Going Overdue

By the end of pregnancy, you're probably ready to be done. You're huge, your belly is pendulous, you can barely sleep, and you have to pee every ten - no wait, every seven - minutes. Most women hope to deliver early, and these hopes soar in the last weeks.

Your due date arrives! And...it passes. No changes in your body, or your dilation, but your mood plummets.

Going overdue often makes pregnant women depressed. You are ready to be finished, prepared for labor, perhaps have family arriving to help with the transition, yet you are still pregnant. You might feel like a failure - after all, you aren't doing your job. No baby to show for your forty weeks of effort. If it goes on, you might feel that you will never go into labor.

If this is where you are, take heart. Forty weeks is an estimate, and your actual due date is an estimate too. Your baby will be born soon. Relax, do something fun, like go see a movie. Try to forget that you're pregnant (it doesn't help to dwell on it - thinking about labor will not cause it to occur any sooner - sometimes trying to forget that you're past your due date is good therapy). Your life will change dramatically very soon.

Avoid induction for arbitrary reasons. If you are more than a week overdue, you will need to be monitored by your OB to make sure that the placenta is functioning and the baby is doing fine. As long as everything is going well, do not be induced. There are complications associated with induction, especially in first-time moms, and you and your baby will be better off if you allow labor to start on its own. Your body will be better able to respond to labor, and you will know that your baby is full-term and ready to be born.

If you have family arriving and feel pressured to have a baby while they're in town, please readjust your priorities. Your baby has one chance to be born, and it should be as free from risk and complications as possible.

One word on how labor begins: The baby's lungs are the last organs to complete their development. Once they are mature, they release a protein, and that protein causes the release of other hormones that initiate labor. If you haven't gone into labor yet, it may be because your baby's lungs are not yet entirely ready. Hang in there. You will go into labor.

If you are concerned about the baby gaining weight, there is usually not cause to worry. Ultrasound weight estimates can be inaccurate by 2 lbs either way, on average. Most methods of estimating fetal weight tend to overdiagnose macrosomia (large babies). Do listen to your doctor, but keep in mind that it is ultimately your decision whether to be induced or not.

If you are overdue and there is no evidence of complications:

• Do not be induced. Labor will begin on its own when both you and your baby are physically ready.
• Do not dwell on your pregnancy. Do something fun. Try to forget you are pregnant.
• It is OK to take yourself off the radar for a while. Do not answer the phone or accept visitors, if you are feeling antisocial. You might want to change your voicemail message to say that you are still pregnant and doing fine. Take care of your emotional needs.
• Use the time to finish up any projects or arrangements you haven't yet completed. Make sure the baby's space is ready. Pack your birth bag. Do some cleaning (getting on your hands and knees to scrub a floor is especially helpful to get the baby in the right position for birth!). Or get some much-needed rest.

You WILL go into labor. This is a tough time for you, but no one is pregnant forever. And you won't be the first, I promise!

Updated to include this press release, dated 21 February 2008:

Lamaze International recommends that a woman allow her body to go into labor on its own, unless there is a true medical reason to induce. Allowing labor to start on its own reduces the possibility of complications, including a vacuum or forceps-assisted birth, fetal heart rate changes, babies with low birth weight or jaundice, and cesarean surgery. Studies consistently show that inducing labor almost doubles a woman's chance of having cesarean surgery.

— Lamaze International Press Release

The State of Birth Around the World

This is by no means a complete list. These are just some of the issues brought up in recent news feeds.

Japan. The current situation is that a low birth rate is driving many obstetricians out of business, leaving many women without needed health care. Maternity wards are closing. This is a sad dilemma. Japanese women have a low fertility rate, which means their needs for obstetrical care are limited. They are also having children later in life, raising the risks for a complicated birth, which has historically produced more lawsuits. Not many obstetricians are willing to work long hours in a highly-litigious career for average pay, and who can blame them?

