SOOO Big

"We just had our first granddaughter! She was born six weeks early, which is really a blessing for her mom, since the baby already weighed 5 pounds."

"The Porters have just added a small blessing to their family -- actually, a rather large blessing, at 8 pounds 12 ounces."

I don't know where we have learned our fear of delivering a large baby. Sometimes babies can get rather big, and sometimes size is a consideration in determining how a baby is born, vaginally or by cesarean section. But our collective fears are exaggerated. Macrosomia (large baby) is frequently misdiagnosed; ultrasounds are notoriously unreliable for determining a baby's weight before birth.

Here are some common myths about birth weight:

• If the baby grows too much in the womb, the shoulders will become stuck during birth. This is called shoulder dystocia, and while it is a rare and very serious problem, its incidence is not connected absolutely with how much the baby weighs. "It has been established that 48 to 89% of SD occur in non-macrosomic fetuses" (Blickstein). Shoulder dystocia is unpredictable and while its likelihood increases with larger babies, it has also been reliably linked to maternal diabetes, labor induction, and the use of pain medication. Cesareans done for suspected macrosomia have resulted in dismal statistics: 100 unnecessary c-sections for one true case of macrosomia. Plus, since there is no assurance of shoulder dystocia occurring even with a large baby, performing a cesarean for the sole reason of avoiding dystocia is unsupported. Causal relationships have been established between shoulder dystocia and the following: increased maternal age, shortened first stage, prolonged second stage, maternal obesity, gestational diabetes, position of the baby during birth, labor induction, epidural use, and a long time period (8 years or more) since the previous birth.

• A larger baby will result in larger vaginal tears. Not necessarily. While there is a limit to how much tissues can stretch to allow the passage of a baby, the most important rule to avoid tearing is to slow down. Pushing too hard, too fast, and not allowing the tissues to stretch out, will almost certainly result in tears. While there is a place for episiotomies, they absolutely do not help women avoid larger tears; they create a weak spot where stress is centered and can cause more injury rather than preventing worse tearing. The best advice for avoiding tearing during birth is to take your time. My midwife told me that "Your body will not grow a baby you can't birth." I'm not certain that that is entirely and completely true, but I do believe that in the great majority of circumstances, a woman can give birth to the baby she is carrying, without it being "too big" for her. As stated on a childbirth website, "your body is designed to accomodate even a large baby."
  


• Babies gain a pound a week during the last weeks of pregnancy. I have heard this misconception many times, and I don't know where it came from. It is a lie. By the end of pregnancy babies can gain as much as one ounce per day - that equals 7 ounces per week, or less than one pound every 2 weeks. This myth leads to...

• Induction before 40 weeks will avoid the trouble of having to birth a large baby. Inducing labor carries with it so many risks that there is no evidence of improved outcomes for women thought to be carrying large babies. Inducing labor before your body is ready to give birth also increases your chances of having a cesarean.

• A large baby's head will get stuck in the mother's pelvis. True cephalopelvic disproportion (CPD) is very rare. The baby may be too large for vaginal birth in some cases, called absolute disproportion, but this is, again, extremely rare. More common causes of CPD are bad positioning of the baby, inflexible tissues of the cervix or vagina, and impatience. Another very rare cause is an abnormally-shaped pelvis (rickety or trefoil). Many women who deliver a baby by cesarean due to a diagnosed CPD will go on to vaginally birth an even larger baby, disproving the initial diagnosis.

• The average birth weight of babies has increased over time, and soon babies will become too large to birth vaginally. There has been an increase, especially noted around the turn of the century (1900, not 2000). The average birth weight suffered a giant drop leading up to around 1900, and then made steady improvements, up until the modern day, the past twenty years or so, when they seem to have levelled off. Accurate birth weight measurements were not in place until the mid-1900s. So while the first part of the statement may appear technically true, the second part is unfounded. The increase in birth weight can be attributed to better health care and prenatal care, better workforce environment, lower levels of hard physical activity, better nutrition, and education.

I am not pleased when people talk about their "giant 8-pound babies". To me, 12 pounds is large, and 8 is pretty darn close to average.

The current average birth weight for all babies is 7 1/2 pounds.

Some are larger, some are smaller. Either extreme may result from and/or cause complications. But by definition, most babies fall within the average, normal category for birth weight.

Both of the quotes above are things I have overheard in the past few months, and it made me want to jump out of my skin.

8 pounds is not huge. Anecdotally, I know many moms who say that their latest, 10-pound baby was their easiest delivery. It isn't all about weight.

Prematurity is not a good tradeoff for low birth weight.

The optimal goal is a good outcome for both mom and baby. Most of the myths I discussed are based on fact but are not exactly true. Each individual needs to research and weigh her own risks and circumstances. My intention is to clarify the truth and dispel the misleading beliefs where appropriate.

Childbirth-easing drugs may affect breastfeeding

11:32 11 December 2006
NewScientist.com news service
Rachel Nowak

Drugs used to ease the pain of childbirth could interfere with breastfeeding, a new study suggests.

Siranda Torvaldsen of the University of Sydney, Australia, found that 416 women who received the opioid drug fentanyl by epidural injection during delivery were twice as likely to have stopped breastfeeding by the time their baby was six months old compared with 312 women who did not receive the drug.

Torvaldsen does not know whether this is because the drug has a direct effect on babies’ ability to suckle or that women who opt for (or need) epidural painkillers are also more likely to stop breastfeeding sooner.

A previous study found that the babies of women who have fentanyl tend to be drowsier at one-day-old, raising the possibility that the drug affects suckling at the critical time when breastfeeding gets established.

"Adverse reaction"

In Australia and the US only around 40% of babies are still receiving at least some breast milk at six months, although the World Health Organization recommends breast feeding exclusively until that age.

