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Your Body and Your Baby throughout Pregnancy

Q1: Is there an increased risk of infection with vaginal exams?
Q2: Should expecting mothers sleep on their left side?
Q3: Is my baby in danger if I do not have a flu shot?
Q4: Should I be concerned about birthing a “big baby”?
Q5: When asking questions of my OB provider, what red flags should I pay attention to?
Q6: What are the dangers of going past 42 weeks gestation?
Q7: Can you tell if a normal, vaginal birth will be successful?
Q8: Is it safe to try for a normal delivery if I have flat pelvis?
Q9: What books should I read to prepare for birth?
Q10: Will my labor be shorter with my third child? When will she engage, and will perineum massage help?
Q11: Are there any risks to get the H1N1 vaccine while pregnant?
Q12: How should I prepare for the third trimester when classes are unavailable?
Q13: Do you carry differently with a boy versus a girl?
Q14: Should I experience lightening by my 38th week?
Q15: What is the difference between delivery to conception and cesarean to conception?
Q16: Is it possible to have a natural birth?
Q17: If I have gestational diabetes, should I receive extra ultrasounds, OB check-ups, and maintain a food/glucose level log?
Q18: Are there any complications to natural birth with a gastric bypass?
Q19: Can I start labor naturally with GD?
Q20: Is there any research evidence to suggest that placentas calcify or "fail" more often with a GD diagnosis?
Q21: I want to comment on one argument that you have made in several replies with regard to labor induction for GD patients at 39 weeks.
Q22: I have controlled GD and additional risk factors (thrombocytopenia, advanced maternal age, IVF pregnancy, previous miscarriages) so is an induction medically necessary?
Q23: Can I help change my breech baby’s position?
Q24: What should I be aware of with only one artery in the umbilical cord?
Q25: As an older woman, do I have a greater risk for stillbirth and therefore should have an induction?
Q26: Are there greater risks for IVF babies to go past their due date?
Q27: I’m diabetic, and my doctor is concerned about placenta viability and the baby’s size – is induction necessary?
Q28: Are there any studies on the risk of UR (or other complications) for a VBAC with a bicornuate uterus?
Q29: I have a bicornate uterus and have had a cesarean section. Is there an increased risk of having another early delivery, or is VBAC an option?
Q30: How can I keep my pregnancy as intervention-free as possible with impaired glucose tolerance (IGT) and other challenges?
Q31: Is there any research about cerebral palsy?
Q32: What are the risks of VBAC if induced?
Q33: Does having GD automatically indicate the need for continuous monitoring or is intermittent auscultation considered a safe alternative if there are no signs of hypertension?
Q34: Will I need to have steroids if I test positive for fetal fibronectin?
Q35: Does the use of probiotics prevent or suppress GBS colonization?
Q36: As a doula and LCCE I seem to be hearing, anecdotally, that women who have had cervical procedures, such as cone biopsies or LEEP, sometimes have issues dilating due to cervical scarring. Do we have any research on this? I imagine this group is growing, and I wonder if there is any good information we can be giving to women to prepare for a different way to dilate, or appropriate care-giver intervention (cervical massage, etc.).
Q37: Are there labor concerns for a mom with heart conditions?
Q38: I had an inverted uterus with my first baby – is it likely this will happen again?
Q39: When should an ECV be done with a breech baby?
Q40: Why do I need a Rhogam shot?
Q41: I have a low-lying placenta; if I am cleared for vaginal birth what interventions should I do or refuse?
Q42: I have GD with low platelet issues; can I take prednisone but refuse insulin in order to stay with my midwife?
Q43: Is a cesarean the only option when diagnosed with placenta previa-complete?
Q44: What are the benefits and risks for an epidural during labor and delivery with twins?
Q45: Do I need to be induced at 39 weeks because of the clotting factor of MTHFR?
Q46: Can I make induction a “natural” process, since I’ve been told I need to be induced due to a need for blood thinners?
Q47: What is a slow release of waters to avoid placental abruption mean?
Q48: What information should I have before pregnancy to avoid PPROM?
Q49: Can I have a natural labor with Group B Strep?
Q50: Do dietary changes and insulin help avoid Cesareans and preeclampsia in GD women?
Q51: How real is the danger of a vaginal birth with a partial abruption?
Q52: Can you tell me more about IUGR?
Q53: As Group B strep positive, what are the risks of the baby contracting it versus the risks of an induced labor?
Q54: What is the likelihood of getting a baby to turn at 38 weeks? Are the risks and pains of a version worth it?
Q55: What are the concerns with advanced maternal age?
Q56: Is there anything I can do to help increase my amniotic fluid?
Q57: Do you have any research regarding ultrasound predictions of lichre levels?
Q58: Why are the recommended blood sugar levels different for pregnant women?
Q59: Will it be hard to get pregnant again after pelvic organ prolapse?
Q60: Can I have a normal delivery if my baby is bigger?
Q61: Why does my urine need to be tested for protein? How do I know when labor begins?
Q62: I’ve been having low intensity contractions – how likely am I to go into preterm labor?
Q63: My previous unborn baby was diagnosed with Down’s syndrome, will this happen again with another pregnancy?
Q64: Is there information linking post-date babies and placenta deterioration?
Q65: Is Cytotec a safe option instead of a D&C for a miscarriage?
Q66: Is it safe to carry twins beyond 40 weeks?
Q67: I’ve received a positive screen result for trisomy 18, and wonder if I should have amniocentesis or an earlier glucose test.
Q68: Is it safe to check out of the hospital (from bed rest) to have a home birth?
Q69: Why do I need a daily NST while on hospital bed rest?
Q70: Are there exercises or activities I can do to grow my pelvis for a normal birth delivery?
Q71: Will a pregnancy with triplets end in an early delivery?
Q72: What are the legitimate needs for induction with advanced maternal age?
Q73: If I need insulin, can I avoid continuous electronic fetal monitoring?
Q74: What are the risks of a prolonged first phase or second phase of labor?
Q75: Would a mucous plug cause breathing concerns and grey appearance in baby?
Q76: What does placenta accrete, and will there be risks with a future pregnancy?
Q77: Is an over 40 birth automatically high-risk?
Q78: Is there a correlation of Cholestasis or bile salt levels and risk of stillbirth?
Q79: With GBS-positive status, how long can I safely wait for Pitocin following the breaking of waters?
Q80: Will the estimated size of my baby keep me from having a normal birth?
Q81: My first baby had severe shoulder dystocia – is there anything I can do to increase my chance for a healthy birth?
Q82: What is some information about skin-to-skin right after birth?
Q83: Are there any benefits of placenta encapsulation?
Q84: Should adoptive parents (present for birth) get skin-to-skin with baby when he/she is born?
Q85: Is breastfeeding not scientifically supported as we believe?
Q86: Is there a postpartum depression treatment that would allow continued breastfeeding?
Q87: Are there any resources or readings to assist with the loss of a ‘normal birth’ dream?
Q88: Is there any help for stress incontinence around the time of ovulation?
Q89: What is pelvic floor and vaginal recovery after childbirth?


 

Q1: Is there an increased risk of infection with vaginal exams?

Q: I am a Lamaze childbirth educator in Southern CA. Here is my question. I discuss that the number of vaginal exams preformed during a labor and delivery experience is limited (or should be!) because the act of doing the exam, although sterile, displaces the normal bacteria from its normal positioning, thereby increasing the chance for infection to develop. Perhaps I need to change that explanation to state that this is true only after the water has broken, but I thought I understood the chance of increased infection was true in either case, only more so after water has broken.

I was asked why infection wouldn’t happen as a result of penis insertion during sexual intercourse and I answered that in a low risk no problem pregnancy there are not sexual restrictions but agreed that I needed to do further research as to why those two scenarios are different. If you can provide me a resource or additional info I would appreciate the learning opportunity.

A: It is my understanding that there is no increased risk of infection with vaginal exams if membranes are intact. As for why vaginal intercourse differs from a digital cervical exam, as you can see in this drawing, the cervix isn't in line with the end of the vagina. During intercourse, the penis slides by it into the closed pouch at the top of the vagina. Furthermore, pregnant women produce more abundant mucous, which I would think would serve to wash bacteria back down and out. By contrast, with a cervical exam, the examiners fingers push into the cervical opening, depositing there any bacteria swept up onto the examiners gloved fingers as they were inserted.

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Q2: Should expecting mothers sleep on their left side?

Q: One of my current students was told by her physician to sleep "mostly on your left side". The expectant mom has no physical problems & has had an uneventful, healthy pregnancy. She's 32 weeks pregnant. While I understand that cardiac return is maximized in this position & that relaxin mediates the effects of the increased blood volume in pregnancy, I cannot find any research either supporting or refuting this advice. Labor is an altogether different matter as this position may be useful when there are complications or when there is fetal distress.

I asked this mother if she's able to sleep on her left side, and she said it's very difficult. I also asked if the physician had said there were any problems in her pregnancy, and she said there were none. To your knowledge, is there any evidence- based research on this subject during a healthy pregnancy?

A: So I ran a search in PubMed on “sleep position and pregnancy,” and darned if I didn’t turn up a study entitled “Association between maternal sleep practices and risk of late stillbirth: a case-control study.” Now, “stillbirth” is a very scary word, but let’s take a deep breath and look at the study more closely. Investigators interviewed 155 New Zealand women about various aspects of sleep practices that could conceivably be connected to fetal wellbeing who had a late stillbirth (at or after 28 weeks gestation) of a baby free of congenital anomalies. They compared their responses with those of 310 women with ongoing singleton pregnancies matched to the same gestational age. They found that among other factors, women who went to sleep on their left side were less likely to have a late stillbirth compared with women who went to sleep in any other position after taking into account age, ethnicity, high BMI, number of previous children, smoking, and social deprivation. The absolute risk of late stillbirth was 2 per 1000 in women falling asleep on their left side versus 4 per 1000 for women who fell asleep in other positions, or an absolute difference of 2 per 1000.

The study, however, had a number of weaknesses:

  • We know that a difference was found in women who went to sleep on their left side, but who knows if they stayed there? The authors acknowledge that they couldn’t ascertain changes in sleep position during the night. They add that they only found an association with stillbirth in women who neither fell asleep nor woke on their left side, but that still doesn’t mean that women slept all night on their left side, and given how uncomfortable it can get in the last trimester, it seems unlikely that they did.
  • Autopsies were only done in half the cases nor are we told the cause of death when they were done. The theory behind the value of sleeping on the left side is that maternal circulation to the placenta may be diminished in other recumbent positions because of pressure from the weight of the uterus on major blood vessels. Without knowing cause of death, we don’t know whether the demise could be tied to compromised oxygenation.
  • “Stillbirth” is defined as deaths occurring during pregnancy or labor. If any of the deaths occurred during labor, sleep position would not have been the cause.
  • The investigators don’t adjust for maternal or fetal medical factors such as maternal hypertension or intrauterine growth restriction that could potentially affect fetal vulnerability to compromise in maternal circulation. This means that we don’t know the implications of sleeping position for a healthy woman carrying a healthy fetus.
  • Statistical significance is a matter of calculating probabilities. A commentary on this study points out that when numerous comparisons are studied, it is likely that some differences will be found to be statistically significant just by chance. I have seen one strategy to compensate for this, which is to raise the threshold for significance from a p-value of 0.05, meaning there is a 5 out of 100 probability that the finding of a significant difference has occurred by chance, to a value of 0.01, or a 1 out of 100 probability. The investigators used the 0.05 threshold.

And let us not forget that finding an association is a long way from demonstrating causation.

All that being said, it still would seem that sleeping on the left side might be a good idea except for one catch: getting less than 6 hours sleep a night was also associated with stillbirth. This brings us back to your student. If she is uncomfortable on her left side, it seems to me that it is also important for her to get her rest. How might this dilemma be resolved? Perhaps she might see if she can make herself comfortable enough at least to settle to sleep on her left side. Does she need two pillows under her head so that her shoulder isn’t scrunched? Does she need a pillow between her legs to ease pressure on the underneath leg? How about a cylindrical or rolled one behind her back for support or a thin one underneath her belly? Is the arm on the upper side more comfortable if she hugs a pillow to her chest with it? If none of that works, she can fall back on the need to get the best rest can in the positions she and her unborn baby find the most comfortable.

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Q3: Is my baby in danger if I do not have a flu shot?

Q: Is it actually unsafe NOT to have a flu shot while pregnant? I have only been partially immunized, and have never had a flu shot, nor do I consider them to be beneficial to my health. But after receiving some opposition to my stance on this, I would like to know more! Is it worth the risk to have the flu shot? Would I be putting my baby in danger because of NOT having a flu shot?

A: Yes, it is unsafe to forgo flu immunization. Here is info on pregnancy & flu shots from the U.S. Centers for Disease Control. I found it by searching on MedlinePlus, the U.S. National Library of Medicine's consumer health website, my go-to website for trustworthy health info. As you can see, the flu vaccine is safe, and the likelihood of serious illness from contracting influenza is higher in pregnancy. (FYI: This is probably because the immune system is partially suppressed in pregnancy to protect the fetus, who, from the immune system's point of view, is foreign protein.)

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Q4: Should I be concerned about birthing a “big baby”?

Q: More and more we hear about "big baby" as a justification for induction or c-section. I was one of those mothers myself before becoming more educated in my options. However, my second baby was 11lbs. at birth. What do you feel are the things to consider when you may be genetically prone to growing a "big baby"? Do you feel the position of the baby is more important than the baby's size when it comes to birthing a "big baby"?

A: Unfavorable position is clearly the bigger problem because it affects babies of all sizes, but while, logically, size has to be an issue as well, there are no neat cut-off points. Here is what the research tells us about big babies that can inform strategies for maximizing safe, healthy birth:

  • High BMI women tend to have bigger babies. Take home message: losing weight sensibly before pregnancy might be beneficial.
  • Eating a healthy diet and exercising regularly optimizes sugar metabolism. Take home message: this, too, could optimize fetal weight.
  • When obstetricians wrongly believe (based on sonographic weight estimates) that the baby will be big, women are much more likely to have a cesarean than when the baby actually is big, but the doctor didn't suspect it and vice versa. Take home message: I'm not sure that refusing a weight estimate will help because, as this makes clear, it is a matter of what the obstetrician believes. I think it would be more useful for women to explore early on how her care provider feels about women's ability to birth bigger babies and how he or she handles that situation. Specifically:
    • Inducing labor for "suspected macrosomia (baby predicted to weigh 8 lb 13 oz or more)” increases cesarean surgery rates without reducing incidence of shoulder dystocia (the head is born but the shoulders hang up behind the pubic bone) or delivery injury rates. Take home message: await spontaneous labor onset.
    • Planning cesarean surgery exposes women to the serious potential harms of major surgery. The best way of determining whether the baby is too big to come out is to go through labor and see. Take home message: don't plan surgery.
    • Labor with a big baby is likely to take longer, at least partly because the cervix may have to open further to pass a bigger head. (The "10 cm diameter" definition of full dilation is actually not really 10 cm. For the last few cm of dilation, clinicians measure, not the diameter, but how much rim is left. This means that the true diameter might be a cm or two bigger.) Take home message: find a care provider willing to be patient with a longer labor and who has no preset time limits for making progress.
    • Epidurals, confining women to bed, pushing while reclining or semi-reclining can all impede progress. Take home message: choose a place of birth that allows freedom of movement and plan alternative means of coping with labor pain so as to bypass or delay an epidural. Also, hire a doula. Doulas can help with strategies to promote good progress and increase comfort as well as with emotional support should labor progress slowly.
    • The best "first response" to shoulder dystocia is assuming a hands-and-knees position: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=9610468. Take home message: either plan to give birth in this position or have a plan with the care provider to turn to this position should the shoulders hang up. (With today's modern "light" epidurals, it should be possible to turn to all fours with assistance even with an epidural in place.)

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Q5: When asking questions of my OB provider, what red flags should I pay attention to?

Q: I found you on the Lamaze Int. website and was wondering if I could get your insight. I am almost 34 weeks pregnant with my first child and have recently been exploring the idea of natural labor and possibly hiring a doula. After starting this process (embarrassingly only about two weeks ago), I learned that there were some important questions that I first needed to ask my OB. I wrote my questions down so that I wouldn't forget them and I need your help interpreting what she said.

My first question was regarding whether or not she would actually be able to be present at my birth. Her reply was that she most likely would be because she didn't have any vacations planned around my due date, however if I wanted to be certain that she could be there she could schedule to induce me so that there was no doubt. This was the first red flag and it scared the hell out of me...I don't want to be INDUCED! I was a little scared at this point trying to figure out how the rest of my questions would be answered. I told her that I didn't want to be induced and moved on to the second question.

  1. Mentioning a scheduled induction. [A: Inducing labor roughly doubles the likelihood of labor ending in cesarean surgery. Any induction (even offhand comment) may tell you your OB is willing to expose you to the harms of a major medical intervention when there are no counterbalancing benefits.]
  2. Not wanting doulas to “get in the way” of decision making as caregiver. [A: Your caregiver may attribute any questioning or resistance on the part of her patients to the bad influence of their doulas. "Get in the way of her decision making" means she does not believe in your bedrock medical right to make informed decisions about your care, which, by definition must include the right to informed refusal as well as informed consent.]

Next I asked her how often do any of her patients have a natural child birth and what her thoughts on the matter were. She couldn't give me an exact number, but she said that plenty of her patients have had natural childbirth and explained that her only reservation is that if she feels the mother has been laboring too long that she prefers to administer pain meds to ensure that the mother can "make it" through the entire birthing process. I didn't know how to interpret this response either? Did that mean that she would insist on giving me pain meds if I appeared to be tired or exhausted? Could I refuse them? How often do women who are trying to have a natural childbirth give in and allow their doctors to administer pain meds?

  1. Natural childbirth when a mother can “make it”. [A: This could indicate your caregiver thinks she is entitled to exert complete control over you, including such personal choices as in what manner you wish to cope with labor pain. This may be concerning, as she may decide to perform a cesarean if she thinks you are too tired. No joke. Here is a study in which 13% of cesareans during labor were performed because the ob, by self-report, decided the woman was too tired or for other nonmedical reasons. You want someone who practices what the American College of Nurse-Midwives calls "optimal care." "Optimal care" is the least use of medical intervention that produces the best outcomes given the individual woman's situation. ]
  2. My care provider needs me in a suitable position when the baby is ready to come out. [A: I interpret this as you can push in whatever position you want so long as she isn't there, but for the birth she wants you in the position most comfortable and convenient for her regardless of what works best for you or is optimal for birthing your baby. In actual fact, I would bet nearly all of her patients have epidurals, so it is a non-issue so far as she is concerned. Also, there is that word "control" again. She delivers babies. The care provider you want assists at births.]
  3. Support for an un-medicated birth. [A: What you want--labor starts on its own, freedom of movement, no medical intervention without good reason--is, BTW, your best option for a safe, healthy birth. My recommendation is that you find a practitioner who shares your beliefs and goals. Here are some ways to do that:
  • See if there is anyone local reviewed on The Birth Survey website who sounds good. Ask them the same questions, possibly adding these from the Coalition for Improving Maternity Services website.
  • Tap into the local doulas, midwives, independent childbirth educators (i.e. not teaching at the hospital or in a clinic), International Cesarean Awareness Network chapter leaders and ask for a recommendation.
  • See if there is a birth resource center or birth network in your community.
  • Call your local hospital(s), ask to speak to the nurse manager in the intrapartum unit and ask which of the midwives or doctors are comfortable working with a woman with your goals and preferences.

Also,  I wouldn't worry about cost if the provider you want is out of network. The cost of staying with someone like this ob could be much higher than you would ever want to pay.]

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Q6: What are the dangers of going past 42 weeks gestation?

A:  There is a slight increase in the risk of fetal demise in pregnancies lasting 42 wks or more. According to an analysis of U.S. national data, the probability of fetal death is 0.9 per 1000 in weeks 40 and 41 but rises to 1.7 per 1000 in week 42. That, of course, is based on all women and unborn babies of whatever health status. The odds would undoubtedly be lower in a healthy woman carrying a healthy baby, but it would not be zero.

If this is your first baby, the only study we have of healthy pregnancies beginning labor spontaneously--you can understand that if you look at statistics in all women, preterm births and inductions will pull the curve to the left--found that the median (half the group began labor before and half after) pregnancy length was 41 weeks 3 days. The curve isn't bell-shaped, however. By 42 weeks, a study carried out before it became usual to induce at 41 weeks found that only about 10% of women will not have begun labor.

Here's the thing, though:  inducing labor with an unfavorable cervix doubles your odds of the labor ending in cesarean surgery compared with women having spontaneous labor onset. Research consistently finds that cervical ripening techniques and agents may do a fine job of ripening the cervix, but they don't reduce the excess likelihood of cesarean with induction. If an induction is under discussion, this risk has to be weighed against the risks of awaiting spontaneous labor.

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Q7: Can you tell if a normal, vaginal birth will be successful?

