Tuesday, December 15, 2009
Sunday, December 06, 2009
Let’s take a minute to recover from that thought, shall we?
Another baby girl made her grand entrance into the world on Novemeber 13th, 2008. She was born in hospital and was home three hours later. With today’s advance Health Care system, how could something like this have occurred?
Nine months prior to this delivery both her mom and dad were shocked that they were expecting another baby. After a traumatic delivery with their first child, born by caesarean section, they had not known if they would risk another pregnancy, another surgical delivery. Mom is quoted to have said ‘if I ever get pregnant again, I will have a Vaginal Birth After Caesarean (VBAC), even if it means we stay at home to deliver the baby’!! The nerve! This topic has remained quite controversial among health care professionals. Some physicians have even gone as far as to suggest that first time caesarean moms schedule surgical deliveries for all subsequent births. Not this mom, she would hear nothing of it. So, as a new reporter for Confessions of a Birth-a-holic, I desperately wanted to chronicle the couple’s experience with this thing called natural birth, and a VBAC at that. How would they succeed? Here is their story…
First of all, these parents took matters into their own hands. They researched and planned for a successful VBAC delivery. How? First they made sure they understood the evidence surrounding the risks and benefits of a VBAC. They were confident in their decision that a VBAC was best for both mom and baby. After much searching, they also located a physician who would support their decision. Many of the doctors they talked with discussed a trial of labour. But this mom was not comfortable with that kind of terminology; she was focussed on a successful natural labour and delivery. Baby’s mom really felt that she had been robbed of the natural childbirth experience with her first baby, who was a footling breech and subsequent caesarean section. With this pregnancy, she was determined to welcome the marvels of womanhood through a vaginal birthing experience. Wow, I think to myself as I reflect on this ideology, the wonders of a woman.
There were many other facets involved with the preparation for the birth. In order to prepare mom for the physical and emotional challenges of labour and delivery, she took a self-instructed hypnobirthing course. That said, during labour she is quoted to have said ‘turn this s--t off’ while listening to her hypnosis CD’s. Apparently the hypnosis preparation was not as efficient as their other chosen support system, a Doula. Huh? What the heck is that you ask? I was dumbfounded upon hearing of this professional but apparently there are women experienced in childbirth who want to provide physical, emotional and informational support to mothers, before, during and after childbirth. News to me (and now you) but not news to this couple! Their Doula was hired because they knew her, liked her, admired her and trusted that she could provide them with the information and support they would require to accomplish their goal of a VBAC.
Since mom had much invested in the vaginal birth of her second child, the Doula had her work cut out for her. She knew personal details about this couple, and the mom specifically (which is a whole other story), that meant she would have to have a heightened awareness of the labour progress and when to head to the hospital. Although mom had earlier said she would rather stay at home than risk a caesarean, she also knew that, as a VBAC patient, her doctor was more comfortable with her delivering in hospital (even if they would have to get a disco ball to give mom the birth experience she so desired).
As luck would have it, baby was one-week post dates (note sarcasm here). Mom went to a doctor’s appointment only to find out that her cervix was posterior. That’s right, there was nothing…notta…zip…zero…ziltch…happening ‘down there’. This news always causes stress for a pregnant mom, since every day after d-day is a ticking time bomb to induction. Not good news for a VBAC mom. But, as luck really would have it, one hour after hearing this news, pressure waves started. Mom had a feeling that these waves were ‘it’ despite having had two previous days of what she referred to as ‘surfing the waves’. So, in response to the realization of the impending birth, mom headed to Fuddrucker’s for a last supper of sorts (it is reported that women labour more efficiently after consuming the Hawaiian Chicken Salad from Fudd’s). Several hours later, mom called her Doula to let her know that the day had arrived, it was a second coming for the mom and she was prepared! The Doula responded by checking in on the emotional state of the couple and setting up a birthing tub for mom to labour in. When mom finally decided to use the tub, she knew the Doula and her tub were God sent.