Asia. The mortality rate for babies is dismal in southeast Asia, where fully one third of all neonatal deaths (that's death occurring within 28 days of birth) occur. "South Asia has the highest rates of newborn deaths in the world, next to Africa. In Afghanistan and Pakistan, for example, up to six percent of infants die in their first month." Probably the most helpful thing for these areas would be government emphasis on and funding for better health care systems.

India. Here, "a woman dies in childbirth every five minutes." From the UNICEF website: "The reasons for this high mortality are that few women have access to skilled birth attendants and fewer still to quality emergency obstetric care." Infant mortality is as high as 63 per 1000 births (for comparison, in the US, infant mortality is about 7 in 1000).

Scandinavian countries. Sweden and Denmark are the top two countries for maternal and infant health. More on Swedish maternity leave policies here.

Poland. With the high cost of health care in Poland, many pregnant women have been giving birth in border clinics in Germany, citing better health care. And, by the way, under the EU agreement, Germany pays for it. But not anymore.

Ireland. The cesarean rate has climbed drastically over the past 10 years, from 7.5% of c-sections being elective, to 45% last year.

No Alcohol is Safe During Pregnancy

Pregnant women told no alcohol at all in new guidelines

When I first saw this, I thought it was a new WHO or national guideline. Well, it is a new national policy, but it's new for New Zealand, not the US. Too bad.

I remember being pregnant with my first baby and attending a work function where alcohol was served. I asked for a root beer instead, and someone near me misunderstood me. "You can't drink!" she said, pointing at my swollen belly. I said, "I'm not! I ordered a root beer."

"One drink is ok during pregnancy," another girl said.

"No, it isn't," I said. "I don't think any alcohol is ok during pregnancy."

The first girl suddenly got defensive. "Well, then, you shouldn't be drinking that soda either, for that matter."

Well said, ex-coworker. Sodas should be taboo during pregnancy also, especially caffeinated ones.

I know one pregnant woman who wanted her Pepsi so bad that she changed OBs until she found one who told her that it was ok to drink as much Pepsi as she wanted during pregnancy.

No matter its source, caffeine has been linked to low birth weight, prematurity, and fetal death.

Ingesting high levels of sugar while pregnant may cause gestational diabetes or birth defects.

Pregnant ladies, stick with your vegetables, fruit, and whole grains. Drink only water. Move your body. Take good care of yourself and your growing baby. Everything you do, everything that happens to you, affects your baby, just as everything you do affects you.

What the WHO Thinks of Midwives

Selections from this article:

Evidence shows that midwives are vital to preventing the estimated 529,000 maternal deaths and 8 million illnesses that occur each year during pregnancy and childbirth. In countries as diverse as Malaysia, Sri Lanka, and Tunisia, investments in training, recruiting and retaining midwives, as well as in emergency obstetric care, have reduced maternal death rates. The lives and health of many millions more would be saved with greater investments in midwives.

UNFPA (United Nations Population Fund) and ICM (International Confederation of Midwives) call for urgent action to address the shortage of midwives if the world is to achieve the international development goals of improving maternal health and reducing child death. The World Health Organization estimates that at least 700,000 more midwives are needed to curb maternal death and illness.

"A strong midwifery profession is the key to achieving safer childbirth, and all women should have access to a midwife," said Kathy Herschderfer, the Secretary-General of the ICM.

"Midwives...transcend the levels of care within health systems, and are essential to the continuum of care during the childbearing cycle."

UNFPA and ICM are working together to strengthen midwifery capacity worldwide to reduce the high levels of deaths and disability among mothers and babies. They are cooperating to promote the professionalization of the midwifery practice, to improve national midwifery standards and to help countries scale up community-based midwifery practice.

ICM, the heart and voice of midwives across the world, was founded in 1919. It is a Confederation of 88 midwifery associations from 75 countries. Its mission is to advance worldwide the aims and aspirations of midwives in attaining improved outcomes for women in their childbearing years, their babies and their families, wherever they reside.