Q: A relative of mine is expecting her first baby. She is still in the first trimester, but her doctor has already told her she is 'borderline' risk because of her size - she is 5'0 and about 100 pounds. She is in her mid-twenties and very fit and healthy. Is she really at higher risk of complications solely because of her size, and if so, what complications are they? Is there any good evidence supporting induction for petite women? From what I've read, you can't tell whether a normal vaginal birth is going to be successful based on measuring the pelvis or guesstimating the baby's size. Also, anecdotally I know of many women who've successfully had healthy average-sized and large babies, but I'd like to have some objective data to point her to.

A: The real risk here is a doctor's belief that you may be unable to birth your baby vaginally. For example, although the specific issue is somewhat different, the concept is the same, I've got six studies all finding that when the ob wrongly believes that the baby is going to weigh more than 4000 grams (8 lb 12 oz), the likelihood of cesarean is substantially increased compared with babies weighing what the baby actually weighs. The reverse is also true: when the baby actually weighs more than 4000 grams, but the ob doesn't suspect it, the cesarean rate is greatly reduced compared with babies actually weighing over 4000 grams. I would strongly suggest you download "Having a Baby? Ten Questions to Ask" from the Coalition for Improving Maternity Services website. It will enable her to gauge whether your doctor practices in a way that best promotes safe, healthy birth. While no one can guarantee you--or any woman, for that matter--that your baby will be born vaginally, you will greatly increase her odds by having a care provider who believes in the ability to birth your baby until proven otherwise.

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Q8: Is it safe to try for a normal delivery if I have flat pelvis?

Q: Is it safe to try for a normal delivery if I have flat pelvis and I would like to have a normal delivery, but my doctor says there is very little chance of delivering. I would like to know if it is safe to try.

A: Short of having a severe pelvic deformity of some kind, the only way to tell if a woman is able to birth a baby is for her to labor. If the baby won't come out despite everybody's best efforts to help that happen--and I emphasize best efforts--then a cesarean may be necessary.  A doctor who is discouraging vaginal birth for less than compelling reasons during pregnancy raises a huge red flag. I recommend you find out your ob's cesarean rate ASAP. If it is much over 15%, the maximum supported by numerous studies and the World Health Organization, or if your ob doesn't know or won't tell you ("I only do them when it's necessary"), take that as a clear sign to find someone else. Even if you decline a recommendation to plan cesarean surgery, you will be laboring under the care of a doctor who has already indicated a preference for cesarean, which means you cannot trust your doctor's judgment. 

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Q9: What books should I read to prepare for birth?

Q: My daughter is having her first baby and is fairly terrified. I bought her a book called Preparation for Birth: The Complete Guide to the Lamaze and I am afraid the comments left in there by other women completely freaked her out even more, so I am looking for another. Is the The Official Lamaze Guide Giving Birth with Confidence any better? Also do you have any classes in London?

A: I have nothing but praise for The Official Lamaze Guide: Giving Birth with Confidence. I also recommend Ina May Gaskin's book, Ina May's Guide to Childbirth for solid, common sense, reassuring information. And if you and your daughter are looking for a book to help your daughter make informed choices about her care, there is my book, The Thinking Woman's Guide to a Better Birth. Finally, on this page, you and your daughter can watch the set of seven "Healthy Birth Practices," which should prove helpful. As for finding a Lamaze educator, I ran a search on "England" on  Lamaze's "find an educator" page, and didn't turn up anyone. Sorry about that.

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Q10: Will my labor be shorter with my third child? When will she engage, and will perineum massage help?

Q: I am 31 weeks pregnant with my third child. I had a few questions that I was hoping you might be able to answer. First because this is my third child does that mean that she won't engage until labor actually starts or will she turn head down before? The perineum massage when should I begin doing that? Will it help at all? Since this is my third child does that mean that this labor will be shorter than the ones I had before?

A: Let me start by clarifying that "engagement" doesn't mean turning head down. Engagement is when the presenting part, normally the head, drops below the pelvic brim into the bowl of the pelvis. In a woman who has had babies before, this often does not happen until labor begins and contractions press the baby downward, but there is no rule about it.

Next, perineal (the tissue between the vagina and the anus) massage has some effect on reducing perineal tears in first-time mothers, but not in women who have given birth before. Much more important is not having a vacuum or forceps delivery, not having an episiotomy, and especially, not having an episiotomy with a vaginal instrumental delivery. Also shown to be helpful is pushing and breathing according to your own internal urges and pushing the head out in between contractions.

As for length of labor, the length is more likely to be like that with your second child than your first, but there is no rule about that either because so many factors can influence labor length. The best I can say is that if you find yourself experiencing a longer labor than you did with your second child, don't worry. It doesn't mean anything is wrong.

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Q11: Are there any risks to get the H1N1 vaccine while pregnant?

Q:  I'm 29 weeks along and I'm in a real quandary trying to decide if I should get the H1N1 vaccine when it becomes available in the next few weeks.  I work with children and their families going into their homes and to daycares and I have lots of contact with school aged children so I am at some risk..  I am a believer in selective, appropriately timed vaccinations but I'm not convinced about the safety or necessity of this one.  My OB is supportive either way but she did say that her (relatively small) practice has already had one woman contract H1N1 and end up on a ventilator. Thankfully she is recovering but she was not as far along as I am/will be and according to my OB the risks are greater the farther along you are.  Is there any info about the research out there on this vaccine?  

A: I have not looked at the research, but as I understand it, pregnant women are at higher risk of severe illness than the general population if they contract H1N1 both because their immune systems are partially suppressed, which is normally advantageous because it protects against reacting to the fetus as a foreign protein, and because pregnancy already puts extra stress on heart and lungs.  The missing piece is the potential harms, if any, of being vaccinated and how likely they are to occur. I suggest you ask your doctor to provide you with sources/info that will give you more information on this side of the equation. She should have access to sources that you (and I, for that matter) do not. I realize that we do not have experience with complication rates with this particular vaccination, but there may be data on similar ones. Meanwhile, here is a Centers for Disease Control (CDC) website with info that you might find helpful. 

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Q12: How should I prepare for the third trimester when classes are unavailable?

Q: I am 29yrs old and in my 7th month of pregnancy.  I am an Indian woman but due to my husband’s job came to Germany.  Due to language problems, I am not able to attend classes. Can you guide me how should I prepare my self in this third trimester? Can I travel? How should I know about the onset of labour? What exercises should I do? Normally I do walking and all household work. Please help me and guide me with your advice and if any literature or cd’s can be provided.

A: I cannot give you any clinical advice such as whether you can travel, but as for how you can prepare yourself, you will find a wealth of information on the "New & Expectant Parents" section of the Lamaze website on how to have a safe and healthy birth. And, in fact, there is a certified Lamaze educator in Germany. I would get in touch with her. Even if she isn't local to you, she may be able to help you further with finding out about your options in Germany.

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Q13: Do you carry differently with a boy versus a girl?

 Q: This is my third pregnancy and I am 32 weeks pregnant. I was never as big as I am now with my two boys. I have had two ultrasounds and the technicians say I’m having a girl. I trust that fully and have even bought pink girlie things. My concern is everyone that sees me and my perfectly round belly say I’m having a boy. I ask them why they say that and they say because of the way I’m carrying. Is it true that you carry differently with a boy than you do with a girl? I thought it was a wives’ tale but more and more people even strangers say it’s a boy. What’s the deal with that??

A: Not to worry. If the sonogram says you are having a girl, it is very seldom wrong. I expect people are just looking for a way to take notice of your pregnancy in a way that isn't too personal, and the old wives’ tales for predicting the baby's sex are a way of doing that.

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Q14: Should I experience lightening by my 38th week?

Q: I am currently in my 38th week and haven't yet experienced lightening. As this is my first pregnancy, I am little worried about the same. I would appreciate if you can tell me some exercise/posture that will help me deliver my baby normally.

A: For some women, the baby does not engage in the pelvis until labor starts. Don't worry too much. Having "dropped" or not "dropped" doesn't change when your baby will be ready to be born. I never noticed any lightening with any of my children (4 of them).

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Q15: What is the difference between delivery to conception and cesarean to conception?

A: Conn Med. 2000 Nov;64(11):659-61.

Interpregnancy interval as a risk factor for placenta accreta. 

Wax JR, Seiler A, Horowitz S, Ingardia CJ.

Source

University of Connecticut School of Medicine, USA.

Abstract

OBJECTIVE: To determine if the interval from a previous delivery or cesarean to the next conception differs between patients with abnormally adherent placentas as compared to those with normally implanted placentas.

METHODS: We identified all histologically confirmed placentas--accreta, increta, and percreta--at our hospital from 1992-1999. Subjects were excluded for primigravidity in the affected pregnancy or inability to identify matched controls. Cases were matched to the next three consecutive women delivering for maternal age (> or = 35 years or < 35 years), placenta previa (yes or no), prior cesarean (yes or no), prior uterine curettage (yes or no), and prior vaginal delivery (yes or no). The primary outcomes were delivery-to-conception and cesarean-to-conception intervals. Secondary outcomes included measures of maternal and neonatal morbidity.

RESULTS: Delivery-to-conception intervals for cases and controls were 37.1 +/- 18.7 months and 37.9 +/- 22.7 months, respectively (P = .91). Cesarean-to-conception intervals for cases and controls were 35.2 +/- 18.2 and 48.1 +/- 31.0 months, respectively (P = .35). Cases were more likely to require uterine curettage (54.5 vs 0%), hysterectomy (81.8 vs 0%), and transfusion (72.7 vs 0%), all P < .001. Subjects with accreta delivered earlier (31.7 +/- 9.4 vs 38.1 +/- 2.6 weeks, P = .054) and smaller infants (2,158 +/- 1,180 g vs 3,159 +/- 781 g, P = .006) who were more likely to have five-minute Apgar scores < 7 (18.2% vs 0%, P = .038). 

CONCLUSIONS: Cesarean-to-conception intervals but not delivery-to-conception intervals are shorter in patients with abnormally adherent placentas. Placenta accreta is associated with significant maternal and perinatal morbidity.

I've pasted in the abstract of the study for convenience. Unfortunately, I can't get a copy of the actual journal article as it's not in a major journal. As far as I can make out from the abstract alone, the authors conclude that women with placenta accreta (cases) had shorter intervals from when they had the cesarean to conception of the next pregnancy than women who had cesareans but didn't develop placenta accreta (controls). This was not true for women who had accreta and had (presumably vaginal) delivery in the prior pregnancy (cases) versus women with vaginal delivery who didn't have accreta (controls). However the p value, the probability that the difference wasn't due to chance, was 0.35, much higher than 0.05, the usual threshold for determining statistical significance. The usual threshold means that there is a 5 in 100, or 1 in 20, probability that the difference is due to chance. Without the study itself, I can't tell more about why they came to this conclusion when the p value didn't justify it. The rest of the outcomes reported in the abstract were what you would expect, that is, women with placenta accreta are at very high risk for severe complications compared with women who don't have accreta. 

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Q16: Is it possible to have a natural birth?

Q: I was referred to you as a source of information related to my previous abdominal myomectomy. I am currently in the second trimester of my pregnancy and have been desperately trying to find evidence to support my desire for a natural birth. I have been able to find information on natural births after an abdominal myomectomy?

A: I have never researched the topic of planned vaginal birth after myomectomy. That being said, I ran a search on PubMed, the (U.S.) National Library of Medicine's website. I limited the search to studies in English published in the last 10 years and found this one and this one and this one (same authors but different population as the first one) and this one turned up when I looked at "related studies" to the first one. However, all of them were studies of laparoscopic myomectomy. The total number of women planning vaginal birth after laparoscopic myomectomy was not huge, but none had a uterine rupture in labor, and the numbers were big enough to show that scar rupture is not unduly frequent. We don't know, though, whether those results would apply to abdominal myomectomy. I wish I could have been more helpful on this point, although in the U.S., at least, it probably wouldn't matter. Few U.S. obs will agree to planned vaginal birth after cesarean, where we do have a great deal of evidence of safety and efficacy, so I would anticipate that even fewer would be willing to take you on.  If you will be planning a cesarean, I recommend this page on the International Cesarean Awareness Network website to help you plan a family centered experience.

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Q17: If I have gestational diabetes, should I receive extra ultrasounds, OB check-ups, and maintain a food/glucose level log?

Q: I am currently 28 weeks pregnant.  I did the routine glucose tolerance test at 19 weeks and it came as a 9.2 after 2 hours.  My fasting level was 5.3, after 1hour it was 10 and then 9.2 after 2 hours.  The 'healthy' range should be no more than 8.0 after 2hours, so I don't consider this really a huge issue.  However I have been labeled with gestational diabetes and have been sent to see an OB to be closely monitored for baby size...they request I do an ultrasound every two weeks and based on results, they may recommend early induction. 

I have done a good journal and taken my blood glucose level 4 times a day with a home kit.  My fasting numbers have always been in the healthy range (less than 5.5) and two hours after meals have also been in healthy range (less than 7.0)...(except when I have indulged a couple of times in high sugar/carbs where the highest was 8.3).  None of these figures worry me at all.  I don't feel they are excessively high at all. 

I have read your articles on gestational diabetes and I really feel they 'gel' with me.  I do not find it necessary to do any extra ultrasounds or see the OB every two weeks, as I am concerned that the belief that I may have a big baby will alter the care I receive (induction etc) and also may affect my positive attitude to my birthing experience. 

I live in a small town in Western Australia and only have access to one public hospital.  We have no home-birth doulas, which is my preference. 

What is your opinion on receiving extra ultrasounds and OB check-ups and maintaining a food log/blood glucose levels...?

A: Blood sugars can rise as pregnancy progresses, so you will probably want to continue eating a diet that puts less stress on your pancreas and monitoring blood sugar as well as getting regular exercise. (Speaking of which, I hope that your OB has referred you to someone trained in advising pregnant women with a tendancy to high blood sugar on diet.) The bigger problem as I see it is that I have skimmed the evidence report underpinning the March 2013 U.S. National Institutes of Health conference on gestational diabetes. Nowhere is there support for frequent ultrasounds or for inducing labor as a means of improving outcomes. In fact, increased induction of labor is listed as one of the harms of being identified as a gestational diabetic. Here are the relevant passages from the report that came out of this conference:

4. Does treatment modify the health outcomes of mothers who meet various criteria for gestational diabetes mellitus and their offspring?

We also have very solid data that inducing for suspected big baby in general increases likelihood of cesarean without improving outcomes and that when the OB suspects the baby is large (estimated birth weight > 4 kg), the woman is much more likely to have a cesarean then when the baby actually is that big, but the OB didn't suspect it. Here are the studies establishing that induction for suspected big baby is not helpful:

Irion O, Boulvain M. Induction of labour for suspected fetal macrosomia. Cochrane Database Syst Rev 1998(2):CD000938.

Sanchez-Ramos L, Bernstein S, Kaunitz AM. Expectant management versus labor induction for suspected fetal macrosomia: a systematic review. Obstet Gynecol 2002;100(5 Pt 1):997-1002.

Here are studies showing that what your OB thinks he knows about your baby's size can hurt you:

Levine AB, Lockwood CJ, Brown B, et al. Sonographic diagnosis of the large for gestational age fetus at term: does it make a difference? Obstet Gynecol 1992;79(1):55-8.

Melamed N, Yogev Y, Meizner I, et al. Sonographic prediction of fetal macrosomia: the consequences of false diagnosis. J Ultrasound Med 2010;29(2):225-30.

Parry S, Severs CP, Sehdev HM, et al. Ultrasonographic prediction of fetal macrosomia. Association with cesarean delivery. J Reprod Med 2000;45(1):17-22.

Sadeh-Mestechkin D, Walfisch A, Shachar R, et al. Suspected macrosomia? Better not tell. Arch Gynecol Obstet 2008;278(3):225-30.

Weeks JW, Pitman T, Spinnato JA, 2nd. Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? Am J Obstet Gynecol 1995;173(4):1215-9.

Weiner Z, Ben-Shlomo I, Beck-Fruchter R, et al. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Eur J Obstet Gynecol Reprod Biol 2002;105(1):20-4.

If you continue to have a healthy pregnancy and blood sugar remains under control, you may wish to refuse monitoring and induction--or any other tests or procedures for that matter--unless your care provider can demonstrate to your satisfaction that the benefits of undergoing them outweigh the potential harms.

. . . One randomized controlled trial has shown higher induction of labor rates in women with GDM compared to normal controls. Women with GDM are more likely to undergo increased maternal and fetal monitoring. Subjective interpretation of ultrasound findings and fetal non-stress tests produces a high rate of false positives and is a factor in unnecessary induction of labor leading to failed inductions and cesarean delivery. Data regarding the effect of changing the diagnostic criteria for GDM on inductions are uncertain.

Cesarean rates may be higher in women given the diagnosis of GDM, and it is uncertain whether treatment can mitigate this increase. Cesarean delivery is associated with a higher rate of short- and long-term complications.

6. Given all of the above, what diagnostic approach(es) for gestational diabetes mellitus should be recommended, if any?

. . . There also is evidence that treatment of women with GDM—diagnosed either by the one-step or two-step approach—may improve some outcomes. Outcomes that have been improved with treatment include the frequencies of macrosomia, large-for-gestational-age birth weight, shoulder dystocia, and hypertensive disease of pregnancy. Despite improvements in these intermediate outcomes, the frequencies of composite neonatal morbidity and cesarean delivery have not been consistently improved with treatment. Long-term outcomes for mothers and their offspring have not been improved in the few studies that have been performed.

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Q18: Are there any complications to natural birth with a gastric bypass?

Q: Are there any complications to natural birth with a gastric bypass? Are there any studies? Any contraindications to a natural labor and delivery or any particular interventions? Thanks!

A: I ran a search on PubMed on the terms "labor, obstetric" and "gastric bypass" and came up with this study. I don't have access to the study, though, to see what were the labor complications mentioned in the abstract. PubMed gives you a list of "related articles" when you call up a study, so I clicked on this review, published in 2009, which found that there could be nutritional problems during the pregnancy. The review can be accessed for free here, so I skimmed it and found that it reported similar cesarean rates rates to those in high BMI women. Another "related article" listing was this review, published in 2012, which said more or less the same thing as the earlier review in its abstract, that is, that there may be nutritionally related complications and that the effect on cesarean rate is unclear. Taken together, I would conclude that while pregnancy after gastric bypass increases the risk of some complications, there is nothing to suggest that labor requires anything special or different provided the woman and fetus are healthy at its onset.

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Q19: Can I start labor naturally with GD?

Q: I am 37 weeks pregnant with my third child. I was diagnosed with GD at 18 weeks; I had it with baby #2, which is why I was screened early. I began my pregnancy with normal BMI and have gained 32 pounds to date. I take 22u of NPH insulin at night to control my morning blood sugars (target below 95). I have successfully controlled daytime blood sugars with diet. Baby has been monitored twice weekly since 32 weeks (NST on Mondays, biophysicals on Thursdays) and has passed each test with flying colors.

Last week, my OB told me she wanted to induce at 39 weeks. She indicated that this was "the standard of care" recommended by ACOG for women with insulin-dependent GD. I protested, saying that I carried my second child to term. (He weighed 8 lb 14 oz - I delivered him without pain meds and with minimal pushing - his blood sugar did crash following the birth, but I labored at home and had not been instructed about how to monitor my glucose levels during labor.)

At today's biophysical, baby measured 7 lb 4 oz. I'm aware of the high margin of error, but I'm worried this measurement is only going to fuel my OB's fire. Can you please provide me with some studies and/or statistics I can share with my OB, to support my desire to start labor naturally? I don't like the idea of laboring with Pitocin (which would likely equal pain meds), nor am I interested in forcing baby out before she's ready.

A: As far as I know, the only reason to induce a woman with well-controlled diabetes is to reduce the likelihood of having a big baby and the problems that can go along with having a big baby, in particular, need for cesarean surgery or shoulder dystocia (the head is born but the shoulders hang up behind the pubic bone). The babies of women whose diabetes is under control are not at increased risk for other harms unless the mother experiences the serious complications affecting her health that can accompany long-term diabetes, a situation that doesn't describe you. You can see logically why the latter should be so: if your sugar levels are normalized by treatment, and you don't have any other medical complications, then you do not differ from a healthy pregnant woman who doesn't have diabetes. Here, then, is a systematic review of the medical research that addresses the "big baby" issue:

Obstet Gynecol. 2002 Nov;100(5 Pt 1):997-1002. Expectant management versus labor induction for suspected fetal macrosomia: a systematic review.

