of pregnancy, and length of labor were tested… Results showed no significant differences between the evening primrose oil group and the control group on age, Apgar score, or days of gestation (P>.05)… This retrospective chart review showed no benefit from taking oral evening primrose oil for the purpose of reducing adverse labor outcomes or for reduction of length of labor.

The study’s abstract gives us more details on the its findings (emphasis mine):

Findings suggest that the oral administration of evening primrose oil from the 37th gestational week until birth does not shorten gestation or decrease the overall length of labor. Further, the use of orally administered evening primrose oil may be associated with an increase in the incidence of prolonged rupture of membranes, oxytocin [Pitocin] augmentation, arrest of descent, and vacuum extraction.

Surprisingly, the one study on oral EPO found that it doesn’t work as we thought it did and it offers considerable risks.

As a result, a December 2009 article published in the American Family Physician recommended,

The use of evening primrose oil during pregnancy is not supported in the literature and should be avoided.

Medline Plus, a website published by the US National Library of Medicine and the National Institutes of Health, published an April 2012 article on EPO.  Medline echoes the sentiments of the American Family Physician article when it said there was,

insufficient evidence to rate effectiveness for [EPO during pregnancy and] research to date suggests that taking evening primrose oil doesn’t seem to shorten labor, prevent high blood pressure (pre-eclampsia), or prevent late deliveries in pregnant women… [Further,] taking evening primrose oil isPOSSIBLY UNSAFE [their emphasis] during pregnancy.  It might increase the chance of having complications. Don’t use it if you are pregnant[emphasis mine.]

Bleeding issues could complicate cesareans

Research on the use of EPO for other aliments among non-pregnant people has suggested there could be a possible association between the use of EPO and bleeding problems during surgery. As a result, Medline recommends that people don’t use it at least 2 weeks before a scheduled surgery.

This poses a special problem for women using EPO during the last weeks of pregnancy. Since we cannot predict who will have a vaginal birth and who will have a cesarean, it is important to consider that EPO could contribute to hemorrhage during a cesarean and possibly even during a normal vaginal delivery. We just don’t know because there is a lack of data.

Dosages and mode of delivery

Another hole in the research and our knowledge relates to dosage.  I see women reporting an incredible range of dosages on the internet.  What is safe?  There are no clinical studies documenting how much women should take.  Maybe X dose of EPO is good, but Y dose introduces XYZ risks.  How long should women take EPO?  The last month of pregnancy?  The last two weeks?  (Remember, we just read how there is a possible bleeding issue.)  Should they take it twice a day or once a day?  Does the body absorb or metabolize EPO differently if it is administrated vaginally or orally?  Does it make a difference if the woman using EPO has a scar on her uterus?  Or multiple scars?  We just don’t know the answers to these questions.

What about our bodies’ innate ability to birth?

It comes down to the fundamental question: Do our bodies need something to help us go into labor? Many natural birth advocates reject the routine use of Pitocin augmentation during labor because they say our bodies know how to birth.  Yet it’s often women from this same mindset that use EPO. Either our bodies work as is, or they don’t.  Either we need something to help us go into labor – whether that is EPO or Pitocin – or we don’t.

Are we less leery of EPO because it comes from a flower?  Because midwives suggest it more than OBs?  Because we can purchase it over the counter?  Because it’s a pill, not an injection?  Because we can administer it to ourselves in the comfort of our home?  Because it’s not produced by “big pharma?”  Because it is used so routinely that no one questions it?  Or is it simply because we all assume since everyone takes it, the evidence must be on the side of EPO?

On (the lack of) evidence: Holding ourselves to the same standard

When I have shared the lack of evidence on EPO’s ability to ripen cervixes or prepare a woman’s body for labor, sometimes women reply with “But there is none [evidence] to suggest it won’t [help] either…….” American OBs used this same rationale when they induced scarred moms with Cytotec in the 1990s. There were no published medical studies on Cytotec induction in scarred women, so we didn’t know the risks and benefits. But people used it because we knew it caused uterine contractions. What can go wrong, right?

But the problem is, when there is a lack of clinical evidence on large populations of women, we are sometimes surprised with dire outcomes that no one could have predicted as was the case of Cytotec.  We cannot look back at that period and think, “How could they have done that” when we are now doing the same thing with EPO: using a chemical without evidence of its benefits and harms.