After a few hours of labouring in the shower, on the bed and in the bathroom, it was finally ‘tub time’ and mom spent four solid hours squatting in that labour tub, with her Doula and her husband never leaving her side. She had finally found her rhythm, as the Doula had counselled them she would. The entire time in the tub, her Doula provided counter pressure on her back during each contraction. Looking back, the mom has said ‘it was almost relaxing…if one can call intense, bulldozing, abdominal pain relaxing’! The Doula also whispered encouraging words and ensured the couple that things were progressing normally. Whew! What a relief to both mom and dad! And speaking of dad, he was also an amazing support during this physically and emotionally demanding task. Eyewitnesses say mom actually bit his leg or hand during some of the contractions. I think we can safely assume that the Doula was happy that she was not on the receiving end of those fangs.
As labour progressed and got more intense, the impending transfer to the hospital was inevitable. The couple desperately wanted to labour at home for as long as possible, in order to avoid unnecessary medical intervention, but they still wanted to deliver in hospital. Time was of the essence and this couple completely trusted their Doula to know when to leave and how to get mom, so far progressed in labour, out of the tub, into the car and to the hospital. And the Doula did. She knew exactly when it was time; she remained calm and supportive while they relocated. They arrived at the hospital 10 cm dilated. Hooray! Mission accomplished. Ah…no…wait…she still had to actually deliver the baby!
Being at the hospital was a whole new experience that required additional support from the Doula. I mean, who makes these hospital policies where the husband is meant to wait in line to fill out forms, whilst a mom in need of physical and emotional support stands alone? Thank goodness for the Doula, who never left the birthing mom’s side. Not to mention, it might have been a bit awkward for a woman to be alone, wearing only a T-shirt and boots in the hallway, leaning over a wheelchair, moaning and groaning. Then again, this is the ER, so maybe not.
Once the paperwork was completed the threesome headed for labour and delivery. This is where mom was in for a real shock. No one had ever told her that the hallway from the elevator to labour and delivery is about a 100-kilometre distance! I was also shocked when she told me. It seems unbelievable. But, I feel it is my duty to let pregnant women know, if you deliver in hospital, you will be required to pass through this extremely long hallway. It’s the only way to get there. Apparently this dad is quoted to have said ‘it doesn’t look that long’ (I believe she may have bit his hand clean off with the next contraction). Luckily, the Doula reassured them that at the end of this little hallway, they would finally reach their destination.
Upon examination by the attending physician, the parents were thrilled to hear that it was time to welcome baby into their waiting arms! They thought this would be quick and easy. The baby would arrive in 20 minutes, give or take a few and they’d be calling all their friends and family with the dirty deets of the birth. Wrong. Thank goodness for the Doula. She was a calm presence, a wealth of knowledge and a great support for the parents while baby took her sweet time descending the birth canal. When the pushing wasn’t progressing, the Doula suggested switching positions, played soothing music, provided physical support and constantly whispered encouraging words to the mother. It was the Doula, not the doctor, nurse or spouse, who eased the fears the mom had of feeling the baby crown and her fear of tearing. She reassured mom that her perineum was being protected and that when the baby crowned, she would be born. It was exactly what mom needed to hear and with the next wave, baby arrived. Finally, with the collaboration of mom, dad, doctor and the Doula, the VBAC birth was successful. Mission accomplished.
I asked this baby’s mom about her feelings on her VBAC experience and this was her response:
“I believe birth is one of the most important, life-impacting journeys a woman goes through. It was a right of passage that I longed for. I wanted to be able to experience the complete submission of myself to my body, to let go and allow my body and my baby do the job they were designed to do. I did this with the support of my husband and my Doula. This was a major accomplishment and despite that, there was no hero cookie handed to me when it was over (which was fine, I wasn’t hungry anyway). Besides, I had my supportive Doula, my proud husband to give me all the kudos I required. The only thing I’ve pondered since the birth of my baby is this, where were the news media and television crews???”
I couldn’t agree more. Woman naturally births 7 lbs 14 oz baby girl! Now that is news worthy!
( this was submitted by an amazing mom who loves to write in third person)
Tuesday, December 01, 2009
Originally posted on Nov 2009 on the MIDIRS WEBSITE
Nausea and vomiting in pregnancy (NVP) is an underrated and often disregarded condition which has immense significance for the mother and her family.
Indeed, it is not simply a condition which affects only the mother, but impacts also on her partner, her children, her job and her everyday life.