UNFPA is an international development agency that promotes the right of every woman, man and child to enjoy a life of health and equal opportunity. UNFPA supports countries in using population data for policies and programmes to reduce poverty and to ensure that every pregnancy is wanted, every birth is safe, every young person is free of HIV/AIDS, and every girl and woman is treated with dignity and respect.

Should men be banned from the delivery room?

This article is from a survey taken by The Royal College of Midwives (love that name!) in the UK. I know, it's trying to be inflammatory. Most of the article ("research") is anecdotal - meaning it's based on a few experiences and not on much actual reliable research - and isn't worth much. But it raises a good question.

I don't think men should be banned from the delivery room. I think, though, that it should be up to the couple to decide, and that men should face no social (or family) stigma if they determine that the man will not attend the birth.

The only problem with my theory: it's anecdotal. It's based on two experiences. OK, maybe three.

The first is my own. My husband, after being by my side throughout twenty hours during my first labor, didn't feel the need to be present for the second one.

I objected to this idea, until I attended a birth as a doula where the husband didn't want to be there at all. It was their third child. He sat in a chair and looked green for most of the labor, and during the delivery he was detached and sickly. I realized that he was not contributing anything, and if anything his reaction detracted from the loveliness of the atmosphere. To me birth is sacred, but if anyone in the room disagrees with that premise, the entire birth team is affected. He wanted to stay at home, and he probably should have.

My husband did attend the birth of our second child, and I am glad he did. Though after that doula experience I didn't think that his presence was required, I felt more supported by him than anyone else, whereas at the first birth I wasn't able to really distinguish one person's support from another's.

But if he truly had not wanted to be there, I would not have demanded it of him.

In another birth situation I witnessed as a doula, the husband watched TV the entire time. His wife, rendered speechless by the strength of her contractions, reached for his hand but he didn't notice. This went on for a few hours.

"Birth is a fundamentally female event." It is difficult to argue with that statement.

If men are required by their women or by society to be there during labor and delivery, well, why should that be the case? What benefit does it give to women if the man is not going to be supportive? Certainly if he's going to turn green and wish the entire time that he didn't have to be there, it would be better to let him be somewhere else.

"A woman who says she prefers not having her partner in the delivery room is doing so to protect him, because she thinks he can't handle it. Why oh why do women keep on treating men like children? And why oh why do men keep on acting as if they were?"

Not all men are the same. Some can handle nearly anything, while others get nauseous by the sounds and smells of childbirth.

"Conception, reception - if you're there for one, you should be there for the other."

Not so! Bad logic! Bad! That's the "you-did-this-to-me-and-you-must-be-made-to-suffer" mindset.

"I think men should be allowed in the delivery room if they want to be - it is an experience not to be missed: very emotional. Unlike watching it on film, you don't tend to notice the blood and mess when it is actually happning before your eyes. However I do think they should stay in a corner out of the way and should not be made to feel guilty if they change their mind and want to go out. The best person to be present is a woman who has been through it.

The best place for a man is actually right outside the door within earshot. That way they don't get in the way but will still know how much the woman has gone through and will be more sympathetic afterwards.

I had my first in hospital and my husband was at home. He expected me to be up and about and cooking the meals immediately afterwards. I had my second at home and he heard everything despite not being in the room and he looked after me better."

First of all, it is a very different experience to watch someone give birth and to give birth yourself. When you are delivering a baby, you don't notice the blood and mess, but when you are watching another person, you certainly do, along with all the smells and unusual sights. That is one of the main objections that the husband of my client had: birth is gross. Sometimes it is. If the man wants to be involved, he should be, and not "put in a corner" to stay out of the way. I doubt there is ever reason to worry about giving too much support to a laboring woman.

"The best person to be present is a woman who has been through it." Amen, amen.

I didn't agree with having men hear the labor so they can understand what their women are going through, but based on her experience, it sounds like it was a good thing. Each man is different. I think that most wouldn't assume that women are exaggerating about the ordeal of birth, but maybe I'm wrong about that. It is work. Sometimes it is very painful. And women tend to want all the sympathy they can get.

And that right there is why men should not ever be banned from the delivery room.