Some rail against “the medical system” because Pitocin/ultrasound/etc hasn’t been “proven safe,” yet we use EPO with no evidence that it does what we think it does, no evidence that it is safe, and the limited evidence we do have says that it’s associated with a variety of complications.

As Hilary Gerber D.O. aka Mom’s Tin Foil Hat says,

As someone who spent many years in the natural supplements industry, I agree that we need to hold natural products to the same scrutiny.

Also, most EPO is extracted with solvents like hexane. I am much more supportive of natural products or interventions that have been used in that form or method for generations (e.g. sexual intercourse at term, ingesting a substance that is a common food item, etc) than a chemically extracted, concentrated, unstudied substance.

Anecdote vs. evidence

OBs who used Cytotec on scarred women in the 1990s inevitably would have said, “I haven’t had a bad outcome yet,” and I suspect that many people who use EPO now would say the same thing.  When we have one woman who used EPO and had an arrest of descent, do care providers recognize that this could be as a result of the EPO?  When we have one women who used EPO and it worked as expected, how can we determine her labor progressed because of the EPO?

When you have a small sample size, it’s hard to make a connection.  It’s even more difficult to connect EPO to it’s possible list of complications when not many care providers are aware of the lack of evidence on EPO and the findings of this one lone study.  Is our limited experience, with relatively few patients, without meticulous record keeping that can detect patterns across groups of patients, sufficient evidence?  I don’t think so.  We would likely need thousands of women in order to create a sample size powerful enough to detect – or rule out – common and more rare EPO complications in addition to answering the many questions I posed above.

Take away message

I’m not saying to use EPO or not.  I’m simply pointing out how little we know about this commonly used substance and questioning if that should make a difference in how we view and/or use it.

There is limited evidence on EPO’s ability to ripen the cervix and aid with labor.  We have one study on the oral use of EPO that looked at this question and none on the vaginal use of EPO among pregnant women.  This is reason enough to not use it.

We have no evidence on an appropriate or safe dosage (if that exists).

We have no evidence on the risks and benefits of oral vs vaginal administration.

In order to make the association between EPO and complications, care providers need to be aware of the complications EPO is associated with.

What research does exist, from a single, small study on the oral use of EPO, found that it doesn’t ripen the cervix and poses considerable risks. We need more large studies to either confirm or refute this one study’s findings. Without that information, we are using a product that we know very little about.

An informal survey

I’d love to take an informal survey of women who used EPO during pregnancy. If you want to participate, please click here.

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Bayles, B., & Usatine, R. (2009, Dec 15). Evening Primrose Oil. American Family Physician, 80(12), 1405-1408. Retrieved fromhttp://www.aafp.org/afp/2009/1215/p1405.html

Dove, D., & Johnson, P. (1999, May-Jun). Oral evening primrose oil: its effect on length of pregnancy and selected intrapartum outcomes in low-risk nulliparous women. Journal of Nurse-Midwifery, 44(3), 320-4. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380450

Gerber, H. (2012, November 13). Facebook comments on evening primrose oil.

McFarlin, B. L., Gibson, M. H., O’Rear, J., & Harman, P. (1999, May-Jun). A national survey of herbal preparation use by nurse-midwives for labor stimulation. Review of the literature and recommendations for practice. Journal of Nurse Midwifery, 44(3), 205-16. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/10380441

Medline Plus. (2012, Apr 10). Evening primrose oil. Retrieved from Medline Plus: A service of the U.S. National Library of Medicine & National Institutes of Health:http://www.nlm.nih.gov/medlineplus/druginfo/natural/1006.html

Senner, Paula. (2003, December). Oral Evening Primrose Oil as a Cervical Ripening Agent in Low Risk Nulliparous Women. Retrieved from Frontier School of Midwifery and Family Nursing, Philadelphia University:http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/f44c26c0836acbb585256dd1006b2a22?OpenDocument

Wagner, Marsden. (1999). Misoprostol (Cytotec) for Labor Induction: A Cautionary Tale. Retrieved from Midwifery Today:http://www.midwiferytoday.com/articles/cytotecwagner.asp