The term ‘morning sickness’ is a misnomer, because whilst many women have early morning nausea on waking, due to hypoglycaemia, many continue to suffer throughout the day and even into the night. Similarly, the traditional midwifery advice that symptoms will resolve spontaneously by the beginning of the second trimester can be discouraging, for many women feel unwell for the duration of the pregnancy, and others, whose condition may have improved in the mid-trimester, may experience a return to NVP towards term as the hormones change in preparation for labour.
Midwives should be able to differentiate clearly between physiological NVP (even when it is severe) and pathological hyperemesis gravidarum. Physiological nausea occurs in up to 85% of pregnant women (Jewell & Young 2003), with approximately half of these experiencing vomiting, but pathological hyperemesis occurs only in about 2.4% of the total (Power et al 2001), or between one and 20 cases per 1000 pregnancies (Kuscu & Koyunco 2002). Hyperemesis is defined as persistent vomiting causing weight loss of more than 5kg, with dehydration requiring fluid replacement, usually in hospital (Power et al 2007). However, undervaluing mothers’ subjective accounts of NVP may contribute to increased stress and unnecessary delays in instigating the appropriate treatment, particularly when the condition becomes pathological (Munch 2000). The effects of NVP are what the mother says they are, and the dismissive attitude of many GPs and some midwives is unhelpful and unkind.
NVP is largely considered to be ‘hormonal’, but this is an easy answer to a complicated question, because many different hormones are involved. Nausea has variously been attributed to oestrogen, progesterone, chorionic gonadotrophin, thyroid stimulating hormone and thyroxine, prostaglandins, testosterone and cortisol as well as other chemicals such as serotonin 5-HT, histamine and dopamine. Vomiting is triggered by changes in the brain, gastrointestinal tract and vestibular apparatus in the ear. NVP is exacerbated by tiredness, stress and anxiety, and appears to be worse in women with a history of muscusloskeletal problems, notably back, neck or jaw conditions (Tiran 2009). However, it is not the purpose of this paper to discuss the myriad causes and predisposing factors which contribute to NVP, and readers are referred to Tiran (2003) for a more comprehensive exploration of the subject.
There are many suggestions which midwives can offer to women with mild to moderate NVP, although, often, women will try to cope alone until the symptoms have persisted for longer than they anticipated. The ubiquitous ‘tea and dry biscuit before getting up’ regime is not always appropriate, although those who feel more nauseous when they are hungry (as on waking) will gain some short term relief from eating. Unfortunately, biscuits are not the best means of satiating hunger, because the fast-release sugar is quickly metabolised and hypoglycaemia follows, leading to a vicious circle of eating – nausea – eating, and the risk of excessive weight gain. Slow-release carbohydrates are better, including bananas, porridge, jacket potatoes, wheatgrain toast, rice crackers etc. Women should not be made to feel guilty about eating a poor diet at this time, but should be encouraged to eat whatever foods are attractive to them, and which are not vomited back.
Nausea may be exacerbated by iron, so avoiding routine ingestion of iron-containing multivitamin supplements in early pregnancy may have some effect in reducing the severity of symptoms (Gill et al 2009). Additionally, the palate tends to be very sensitive and resulting stimulation of the gag reflex triggers retching and vomiting, so attempting to swallow large tablets (such as vitamin B) is ill-advised (Koren & Pairaideau 2006); a liquid preparation such as Floradix™ may be more palatable if a mother is known to be vitamin and mineral deficient. Conversely, some authorities advocate the use of vitamin B6 as a treatment for gestational sickness (Power et al 2007), although Masino & Kahle (2002) advise caution as there is some suggestion that large doses may affect neurological development which could be permanent after fetal exposure. For women who are able to eat relatively normally, consuming foods rich in vitamin B6, such as avocado, bananas, yeast extract, wheat bran, wheat germ, sardines, mackerel, beef, poultry, brown rice, cabbage and free range eggs may help.
Rest and sleep are important to reduce fatigue and it has been shown that many women spontaneously resort to ‘napping’ (O’Brien et al 1997), although occupational commitments or dealing with other children may preclude this as a long term strategy. Any means of alleviating stress should be advised, including taking time off work or adapting working practices where possible, such as working from home. Manageable exercise and obtaining fresh air should be encouraged if the NVP is not so severe that it confines the mother to bed, and relaxation and complementary therapies can be advised (see below). It is also necessary to ensure that partners and family members appreciate the nature of the problem. Some partners become over-solicitous and fear that the NVP will be harmful to the mother or baby, athough it appears to be nature’s way of protecting the materno-fetal unit (Brown et al 1997, Huxley 2000). However most men find it difficult to cope if the NVP lasts more than a few weeks, and diplomatic counselling may be needed to assist them in dealing with the situation.