OBJECTIVE: To systematically review and summarize the medical literature regarding the effects of expectant management and labor induction on mode of delivery and perinatal outcomes in patients with suspected fetal macrosomia. DATA SOURCES: We supplemented a search of entries in electronic databases with references cited in original studies and review articles to identify studies assessing management of patients with suspected fetal macrosomia. METHODS OF STUDY SELECTION: We evaluated, abstracted data, and performed quantitative analyses in studies assessing the outcome of patients with suspected fetal macrosomia. Observational studies and randomized trials were included in this systematic review. TABULATION, INTEGRATION, AND RESULTS: Twenty-nine studies were identified, 11 of which met our criteria for systematic review and meta-analysis. These 11 studies included 3751 subjects. Of these, 2700 were managed expectantly, and 1051 underwent labor induction. We calculated an estimate of the odds ratio (OR) with 95% confidence intervals (CIs) for dichotomous outcomes, using random- and fixed-effects models for outcomes. Summary statistics for the nine observational studies showed that, compared with those whose labor was induced, women who experienced spontaneous onset of labor had a lower incidence of cesarean delivery (OR 0.39, 95% CI 0.30, 0.50) and higher rates of spontaneous vaginal delivery (OR 2.07, 95% CI 1.34, 3,19); however, significant differences in these outcomes were not noted when the two randomized trials were assessed. No differences were noted in rates of operative vaginal deliveries, incidence of shoulder dystocia, or abnormal Apgar scores in the analyses of the observational or randomized studies. CONCLUSION: Based on data from observational studies, labor induction for suspected fetal macrosomia results in an increased cesarean delivery rate without improving perinatal outcomes. Although their statistical power is limited, randomized clinical trials have not confirmed these findings.

The best way to avert harm from shoulder dystocia to either baby or mother is the Gaskin maneuver, which is getting onto all fours either when a big baby is anticipated and the care provider believes shoulder dystocia is likely or in response to it. It can be done even if the woman has had an epidural if she has a little assistance, but my personal recommendation would be to avoid an epidural when the odds are good, as they are in your case, that the baby is going to be on the large side. You will be able to push more effectively and in a greater variety of positions. Here is the study on the Gaskin maneuver. The abstract doesn't tell you this, but the study compares outcomes with other studies using other techniques, and the Gaskin maneuver wins hands down in terms of safely getting the baby born.

Bruner JP, Drummond SB, Meenan AL, et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43.

OBJECTIVE: To report on a large amount of clinical experience with shoulder dystocia managed primarily with the all-fours maneuver. STUDY DESIGN: The all-fours maneuver consists of moving the laboring patient to her hands and knees. Eighty-two consecutive cases of shoulder dystocia managed with this technique were reported to a registry through January 1996. RESULTS: The incidence of shoulder dystocia was 1.8%, and half of the newborns weighed > or = 4,000 g. Sixty-eight women (83%) delivered without the need for any additional maneuvers. The mean diagnosis-to-delivery interval was 2.3 +/- 1.0 (SD) minutes (range, 1-6). No maternal or perinatal mortality occurred. Morbidity was noted in only four deliveries: a single case of postpartum hemorrhage that did not require transfusion (maternal morbidity, 1.2%), one infant with a fractured humerus and three with low Apgar scores (neonatal morbidity, 4.9%). All morbidity occurred in cases with a birth weight > 4,500 g (P = .0009). CONCLUSION: The all-fours maneuver appears to be a rapid, safe and effective technique for reducing shoulder dystocia in laboring women.

In order to make an informed decision, you are entitled to information on the benefits vs. harms of all your options, including doing nothing. The fact that ACOG recommends a practice does not tell you anything about these. You may well wish to find out on what grounds ACOG recommends induction at 39 weeks. Don't allow yourself to be rushed into a decision. As a friend of mine says, "Deciding to induce labor is never an emergency." Finally, if, after considering the pros and cons of inducing labor vs. awaiting spontaneous labor, you decide to await labor, you should know that you have a right to informed refusal as well as informed consent.

One more thing to be aware of:  the tests of fetal well-being all have high false-positive rates, that is, the test says the baby has a problem when it doesn't. If a test comes up "iffy," repeating the test or doing a different test will reduce the odds of a false positive. Also, make sure you are not dehydrated before having amniotic fluid volume measured.

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Q20: Is there any research evidence to suggest that placentas calcify or "fail" more often with a GD diagnosis?

Q: In our area, the OBs and even CNMs play the "failing placenta" card with GD moms to coerce them into induction. Is there any research evidence to suggest that placentas calcify or "fail" more often with a GD diagnosis? I would be interested in an analysis of the literature, as they do talk about "the studies," and even those CNMs who would not induce for "big baby" do seem genuinely concerned with BPPs and induction for GD moms, because of this placenta/stillbirth concern.

A: Not that I'm aware of but then I haven't systematically researched GD for several years. Still, if a woman's sugar levels are under control, and she was not a pregestational diabetic, how is she different from a pregnant woman who doesn't have GD? It is also important to remember that inducing labor is not harmless. Among other potential harms, it increases the likelihood of cesarean surgery, especially in first-time mothers. I would ask those who refer to "the studies" for copies so you can educate yourself on this issue. If they have some, I would be happy to review them and comment.

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Q21: I want to comment on one argument that you have made in several replies with regard to labor induction for GD patients at 39 weeks.

Q: I want to comment on one argument that you have made in several replies with regard to labor induction for GD patients at 39 weeks. Your argument is that if the patient has good blood sugar control, then she does not differ from other normal pregnant women. It follows that her treatment should not differ from others as well. This argument is not necessarily water-tight. A GD patient with good sugar control may appear to be the same as normal pregnant women in terms of blood sugar level, but she has the underlying etiology, which can produce problems even when sugar level is under control. Unless one assumes that sugar level is the only damage to a pregnancy, and denies other possible effects caused by the underlying etiology, one simply cannot treat GD women the same way as other normal pregnancies.

A: Yes, but what is the etiology associated with stillbirth? Women with diabetes of long standing, almost certainly type 1 (insufficient insulin) if we are talking of women of childbearing age, are at risk because over time, diabetes can damage blood vessels and kidneys, which poses risk to the fetus. Wild swings in sugar levels--sugar control becomes more difficult in pregnancy with type 1 diabetics--can also harm the fetus. With rare exceptions, women with GD do not have diabetes of long standing. They also have a different type, a version of type 2 (insulin resistance). They make adequate amounts of insulin but blood sugars are elevated nonetheless. In fact, most GD women would not be considered to have diabetes at all were they not pregnant. The diagnostic criteria are lower than that for anyone else, and the threshold is arbitrary. It marks neither the onset nor increase in adverse outcomes. And there is another explanation for an association: women with elevated blood sugar are much more more likely to be women of high body mass index (BMI). Women with high BMI are also more likely to have medical problems such as hypertension that increase fetal risk. In other words, GD isn't causal but associated with complications that are the real risk, and, in fact, I have a study from years ago that showed that the excess stillbirth rate in a population of women with GD could be explained by other risk factors.

The only strong stance I take is that women should make informed choices based on accurate, unbiased information on the potential benefits and harms of all their options, including doing nothing. This, unfortunately, is hard to come by with conventional medical management.

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Q22: I have controlled GD and additional risk factors (thrombocytopenia, advanced maternal age, IVF pregnancy, previous miscarriages) so is an induction medically necessary?

Q: I have controlled GD and additional risk factors (thrombocytopenia, advanced maternal age, IVF pregnancy, previous miscarriages) so is an induction medically necessary? So all in all, I wanted to ask your opinion - do any of these risk factors, combined with the controlled GD, mean that an induction is something medically necessary?

A: What leapt off the page in your post is that you are at risk for excessive bleeding because of a low platelet count. Inducing labor has consistently been found to be associated with postpartum hemorrhage (see below for list of studies), and with your condition, you would be at extra risk for this. Furthermore, inducing labor with an unripe cervix, something that would be more likely if you are induced based on a preset pregnancy duration, is strongly associated in 1st-time mothers with labor ending in c/sec surgery. (Strategies to ripen the cervix do a good job at this, but they don't reduce the excess risk of c/sec compared with labors that start on their own probably because there is more to the uterus being ready to contract effectively than a favorable cervix.) C/sec surgery is also more likely to result in excessive bleeding among its many other potential complications.

If, after discussion with your doctor, you agree that induction is medically necessary in your case, here's what I would do in your shoes:

  • I would discuss the balance of benefits vs. harms if the cervix isn't ready to go.
  • If it isn't already your doctor's policy, I would insist on using the dosing regimen listed on the Pitocin package (see below), NOT a high-dose/short interval regimen. The dosages on the package are in line with what your body produces naturally, and an interval of at least 30 min before increasing the dose allows it to reach its full effect. Postpartum hemorrhage with induction is strongly associated with what dose you receive and over how long a period: Grotegut CA, Paglia MJ, Johnson LN, et al. Oxytocin exposure during labor among women with postpartum hemorrhage secondary to uterine atony. Am J Obstet Gynecol 2010. 
  • I would refuse rupture of membranes. That way, if the induction doesn't "take," you can stop, go home, and try another day, but once membranes are ruptured, you are committed to delivery. 

Al-Zirqi I, Vangen S, Forsen L, et al. Effects of onset of labor and mode of delivery on severe postpartum hemorrhage. Am J Obstet Gynecol 2009;201(3):273 e1-9.

Al-Zirqi I, Vangen S, Forsen L, et al. Prevalence and risk factors of severe obstetric haemorrhage. BJOG 2008;115(10):1265-72.

Bais JM, Eskes M, Pel M, et al. Postpartum haemorrhage in nulliparous women: incidence and risk factors in low and high risk women. A Dutch population-based cohort study on standard (> or = 500 ml) and severe (> or = 1000 ml) postpartum haemorrhage. Eur J Obstet Gynecol Reprod Biol 2004;115(2):166-72.

Combs CA, Murphy EL, Laros RK, Jr. Factors associated with postpartum hemorrhage with vaginal birth. Obstet Gynecol 1991;77(1):69-76.

Driessen M, Bouvier-Colle MH, Dupont C, et al. Postpartum Hemorrhage Resulting From Uterine Atony After Vaginal Delivery: Factors Associated With Severity. Obstet Gynecol 2011;117(1):21-31. 

Magann EF, Evans S, Hutchinson M, Collins R, Howard BC, Morrison JC. Postpartum hemorrhage after vaginal birth: an analysis of risk factors. South Med J 2005;98:419-22.

Rossen J, Okland I, Nilsen OB, et al. Is there an increase of postpartum hemorrhage, and is severe hemorrhage associated with more frequent use of obstetric interventions? Acta Obstet Gynecol Scand 2010;89(10):1248-55.

_____________________________________________________________________________

Pitocin Label Excerpt (King Pharmaceuticals 2007)

Administration: The initial dose should be 0.5-1 mU/min . . . . At 30-60 minute intervals the dose should be gradually increased in increments of 1-2 mU/min . . . . [I]nfusion rates up to 6 mU/min give the same oxytocin levels that are found in spontaneous labor. . . . [R]ates exceeding 9-10 mU/min are rarely required. Overdosage: Hyperstimulation with strong (hypertonic) or prolonged (tetanic) contractions or a resting tone of 15 to 20 mm H2O or more between contractions can lead to tumultuous labor, uterine rupture, cervical and vaginal lacerations, postpartum hemorrhage, uteroplacental hypoperfusion, and variable deceleration of fetal heart, fetal hypoxia, hypercapnia, perinatal hepatic necrosis or death.

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Q23: Can I help change my breech baby’s position?

Q: I am pregnant with my first Baby and I am 33 weeks. I just went to my doctor and she told me that my baby is in a breech position. I know there is still time and he can turn to the right position but I don't want to take any chances on having a c-section. Are there exercises or something to do to make my baby change his position?

A: Yes, there is. Here are two strategies for turning a breech baby: moxibustion and the Webster chiropractic technique. If the baby doesn't turn, ask your midwife or doctor to schedule an external cephalic version at around 36 weeks or so. This is a hands to belly technique in which guided by an ultrasound image, the doctor tries to turn the baby into a head down position. 

You should also know that planned vaginal birth with a breech baby is a reasonable option for most women carrying a breech. You may wish to see if any care providers in your community are knowledgeable and skilled in vaginal breech birth. Unfortunately, few care providers have acquired the skill, but it is always possible. If there is a local birth network or an ICAN chapter, they are likely to know. Some communities have a birth resource center, and the folks there are likely to know as well.

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Q24: What should I be aware of with only one artery in the umbilical cord?

Q: My problem is this:  At about 20 weeks the doctors said they found only one artery in the umbilical cord.  Since then it had been non-stop monitoring.  I have been getting an ultrasound every three weeks all in the name of “better safe than sorry”.  Every time I go in they tell me about the eventual problems that may occur, but scans have always shown the baby having a normal growth rate and further ultrasounds ruled out any birth defects. At my last visit they said that the umbilical flow is “borderline normal” and now they want to monitor me with ultrasounds once a week.

My questions are these:  How do I stay confident?  All this testing and constant hospital visits make me feel incapable, what can I do?  Sometimes I would like to quit all this testing and just carry out the pregnancy normally, would that be a irresponsible decision?  Do you know what could happen to me or my baby if I refused further monitoring?

Have you ever heard of such a situation or know to whom I could refer that has had experience with something similar? If you could offer me any kind of advice, it would be greatly appreciated.  If not could you refer me to anyone (or anything online) that could help answer my questions?   

A: I searched on "single umbilical artery" on Medline Plus, the U.S. National Library of Medicine's consumer health site and came up with this. It doesn't say anything more than what you already know, that is, that babies are more likely to have other abnormalities, which has been ruled out in your case.

From what I can judge from your post, it isn't so much that your baby has a problem that is causing you distress but that you are feeling in the dark about what the problem means and what might need to be done about it. Here are some questions you may wish to ask:

  1. Now that we have ruled out other abnormalities, what are the potential problems, if any, with having a single uterine artery? If there are problems, how likely are they to occur?
  2. What are you looking for when you perform (insert name of test)? How accurate is this test at predicting a problem?
  3. What treatment will you recommend if (insert name of problem) occurs? If that doesn't resolve the problem, what would be the next step?
  4. Can you please direct me to where I can get more information on this issue?

Barring an emergency, you will want to make informed decisions about your care. This is not only what will best take care of you and your baby, it is also your legal right. This acronymn will help.

Benefits: Why is this drug/procedure/restriction being recommended?

Risks: What are its risks? How likely are they to occur? What other medical interventions might be needed as a result of this one?

Alternatives: What are my other options, including doing nothing? What are the benefits and risks of each of those?

Intuition/instinct: Once you have the information, allow yourself time to process it, and then listen to what your heart is telling you.

No or not now: You ask if it would be irresponsible to refuse further tests or treatments. Once you know the benefits and risks of the proposed test or treatment, you will know the answer to this question. If you decide to say "no" or "not now," discuss the circumstances that would change that answer.

During the discussion, ask yourself whether you are getting information or feelings. Hopefully, you are getting facts neutrally presented, but unfortunately, it is not uncommon for care providers to attempt to scare or bully women into doing what the care provider wants to do. If you find this to be the case, I would seriously think about changing care providers. Whatever the situation, you want care providers who respect and trust you and consider you a full partner in the decisions made about your and your baby's care. If it comes to looking for a different doctor, get back to me. I can give you some ideas for how to go about that and what to look for.

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Q25: As an older woman, do I have a greater risk for stillbirth and therefore should have an induction?

Q: I now have a client who is older and her doctor suggests induction at 40 weeks because she is at greater risk for stillbirth. I have done some checking on line with various studies and found a systematic review from nbci. and they conclude that older women are at risk for stillbirth. http://www.ncbi.nlm.nih.gov/pubmed/18195290

An excerpt from this link: 'INTERPRETATION: Women with advanced maternal age have an increased risk of stillbirth. However, the magnitude and mechanisms of the increased risk are not clear, and prospective studies are warranted.'

As well there is this link: http://www.scienceandsensibility.org/?tag=risks-of-stillbirth which discusses a very large Norwegian study done that came to the same conclusion regarding maternal age and increased risk of stillbirth.

Based on this information it would appear that induction should be undertaken. Is there any other more recent study or studies that have given a clearer interpretation, reducing the variables to rule out factors such as diet, whether a first or subsequent pregnancy, previous C-sec, etc.?

My client wants to avoid unnecessary interventions, a C-section and induction but in light of this research, how can she say no? She is also aware of the risk of induction increasing her chances of a Cesarean. Caught between a rock and a hard place. Any other information would be greatly appreciated so she can be fully informed prior to making a decision.

A: I could take a look at the studies, and I'm willing to bet there are weaknesses--indeed, Kimmelin points out some in the Norwegian study in her Science and Sensibility post. One I've found before is that investigators fail to take "prior cesarean" into account, which a number of studies have found to be associated with unexplained stillbirth. (The placental attachment complications associated with prior cesarean increase risk of stillbirth as well, although these may be accounted for by excluding women with antenatal hemorrhage.) Older women are, of course, more likely to have a prior child or children. However, I think the best that can be done here if your client is feeling anxious is to minimize the risk of an induction ending in a preventable cesarean. This she can do by refusing induction unless the cervix is ripe (Bishop score of at least 6 on a scale of 1-10 and higher is better). Cervical ripening does a great job of ripening the cervix, but it doesn't reduce the excess c/section rate. If her cervix isn't ready for labor, the risks of cesarean for her and her baby and any future babies will surely outweigh the miniscule risk of a sudden antenatal demise in a healthy woman carrying a healthy baby. If she is induced, refuse rupture of membranes. That way, if the induction doesn't take, she can go home and try again another day, but once membranes are ruptured, she is committed to delivery by one route or the other. She should also request a physiologic oxytocin (Pitocin) dosing regimen, as opposed to an "active management" one. This will minimize the chance of fetal distress, and it will get the job done, although it may take longer. The dosing regimen comes with the Pitocin package. A gentle, serial oxytocin induction is actually a good way to go, although I doubt it will ever catch on because it isn't as cost effective for the hospital.

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Q26: Are there greater risks for IVF babies to go past their due date?

Q:  I'm 40 weeks, 4 days - 4 days past my due date.  The expected baby is a mini-IVF baby.  I understand that Lamaze's healthy birth practice is to let labor start on its own.  Are there any reasons why this may not apply to IVF babies?  I did some Googling and it appears that some doctors are very nervous about having IVF babies go past their due date, perhaps because of concerns that the placenta may not hold up as well as for non-IVF babies due to deterioration of placenta.

My doctor would like to start induction tonight because the baby is past its due date, because the head size is in the 99th percentile, and also there was a blip on the non-stress test which may possibly indicate impingement of umbilical cord. He says there is increased risk of sudden fetal death syndrome if one waits past the due date.  Of course, I'd prefer the natural route if at all possible if safe for the baby and myself. 

A: I do not know whether IVF poses any excess risk to the baby after an otherwise healthy pregnancy compared with babies conceived without the use of technology, but I can tell you that risk in general does not rise after passing a 40 wk due date. According to an analysis of U.S. national data, the rate of antenatal demise holds steady in weeks 40 and 41 at 1 per 1000 and then rises in the 42nd week to 2 per 1000. Moreover, that is in the population overall. Many factors affect the risk of stillbirth, so the risk is undoubtedly less for a healthy woman carrying a healthy baby.

I can also tell you that women are not "overdue" at 40 wks. The whole concept of a 40-week due date arose from a German obstetrics professor who declared by fiat that pregnancy lasted 10 lunar months (10 months of 4 weeks each) starting from the beginning of the last menstrual period. In actual fact, a large study found that, depending on age and and whether this a first or subsequent birth, at least 25% of women had not given birth by 41 completed weeks (287 d) whereas by 42 weeks, only 10% remained undelivered. Ten percent is a defensible definition for postterm; 25% or more is not. Moreover, in population studies, preterm births and induced labors pull the statistical curve to the left. A study of healthy women with a single, healthy baby who reached term found that the median length of pregnancy in 1st-time moms was 41 wk 1 day. That is, half the population gave birth before that day and half after with all but a few percent going into labor by 42 completed weeks. For women with prior births, the median length was 40 wk 3 days.

The reason all this matters is that inducing labor is not harmless. In first-time moms, it roughly doubles their likelihood of cesarean surgery, which has potentially serious adverse effects not only for the mom and babe of the current pregnancy but of future pregnancies as well.

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Q27: I’m diabetic, and my doctor is concerned about placenta viability and the baby’s size – is induction necessary?

Q: I was diagnosed with Type 2 Diabetes in January and conceived in April just after getting my blood sugar under control (after it being at near-comatose levels).  I had my first child in 2000 and she was 9lbs 14oz and I carried her a month over her due date.  I was young and now looking back on things I realize that the doctors and nurses did not take the time to give me options that they should have, nor did they keep adequate monitoring of my baby as she grew so we would know (a) that the due date they first gave me was wrong (everyone went by implantation date instead of actual last menstrual date) and (b) she was so large.  Her size shocked everyone involved and I had a very difficult labor and delivery.  Combine that with the fact that my spine is not straight enough to allow an epidural to be effective and the fact that they gave me Pitocin at just about five hours after the start of labor (they decided labor wasn't proceeding fast enough), as well as the fact that I hemorrhaged after giving birth to my daughter due to the uterus no longer contracting (enough so that they had to give me 4pts of blood before I left the hospital)...and you have a very difficult and traumatic first labor experience.

Bottom line, after telling my OB all of this, she informed me that they would rather induce labor and not let the pregnancy go beyond 40 weeks.  She said that she's concerned about placenta viability and the size of the baby.  So far, his growth is normal, but that can apparently change (what, with my having an ability to create larger babies anyway and that having been prior to being diabetic).

My question is this: With being now 31 and now diabetic, is induction really necessary?  I would prefer to have as natural a birth as possible (including no pain meds and would rather not induce), so I would like to avoid induction if possible.  Is it outlandish to ask my OB to NOT induce?  Or is this a sufficiently high-risk pregnancy that I have to go ahead with the induction process?