“Now we’re aware that painkillers may affect breastfeeding, we need to be sure that women who take them get adequate help,” says Torvaldsen.

Sue Jordan of Swansea University, UK, who is an expert on the effects of labour drugs and mental health, says the effect of opioids and epidurals on breastfeeding should be seen as an "adverse drug reaction".

In an article accompanying Torvaldsen’s study in International Breastfeeding Journal, Jordan calls for extra support for the most vulnerable women "to ensure that their infants are not disadvantaged by this hidden, but far-reaching, adverse drug reaction".

Journal reference: International Breastfeeding Journal (DOI: 10.1186/1746-4358-1-24)

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I am not anti-epidural. I'm becoming more anti-hospital, though I still maintain my belief that women need to be where and with whom they feel safe.

But I wonder how much publicity this little bit of information will receive.

People who are already opposed to the routine use of epidurals for all moms will think it's great.

Those who can't imagine why anyone would do anything other than opt for an epidural as soon as it can be given, will dismiss it as unsubstantiated.

The medical community probably won't even blink.

What does it take to cause change? What needs to happen, what needs to be discovered, for real changes to begin happening?

I want to see women seeking education about birth before they seek escape from it. If they ultimately decide that epidurals are definitely for them, at least it will be an educated choice and not a decision made in a vacuum - "I don't know what to expect and I don't wanna know."

I have heard of childbirth educators telling their classes, "Ninety-five percent of you will be getting epidurals anyway, so I won't go over relaxation techniques."

I have heard of nurses begging laboring moms to get pain relief. Even constantly asking the mom, "Do you want your epidural yet?" without knowing what her preferences are, or continually offering "something to take the edge off the pain" without using the word narcotic...these are all actions hostile to unmedicated birth, and apparently to the breastfeeding relationship, too.

So why doesn't this garner more of a reaction? Why don't mothers care more about it? If mothers cared, they would demand change, and the medical community would have to adapt, and men and sons and daughters would learn to act differently towards birth.

Virginia Woolf believed that if libraries were available to women in her time, that the world would split open. She too thought that knowledge would be enough.

I'm dismayed that women don't seek out their own education on certain things, especially childbirth.

It would be nice if every doctor made time to sit down with a pregnant woman and ask, "So what kind of birth do you want?" ...

It would be great if all doctors had a certain reverence for birth, understanding what is inappropriate to do or say when a woman is giving birth, reacting when needed, but showing restraint and respect when needed...

It would be nice if L&D nurses were trained so thoroughly that no laboring mom or doula would ever suspect that she knew more about birth than the nurse(s)...and if nurses all knew how important it is to support and nurture the connection between mom and baby...

It would be great if all childbirth educators were trained to help women find what kind of birth they want, how to increase their chances of having that experience, what to do if it doesn't happen, and how to recognize if something is going wrong, either during the birth or during the initial postpartum time...

But the reality is that none of these things are common or guaranteed.

So it's up to women, it's up to each woman to educate herself and learn to stand up for herself.

No more assuming that because someone went to nursing or medical school, they must therefore know what they're doing and would NEVER do anything destructive to the health and well-being of mom and baby. No more thinking that taking a single childbirth class covers all the bases and prepares you for anything, especially childbirth.

No more denying responsibility.

There is so much to learn. Do your research. Ask questions. Change care providers. Read everything you can.

It's all up to you.

More on Prodromal Labor

My previous writings on prodromal labor were strictly theoretical. I have never experienced it, and I had never before attended someone who was in prodromal labor. This past weekend, I did. I have much more to say about it now.

Prodromal labor is a term for early labor that lasts for a long while without progressing into active labor. It is a nightmare. This is the labor pattern that lasts for days, causing the mother to lose sleep, disrupt her appetite, and causes exhaustion. It will probably eventually change into an active labor pattern, but even if this happens, the biggest danger is depletion of emotional and physical resources: the mother may not be able to continue with the labor and may need pain relief or even a cesarean. This is not the kind of labor that any woman wants to experience.

The article I wrote before stands out to me now as something written by a person who has read about a topic and knows nothing of it. It strikes me now as profoundly unhelpful.

When a woman is in prodromal labor, also called arrest of the first stage of labor, one of two options should be considered: should active labor be encouraged, or should attempts be made to slow or stop the contractions?

For either option, there are universal precautions: save your energy (no marathon shopping trips), eat as much as you can (even if it's only smoothies and toast - you will need the energy), and sleep if possible.

To encourage labor to progress, stay upright and walking if you can. Sway your hips - sitting on a birth ball or slow-dancing with your sweetie are great ideas. You may want to consider using nipple stimulation.

If you wish to try to halt the contractions, you need to relax. Sleep as much as you can. Take lots of baths or showers. Get a massage. You may not be able to stop the labor from progressing into active labor, but you will increase your chances of being a little more rested, and it will make a difference.

Prodromal labor can last for days. Its cause can be a complex combination of physical and emotional reasons. To avoid physical causes, do not be induced without a medical indication. Emotional work may be needed. Are you afraid of having your baby? Are you scared of what changes it will bring to your life, especially to your relationship? Are you afraid that your partner might leave you? Are you a single mom without a partner? It is time to work through these fears. It may help your labor to do so.

Sometimes new mothers will focus too much on early labor. This is not necessarily the same thing as real prodromal labor, which takes longer than usual to progress - though the same principle applies: the excitement of steady contractions can cause women to become exhausted, if they are focusing on the contractions and spending too much energy when labor is easy. If the contractions are not stopping you in your tracks or preventing you from speaking, you're very likely in early, early labor, and need to conserve your energy. Do not spend too much effort on these contractions.

If you gained nothing else from reading this, I hope that the main point that stands out is this: if you are in prodromal labor, you need to rest.

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.