Ginger, in the form of capsules, syrup or a tea made from the root has been shown in numerous studies to be an effective antiemetic (Ozgoli et al 2009), reducing the number of vomiting episodes and comparing favourably with vitamin B6 supplements (Ensiyeh & Sakineh 2008) and other prescribed medications (Pongrojpaw et al 2007). Ginger appears to be almost universally known as a remedy for morning sickness and is readily advocated by midwives (personal communications), despite many having insufficient information to advise women accurately and safely. Ginger is also recommended by many obstetricians (Power et al 2007) although little advice appears to be given regarding dosages and there is scant acknowledgement of the pharmacological nature of ginger, despite wide variations in the proportions of the active components in many commercially available preparations (Schwertner et al 2006). It should be remembered that ginger is a herbal medicine which works pharmacologically, with side effects such as heartburn, and that it also has the potential to interact with drugs (Marcus & Snodgrass 2005). There is evidence to suggest that ginger has anticoagulant effects, especially if taken in excessive amounts or for prolonged periods of time, a factor which may preclude its use by women with haematological conditions, those on warfarin or other drugs with anticoagulant effects, and in those suffering threatened miscarriage (Thomson et al 2002, Borrelli et al 2005, Jiang et al 2005). Mothers and midwives mistakenly believe that ginger biscuits are acceptable but, although the large amount of sugar may bring temporary relief from a rise in serum glucose, any antiemetic effect is not due to the minimal amount of ginger in a biscuit. In addition, ginger is, in Chinese medicine terms, a ‘hot’ or ‘Yang’ remedy which, if taken by a woman who is already too ‘Yang’, will only serve to increase her symptoms (Tiran & Budd 2005).
Commercially produced wristbands, originally intended for travel sickness, are widely available and can be very effective. They work by stimulating an acupuncture point, the Pericardium (P6) or Neiguan point, on the inner aspect of the wrist, from where an acupuncture energy line (meridian) travels through the body to rebalance internal energies to and from the heart. Stimulation of the P6 point with acupuncture needles can also be undertaken by appropriately trained professionals. There have been numerous good calibre research studies on P6 stimulation and sickness of various aetiology, including NVP (Helmreich et al 2006, Streitberger et al 2006, Shin et al 2007, Can Gürkan & Arslan 2008). Siting of the wristband, with the stimulation button directly over the precise area for the P6 point, is important as incorrect positioning will make the bands ineffective, and is one of the reasons why use of P6 stimulation may be unsuccessful in some women. Stimulation of the P6 and other relevant points may also be undertaken by an acupuncturist, but mothers should be advised to find a qualified practitioner, preferably one who is experienced in treating pregnant women.
NVP is triggered, and can be exacerbated by, abnormal effects on the vestibular (balancing) mechanism in the ear (Black 2002). NVP is often worse for women prone to travel sickness, and normalisation of the balancing mechanism can be a simple means of reducing the severity of symptoms. A study of women with hyperemesis gravidarum indicated that electrical stimulation of the vestibular apparatus was effective in reducing nausea and excessive vomiting (Golaszewski et al 1995), and a contemporary commercial DVD (Morningwell™) is now available from the National Childbirth Trust. This uses inaudible pulsed frequencies overlaid with music, and must be used with personal headphones so that the pulsations rebound on the vestibular apparatus in the ears. The manufacturers claim this to be 90% successful in suppressing NVP, a fact which was borne out by a small study by a midwife in Hampshire (Mayo 2001).
Relaxation complementary therapies
Relaxation therapies can be helpful in cases where the NVP is worsened by stress and psychological factors, but midwives with little knowledge of complementary therapies should be cautious when advising women about these. Aromatherapy is not always acceptable because of the dramatic changes in the woman’s sense of smell which can occur, and because many essential oils are contraindicated in pregnancy (Tiran 2001). Reflexology can be helpful when administered by an experienced and well trained therapist, but it should be noted that most reflexology training courses discourage practitioners from treating women in the first trimester. On the other hand, reflex zone therapy, practised primarily by conventional healthcare professionals including midwives, nurses and physiotherapists, can be extremely effective in reducing the severity of symptoms, in some cases completely resolving the condition (Tiran 2009). Shiatsu, given by a practitioner who is trained to treat pregnant women, can also be beneficial, and massage may appeal to some women (Agren & Berg 2006). Psychological therapies such as hypnosis may also be of use (Simon & Schwartz 1999). Often, just listening to the mother and validating her symptoms can be a relief which enhances her coping mechanisms.