I should add that my blood sugar is being nicely monitored and kept at correct levels via use of insulin, and my diabetes doctor and nurse are VERY happy with my ability to keep it under control and at my health status.  They're very pleased that I'm doing so well!  So, this isn't a case where things are out of control or crazy...it's going very very well.

A:  Logically, if your blood sugar is under good control and you have no other health problems such has hypertension, then there should be no reason to put you at higher risk for placental insufficiency and therefore to treat you any differently from any other healthy woman whose blood sugars remain within normal range without need for extra insulin. If the concern is the size of the baby, birth weight is far more strongly associated with maternal prepregnant weight than her blood sugar. This means that if you are a plus-sized woman--which your story suggests you might be--your baby is likely to be bigger than average regardless of your blood sugars. So let's focus in on what maximizes your chances of a safe, healthy, normal birth of a plus-sized baby. 

Let me start by saying that the problems with your first birth might have been inevitable, but how your labor was managed could well have contributed to or caused your problems. Pitocin (oxytocin) in high doses is strongly associated with postpartum hemorrhage. You do not say whether your ob cut an episiotomy or whether you had a vacuum extraction or forceps delivery, but these, too, increase bleeding. As for starting Pitocin, slower progress is normal with a bigger baby. It isn't clear whether there was truly a need to get things or going or what was needed was more patience. Moreover, labor progress can be inhibited when the woman is in an environment that provokes fear and anxiety, she lacks good labor support, is kept from eating and drinking, and has little or no freedom of movement in the dilation phase and is not free to choose her pushing position. 

The good news is that you birthed a baby of this size vaginally at your first birth. That means you have a wonderful pelvis and a terrific uterus and are almost guaranteed to be able to birth a baby of the same size or bigger with greater ease at this next birth! Here is some general information on what makes for a safe, healthy birth. When expecting a baby of size, the recommendations of having labor start on its own, mobility, avoidance of epidural analgesia, pushing according to your inner urges in the position(s) of your choice have even more importance. In addition, giving birth on hands and knees or side-lying is the best way to minimize the chance of shoulder dystocia (the head is born but the shoulders get caught behind the pubic bone). Should it occur, turning to hands and knees is the best way to prevent adverse outcomes for baby and mother, as this study makes clear. You may also want to feel out your ob's confidence in your ability to birth a big baby. I have a bunch of studies of ultrasound weight estimates (which are often inaccurate) consistently showing that when the doctor believes the baby is going to be large (over 8 lb 12 oz), the woman is far more likely to deliver via cesarean surgery than when the baby is actually in that weight range, but the doctor didn't suspect it. You are in a better position by virture of having birthed a prior big baby vaginally, but you are not out of the woods. You want a birth attendant who thinks you can birth this baby on your own until proven otherwise.

So the answer to your question of whether you can refuse induction at 40 wk is "yes." You have the right to refuse any treatment. Whether you decide that is the best thing to do is up to you, but certainly, as you have told your story, it would not be unreasonable to do so and could serve you better. If you decide to agree, you can minimize the likelihood of induction-related complications by refusing induction with an unfavorable cervix. Cervical ripening agents and strategies do not decrease the excess risk of cesarean with an unripe cervix, which, while smaller in a woman with prior vaginal birth, is not zero. You can insist on the oxytocin dosing protocol that comes on the package as many obs use one with higher doses and dose increases at shorter intervals, which increases risk of overly long, overly strong contractions causing fetal distress. You can ask that the drip be turned off once you are in active, progressive labor. Many women will continue on their own once the pump is primed, so to speak. (The drip can be restarted if contractions die away.) Finally, if you are a woman of size, "The Well-Rounded Mama" offers solid information and good advice.

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Q28: Are there any studies on the risk of UR (or other complications) for a VBAC with a bicornuate uterus?

A: Unfortunately, according to one review of the medical literature, you are at greater risk for the scar giving way:

Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 2001;44(3):609-21.

Lieberman cites a study of planned VBAC in 25 women with uteruses that were not the usual shape compared with 1,788 women with the usual upside-down pear shape. The scar gave way in 2 (8%) cases in women with bicornuate, unicornuate, didelphic, or septate uteruses versus 11 cases (0.6%) in women with the usual shape.

The latter percentage falls in the typical range for scar problems, but 8% is quite high. Still, you have 92% odds that the scar will not be a problem. I also have no details from the cited study. For example, were the women with unusual uterine shapes all given oxytocin to stimulate stronger contractions? That would increase their risk of scar rupture. And, of course, a third cesarean surgery is not risk free, so there are trade-offs to be considered in making your decision. If you do decide to plan a VBAC, you, more than the typical woman with prior cesareans, might be wise to have it in a hospital capable of handling an urgent cesarean 24/7.

A: Unfortunately, according to one review of the medical literature, you are at greater risk for the scar giving way:

Lieberman E. Risk factors for uterine rupture during a trial of labor after cesarean. Clin Obstet Gynecol 2001;44(3):609-21.

Lieberman cites a study of planned VBAC in 25 women with uteruses that were not the usual shape compared with 1,788 women with the usual upside-down pear shape. The scar gave way in 2 (8%) cases in women with bicornuate, unicornuate, didelphic, or septate uteruses versus 11 cases (0.6%) in women with the usual shape.

The latter percentage falls in the typical range for scar problems, but 8% is quite high. Still, you have 92% odds that the scar will not be a problem. I also have no details from the cited study. For example, were the women with unusual uterine shapes all given oxytocin to stimulate stronger contractions? That would increase their risk of scar rupture. And, of course, a third cesarean surgery is not risk free, so there are trade-offs to be considered in making your decision. If you do decide to plan a VBAC, you, more than the typical woman with prior cesareans, might be wise to have it in a hospital capable of handling an urgent cesarean 24/7.

Another study I just received in the International Cesarean Awareness Network's bimonthly newsletter deals with Mullerian anomalies and VBAC. Mullerian anomalies, BTW, refers to abnormal development of the embryonic tube that develops into the Fallopian tubes, uterus, and vagina. I spent an extremely frustrating half hour trying to get the actual study to no avail. Here, at least, is the citation and abstract from PubMed, but, of course, the devil is in the details.

Am J Obstet Gynecol. 2007

Trial of labor and vaginal birth after cesarean section in patients with uterine Müllerian anomalies: a population-based study.

OBJECTIVE: The aim of our study was to determine the success rate of vaginal birth after cesarean section among patients with Müllerian anomalies in comparison to the success rate of vaginal birth after cesarean section in patients with normal uterus with emphasis on the rate of uterine rupture. STUDY DESIGN: A retrospective population-based study was designed, including all patients with a previous cesarean section that attempted vaginal birth after cesarean section during the study period. Women with known Müllerian anomalies were included in the study group. The control group consisted of women with normal uterus. The rates of vaginal birth after cesarean section, uterine rupture, maternal morbidity, and perinatal outcome were compared between the groups. RESULTS: Of 5571 eligible patients, 165 (2.96%) had Müllerian anomalies. The rate of vaginal birth after cesarean section was significantly lower among patients with Müllerian anomalies than in patients with normal uterus, 37.6% (62/165) vs 50.7% (2740/5406), respectively (P = .0009). During the study period, there were 10 cases of uterine rupture, all in patients with normal uterus. The major indication for repeated cesarean delivery among Müllerian anomalies patients was malpresentation, 58.3% (60/103) vs 14.4% (385/2666) in patients with normal uterus (P < .001). CONCLUSION: A trial of vaginal birth after cesarean section in patients with uterine Müllerian malformations and cephalic presentation is not associated with a higher rate of maternal morbidity and uterine rupture. PMID: 17547885 [PubMed - in process]

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Q29: I have a bicornate uterus and have had a cesarean section. Is there an increased risk of having another early delivery, or is VBAC an option?

A: I'm afraid that I haven't researched the effect of a bicornate uterus on length of pregnancy or labor. What I can tell you is the risk of scar rupture in a VBAC labor based on what little data we have. I have two studies of VBAC in women with uterine anomalies, one of 25 women (Ravasia 1999) and one of 103 women (Erez 2007). The bigger study reported no scar ruptures while the smaller study reported 2, both in women who had been induced. Induction of labor is known to increase risk of scar rupture. Leaving the question of induction predisposing to scar rupture aside, the overall rate in the two studies combined is 2/128 = 1.6%. This is higher than what the rate can (and should) be in a woman without a complication predisposing to scar rupture, which is 0.5%. Still, looked at another way, there is a 98% chance the scar will be just fine and possibly higher, since the women whose scars gave way had been induced.

As to what happens to the baby if it does give way, according to the latest data, a huge review of the research that underpinned a National Institutes of Health conference in the spring of last year (Guise 2010), the likelihood that you will lose the baby in the case of scar rupture is 6% provided you are in an environment where staff can respond promptly. To find out the risk of losing the baby to scar rupture as a result of planning a VBAC, multiply 1.6% (the odds of scar rupture) by 6% (the odds of mortality) and you get 0.1% or 1 perinatal death per 1000 VBAC labors in a woman with an abnormally shaped uterus due to scar rupture. There is also a risk that the baby will survive but be brain injured. This risk, too, is very small. I should add as well that maternal complications are more likely in a VBAC labor that ends in cesarean than in a planned cesarean.  Against that risk you must weigh the risks of accumulating cesarean scars for you and any future babies. These include increasing risk of placenta previa (placenta partially or completely covers the cervix) and placenta accreta (the placenta grows through the uterine lining into the underlying muscle and sometimes even through the uterus), both of which pose serious threats to you and the future baby, as well as the likelihood of your forming dense adhesions, internal scar tissue that can cause chronic pain and make any future surgeries more difficult and more likely to result in surgical injury to internal organs or blood vessels.

The missing piece in this calculation is how likely a VBAC would be to end in a vaginal birth? Without that information, you can't decide whether the risks attached to planned VBAC or elective repeat cesarean are more acceptable to you. All of this is irrelevant, though, if your ob won't talk to you about it. Maybe the first step is to find one who will.

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Q30: How can I keep my pregnancy as intervention-free as possible with impaired glucose tolerance (IGT) and other challenges?

Q: I've been trying do research to keep my pregnancy as intervention-free as possible.  Unfortunately, almost every resource I come across says something to the effect of "this is unnecessary in normal, healthy pregnancies" It would seem my pregnancy is not seen as normal or healthy and I'm having a hard time finding resources that fit my reality.

I'm older, have a previous c/s, lost my last baby under debatable circumstances (depending on who you talk to, it was a late-term miscarriage (19wks) or an 'almost' missed miscarriage (baby died at approx. 10wks.)) and I suffer from PCOS, which has left me with impaired glucose tolerance (IGT) (but not yet diabetic) and overweight.

I saw my midwife a couple of weeks ago and she told me IGT is treated the same as GD now (which is different than how I was treated with my son 5yrs ago) and I should be prepared to be induced by 38wks because of it, my PCOS and associated hormone profile is likely what led to my labour failure with my son, and she would be required to refer me to an OB because of my pre-existing conditions.  I fear I'm in for a lot of arguments as I move forward and I'm having a hard time finding resources that speak about: declining inductions if you have IGT and the affects of PCOS ON pregnancy as opposed to becoming pregnant.  My son was also macrosomic (4510g,) so I'm sure they're going to pull that out on me too.  (I believe he was just genetically destined to be large and it had nothing to do with my pregnancy... he's still at 5yo above the growth curve and the tallest kid in his class.)

Can you offer any advice and/or resources to this conflicted mother?

A: If you can find a care provider you can trust, you don't have to have all the answers yourself, and ascertaining this is within your scope. A care provider you can trust will share your philosophy of minimizing use of intervention, which means you can then rely on his or her judgment when intervention is recommended. "Having a Baby? Ten Questions to Ask" , put out by the Coalition for Improving Maternity Services, can help you determine this. A care provider you can trust will also provide you with answers to the BRAIN acronym questions without trying to manipulate you emotionally. And a care provider you can trust trusts you. He or she regards you as a full partner in any decisions made and respects your right to have the ultimate say. Whether these last two are the case will become clear during the interview. If you can find such a person, you can relax. 

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Q31: Is there any research about cerebral palsy?

Q: Is there any research about cerebral palsy? Recent news reports of a $58 million judgment against a doctor who delivered a baby ultimately diagnosed with cerebral palsy. What does the research say about the timing of the insult to the brain? In other words, does the research make it clear how to determine who is "at fault". I am a midwife and I attended a birth many years ago that was totally uncomplicated except for a long pushing phase of 4 hours. Fetal heart tones were never a concern, the lowest one being 100 at the crowning of the head. I always wondered if I missed something. It seems to me that the anoxia could've happened in the antepartum, intrapartum or postpartum period, and we don't really have any good methods of diagnosing this

A: The current wisdom is that most cases of cerebral palsy have origins other than intrapartum events, although it is certainly also possible that the normal stress of labor or the excessive stress of induced or augmented labor could overwhelm a compromised baby's ability to compensate. Research obstetricians have been trying to come up with a set of symptoms indicative of intrapartum hypoxia so as to identify those cases of neurologic injury that can be attributed to labor events. Leaving aside acute events such as uterine scar rupture, tetanic contractions, or umbilical cord prolapse, this isn't as easy as you would think. Neonatal seizure, for example, can be precipitated by overheating due to maternal fever, hyponatremia (low blood sodium) from too much IV fluid with insufficient salt, infection, congenital abnormality, etc. Other symptoms such as abnormal fetal heart rate or low blood pH at birth have very low predictive value for long-term outcome. In fact, those symptoms may represent a healthy compensation mechanism, and the absence of response may be more ominous. The fascinating thing to me is that in the U.S., at least, obstetricians are furiously back pedaling from the idea that continuous EFM allows intervention in time to prevent cerebral palsy but not back pedaling from using it.

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Q32: What are the risks of VBAC if induced?

Q: Is there any true medical evidence into stillbirth of type 1 diabetic mothers past 38wks, and is this the only reason other than larger babies?

How much of a risk would I be taking if I decided to try for VBA2C if I am induced again? 

Do 3rd babies tend to be bigger as a guide i.e. the first smallest, 2nd a bit more so on so forth?

A: I can speak to the VBAC issue and to induction with a uterine scar or scar rupture, but I have never researched Type 1 diabetes and timing of delivery. If you want to surf the VBAC topic on the Forum, you will find the research on the risk of scar rupture after two cesareans (not different from one uterine scar) and likelihood of VBAC (similar to rate with one scar). You will also find the research showing that induction can, but does not necessarily, increase risk of the scar giving way. It does not increase risk if the cervix is ripe, that is, softened, effaced, and ready to labor. Also, using a physiologic oxytocin (Pitocin, Syntocinon) protocol, as opposed to an "active management" protocol, should reduce risk. (Dose increments and interval for physiologic induction come in the package.) Induction does, however, decrease likelihood of vaginal birth, so that has to be weighed in the mix, although I would think that it is probably less likely to do so in women who were induced with a ripe cervix and who have a patient care provider. A recent, large, multicenter U.S. study showed that VBAC women were likely to have cesareans for slow progress while still in early labor and especially likely to have cesareans before active labor when they were being induced. As for the concern about possible shoulder dystocia, the best way to prevent/resolve shoulder dystocia is to give birth on hands and knees or turn to hands and knees if the shoulders hang up behind the pubic bone. With today's modern epidurals, turning to hands and knees is not precluded, but you would probably need assistance. Finally, I wouldn't be terribly worried about whether your next baby might be bigger. Women frequently give birth vaginally to bigger babies than the one they supposedly couldn't birth the first time. Then, too, some factors are modifiable such as pushing in upright positions so that gravity can assist in bringing the baby down or at least not pushing on your back where your weight against the bed keeps your tailbone from flexing open.   

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Q33: Does having GD automatically indicate the need for continuous monitoring or is intermittent auscultation considered a safe alternative if there are no signs of hypertension?

Q: Do you have any resources that specifically discuss the practice of continuous fetal monitoring in labor on women with gestational diabetes?  Does having GD automatically indicate the need for continuous monitoring or is intermittent auscultation considered a safe alternative if there are no signs of hypertension?

A: It is probably all part of the "GD as high-risk condition" package. In actual fact, according to the Cochrane systematic review on this topic, we don't have any evidence that continuous EFM improves outcomes even in women with high-risk conditions, which I would argue well-controlled GD with no other health problems is not. (See other posts on GD on this Forum.) Here is what I wrote summarizing data from the review in the manuscript of the EFM chapter in the forthcoming new edition of Obstetric Myths Versus Research Realities: "Among high-risk women (not defined) continuous EFM failed to reduce Apgar scores < 4 at 5 minutes (3 trials, 941 women), NICU admissions (4 trials, 1528 women), neonatal seizures (6 trials, 4805 women), or perinatal death (6 trials, 1974 women)." On the other hand, the same review establishes that continuous EFM has harms. It increases risk of cesarean surgery and of instrumental vaginal delivery.

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Q34: Will I need to have steroids if I test positive for fetal fibronectin?

Q: Will I need to have steroids if I test positive for fetal fibronectin?  I have recently been diagnosed with gestational diabetes/insulin dependent and my prenatal care is now considered "high risk" and can no longer be managed by the midwives that I was seeing.  This is a great disappointment to me.  I have NST's 2x per week along with once a week ob appointments.  My dilemma is that I am currently 33.3 weeks pregnant and about a week ago during an NST it was discovered that I was having contractions along with and what the ob describes as "uterine irritation."  My cervix was closed but yesterday when my contractions did not subside with medication I was sent to the hospital and found out that I am 1 centimeter dilated.  I had a fetal fibronectin test and I will get the results tomorrow.  They stated that if the test is positive they will want to give me steroids to beef up up the baby's lungs.  I am concerned that if they do give me the steroids it will make my blood sugar go nuts.  My sugar has already been very difficult to manage.  It seems like the steroids may have more of a negative impact given that the baby is almost 34 weeks and they told me they do not recommend giving steroids after that point.  Not sure what to do.

A: The key issue here is that you want to be making informed decisions based on knowledge of the benefits versus harms of your options. The Childbirth Connection website has some good information on this. FYI: In case bed rest is recommended to prevent preterm birth, while it might not be a bad idea to take it easy, bed rest has not been shown to be effective at preventing preterm birth and it has harms.

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Q35: Does the use of probiotics prevent or suppress GBS colonization?

Q: I would like to know if there is any valid data (studies or clinical trials) that show that probiotic supplementation through the diet or using probiotic preparations directly on or in the vagina will prevent GBS colonization. I read blogs about stillbirth often because it is what I most fear about becoming a midwife and there seems to be some evidence that 4-10 percent of unexplained stillbirth may actually be caused by intrauterine infections caused by GBS.

In my reading of these blogs I came across a particularly well-educated woman with a science background of some kind that was pregnant after stillbirth. An intrauterine GBS infection with an intact bag of waters played a role in the death of her baby and she and her doctor had laid out a plan to do monthly GBS tests throughout the pregnancy, treating with antibiotics anytime GBS was detected. Another person commented that the antibiotics may cause the GBS colonization to worsen and suggested a daily intake of probiotic foods and/or a probiotic supplement to prevent colonization.

To this suggestion the pregnant woman replied that there was no evidence that probiotics could help suppress GBS colonization and that the commenter was mistaken. The commenter posted back with a few different Pubmed abstracts that related to GBS suppression with different applications of probiotics. What I'm wondering is if it is yet known scientifically whether or not probiotics will actually prevent or suppress GBS colonization. The pregnant woman with a science background did not seem to think that any of the studies showed probiotics could be beneficial in this application. Here is a link to the site where I read about all of this. I thank anyone who can shed some light on this for me. I will suggest daily probiotic use to all my pregnant clients if this is the case.

A1: I have not searched out any research on the effectiveness of probiotics, but my understanding of probiotics is that they can help maintain and restore the normal harmless and beneficial flora and fauna that are indiscriminately killed off by antibiotics, not that they have any antibacterial effect themselves. In women who are given antibiotics, such as GBS + women, they are useful for preventing problems such as thrush, a yeast infection that can, for example, inflame nipples and the baby's mouth, wreaking havoc with breastfeeding.

A2: Here are two abstracts from studies listed in PubMed relating to probiotics and pathogens in the urogenital tract.

Açikgöz ZC, Gamberzade S, Göçer S, Ceylan P.

Neonatal group B streptococcal (GBS) infections are one of the important health problems because of their high mortality and morbidity rates in certain countries. There are some preventive approaches, including perinatal antibiotic therapy against these infections. Recently, vaccination with conjugated GBS polysaccharides has also been practised. In this study, the in vitro inhibitory effects of 51 lactobacilli (of them 50 were purified from vaginal swabs, 1 from a commercial vaginal tablet) on five GBS (4 clinical isolates and 1 standard strain) were investigated by sandwich plate technique and deferred antagonism well technique. Ten clinical isolates (20%) and the drug-purified Lactobacilli expressed pronounced inhibitory effects on growth of GBS. All of the inhibitory isolates and 10 randomly selected non-inhibitory isolates were identified by API 50CHL kit (BioMeriéx, France). Seven (70%) of the inhibitory clinical isolates were Lactobacillus rhamnosus. The inhibitory isolates had higher acid production than the non-inhibitory ones (p < 0.05), and pH-adjustment destroyed their inhibitory effects entirely. If these results could be applied in vivo, it could be postulated that administration of certain lactobacilli as probiotics via an appropriate regimen may be a safe, physiological and cheaper alternative for prevention of neonatal GBS infections. PMID: 15900833 [PubMed - indexed for MEDLINE]

Rönnqvist PD, Forsgren-Brusk UB, Grahn-Håkansson EE.

BACKGROUND: The relationship between lactobacilli and other microbes and the association with vaginal pH in the female genital tract were examined. The study also included evaluation of the possibility of supplying probiotics to the genital tract by using panty liners impregnated with the probiotic strain Lactobacillus plantarum LB931. METHODS: This was a randomized, placebo-controlled, double-blind, multicenter study involving 191 healthy fertile women. Specified microbes were counted and vaginal pH was measured once a month for five consecutive months. RESULTS: Major individual variations in the genital microflora composition and the vaginal pH were found among the women. The number of lactobacilli was significantly related to vaginal pH.

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Q36: As a doula and LCCE I seem to be hearing, anecdotally, that women who have had cervical procedures, such as cone biopsies or LEEP, sometimes have issues dilating due to cervical scarring. Do we have any research on this? I imagine this group is growing, and I wonder if there is any good information we can be giving to women to prepare for a different way to dilate, or appropriate care-giver intervention (cervical massage, etc.).

A: I haven't got anything but anecdotal evidence, but word on the street is that, yes, cervical procedures can interfere with dilation but that cervical massage in labor can break up scar tissue. I found these pages by searching on Yahoo's browser using the terms "cervical scarring labor dilation."

http://birthfaith.org/midwives/cervical-scar-tissue

http://www.mothering.com/discussion...52588.html

http://www.naturalchildbirth.org/na...abor24.htm

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Q37: Are there labor concerns for a mom with heart conditions?

Q: I had an inquiry for doula care. The mom to be has a congenital heart abnormality and has been told she may need a Cesarean section as opposed to laboring. She is being monitored in her pregnancy and her aorta is enlarged now at 26 weeks. Do you know of any studies or research that she can find to help her with a decision? I've been looking on the net but haven't found much yet. I remember years ago I thought there had been a short video done on women who had heart conditions and birthed squatting and without adding any extra pushing or effort and they all did fine. I know one must take each woman individually yet am curious about any data out there to support trying at least with some labor first as opposed to straight to a Cesarean. As well, I think one would want to look at the risks of Cesarean with a heart abnormality too. What would be the caregivers concern regarding laboring?

A: My area of expertise is in best practices for women free of medical complications, so I don't have any research to recommend. The best I can suggest is for your client to find an ob with a commitment to vaginal birth (overall c/sec rate 15% or less, promotes VBAC) and get his or her opinion based on this mom's particular condition and its severity. If a pro vaginal birth ob recommends planned c/sec, then she can trust the ob's judgment. If a cesarean is recommended, the benefits vs. harms of awaiting spontaneous labor onset should be part of the discussion.

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Q38: I had an inverted uterus with my first baby – is it likely this will happen again?

Q: I've tried to find out more about this topic for a client of mine, but what happened to her seems pretty rare that I'm having a difficult time.;

What do we know about the possible effects on the second birth after the mother had had an inverted uterus following the birth of her first baby?  I do not know much more than that it was traumatic and life-threatening for her.  Because it happened once, is it more likely to happen again?  I do not know if or how much the caregiver used pitocin and/or traction of the cord, etc., and will talk about expectant management of birthing of the placenta.  And, obviously, relaxation techniques for her and her partner. Any thoughts you can share are much appreciated! 

A: The best I can tell you is find out not only if someone was pulling on the umbilical cord when it happened but whether someone was pushing on the top of her belly (fundal pressure). If either was the case, then it is less likely to repeat if no one does those things to her, but that won't help much since she still doesn't know her odds. I would add, too, as a common sense measure that she will want to allow the contractions to deliver the baby rather than actively pushing as the baby emerges and that if any pushing is needed for the shoulders to go gently. Beyond that, I am sorry that I have nothing more helpful. Anyone out there who does? [Follow – up response:I just wanted to report back.  The mom had a beautiful baby, and the mom was doing well, too.  Her uterus inverted again.  Her medical team was prepared, and the mom recooperated well.  The mom used natural comfort techniques and had the help of her partner and a very experienced doula and group of nurses. I don't know all the details of her first or second birth, but it seems as if with all the research and preparation she and her husband did, she was able to have the kind of natural childbirth she had wanted.”]

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Q39: When should an ECV be done with a breech baby?

Q: I am wondering if you can point me in the direction of any evidence, regarding a friends upcoming c-section. Her baby is breech, and doctor wants to do an ECV at 36 weeks (he says that is full-term). She is very interested in having as normal a birth as possible, and would much rather wait until 37 weeks, just in case the ECV sends her into labour. She is hopeful that they will be able to resolve that issue at her next appt. However her bigger concern is this: if the version is not successful, what are the risks of allowing her body/baby to go into labour naturally, and THEN go to the hospital for the c-section? This is her first pregnancy and she is otherwise very fit and healthy.

A: Attempting an ECV is more likely to be successful earlier than later because there is more amniotic fluid and the presenting part is less likely to be engaged. Also, as pregnancy advances, the likelihood of labor beginning rises, and the woman may miss her opportunity. (See below for evidence.) Usually, women are given a uterine relaxant (tocolytic) as part of the procedure to prevent the uterus from tightening in response to the manipulation, so I don't think she need worry about triggering labor.  Few babies flip back to breech once turned, if they do, the procedure can be repeated, and inducing with an unfavorable cervix greatly increases chances of the induction ending in a c/section regardless of use of cervical ripening agents. Also, doing them under an epidural removes an element of safety. Excessive pain during the procedure is a sign to stop.

As for going into labor naturally, it remains true that the best way to tell when the baby is ready to be born is to await spontaneous labor. Also, labor stimulates the baby in ways that prepare it to be in the outside world, notably, catecholamines work to dry out the lungs. I think the question she has for her doctor is why not await labor onset? The only reason I can think of is doctor's convenience of scheduling and the issue of possibly needing to assemble a surgery team at night, but any hospital I would want to be at ought to be able to handle this contingency. Still, there may be others.

Excerpt from Thinking Woman's Guide to a Better Birth (c) 1999 by Henci Goer

Two [studies] reported success rates in three-quarters or more of attempts made before 37 weeks, dropping to half of attempts in one study and two-thirds of attempts in the other when done later .

Kornman MT, Kimball KT, and Reeves KO. Preterm external cephalic version in an outpatient environment. Am J Obstet Gynecol 1995;172(6):1734-41.

Scaling ST. External cephalic version without tocolysis. Am J Obstet Gynecol 1988;158(6 Pt 1):1424-1430.

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Q40: Why do I need a Rhogam shot?

Q40: I am just moving into my 32nd week of a so far healthy and easy pregnancy, my first. I really didn't have any sickness and have had a blast as my tummy is still pretty small and my body is coping well. However, a few weeks ago I mentioned to my OB that I am O neg and he immediately insisted I have the Rhogam shot and all that jazz, only to discover I already have antibodies present. GRRR! He should have known my blood type as I had given them about eighteen vials of blood before this but anyway that's neither here nor there. He insisted as long as the levels stayed at 1-4 everything was jolly. Of course that didn't happen, they have risen and now I have to have NSTs twice a week. My question is, what are they looking for to happen during these NSTs and would any of it be true cause for concern? What would they do in the event something was going wrong? A little update: saw the specialist today in the big city. She said at the moment the baby is fine but she really wants to take him early to get him out of that "hostile environment". That one made me cry. They've scheduled an amniocentesis in four weeks to check levels for something, not sure what she said I was too emotional. Oh, and while I was leaving that awful place she decided spur of the moment to give me a steroid shot! Emotional AND physical pain. Wonderful!

A: For information on Rh negative tests and treatments in pregnancy, here is a page on the topic from the March of Dimes website. I found it by searching on "Rh negative pregnancy" on Medline Plus, the U.S. National Library of Medicine and National Institutes of Health consumer medical information website.

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Q41: I have a low-lying placenta; if I am cleared for vaginal birth what interventions should I do or refuse?

A: You can refuse any intervention, but the question is "Would it be wise to do so?" I certainly am not qualified to tell you that, and based on what you write, the conversation with your care provider that would allow you to answer this question hasn't happened. Your ob appears to be telling you what he plans to do, and you are to like it or lump it. He has not explained all your options to you--including doing nothing--along with the potential benefits and harms of each. In particular, you have not been told the risks of cesarean surgery.

The Childbirth Connection website has a great webpage on informed consent and refusal, but I think your first task is to determine whether you can trust your care provider's judgement, because his failure to provide the information to make an informed decision is already a red flag. The touchstone for this is to ask his cesarean rate. If it is more than 15%, the rate established by the World Health Organization and numerous studies as the reasonable maximum, you will know that you can't. If he hedges, for ex., "I only do them when they are necessary," or won't tell you or says he doesn't know, consider that another red flag. Should either of these be the case, I strongly advise consulting with an ob willing to assist you in arriving at an informed choice and whose judgment you can trust. That, by the way, almost certainly won't be another ob in the same office. One practice partner is unlikely to openly disagree with another. If there is a birth network, an International Cesarean Awareness Network chapter, or a birth resource center, they are likely to know who the progressive obs are. The local doulas are also likely to know as well. Failing that, you might call your local hospital(s) and ask the L&D nurse manager which of the obs is the most encouraging of natural childbirth. You can also see if any of the local obs has been reviewed on the Birth Survey. Hopefully, your insurance will cover seeking a second opinion, but even if it will not, this will be money well spent.

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Q42: I have GD with low platelet issues; can I take prednisone but refuse insulin in order to stay with my midwife?

Q: I have been diagnosed with GD and have been controlling it excellently with diet. My midwife says as long as I continue to do so, I will have no problem staying with her and having my natural, non-medicated birth. However, I also have a low platelet issue, which they did have to start me on prednisone with my last one (he is now 2 yrs old) to bump it up for the birth. (That birth was completely uncomplicated and natural all the way.)

A call from the doctor just now says they want to put me back on prednisone (platelets are at 68,000) and I will need to go on insulin because it will raise my blood sugars. I have fought so hard to keep them from doing any kind of treatment (refused the non-stress tests and BPP's as well), because I know from everything I've read on this website that it only makes me more at risk for intervention.

Can I go ahead and take the prednisone and refuse the insulin treatments? Once I start insulin, I lose my midwife and have to go to an OB. There is no such thing as an enlightened OB around here and I'm so afraid they will just want to induce or even worse have a c-section.

A: Pregnant women experiencing complications should be able to get the treatment they need without being forced to give up having mother-friendly care. I can't think of a good reason why your midwife would not be able to care for you during labor in a hospital where, should it become necessary, there is the ready ability to consult with or transfer care to a specialist and immediate access to the hospital's diagnostic and treatment resources.

The best strategy I can think of is to try to get the hospital to make an exception. Start with asking your MW what she suggests. If you don't get anything useful from her, find out who has the power to make an exception and schedule a meeting with that person, you, and your partner. At the meeting, start with the old salesman's trick of making a statement that can't be disagreed with, for example, "I know we all have the goal of a healthy baby and healthy mother. It stands to reason that goal can best be achieved by care in which I get the treatment I need for the complications I am experiencing but avoid treatments or restrictions I don't need. I would like to combine the best of both worlds by continuing my care with my midwife while having the peace of mind of knowing that the doctors and hospital resources are there if I need them. I understand that hospital policy makes that a problem, but I am sure that by doing some brainstorming together, you will be able to help us achieve that goal." Another salesman's trick: if you get an answer you don't like, wait. Say nothing. The silence will be uncomfortable and often leads to the other person making another suggestion. Wait until you get one you like and then agree. Now it's the other guy's idea. If you start to cry, turn it to your advantage. That's the cue for your partner to say, "You can see how important this is to her. Surely, we can work something out." If neither idea works and you are stuck with an ob whose judgment you can't trust, here are a couple of recommendations:

  • Hire a doula. Just having someone in your corner can help if you are being leaned on.
  • Barring an emergency, make an informed decision when agreeing or refusing an intervention. Induction, BTW, is never an emergency.
  • Ask for a nurse who is comfortable with women who want natural childbirth and to avoid intervention and who will help you make decisions by explaining your options. Repeat at each shift change.

The good news is that this isn't your first baby, which makes it harder for you to be bullied. 

I hear what you are saying about the GD test, but if diet does not control your blood sugar levels, I can't see that it makes sense to refuse insulin and have them be out of control. And I don't think refusing insulin would solve the problem of them risking you out of midwifery care. Now they would have a "noncompliant patient" on prednisone with high blood sugars. Ditto for refusing prednisone. Then they would have a "noncompliant patient" at risk for hemorrhage. 

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Q43: Is a cesarean the only option when diagnosed with placenta previa-complete?

Q: Recently I was contacted by a student who is set to begin classes shortly. She is about 21 weeks and at her ultrasound, she discovered she has placenta previa-complete. In my pregnancy, I had a low-lying placenta but it moved as the pregnancy progressed. Because of this upset, I invited her to attend my classes for free for now in the event the placenta does move. I'd like her to be prepared for an unmedicated birth in the event things move in her favor.

Anyway, I was wondering if you can direct me to some good information on the topic of previa. I do know it is rare, but as I said, I like to give out the information to the students so they can make informed choices for themselves. I am also a bit leary of the practice she has chosen. They give the impression they really advocate for women because most of the docs are women (no midwives at the practice). The hospital they work at has a c-section rate of 40% and of that 75% of them are first-time moms. My concern (on the side) is that even if the placenta does look like it's moving that this practice might want to go the conservative route and recommend the c-section anyway. Do you think she should consider the second opinion? I know of a couple of great docs in the area that have c-section rates under 10% which, in IL is hard to find since we don't even have real birth centers.

A: I think that suggesting she get a second a opinion from a doc who tries to avoid c/secs is a great idea. You took the words right out of my mouth. Here is the argument I have used repeatedly in my responses on this Forum: if the ob has c/sec surgery rates much higher than 15%, the maximum rate recommended by the World Health Organization and backed up by any number of studies, then you know you cannot trust the ob's judgment.

As for the chances of the placenta moving away from the cervix, I got this passage from here:

Placentia previa may be observed in as many as 1 in every 3 pregnancies before the 20th week of pregnancy. As the uterus grows, the placenta usually moves higher in the uterus, away from the cervix. But if it remains near the cervix as your due date nears -- which happens in about 1 in 200 pregnancies -- you're at risk for bleeding, especially during labor as the cervix thins (effaces) and opens (dilates). This can cause major blood loss in the mother. For this reason, women with a placenta previa are usually delivered by cesarean delivery.

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Q44: What are the benefits and risks for an epidural during labor and delivery with twins?

Q: In my region, families expecting twins are recommended to have an epidural during labour, regardless of the health and positions of the babies.  From what I can gather, the physicians are recommending an epidural in labour "just in case" , because of the increased risk of caesarian birth with twins.

The moms have expressed some concern with having an epidural, because of the known risks associated with epidurals for single births. 

I would like to know what the benefits and risks are for an epidural during twin labour and delivery.

A: I am not aware of any studies of epidural effects specifically in labor with twins, but there is no reason to believe that laboring with twins would somehow reduce its potential adverse effects. In fact, I would think some adverse effects might have worse consequences for twins, who might be more vulnerable in labor and present a more complicated delivery. Epidurals greatly increase the risk of an episode of maternal hypotension, which would reduce placental perfusion and therefore fetal oxygen supply, and epidurals interfere with the ability to push effectively, which might be required at a twin birth.  If the concern is the unexpected need for instrumental or surgical delivery of the second twin, I have been told by clinicians that spinal anesthesia can be administered quickly and will take effect rapidly. I would flip the obs' recommendation and say I think it might be a good idea to avoid an epidural "just in case."

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Q45: Do I need to be induced at 39 weeks because of the clotting factor of MTHFR?

Q: I'm 31 weeks into a pretty normal pregnancy.  My OB today stated that she wants to induce me at 39 weeks because I have a clotting factor called MTHFR, but not the bad version of it.  They say it is necessary because I have to stop the baby aspirin at that point and they don't want the clotting to be an issue.  I have never had a clotting issue with either or my previous two children.  Does this make sense?  I don't want to be induced but am concerned for the baby and myself.

A: The problem is that you don't have enough information to know whether your OB's recommendation makes sense or not. In order to make an informed decision, you need (and are legally entitled) to know:

  • what treatment is being proposed. This should include what tests or treatments would become necessary or would be likely as a result of having this this one.
  • the pros and cons of the recommended treatment.
  • the alternatives, including doing nothing.
  • the pros and cons of the alternatives.

You can find more information on informed decision-making here.

If I were you, I would also want to know what has changed since, as I understand your post, this clotting issue is a problem of long standing, and your dr didn't recommend induction with the previous two children. You may also wish your ob to show you the evidence supporting induction for women with your condition. If your dr cannot, that would be a red flag as would be any attempt to scare you into agreeing, as opposed to objectively giving you facts. You should also know that as a woman with previous vaginal births, you are at much less risk for a c/sec than a 1st-time mother who is being induced, but induction is not risk free--telling you that it is would be another red flag--and it remains true that the best way to tell when a baby is ready to be born is to await spontaneous labor. 

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Q46: Can I make induction a “natural” process, since I’ve been told I need to be induced due to a need for blood thinners?

Q: About a year and a half prior to my first pregnancy I got a DVT.  At my first OB doctor appointment I was placed on a low dose of Lovenox to thin my blood. My OB also informed me that because of my blood clot history, I would need to be taken off of Lovenox and placed on an IV Heparin drip for 24 hours prior to delivery. Because of my need for blood thinners she is planning to induce me at 39 weeks. Do you have any suggestions on how I can help make this a "natural" process?

A: Let's start with the induction process itself. Here are some suggestions that maximize your chances of having a complication free induction. To begin with, confirm that your ob plans the induction at 39 completed weeks, which would be the beginning of the week that ends with your due date. If your cervix is not yet ready for labor and needs ripening, refuse misoprostol (trade name: Cytotec). For more information on why, I wrote a blog post on Cytotec inductions for Science and Sensibility. Prostaglandin E2 (trade names: Cervidil and Prepidil) work equally well.   I recommend not agreeing to having membranes ruptured until labor is well established and you are making progress if you agree to it at all. If membranes are intact, and the induction isn't working, you can stop the induction, go home, and try again another day, but if the bag of waters has been broken, you are committed to delivery. Once you are in active labor, the oxytocin drip can be turned off to see if labor continues on its own. Often, it will, and if not, the drip can be restarted. You will need to arrange for this ahead of time because it isn't usual practice.

As for making the experience more natural, find out if your hospital has telemetry electronic fetal monitoring or whether you can be monitored intermittently, especially in early labor before things kick in. This will enable you to be up and around, which will make you feel better and can help the labor. Even if you must be tethered to the monitor, you can be detached to use the bathroom, which you should do periodically, and there is no reason you cannot stand up, sit in a chair, or change positions on the bed. It is also possible to avoid pain medication, although it can be more difficult because induced contractions tend to be harder to handle. A good set of childbirth classes oriented toward natural birth can help you with alternative strategies. Finally, I strongly recommend hiring a good doula. Unlike the nurse, who does not know you, has other responsibilities, and will almost certainly spend little time with you, a doula meets with you and your partner ahead of time, knows you and your partner and your goals, will be with you continuously, and has special training in providing supportive care in labor--physically supportive to you and emotionally supportive to you and your partner.  

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Q47: What is a slow release of waters to avoid placental abruption mean?

Q: I had an ultrasound at 34w and have an AFI of 30cm. My OB didn't seem too concerned and had me get blood drawn to check my sugars over 3 months, but that came back "excellent". So there doesn't seem to be an apparent cause (which I know is common), but she did mention something I'm not sure I'm comfortable with regarding delivery. She said a lot of times they want to do a slow release of the waters to avoid placental abruption. I understand that abruption is a concern with this, but I have other concerns.

1) In my last labor (my first labor, 2nd pregnancy, VBAC) I didn't dilate until labor, so they won't be able to do an amniotomy with no dilation.

2) The baby didn't engage until I was almost pushing. I know this greatly increases risk of prolapsed cord.

3) I delivered at 42 weeks last time. I know there is a chance of going earlier with poly, and I have had BH contractions, which I did not in my last pregnancy.

4) I REALLY want and plan to have a natural, low intervention birth and I planned to do that with my waters intact. It also seems like a good idea to have CFM if this is the plan, which I know comes with a whole other set of pros and cons.

I really like my OB (she has delivered twice drug free) and she supports my birth plan. We do plan to keep an eye on the fluid and I know a lot could change in another few weeks even. I just want to know if this is really the best course of action for excessive fluid.