Other complementary therapies
Osteopathy and chiropractic, which are ‘professions supplementary to medicine’ and whose practitioners are statutorily regulated in the same way as midwives, are safe in pregnancy and will be effective for many women with NVP, but particularly those with a history of musculoskeletal problems. Homeopathic remedies can be useful for some, but it is important that the remedy is selected carefully in accordance with the individual mother’s precise symptoms. Although many homeopathic remedies are available over-the-counter, inappropriate administration can prolong the symptoms and may exacerbate the condition. Other herbal medicines can sometimes be beneficial, but mothers are best advised to consult a qualified and experienced practitioner, rather than self-administering remedies which may not be safe during pregnancy.
NVP is a common physiological condition of pregnancy, but one for which the incidence appears to be growing, perhaps due to stressed lifestyles, work commitments, delay in childbearing, environmental toxins and other factors. Whilst midwives may not always see women in the first trimester and be in a position to advise them in the early stages, they frequently come into contact with mothers in later pregnancy who are still suffering. Advice about lifestyle, dietary adaptation and simple self-administration of natural remedies may be sufficient to ease the severity of symptoms in many women, and midwives can also refer women to appropriately qualified complementary practitioners. This is, however, a specialist area of midwifery practice which deserves more attention in pre-registration education and subsequently in clinical practice.
Ginger use during pregnancy is being questioned due to a new report from the Finnish government. Finnish authorities are warning pregnant women not to consume ginger supplements, drinks, or teas. Ginger contains chemicals that are cytotoxic in vitro. The concern is that these chemicals MIGHT be harmful if consumed in large quantities. So far, no obvious problems have been seen in pregnant women taking ginger supplements in doses of about one gram daily. Advise women not to overdo it. More is not necessarily better. Also, consider recommending pyridoxine (vitamin B6) first for morning sickness. Vitamin B6 12.5 - 25 mg three or four times daily is safe and often effective for mild nausea.
Agren A, Berg M (2006). Tactile massage and severe nausea and vomiting during pregnancy-women's experiences. Scandinavian Journal of Caring Sciences 20(2):169-76.
Black FO (2002). Maternal susceptibility to nausea and vomiting of pregnancy: is the vestibular system involved? American Journal of Obstetrics and Gynecology 186(5) (Suppl):S204-9.
Borrelli F, Capasso R, Aviello G et al (2005). Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstetrics and Gynecology 105(4):849-56.
Brown JE, Kahn ES, Hartman TJ (1997). Profet, profits and proof: do nausea and vomiting of early pregnancy protect women from “harmful” vegetables? American Journal of Obstetrics and Gynecology 176(1 pt 1):179-81.
Can Gürkan O, Arslan H (2008). Effect of acupressure on nausea and vomiting during pregnancy. Complementary Therapies in Clinical Practice 14(1):46-52.
Ensiyeh J, Sakineh MA (2008). Comparing ginger and vitamin B6 for the treatment of nausea and vomiting in pregnancy: a randomised controlled trial. Midwifery Feb 11. [Epub ahead of print].
Gill SK, Maltepe C, Koren G (2009). The effectiveness of discontinuing iron-containing prenatal multivitamins on reducing the severity of nausea and vomiting of pregnancy. Journal of Obstetrics and Gynaecology 29(1):13-6.
Golaszewski T, Frigo P, Mark HE et al (1995). Treatment of hyperemesis gravidarum by electrostimulation of the vestibular apparatus. Zeitschrift fϋr Geburtshilfe Neonatologie 199(3):107-10 [Article in German].
Helmreich RJ, Shiao SY, Dune LS (2006). Meta-analysis of acustimulation effects on nausea and vomiting in pregnant women. Explore (NY) 2(5):412-21.
Huxley RR (2000). Nausea and vomiting in early pregnancy: its role in placental development. Obstetrics and Gynecology 95(5):779-82.