A: Here's what you need in order to make an informed choice:

    • An explanation in plain English of what the procedure involves: How does one do a slow release of the amniotic fluid? The common procedure is to snag the membranes with an amnihook (it looks like a crochet hook with a little tooth under the curved tip). My experience seeing this done back in the day when I was a doula was that that rupturing membranes was followed by a gush rather like breaking a water balloon.
    • The potential benefits of what your ob is proposing: You have this piece already, i.e. to prevent the placenta from detaching prematurely. What is missing, though, is how likely is this to happen. One in ten? One in a thousand? One in ten thousand? Without this, you can't decide whether it is worth running the risks of rupturing membranes.
    • The potential harms of rupturing membranes: As you say, with a high head and lots of amniotic fluid, you run an increased risk of cord prolapse. How likely is that to happen? Any way to prevent it? Apart from issues of rupturing membranes with a high head, the procedure itself has risks. Some studies find more episodes of abnormal fetal heart rate, and a systematic review (a kind of study of studies) of trials in which women were assigned to early rupture of membranes or not reported a trend toward more cesareans, although I think this will be much less of an issue for you because you have had a vaginal birth before. It also sounds as if your ob is talking about inducing labor to prevent spontaneous rupture at home. If that is so, you will want to weigh the trade-offs of induction versus the odds of membranes rupturing at home and the possible consequences of that. For example, inducing labor with pharmacologic agents can increase the likelihood of having the uterine scar give way, although it is moderated by whether the cervix is ready to labor and whether the woman has had prior vaginal births.
    • What other medical interventions might or would become necessary as a result of this one and the pros and cons of those.
    • What alternatives you have, including doing nothing.
    • The benefits and harms of your alternatives.

As you can see, and doubtless, already know, your decision isn't a straightforward one. It requires weighing a number of factors relevant to your individual case and taking into account parameters that may change over time. Maybe the best thing would be not to make a firm decision one way or the other now but to discuss what makes the most sense under a set of likely possible scenarios.

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Q48: What information should I have before pregnancy to avoid PPROM?

      Q48: I am not currently pregnant, but I am in the preconception phase. Last time, I was planning a home birth and ended up in the hospital due to PPROM at 35w, 5d. I am obese, I do not smoke, was not sexually active with a partner at the time, was a frequent bath taker, and was bad about checking my own cervix. My early bloodwork showed that my neutrophils were elevated, as they were on delivery. I ended up with pitocin as labor did not commence. Ended up with epidural as pitocin hurt A LOT.

I would really like to try to prevent it for the next time. I am working on losing weight, but would like some other ideas. I would like to arm myself with knowledge in case it happens again. What are your thoughts on potentially going on antibiotics if there is a late rupture to get to term?

A: Good for you for working on losing weight before another pregnancy! That will reduce the chances of complications for you and your baby, not to mention the benefits for your own health down the road, although I don't know as it will affect the likelihood of preterm prelabor rupture of membranes.

One theory of a cause for PPROM is a silent vaginal infection. There is a systematic review (a study of studies on a particular topic) of the medical research on antibiotic treatment to prevent PPROM that reported that while the studies weren't high quality, when data from them were pooled and analyzed, results showed that antibiotic treatment cleared the infection, and women were 1/3 less likely to have a low-birth-weight baby, but preterm birth rates were not reduced. If you want to try this, you may want to do something to rebuild normal harmless vaginal flora and fauna so you don't end up with a yeast or fungal infection. As for bathing, bath water does not enter the vagina during bathing. An elegant experiment decades ago proved that. Researchers impregnated tampons with starch and had pregnant women bathe in water that had iodine in it. If the water had entered the vagina, the tampons would have turned purple. None of them did. There is also a systematic review of antibiotic treatment with PPROM concluding that it reduced newborn infections, which is an important benefit whether it delayed labor or not.

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Q49: Can I have a natural labor with Group B Strep?

Q: How does Lamaze/natural labor work or fit for women who test positive for Group B Strep?  Don't they have to be connected to IV antibiotics for at least 4 hours prior to delivery in order to protect their babies?

A: That is the recommendation, but treatment with I.V. antibiotics need not interfere with use of Lamaze techniques, comfort measures, or practices that promote safe, healthy birth.

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Q50: Do dietary changes and insulin help avoid Cesareans and preeclampsia in GD women?

Q:  I'm a childbirth educator who's been handing out your articles on gestational diabetes for years; my students are well aware that GD is a diagnosis in search of a disease, with little research support.

Now there's a brand-new study in NEJM on 958 women with "mild" GD, which found that treating them with dietary changes and insulin produced fewer Caesareans and fewer cases of preeclampsia.  I grant that switching women to a healthier diet will reduce preeclampsia -- I teach the Brewer Diet, after all -- but I'm wondering about the supposed reduction in C-sections.

I haven't yet seen the full text of the study (they charge non-subscribers and I already used up a free trial), but I am deeply dubious.  Have you seen it, and do you have thoughts on confounding factors?

A: I've downloaded the trial and reviewed it:

Women with normal fasting blood sugar and elevated blood sugar after eating (N=958) were randomly allocated to treatment or usual care. As one would expect, women were mostly multiparous (75-79%) and had high BMI (mean 30). To partially mask the control group, investigators also included 931 women with normal glucose tolerance matched for race and BMI above or below 27 in the control group. Their outcomes were not reported, so I am not sure what effect their inclusion had on the care of control group women.

Treated women were managed according to American Diabetes Assoc. guidelines and were given insulin if blood sugars were not normalized. Few women required insulin (8%). The short version of the ADA recommendations (I obtained the guidelines the investigators referenced) are essentially a healthy diet and exercise, and while high BMI women should not be put on a weight-loss diet, calories can be restricted somewhat to limit weight gain with monitoring to ensure avoidance of low blood sugar. No information is given on details of usual care.

No babies were stillborn or died neonatally, and birth trauma rates were similar, but a much larger study would be needed to detect differences between groups. Babies in the treatment group were less likely to weigh over 4000 g (8 lb 13 oz) (6% vs. 14%) and to be in the upper 10% of weight for their gestational age (7% vs. 15%) without increasing likelihood of being small for gestational age--an important point because aggressive sugar control can result in more undersized babies.

Treated women gained less weight after trial enrollment (mean 3 kg vs. 5 kg or 6.5 lb vs. 11 lb), had a lower BMI at delivery (31 vs. 32), and their babies were less likely to experience shoulder dystocia (head is born but shoulders hang up behind the pubic bone) (1.5% vs. 4%). Treated women were less likely to have c/secs both overall (27% vs. 34%) and after excluding women with conditions unrelated to gestational diabetes that would increase likelihood of c/sec such as prior c/secs or abnormal presentation (13% vs. 20%). They were also less likely to experience pregnancy hypertension (9% vs. 14%) and preeclampsia (2.5% vs. 5.5%).

What do we learn from this? If you take a group of high-BMI women, give them a strong motivation to eat right (probably under the guidance of a registered dietician since these were academic institutions) and exercise more, and monitor them closely, you will see the benefits of that compared with when you don't. And if their obstetricians both believe that treatment works and see differences that support the belief that the baby will be deliverable vaginally, such as less weight gain, they will be less likely to operate. (Lord knows we have enough studies showing that clinician belief is the primary factor affecting c/sec rates.) So what's new? I have always maintained that if all GD screening did was identify women with what should better be called "carbohydrate intolerance" and helped them with diet and lifestyle, it would be a good thing, and I would be all for it. Kudos to these investigators for confirming that. I maintain, though, first, that they probably could have accomplished the same thing merely by treating women according to BMI, which would also have benefited normoglycemic high BMI women, and second, that a trial carried out in a group of academic institutions does not reflect the way the typical community ob identifies and treats GD--and probably not even academic institutions not participating in a trial of GD treatment--to the detriment of women so labeled. 

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Q51: How real is the danger of a vaginal birth with a partial abruption?

Q: I was diagnosed with placental abruption after already being on bedrest for PTL. I was originally on bedrest at 26 weeks, started spotting at 31 weeks. The spotting lasted 3 days. Previa was ruled out with u/s. Diagnosed with abruption because of tenderness, pain and, of course, the bleeding. I was told I would have to have a c-section around 37 weeks. How real is the danger of a vaginal birth with a partial abruption? I am on bedrest until I deliver, but I want to be able to deliver naturally. This is my second, and I had no problems with her. She was a natural delivery. Thanks!

A: I am a midwife and management of pregnancies complicated by abruption are outside of my scope of practice, however I am happy to share a little about the evidence and some common sense thoughts on having a safe and healthy birth. 

A review of the management and outcomes of placental abruption in the UptoDate database (a database of evidence-based reviews accessible by clinicians only) begins:

"Although the impact of placental abruption on pregnancy outcomes is fairly well-described, very few studies have examined the management of pregnancies complicated by abruption. Thus, guidelines regarding management of placental abruption are based on anecdotal experience, published literature, and good clinical sense."

These guidelines, which, again, are not necessarily based on good quality evidence, state that "Vaginal delivery is reasonable if the maternal status is stable and the fetal heart tracing is reassuring." The authors state that oxytocin and artificial rupture of the membranes can ensure that the baby is delivered "as quickly as possible" but I would argue strongly against the routine or liberal use of these measures, as they can put additional stress on an already stressed baby, resulting in injuries related to reduced oxygenation. They could also lead to ominous heart rate changes that could lead to cesarean section (necessary or otherwise).  The goal should not be a quick birth, but a safe birth and one that is as gentle as possible on the baby. Staying off your back in labor and using spontaneous pushing (following your own urge to push, rather than holding your breath for prolong periods which others coach you to push) are two ways to keep birth as gentle as possible and provide plenty of oxygen to your baby.

The guidelines stress, and I would certainly agree, that continuous electronic fetal monitoring and at least one intravenous line should be used. The risk of hemorrhage - both during labor or postpartum - is elevated, so the IV line can provide access to give fluids or blood products if necessary. The elevated risk of postpartum hemorrhage means that active management of this stage of labor (with oxytocin infusion and fundal massage to deliver the placenta) may be prudent. 

If you have ongoing major blood loss or there are signs that your baby is compromised, c-section is the safest route for giving birth.

I hope this information is helpful. Based on the UptoDate review, it does not seem that cesarean delivery at 37 weeks is necessary for every woman experiencing partial abruption, although the recommendation in your individual case may be different. It might be helpful for you to know your doctor's c-section rate. A rate around 15-20% would indicate that your doctor uses cesarean sparingly when real complications arise. A cesarean rate above 30% is a strong indicator that your obstetrician recommends cesarean frequently without looking at individual circumstances. You may need to change providers if you do not think your current provider will work with you to make a plan for the safest, healthiest birth possible.

Even if you plan for a vaginal birth, your risk of needing a cesarean is certainly increased. You may want to find a support group online of other mothers or a good childbirth educator or doula who can help you clarify your birth plan and priorities if a cesarean becomes necessary. Such a support group can also help you handle the emotional and physical toll of life on bedrest.

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Q52: Can you tell me more about IUGR?

Q: I need more info about small for gestational size babies or IUGR. I have a doula client 36 w 4 day who measured 35 weeks the past two visits, in the same week. Her physician wants to do an ultrasound to determine baby's size and if it is growing properly. My gut tells me that this is a set up and the beginnings of the slippery slope to induction. I've seen many studies on macrosomia but what about suspected IUGR? What studies can she look at to know if there is true need to be concerned?

A1: This isn't an issue that I have researched, so I don't have any studies to recommend. For an overview, though, here is a link to the National Library of Medicine's consumer information material on IUGR, which might be useful, and here is a link to informed decision making on Childbirth Connection's website, which can help your client in making decisions about her care.

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Q53: As Group B strep positive, what are the risks of the baby contracting it versus the risks of an induced labor?

Q: Greetings!!  I am Group B strep positive and my midwife has recommended an induction of labor so that I may receive the 2 doses of antibiotics in the appropriate amount of time before the baby is born.  This is my 4th baby and with babies #2 & #3 my labor was between 80 and 90 minutes from first pain to birth.  If this labor is just as quick, there will not be time for the I.V. antibiotics.  I would like to weigh the risk of the baby contracting Group B Strep with the risks to the baby during an induced labor.  I have read information on both yet am having a hard time assimilating it all as it seems that very few people are objective.   My midwife recommends that I receive the 2 doses of antibiotics according to the recommended timing and then break my waters to induce labor.  The idea of induction does not sit well with me but neither does a potentially sick baby.  Please share you knowledge and opinion on this subject. 

A: I have reviewed the U.S. Centers for Disease Control guidelines for women testing positive for group B strep. Nothing is said about induction in the recommendations. However, here is what the CDC guidelines say about women who give birth too quickly to receive the recommended antibiotic dose:

In the event that intrapartum antibiotics are not given despite an indication (e.g., delivery occurred precipitously before antibiotics could be administered to a GBS-positive woman), sufficient data are not available on which to recommend a single management strategy for the newborn. Some centers provide intramuscular penicillin to asymptomatic infants within 1 hour of birth, based on results of observational studies showing declines in early-onset GBS disease coincident with a policy of universal administration of intramuscular penicillin to all newborns (121).

Whereas they say infants of mothers who received the recommended dose do not need any special treatment unless they show signs of illness.

Now that you have the link to the CDC guidelines, you can read through them and decide for yourself in collaboration with your midwife what you think the best course of action should be. You will want to consider not only the benefits of induction but the potential harms, whether having your baby have an injection of penicillin is acceptable to you, and what the risks would be in your individual case because risk of infection varies depending on how heavy the colonization, whether the baby is full-term, and how long the baby is exposed to possible infection during labor. Speaking of which, on general principles, I recommend avoiding any procedure that could carry the microbe up from the lower vagina, where it usually lives, onto the cervix or giving it access into the womb unless there is a compelling reason for doing it. This would include vaginal exams, stripping membranes, rupturing membranes, or internal electronic fetal monitoring (cardiotocography).

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Q54: What is the likelihood of getting a baby to turn at 38 weeks? Are the risks and pains of a version worth it?

Q: Just before my 36th week appointment, my baby turned breech.  The Midwife truly thought she felt him head down, but couldn't find his heartbeat until she went really high.   This is my fourth child and I have never had a baby in a breech position before, so I never even considered this option.  My next appointment is Wednesday and I will be 37.5 weeks.  The Dr. will confirm (probably through ultrasound) the position of the baby.  If the baby is still breech, she will probably either offer to schedule a section or do an external version, which is required to be done at the hospital. 

I have heard that, because of the higher risks of an emergency c section vs. a planned one, an external version is not always best.  I have also had a slightly low-lying placenta and am not sure how an external version will affect this.  Delivering a baby breech is not an option my Dr. would consider, especially considering that my labors have always been induced and very, very slow to progress. 

Does anyone have any thoughts on this - what is the likelihood of getting a baby to turn at almost 38 weeks (they would probably try the version on Friday) and are the risks and pains of a version (which they say doesn't usually work) worth it? 

A: By all means go ahead with the external cephalic version (ECV). Done properly, that is, with care and not forcing a baby who is resistant to turning, it is safe and effective. Added bonus: since you have had babies before, ECV is more likely to work for you. You can also try two different alternative medicine techniques. Neither will do you or the baby any harm as neither involves manipulating the baby. You can find a chiropractor who knows the Webster technique, or try moxibustion, or, better yet, both.

If the baby doesn't turn, you may wish to consider whether you want to schedule a cesarean. This is not so straightforward a choice as your obstetrician may have presented it. Cesarean surgery has its risks too, some of them serious, especially if you are planning to have more children, and vaginal breech birth has gotten a bad rap. In suitable candidates--frank breech (buttocks down), normally-formed average-size baby, head tucked--breech birth outcomes are just as good as with planned cesarean. (See below.) Having had children before makes you a more favorable candidate for vaginal breech birth as well as ECV. The catch is, though, in the conclusion of the study summary. The problem in the U.S., at least, is finding a practitioner who knows how to assist at a breech birth. Obstetricians are squarely to blame for their failure to acquire those skills. You can always learn something you want to learn, and these days, simulation models make it possible to learn delivery skills without needing to practice on a live mother and baby. Nonetheless, U.S. obs rarely have the skills, and the last thing you want is a panicked doctor who doesn't know what he or she is doing. You may wish to see if someone in your community has the skills. If none exist or you prefer to go ahead and plan the cesarean, here are a couple of suggestions that are not necessarily standard practice that will make cesarean surgery safer:

  • Do not schedule surgery until 39 completed weeks of pregnancy. This minimizes the chance of your baby having potentially serious respiratory problems after delivery. In fact, since you have a history of slow labors, you may wish to await labor onset. The best way of telling when a baby is ready to be born is by allowing labor to start spontaneously.
  • Insist on double-layer uterine suturing. Single-layer suturing appears to increase the risk of scar rupture in future labors, and while there is some disagreement in the research on this point, why take the chance when we know the results with double-layer are good. 

Beyond that, consider and plan with your doctor for a positive cesarean experience. Also, deciding that a cesarean is best and safest for your baby doesn't mean you have to like it. Allow yourself to experience whatever feelings you need to. 

FYI:

Goffinet F, Carayol M, Foidart JM, et al. Is planned vaginal delivery for breech presentation at term still an option? Results of an observational prospective survey in France and Belgium. Am J Obstet Gynecol 2006;194(4):1002-11.

OBJECTIVE: A large trial published in 2000 concluded that planned vaginal delivery of term breech births is associated with high neonatal risks. Because the obstetric practices in that study differed from those in countries where planned vaginal delivery is still common, we conducted an observational prospective study to describe neonatal outcome according to the planned mode of delivery for term breech births in 2 such countries. STUDY DESIGN: Observational prospective study with an intent-to-treat analysis to compare the groups for which cesarean and vaginal deliveries were planned. Associations between the outcome and planned mode of delivery were controlled for confounding by multivariate analysis. The main outcome measure was a variable that combined fetal and neonatal mortality and severe neonatal morbidity. The study population consisted of 8105 pregnant women delivering singleton fetuses in breech presentation at term in 138 French and 36 Belgian maternity units. RESULTS: Cesarean delivery was planned for 5579 women (68.8%) and vaginal delivery for 2526 (31.2%). Of the women with planned vaginal deliveries, 1796 delivered vaginally (71.0%). The rate of the combined neonatal outcome measure was low in the overall population (1.59%; 95% CI [1.33-1.89]) and in the planned vaginal delivery group (1.60%; 95% CI [1.14-2.17]). It did not differ significantly between the planned vaginal and cesarean delivery groups (unadjusted odds ratio = 1.10, 95% CI [0.75-1.61]), even after controlling for confounding variables (adjusted odds ratio = 1.40, 95% CI [0.89-2.23]). CONCLUSION: In places where planned vaginal delivery is a common practice and when strict criteria are met before and during labor, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women.

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Q55: What are the concerns with advanced maternal age?

Q:We are looking for evidence based science concerning the connection between maternal age (43) and:

1. the strength of contractions (they think the uterus of an older woman is slow and weak which will make it difficult to contract strongly and firm.)

2. post partum fluxus

3) diabetes gravidarum

4) low Hb

5) the connection between macrosomic babies and diabetus gravidarum

6) the chance of getting another "huge" baby (last baby was 4300 grams)

7) the connection between big baby and shoulder dystocia

8) the dangers of opening up slowly (she needs more than 12 hours to get 10 cm)

A: I'm not sure how much help I can be because I haven't specifically researched the connection between these issues and maternal age. Still, if your friend is in good health and has birthed big babies vaginally before who were in good condition at birth, other than the genetic concerns, I'm not sure what the fuss is about other than the usual one, that is, to make variation from average "abnormal." It seems to me that your friend needs only to take care of herself in the ways any pregnant woman should regardless of age. She needs to eat right, take iron if she is anemic, and get regular, moderate exercise. It is likely she will be having another large baby, so it would be prudent to avoid epidural analgesia so that she can be mobile and can push effectively. She might also think about giving birth on hands and knees, which is the most favorable position for avoiding and alleviating shoulder dystocia (the head is born, and the shoulders hang up behind the pubic bone), or at least she should be prepared to turn to hands and knees should shoulder dystocia occur. If she is a large woman or has birthed several children, she may have a pendulous abdomen. Some midwives recommend a belly band (a towel or sheet can be used) to bring the belly back up and in so that the uterus lines up with the vagina. This can make contractions more effective. The other thing, of course, is to find a care provider who practices physiologic care and treats according to the specific situation in individual women, not by category.

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Q56: Is there anything I can do to help increase my amniotic fluid?

Q: I am currently 33 weeks expecting and just had a ultrasound.  The doctor saw a pocket where there was no amniotic fluid.  The doctor wants to perform a Amniotic Fluid Index in two weeks.  He said that if the number is "4" or below, baby has to come.  I have been distraught with this.  I want a vaginal normal birth and inducing early could very likely lead to a "C".  I have been trying to take it easy, drink tons of water, and get back to high protein.  I have been quite vigorous keeping busy (I have twins) and have been feeling pretty dehydrated.  So I am trying to hopefully reverse this condition.  Do you think this can be reversed to where the pocket would be gone on the next test?  What can I do to help that?  Since the doctor is having me come in two weeks, perhaps this is not as bad as it seems?  I hope so.  I am 44 and the doctor is already biased against older women such as thinking that dysfunctional uterus is pretty common with older women and they needing help for labor.  I just had twins two years ago with this doctor.  They were delivered vaginally and the second breech.  I defied some of his pre-conceived ideas.  I was thankful that he was willing to deliver baby B breech.  Most OB's don't here.  So I am hoping that this pregnancy will go well.  I appreciate any comments you may have. 

A: First, amniotic fluid volume is not fixed because it is continually being absorbed and secreted. Second, amniotic fluid volume measurements are at best not terribly accurate "guesstimates" because the baby is an extremely complex shape, and the baby is moving. Third, I have no idea what your doctor means by "a pocket" that has no fluid. "Pockets" would obviously come and go as the baby shifted position. There is also a recent study (see below) concluding that when low amniotic fluid volume is the only symptom, inducing labor does not improve outcomes, but it increases cesarean surgery and instrumental vaginal delivery rates, including cesarean and instrumental vaginal delivery rates for nonreassuring fetal heart rate. It makes sense that you would see more surgical and instrumental deliveries for nonreassuring status with induction. If low amniotic fluid volume indicates the baby is somewhat stressed, the baby would be less able to tolerate the increased stress of induced contractions. (Despite their own results, though, the investigators recommended inducing labor anyway. Go figure.)

As I was writing this, the thought occurred that perhaps you have other concerning symptoms that led your doctor to order an amniotic fluid volume evaluation. It certainly isn't usual to do so at 33 wks. If something else is going on, the results of that study do not apply, although you would still want to weigh the risks of induction versus awaiting labor for you and your baby. If your doctor did it as a matter of routine, while this doctor may have been your best option with the twins, you may wish to consider whether he is your best option with this pregnancy. Have you, for example, considered having your baby with a midwife in the hospital, in an out-of-hospital birth center, if one is in your area, or at home? 

Manzanares S, Carrillo MP, Gonzalez-Peran E, et al. Isolated oligohydramnios in term pregnancy as an indication for induction of labor. J Matern Fetal Neonatal Med 2007;20(3):221-4.

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Q57: Do you have any research regarding ultrasound predictions of lichre levels?

Q: I am an independent childbirth educator in India. Over the past several months, I have been hearing an increased diagnosis of either decreased amniotic fluid or increased amniotic fluid in otherwise healthy, low-risk expectant moms. Mostly, it is the decrease in fluid levels that are being diagnosed and as a result the C-section rates, which are anyway through the roof, are tending to go even higher, with inductions being scheduled left, right and center. When I questioned one of the OB/GYNs about this, she said "I don't know - maybe the reason is something in the environment" - and, I was shocked.

In India, in most hospitals, moms are subjected to Ultrasound scans almost at every prenatal visit, and this means weekly US towards the end of their pregnancy. Do you have any research which points out the accuracy or inaccuracy of ultrasound predictions of lichre levels as the pregnancy advances? On another note, I have already shared FDA advisory regarding unnecessary use of US in pregnancy with our OB/GYN.

A: I am sorry to hear that obstetrics is practiced this way in India. This is not, repeat, not either safe or effective care, and the consequences of these unnecessary cesareans can be dire for mothers and babies and the babies of future pregnancies. I know I should feel shocked too, but blaming everything but their own actions when confronted with the harm they do is unfortunately so common a response by obstetricians that it has lost its shock value. Sad to say, I am rather more surprised when an obstetrician doesn't.

If you mean amniotic fluid volume when you wrote "lichre levels," I haven't researched this issue, other than the study mentioned in the thread, but here is a summary (abstract) from a Cochrane systematic review:

Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. In this one, one type of measurement resulted in more inductions and c/sections without improving outcomes, but there is no control group that did not have the screening. Without that, we do not know if having either type of fluid volume measurement improved newborn outcomes, although it's a safe bet that having any type would increase inductions and cesareans. In any case, the study cited above in this thread says that it doesn't matter how accurate the diagnosis, low fluid volume in the absence of other symptoms is benign.

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Q58: Why are the recommended blood sugar levels different for pregnant women?

Q: Why are the recommended blood sugar levels different for pregnant women?

A: I'm going to paste in a paragraph from What is gestational diabetes

"Gestational diabetes (GD) simply means elevated blood sugar during pregnancy. To understand it, you must first understand the normal changes in pregnancy metabolism. When you are pregnant, certain hormones make your insulin less effective at transporting glucose, the body’s fuel, out of your bloodstream into your cells. This increases the amount of circulating glucose, making it available to your baby for growth and development. This “insulin resistance” increases as pregnancy advances. As a result, your blood glucose levels after eating rise linearly throughout pregnancy. By the third trimester, you will tend to have higher blood glucose levels after eating than nonpregnant women (hyperglycemia), despite secreting normal and above normal amounts of insulin. During overnight sleep, the excess insulin has a chance to mop up, which causes morning glucose levels to be lower on average than in nonpregnant women (hypoglycemia).

"In the 1950s, some researchers wondered whether sugar values at the high end of the range for pregnancy would predict the development of diabetes later in life. They tracked a population of women and in 1964, they reported that, yes, it did. The extra stress of pregnancy revealed a woman’s “prediabetic” status. This shouldn’t have surprised anyone, because high-weight women are much more likely to have higher glucose values in pregnancy than average-weight women and to eventually develop diabetes. However, doctors knew diabetes posed grave threats to the unborn baby, so they worried that glucose levels that were high, but not in the diabetic range, might also do harm. This concern launched what eventually became an avalanche of studies that ended by defining a whole new category of pregnancy complication called “gestational diabetes,” although “glucose intolerance of pregnancy” would be a more accurate description."

The article goes on to explain how doctors came to believe that subdiabetic blood sugar elevations posed a risk and the flaws in the studies and weaknesses in their reasoning. A principle flaw is that high-weight women are both more likely to have elevated blood sugar and big babies and other health problems such as high blood pressure. In other words, high blood sugar is merely a marker for these women, but doctors have confused a symptom with the underlying issue.

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Q59: Will it be hard to get pregnant again after pelvic organ prolapse?

Q: I have an appointment coming up to see and OB/GYN about pelvic organ prolapse.  I'm not sure specifically which organs suffered--definitely the bladder (obvious from the incontinence) and possibly the uterus.  I'm not prolapsed "all the way" but I do worry about getting pregnant again. 

Will it be harder to get pregnant?  Could  a future pregnancy make things worse (my first baby was 10 lbs. and OP)?  Do pessaries really work, and if so, do they only work while worn?

I don't have access to any fancy research databases, but from skimming abstracts, I've become pretty convinced that corrective surgery is not the best option for me at this time.  Not that I'm closed to hearing out the doctor, but I'm skeptical about the failure rate.   

I've also been responding really well to physical therapy. 

Could Henci or anybody here enlighten me a little on this topic?  I spent a long time digging for information on a local doctor who wouldn't rush to sell me on surgery.  Based on what I've heard, he probably won't play the "must-have-cesarean" card re: future pregnancies. 

A1: Apologies, but this isn't something I know a lot about. But if a conservative remedy such as physical therapy is helping, I would stick with that. Also, if you are a high weight woman, studies show that losing weight can help. As for repair surgery for incontinence, unless there have been some major improvements in surgical techniques--which is entirely possible because, as I said, I'm not on top of this issue--repair surgery often doesn't work all that well or only works for awhile. I don't know whether prolapse makes conception more difficult. If you are interested in doing some research on your own, for free you can get at the summaries of the systematic reviews in the Cochrane Library and you can read the summaries of pretty much every study published in the medical literature on the PubMed website. In some cases, the full studies may be available for free on the PubMed website.

A2: Here are some links on prolapse:

http://www.moondragon.org/obgyn/disorders/uterineprolapse.html

http://www.urogynaecology.com.au/Causes.htm

http://www.firstaidforprolapse.com/

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Q60: Can I have a normal delivery if my baby is bigger?

Q: I had Fetal growth scan done in my 33rd week, its report showed that my baby was already 2 kilos and 421 grams and my doctor suggested that if baby grows at this pace, she might need to do caesarian, as the passage may be smaller for a big baby. Can i still have a normal delivery in spite of baby being bigger?

A: I would be concerned about an OB who is talking "cesarean" on the grounds that the baby is going to be big. I recommend finding out your OB's cesarean surgery rate if for no other reason than you will have a sense of to what degree you can trust your doctor's judgment. As for what that rate should reasonably be, any number of studies show that the cesarean rate can safely be under 15% in a run-of-the-mill population of pregnant women. The U.S. national average by contrast is twice that.

In anticipation of what is likely to come up as you approach your due date, I will tell you that studies show no benefits for planned induction or planned cesarean surgery for suspected big baby. Your best bet is going into labor on your own. I also recommend following Lamaze's Healthy Birth Practices, which includes the suggestion to have a doula.

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Q61: Why does my urine need to be tested for protein? How do I know when labor begins?

Q: I am 37 weeks pregnant with my first baby.  At my last doctor’s appointment my blood pressure was high so I have been ordered to save urine for 24 hours for testing.  They said that they need to test for protein.  Why?

 I have had many contractions over the last month but nothing that I believe resembles labor.  I have been getting increasingly depressed the farther along I get.  I can’t stand having gained all this weight (60 pounds)!!!!  I am embarrassed of my body to the point that I would rather not leave my house or be in public at all.  It is getting harder and harder for me to breath, my hands and feet are swollen.  How do I know when I am really in labor?  I’m having little contractions right now but have not lost my water or mucus plug yet.  All I have as a reference is what I have seen on TV and in the movies.  I am afraid I won’t know that I am in labor. 

A: I am sorry the end of pregnancy is proving to be so difficult for you. Let me take one thing at a time.

Your doctor wants to test your urine for protein because whether you have protein in your urine and how much will help your doctor decide how much concern there should be over your high blood pressure. Protein in the urine is an indicator that kidneys are not working as well as they should. Spilling a little protein is common because pregnancy--especially at the end--pretty much stresses every organ, but having high blood pressure and more than a little protein is a more worrisome combination than high blood pressure alone. Of course, how high your blood pressure is also enters into the equation.

I hear your distress over your weight gain and appearance. Soon you will have the baby. Until that time, eat sensibly, get moderate exercise if your doctor says it's ok with the high BP, and know that once the baby is born, you can begin a sensible weight-loss diet. (I believe there are safe weight-loss programs for breastfeeding mothers, but I don't know where to direct you for those. Anybody out there want to chime in?)

Unless there are medical reasons to end the pregnancy, impatience is your enemy. Your best chance for a safe, healthy birth for you and your baby is to allow labor to begin when the baby is ready. The fact that you're having lots of little contractions is a good thing. It is your body warming up for the big event, but if this is your first baby, that will probably mean waiting a few more weeks. If this is your first baby, the median length of pregnancy (half the population gives birth before this time, half after) in women who reach full term (37 weeks) is 41 weeks 1 day.

Finally, here is an article on how to tell when you're in labor.

It sounds like a good all-around pregnancy book might be helpful. You cannot do better than The Official Lamaze Guide: Giving Birth with Confidence by Lothian and Devries.

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Q62: I’ve been having low intensity contractions – how likely am I to go into preterm labor?

Q: Yesterday my doctor discovered that I have low intensity contractions every 3minutes (which I did not feel at all). They gave me 1 litre of water to drink and IV normal saline 1000ml. The contractions stopped and I went home. I was told to monitor my contractions, but I don't feel any. I am 34 weeks pregnant. How likely am I to go into preterm labor? This is my first baby and so far no complications.

A: Roughly half of the group of women who experience preterm labor will go on to have a preterm baby. No medications will hold off preterm labor for more than a short period. Bedrest does not avert preterm birth either. In other words, if you are in the half destined to deliver preterm, you can't do much about it. On the other hand, it would not hurt to take it easy as much as you can and reduce stress in your life as much as possible. For example, if you work standing, such as at a cash register, request a chair. Try to get more rest. Get help, if you can, with household chores and responsibilities and let things go that are not essential.

As for staying hydrated, while it is true that dehydration can be a problem, especially in summer, overhydration can also be a problem with intake of large amounts of liquids, although it is less of a concern if you are drinking fluids with electrolytes in them and not pure water. Ask your care provider how much you should be drinking.

The good news is that if worst comes to worst and the baby comes early, you are already past the point where there is real anxiety about an otherwise healthy baby's chances for survival and ultimate well-being.

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Q63: My previous unborn baby was diagnosed with Down’s syndrome, will this happen again with another pregnancy?

Q: I am pregnant after an abortion in the fifth month, my unborn baby was diagnosed with Down's syndrome, and we had to medically abort the baby at fifth month. I got pregnant after 4 months, will the case repeat again, am very concerned. Emotionally I still have not come to terms with unfortunate loss of first baby. I am scared and worried.

A: I am so sorry. Many hospitals have genetic counselors. If yours does not, perhaps your care provider can refer you. A genetic counselor should be able to tell you how likely it is that you would conceive another baby with Downs syndrome. A counselor might also be able to refer you to someone who can help you deal with your very understandable fears and distress.

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Q64: Is there information linking post-date babies and placenta deterioration?

Q: I am looking for information about post date babies and placenta deterioration. Do you know of any research linking the two? Thanks!

A: Here is a quote from Chapter 37 Postterm Pregnancy from Williams' Obstetrics: PLACENTAL DYSFUNCTION Clifford (1954) proposed that the skin changes of postmaturity were due to loss of the protective effects of vernix caseosa. He also attributed the postmaturity syndrome to placental senescence, although he did not find placental degeneration histologically. Still, the concept that postmaturity is due to placental insufficiency has persisted despite an absence of morphological or signficant quantitative findings (Larson and co-workers, 1995; Rushton, 1991). In Chapter 27 of Williams' Obstetrics (page 621) Degenerative Placental Lesions' Extensive calcification is found in 10 to 15 percent of all placentas at term. This can be seen with sonography, and Spirt and colleagues (1982) reported that by 33 weeks more than half of placentas have some degree of calcification. It is difficult to correlate the degree of calcium deposition with pregnancy outcome (Benirschke and kaufmann, 2000). To summarize, placental changes such as calcification are common and do not predict pregnancy outcome. Placentas from babies born with postmaturity findings have not been found to have any telltale signs. According to an obstetrical textbook.

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Q65: Is Cytotec a safe option instead of a D&C for a miscarriage?

Q:  I learned 2 weeks ago that I have a 'blighted ovum'.  I had the same type of miscarriage back in December (so second BO in 5 months).    Doc and a friend's midwife say both are flukes.   We were easily able to conceive my son and I have no history of prior miscarriage.  I am 30 and what most would consider very healthy.  For first in Dec, I waited 10 days after confirmation and then had the D&C.    I REALLY didn't want to, but the emotional pain was so unbearable that I thought I might lose my mind.    This round we are on day 14.   I would prefer not to have the D&C and the doc has offered Cytotec. 

At this moment, I am doing fairly well both physically and emotionally.    I am just not quite sure how long I can wait.  I would strongly prefer my body to take care of this naturally and I know it will, just not sure if my mind can wait much longer.  It is true mental torture and every day seems to make it a tiny bit worse. 

Is Cytotec safe in a situation like this?   What are the risks?   Can you direct me to any literature that could help me to decide? 

A1: I am so sorry that you are going through this emotionally painful experience. Unfortunately, I am not knowledgeable about the advantages and disadvantages of your options for ending the pregnancy in cases such as yours. Hopefully, your care providers can tell you the potential benefits and harms of the three possibilities. Information about harms should include how likely those harms are to occur, long-term as well as short-term potential for problems, and what will be done should a complication occur. Once you have the facts, you will want to take into account your gut feelings, values, and preferences.  Give yourself time and space to consider and allow your heart to tell you what is right for you. 

A2: I wanted to suggest that you go to the http://www.misdiagnosedmiscarriage.com web-site.  There is information there about how to test out a miscarriage to make sure there is no misdiagnosis.  There are also articles about miscarriage options.  One of them is the use of Cyotec which has some problems associated with it.  If possible, a natural miscarriage is the best option.  There is some journal articles about that.  Many women have found that when their hcg levels reach about 1000, that is when they miscarry naturally.  I am sure that each case is different.  I don't know how many weeks that you are.  It is best to wait until at 12 wks to make sure there is no misdiagnosis.  The fetus is larger at that time and can be seen much easier on ultrasound.  That way you will know that there is no misdiagnosis.  We have seen close to 200 babies saved by testing out their diagnosis when doctors were so sure that they were miscarrying.  Ultrasounds can be faulty and depending upon the tilt of the uterus, it can be hard to get a good view.  Also, women don't always ovulate at the standard 14 days that many doctors base due date upon.  So a woman can be not as far along as her and her doctor thinks.

I am so sorry that you are going through this difficult time.  I know personally how tormenting it is.  I wish you well.  I hope that all goes smoothly for you. You take care!

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Q66: Is it safe to carry twins beyond 40 weeks?

Q: My daughter is 39 weeks pregnant with twins, and her doctor told her last week that she won't let her go beyond 40 weeks because of the danger to the babies. The doctor wants to do a C-section.

I have read that more than half of twins arrive before their due date, so that leaves a lot who don't, so why would a doctor want to take them? Her doctor said that it's dangerous to carry twins beyond 40 weeks because of degrading of the placenta, etc.

A: The question here is whether your daughter can trust her doctor's judgment. My recommendation is for her to ask him his c/section rate. If the number is higher than 15%, she will know that she can't because her ob does more cesarean surgeries than are justifiable. Both the World Health Organization and any number of studies on practice variation show that in a mixed risk population, that is, the normal run where some women in the practice are high risk but most aren't, the cesarean rate can safely be under 15%. If he won't say what his rate is, that’s a red flag too. He should be keeping track of this important statistic. If her ob’s rate is in the range supported by the research, she can have confidence in his judgment.

If it turns out her ob’s cesarean surgery rate is high, she should seek out an ob who has a cesarean rate in the appropriate range, although I have to say that finding one may be difficult. Local doulas, educators, or midwives may know who the appropriate cesarean rate obs are. Once she has found such a doc, she can get a 2nd opinion. If the 2nd ob concurs with the 1st, then again, she can have confidence in the 1st ob’s judgment. If the 2nd ob disagrees, she’ll have a much better notion of where she stands.

I also recommend reading What you need to know about cesarean section. In order to make an informed decision, she should know the benefits and harms of all her options. So far, it sounds like she has only heard the (possible) harms of planned vaginal birth.

I don't know if you noticed, but there is another thread on this issue as part of this Forum. You might find useful information there too.

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Q67: I’ve received a positive screen result for trisomy 18, and wonder if I should have amniocentesis or an earlier glucose test

A: Let me start by saying I'm sorry you have had this news. It must be very distressing for you and your family. In answer to your question, if you would not terminate the pregnancy, then the main reason for having an amniocentesis disappears, and I see a reason not to have one:  There is a slight chance that the procedure could cause a miscarriage, which means you could lose a healthy baby. What is more, if your baby does, indeed, have an inborn genetic problem, your baby is at higher risk of miscarrying spontaneously. If you have the amniocentesis and a miscarriage occurs, you won’t know if choosing to have the procedure caused the loss. The only advantage that I have heard for a woman who will not terminate the pregnancy having an amniocentesis is so that medical staff can be prepared at the birth. But another way to address the possibility that your baby may need special care immediately is to have your baby at a hospital capable of providing such care if necessary 24/7. That would be a hospital with in-house pediatric staff and a neonatal intensive care unit. Then foreknowledge of the baby’s condition wouldn’t matter. Thinking about it more, I do see one reason you may wish to have an amniocentesis: to end the stress and anxiety of not knowing. I also wonder if you have an alternative for getting more information about your baby noninvasively:  Ultrasound technology has advanced to the point where doctors can get extremely detailed images of the unborn baby. If you had a high-level sonogram, could the baby’s appearance reassure or confirm the presence of genetic abnormality?

As for the glucose testing, yes, earlier is better than later. Blood sugar levels normally rise as the pregnancy continues, but the thresholds are based on averages over the third trimester. Therefore, you are more likely to “pass” if you have the test early in the third trimester. If you read my article, you will know that the Oral Glucose Tolerance Test is neither a reproducible nor a reliable test. You will also know that values for diagnosing gestational diabetes are arbitrary. They do not represent thresholds after which complications either begin occurring or increase markedly. As I have said before, if all that happened was that a woman with what, in most cases, should be called “glucose intolerance of pregnancy,” not true diabetes, was counseled to be extra careful to eat a diet high in fruits and veggies and moderate in fat, to avoid junk food, and to exercise regularly, I think screening would be a great thing. It would also be a good thing to pick up the few women who test as true diabetics. Unfortunately, the diagnosis labels women as “high-risk” and subjects them to high-stress, high-anxiety pregnancies and a much higher rate of medical interventions that have the potential to do them and their babies far more harm then running somewhat high blood sugars during the last trimester of the pregnancy.

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Q68: Is it safe to check out of the hospital (from bed rest) to have a home birth?