Jewell D, Young G (2003). Interventions for nausea and vomiting in early pregnancy. The Cochrane Database of Systematic Reviews, issue 4.
Jiang X, Williams KM, Liauw WS et al (2005). Effect of ginkgo and ginger on the pharmacokinetics and pharmacodynamics of warfarin in healthy subjects. British Journal of Clinical Pharmacology 59(4):425-32.
Koren G, Pairaideau N (2006). Compliance with prenatal vitamins. Patients with morning sickness sometimes find it difficult. Canadian Family Physician 52(11):1392-3.
Kuscu NK, Koyuncu F (2002). Hyperemesis gravidarum: current concepts and management. Postgraduate Medical Journal 78(916):76-9.
Marcus DM, Snodgrass WR (2005). Effectiveness and safety of ginger in the treatment of pregnancy-induced nausea and vomiting. Obstetrics and Gynecology 106(3):640.
Masino SA, Kahle JS (2002). Vitamin B6 therapy during childbearing years: cause for caution? Nutritional Neuroscience 5(4):241-2.
Mayo L (2001). A sound remedy? A new treatment for ‘morning sickness’. Practising Midwife 4(10):16-7.
Munch S (2000). A qualitative analysis of physician humanism: women’s experiences with hyperemesis gravidarum. Journal of Perinatology 20(8 pt 1):540-7.
O’Brien B, Relyea J, Lidstone T (1997). Diary reports of nausea and vomiting during pregnancy. Clinical Nursing Research 6(3):239-52.
Ozgoli G, Goli M, Simbar M (2009). Effects of ginger capsules on pregnancy, nausea, and vomiting. Journal of Alternative and Complementary Medicine 15(3):243-6.
Pongrojpaw D, Somprasit C, Chanthasenanont A (2007). A randomized comparison of ginger and dimenhydrinate in the treatment of nausea and vomiting in pregnancy. Journal of the Medical Association of Thailand 90(9):1703-9.
Power ML, Holzman GB, Schulkin J (2001). A survey on the management of nausea and vomiting in pregnancy by obstetricians/gynecologists. Primary Care Update for Obs/Gyns 8(2):69-72.
Power ML, Milligan LA, Schulkin J (2007). Managing nausea and vomiting of pregnancy: a survey of obstetrician-gynecologists. Journal of Reproductive Medicine 52(10):922-8.
Schwertner HA, Rios DC, Pascoe JE (2006). Variation in concentration and labeling of ginger root dietary supplements. Obstetrics and Gynecology 107(6):1337-43.
Shin HS, Song YA, Seo S (2007). Effect of Nei-Guan point (P6) acupressure on ketonuria levels, nausea and vomiting in women with hyperemesis gravidarum. Journal of Advanced Nursing 59(5):510-9.
Simon EP, Schwartz J (1999). Medical hypnosis for hyperemesis gravidarum. Birth 26(4):248-54.
Streitberger K, Ezzo J, Schneider A (2006). Acupuncture for nausea and vomiting: an update of clinical and experimental studies. Autonomic Neuroscience 129(1-2):107-17.
Thomson M, Al-Qattan KK, Al-Sawan SM et al (2002). The use of ginger (Zingiber officinale Rosc.) as a potential anti-inflammatory and antithrombotic agent. Prostaglandins Leukotrienes and Essential Fatty Acids 67(6):475-8.
Tiran D (2001). Clinical aromatherapy for pregnancy and childbirth. 2nd ed. Edinburgh: Churchill Livingstone.
Tiran D (2003). Nausea and vomiting in pregnancy: an integrated approach to care. London: Elsevier Science.
Tiran D, Budd S (2005). Ginger is not a universal remedy for nausea and vomiting in pregnancy. MIDIRS Midwifery Digest 15(3):335-9.
Tiran D (2009). Reflexology for pregnancy and childbirth: a definitive guide for healthcare professionals. Edinburgh: Elsevier Science.
Denise Tiran is Director of ‘Expectancy’, the leading provider of professional education on safety of complementary therapies in pregnancy and childbirth. She would be interested to hear from midwives who would like to consider training to become Expectancy registered ‘morning sickness’ consultants.
- ► 2010 (23)
- ▼ December (3)
- ► 2008 (29)
- ► 2007 (17)