Q: Hello. My name is Julie. I am currently on bed rest in a hospital in Utah after a pPROM at 31 weeks. I am currently 33w5d. No signs of labor, no infection, no problems, I feel great with all this tlc and food and rest. This was to be my third homebirth. I am ONLY in the hospital so that if my baby decides to come before 36 weeks, she will be in a "safer" environment than my home, which is currently 1 hour away from the closest hospital with an NICU, we have very iffy weather right now, and I am home alone all day. I am expecting a fast birth. I am very non-intervention, and have managed to fend off MANY of the things they have wanted to do to me here. However, as you can imagine, I am "subjected" to a daily NST test. Which in the beginning I didn't mind so much. Now, 2.5 weeks later, they are really starting to stress me out and I am losing what little peace I have left. I want that back. I started out with a great attitude, and over the last 2 days, it has kind of fallen apart. Basically, I am writing to ask for a little advice or thoughts on a couple of things, as I do not trust doctors to give me a truthful and natural birthing viewpoint. I find them busy at the task of finding something "wrong" with me, and there just ISN'T.

How early do you believe is TOO early to check out of this hospital and go home to birth? I guesstimate my baby pushing about 5 lbs. right now. I had steroid shots when I came to the hospital just over two weeks ago. Both my other babies were healthy and large 42 weeker at 8lb.10oz & 37 weeker at 6lb.8oz.

A: Here's the thing: you have the right to complete, objective information about your options so that you can make informed decisions, and the right to make an informed decision includes the right to informed refusal. As I read your post, you have two questions: One is "What is the best estimate of the risks to my baby in my specific case if I leave the hospital altogether and how likely are they to occur?" I say "your specific case" because your baby's estimated weight and condition should be factored in as well as such things as your distance from the hospital. This equation changes, of course, as time passes. Factor in as well that most home birth midwives confine their practices to women who do not have medical or obstetrical problems at onset of labor, which would preclude preterm labors. The other question is "What care do I agree to while in the hospital?" It isn't, as it appears to be, an all-or-nothing issue. You could refuse any monitoring and interventions for which, after hearing the pros and the cons, you think the harms outweigh the benefits--and your mental distress is definitely a harm that should be counted as a "con."

Here are some useful sources from the Childbirth Connection website: The Rights of Childbearing Women, and Informed Consent, Informed Refusal. And if you need a bit more muscle, here are your rights according to HIPAA, which is a set of government regulations:

Consumer Bill of Rights and Responsibilities: Participation in Treatment Decisions

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Q69: Why do I need a daily NST while on hospital bed rest?

Q: I've already had to fend off today's resident on call about the daily NST's. She is on her way to "tell on me" and send over the head OB to argue the case again. Are there any studies I can arm myself with in relation to NST use and actual outcomes? I'm not convinced they are going to "make or break" my baby's life or death, however I know what they are doing to ME. I guess I'd like some studies on how useless I am starting to see they are, at least, in my case.

A: This is an easy one. It isn't up to you to find research that supports not doing NSTs; it is up to them to show you research that supports doing them. If they can't show you research that NSTs improve outcomes of babies born preterm--and I will bet the mortgage they can't--then you are home free. Keep in mind as well that the argument that they don't do any harm isn't good enough because NSTs aren't harmless. As with all fetal surveillance tests, they have a high false-positive rate, that is, the test says the baby has a problem when the baby is really fine. This means you could end up with an induction and a premature baby or cesarean surgery that you didn't actually need. And, of course, there is your ongoing stress, which isn't good for you or the baby.

If I am wrong, and research exists, you may wish to rethink your position--or not. Your right to informed refusal doesn't depend on anything but your own judgment of your situation.

If you want to stand put, I think your best bet is not to let yourself get drawn into arguments. Just keep politely insisting on your right to informed refusal of NSTs. You may also need to make clear that you are not refusing any and all care and monitoring if that is not the case. You could, for example, refuse NSTs while agreeing to monitoring for signs of infection. Also, make sure that anyone close to you to whom medical staff have access are on board with you. It isn't uncommon for staff to attempt to co-opt them.

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Q70: Are there exercises or activities I can do to grow my pelvis for a normal birth delivery?

Q: I'm currently 26 weeks pregnant. The doctor told me my pelvis was small when he first checked in at 2 weeks pregnant. He said there's a possibility that I might need a cesarean if my pelvis doesn't grow. Are there any exercises or anything I can do to have a normal birth delivery?

A: Yes, there is. You can find another care provider. Unless you have a malformed pelvis, either because you were born that way or you had an illness, such as rickets, or an accident, there is no way a care provider can say that the baby probably won't fit through your pelvis. This is because it isn't a matter of fixed measurements. The hormones of pregnancy loosen the normally rigid joints between the bones of your pelvis so that by the time of the birth, the pelvis has "give" to it. In addition, the bones of the baby's skull have not fused together and there are openings where there is no bone. This allows the baby's head to mold to the shape of the pelvic opening. In addition, other factors having to do with labor management, such as pushing while lying on your back, can impede progress and lead to an unnecessary cesarean. Meanwhile, the fact that he is already planting the seed that you will need a cesarean is a red flag. If your obstetrician doesn't believe you can birth your baby, it will affect his judgment in ways that work against you. He may, for example, set arbitrary time limits on your making progress. It will also undermine your confidence. Labor is challenging, and you will need faith in your body. Imagine if you were trying to run a marathon with your trainer telling you beforehand that he doubted you could succeed. I suggest you ask your obstetrician his cesarean rate. A diplomatic way to phrase it is, "How often do you find it necessary to do a cesarean?" If you get a number higher than 15%, the percentage supported by studies that have looked at what constitutes a reasonable cesarean rate, you know that you cannot trust his judgment on whether cesarean surgery is necessary. If there is, in fact, some reason why your pelvis might be unusually small, seek a second opinion from a care provider who has a cesarean rate in this range or 10% or less if you are getting an opinion from a midwife. (The lower number is because midwives don't take care of high-risk women.) If your ob doesn't know his cesarean rate or won't tell you, that is another red flag. It's an important number. He should know it. Here are some sites where you can get additional information on cesarean surgery and on how to choose a care provider whose practices are in line with the best medical research:

Care Practices that Support Normal Birth

You can also find information on cesarean section and choosing a care provider in my book, The Thinking Woman's Guide to a Better Birth. It is available in book stores, but you can also order it from my personal website. Don't delay. Many care providers these days don't accept new clients past a certain point in pregnancy.

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Q71: Will a pregnancy with triplets end in an early delivery?

Q71: I may be way out of my league as I am a male but I am just on pins and needles with my wife's current pregnancy. Three years ago in December, my wife gave birth to identical twin girls-no complications in either pregnancy, labor, or delivery.

Now, my wife is pregnant with triplets-I know, what luck-and more than once have doctors tried to stall labor but so far it looks like my wife could end up delivering any day now and she's only six months in.

Please, can someone tell me why they think this is happening or what I can do to ease the mind of my wife?

A: I can only imagine what an anxious time you and your wife must be experiencing. I don't know that anyone can say exactly why this pregnancy is going so differently than the twin pregnancy except to say that triplets put even more stress on the body than twins. Your doctors may have a better explanation. It sounds like your wife's doctors are doing all they can, and every day that goes by, your babies will be that much bigger and stronger.

I have one suggestion. I don't know that it will help, but it won't do any harm as it is just a visualization. She can do this on her own, or you can talk her through it. If you do the talking, keep your voice low and gentle. Whichever of you is doing it, don't rush. Take the time to experience each part of it with all the senses .

Have your wife find a quiet time when she will not be interrupted. She should get as comfortable as she can. She begins by focusing on taking easy, slow breaths and as she relaxes, she allows her eyes to close. When she is ready, the visualization begins by imagining that she is in her bedroom and that everything is just the way she wants it. She is warm, and comfortable, and cozy. When she is ready, she goes to the closet, and inside are stairs leading down. She descends the stairs, and at the bottom, is a beautiful lake beach with a little rowboat drawn up on the sand. The waves are lapping quietly on the shore. In the middle of the lake is an island and in the middle of the island is a magnificent tree that shades it. Your babies are living on this island, and the tree provides them with all the good things that they need for the present. Your wife gets in the boat and rows out to the island. Once there, she gets out of the boat and goes to greet your children. She can imagine herself playing with them, cuddling them, whatever she would like to do. She tells them, though, that it is not yet time for them to cross over the lake with her. For now, they should stay safe on the island where the tree will provide them with what they need to grow big and strong. When she feels ready, she can tell them goodbye and that she will come back to visit them very soon (which she can do whenever she wants by repeating the visualization). Then she gets back in the boat, rows back to the shore, and returns up the stairs into her bedroom. To end the visualization, she allows herself to become aware of her surroundings, and when she is ready, she opens her eyes and stretches.

Visualization can be powerful, so it might help, and, as I said, it certainly won't do any harm. At the very least, it might help your wife feel calmer and more relaxed at least for a time. 

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Q72: What are the legitimate needs for induction with advanced maternal age?

Q: I am 43 years old and pregnant with my first child, due in January. I have concluded that I want to deliver at a birth center if at all possible, which means switching from my current OB & the hospital at which she delivers (which has the highest C-section rate in my state). I'll be touring a birth center soon. I'm wondering what the research says regarding AMA and legitimate need for induction and/or other interventions due solely to age in the absence of identified problems, as I'd like to avoid interventions as much as possible.  Many thanks.

A: I haven't researched the issue of older women expecting first children. I know the cesarean surgery rate is sky high, but that is primarily due to obstetric biases. If an obstetrician thinks you are going to need a cesarean, it becomes a self-fulfilling prophecy. Therefore it was a good move on your part to dump the OB and the high cesarean surgery rate hospital. Also, as you point out, the older we get, the more likely we are to develop problems such as high blood pressure that could affect a pregnancy, but age itself isn't the problem. There is, of course, the issue of increased likelihood of Downs syndrome with advancing age, but I'm sure you know about that too. 

I think your best bet is to do exactly what you have done: seek out a caregiver whose primary approach is supportive care that facilitates and promotes the natural process and who has low rates of inducing labor (10% or less) and cesarean surgery (15% or less for an ob and 10% or less for a midwife). That way, if an intervention is recommended in your case, you can trust your care provider's judgment. The rest is up to you. Eat right; get moderate exercise; take a good set of childbirth classes from an independent source, not the hospital; hire a doula; and read books, hang out on internet sites, and view media that portray labor and birth in a positive light. I particularly recommend the Giving Birth with Confidence blog at http://birthwithconfidence.blogs.lamaze.org/ and www.childbirthconnection.org. Finally, be prepared to be patient with yourself in labor. Things might take a bit longer than they might have in your 20s. ;-)

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Q73: If I need insulin, can I avoid continuous electronic fetal monitoring?

Q: I really want to avoid continuous electronic fetal monitoring.  I've read there's no evidence that EFM improves outcomes for low-risk women. 

Does my requiring insulin make me high risk in and of itself? 

Even if I am high risk, is there any evidence that EFM improves outcomes for high risk women?

A: If your sugars are under control, I don't see how you or your baby would be at excess risk, but I am not a clinician. Regardless, continuous EFM has not proven beneficial for low- or high-risk labors with one exception: When high-dose oxytocin (A.K.A. Active Management of Labor) is being given, continuous EFM reduces the incidence of newborn seizure, although even here, no differences in long-term outcomes were seen. It may be wise, though, to err on the conservative side and accept continuous EFM when being given oxytocin regardless of dosage regimen. Here's the skinny on EFM:

Alfirevic Z, Devane D, Gyte GM. Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev 2006;3:CD006066. 

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Q74: What are the risks of a prolonged first phase or second phase of labor?

Q: I understand that once membranes rupture, the risk of infection increases over time. In cases without rupture of membranes though, can someone please explain to me what the risks are of a prolonged first phase or second phase of labor?

A: Let me start by saying that it is by no means the case that rates of infection increase with length of time after membrane rupture if examining fingers, monitoring devices, tampons, whatever are kept out of the vagina--or even if they are not. (Women who test positive for GBS may be exceptions to this, but even their babies are fine provided they get their antibiotics onboard.) It is also possible that a brewing infection breaches membranes and releases the fluid rather than vice versa, especially with preterm rupture of membranes.

Returning to your question of the problem with prolonged labor with intact membranes, it isn't that there is inherent risk in some preset amount of time passing, but of how well the baby is tolerating a lengthy labor and whether something is keeping the baby from coming out no matter how much time is given or what is tried (obstructed labor). Obstructed labor during the pushing phase can injure the pelvic floor, leading to fistulas. This is a big problem in developing countries where malnourished women are married and having children too young to have fully developed pelvises and who live in rural villages and must travel for hours or days to get to a hospital with cesarean capability. And, of course, where there is no timely access to cesarean surgery, a baby who is not tolerating labor will die.

In short, how long is too long is a judgment call. Unfortunately for women in most developed countries, it is a call usually made well before it needs to be.

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Q75: Would a mucous plug cause breathing concerns and grey appearance in baby?

Q:  I am asking a question regarding my friend's recent delivery both for my and her knowledge. She had her baby at home--not her first child or first homebirth. The cord was very short and the midwife said that she thought the placenta might have been tearing loose during labor, so it was good my friend's contractions never got strong (she had to really work to push this one out) or it could have completely torn loose and baby would have been in trouble. The baby was born really grey looking--my friend describes photos of her husband dressing the baby as looking like he was dressing a dead baby. Baby went into several stopped-breathing fits during the first 24 hours. When the midwife consulted with a Dr. (baby was never seen by Dr.), they decided it was a mucous plug. Baby finally cleared it and pinked up about 24 hours after birth. Midwife seems unconcerned that anything was wrong and said as long as baby didn't lose oxygen for more than 10 minutes, everything will be fine. So far, at one month, baby seems fine. My friend is bothered by this since none of the other babies had breathing problems.

My questions are: What is this mucous plug they are talking about?

Is there possibly anything more that should have been done for the baby? Suctioning? Transport to hospital?

What would have been done differently in a hospital, and would it have been beneficial, debatably beneficial, or harmful?

Was this a potentially serious problem, or was the midwife's unconcerned attitude ok? It just doesn't seem right to me for a baby to be grey (not getting enough oxygen) for its first 24 hours.

A: A mucous plug is a glob of mucous that is stuck in the airway somewhere. It blocks or restricts the amount of air that goes to the lungs and alveoli where the gas exchange takes place. This results in breathing difficulties for baby and lower oxygen saturation. It is not an uncommon occurrence. At birth babies are assessed for their Airway, Breathing and Circulation (ABC's). If a baby is not pinking up you start with airway management which means positioning and suctioning to clear the airway. If the baby is breathing normally and has a normal heart rate but still not pink with a clear airway you give oxygen by free flow mask and monitor the SaO2 (oxygen level in the blood). If the respirations are weak or irregular you would give baby oxygen by bag and mask resuscitation and possibly intubate. If the heart rate is below 100 you would start cardiac compressions. You would listen to the breath sound with a stethoscope to ensure air entry to the lungs. A chest X-ray and blood gasses would be obtained. These would be helpful to see that the airway was indeed clear and if there were other factors like a collapsed lung that were contributing to the problem. I agree that a baby should not be grey after birth. There are numerous things that may have caused it. If I was attending this birth I would have actively managed the ABC's and had baby transported to hospital. I am so glad baby seems OK. It must have been a worrying time for the family and IMHO should have been for the midwife who should be current on her NRP skills/certification.

Not being a nurse, I wouldn't know what steps are taken to care for babies having respiratory difficulties. Clinical background aside, it seems obvious to me that this baby was having problems deserving of evaluation. I suggest in my book, Thinking Woman's Guide to a Better Birth, that one interview question when considering a home birth attendant is:  "Under what circumstances would you recommend transfer to hospital care?" This story illustrates why that question should be asked. While you don't want a midwife who jumps at shadows, you don't want one who is too cavalier either.

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Q76: What does placenta accrete, and will there be risks with a future pregnancy?

Q: I have been pregnant twice and had both my children at planned, CPM-attended homebirths after healthy, normal pregnancies.  After my second birth, I retained parts of the placenta, hemorraged, and required an emergency transfer to the hospital for attempted manual extraction then a D&C followed by blood transfusions.   At a post-partum check, my midwife told me that I had retained the placenta because of placenta accreta. 

I am having a difficult time finding consistent information on future risks.  Some sources say that accreta rarely reoccurs; others say that reoccurrence of accreta (or increta or percreta) is common. 

Where can I find reliable information on accreta and future risks when deciding whether to have a third baby and if so, whether another homebirth would be safe for me?

A: Here’s what I could find in my files: Placenta accreta in the absence of a predisposing factor such as uterine scar from a prior cesarean is vanishingly rare. Miller found that in women with no prior cesareans, 1 in 10,000 (16 out of 138,000 women) had a placenta accreta. I’m sorry that you were the rare unlucky one. It does, look, though, as if having had placenta accreta once puts you at somewhat higher risk to have it happen again. Gielchinsky reported an overall rate of 0.9% (310 among 34,500 deliveries), which included women with prior cesareans. However, 49 women of the 310 had a repeat accreta, of whom 4 women had a repeat cesarean. Those 49 women represented 16% of women with placenta accretas.

Gielchinsky Y, Rojansky N, Fasouliotis SJ, et al. Placenta accreta--summary of 10 years: a survey of 310 cases. Placenta 2002;23(2-3):210-4.

Miller DA, Chollet JA, Goodwin TM. Clinical risk factors for placenta previa-placenta accreta. Am J Obstet Gynecol 1997;177(1):210-4.

I hope this gives you somewhat more information on which to base your decision.

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Q77: Is an over 40 birth automatically high-risk?

Q: I am wondering about this study. The recommendation is for universal testing of all pregnant women over 40 starting at 38 weeks. With homebirth clients, this could be difficult. Is over-40 birth headed for automatic high-risk status? Should it be?

A: For those of you who didn't follow the link, the article is about an analysis of a national perinatal database that concludes that pregnancy over age 40 is an independent risk, that is, a risk unconnected with other risk factors such as high blood pressure, for late fetal demise and stillbirth. The article states that routine testing beginning at 38 weeks would reduce this risk.

Unfortunately, the article is based on a presentation at a medical conference. There isn't a published study that I can look up, read, and evaluate. What I can say in the absence of more data is that it is a leap of logic to think that fetal surveillance testing could avert this risk. For example, women over age 40 may be more likely to have babies with fatal congenital anomalies, or the problem may be one that comes on suddenly and would not be picked up by periodic testing.

Also arguing against the practice is that we have no evidence that routine fetal surveillance testing improves outcomes in low- or high-risk women. Moreover, testing of this type has a high false-positive rate, meaning the test says there is a problem when nothing is wrong. When the odds of something being wrong are tiny, as they almost certainly will be here, the odds of a false positive are much higher than a true positive. A positive test will result in inducing labor or scheduling cesarean surgery. This is not benign. Both procedures carry risks for babies and mothers. Among other adverse effects, even at 38 weeks, which is officially full-term, babies born from other than spontaneous onset labors are more likely to have respiratory and feeding difficulties. 

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Q78: Is there a correlation of Cholestasis or bile salt levels and risk of stillbirth?

Q: I’m 32 weeks pregnant and was just diagnosed with Cholestasis of Pregnancy due to elevated bile salt (aka bile acid) levels in a blood test. My bile salts are 13.4. My doctor told me they watch any levels over 8 (meaning I have to get non-stress tests twice a week and blood tests once a week) because there’s an increased risk of stillbirth. I’ve been planning for a natural childbirth, but my OB group told me if my levels go up to 40, they will induce labor. If they stay where they are, they’ll induce labor at 39 weeks. Even if I go into labor naturally b/4 39 weeks, the doctor said I’ll need to be on the Electronic Fetal Monitor continuously, which I was hoping to avoid. Do you know anything about Obstetric Cholestasis or normal bile salt levels? What are the true risks of stillbirth associated with it? Is it necessary to induce labor to prevent stillbirth? I’d like to know any information you are aware of.

A:  I don't have any information on this pregnancy complication. I suggest you ask the questions you posted of your care provider. I also recommend asking where you can go to get further information on your problem, its potential consequences, and the treatment for it. What I can do is provide some questions to ask that will get you the information you need to make informed decisions about your care. For treatments, the list is:

*What exactly is involved with this treatment? This should be explained to you in language you can understand.

* What are the benefits of this treatment? How likely is it that I will get the benefits?

* What are the potential harms of this treatment, and how likely are they to occur? There always are some. For example, inducing labor roughly doubles the chance of your having a c/sec, and inducing at 38 wks increases the likelihood of the baby having breathing and breastfeeding problems, but those are risks you may well wish to take if inducing reduces the risk of stillbirth.

* What are my alternatives, including doing nothing?

* What are the potential benefits and harms of my alternatives, including doing nothing?

* How urgent is it that we begin treatment? For tests, you will want to know pretty much the same thing with one addition: How accurate is this test? And, of course, you will want to have test results explained to you in language you can understand.

For further information on the issue of making an informed decision, take a look at Informed Decision Making on the Childbirth Connection website.

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Q79: With GBS-positive status, how long can I safely wait for Pitocin following the breaking of waters?

Q:  A question that I have is regarding the delivery of my first baby. I had premature rupture of the membranes, and then my labor wouldn't start...contractions were very weak. I was GBS-positive, so as soon as my water broke, we headed to the hospital for antibiotic therapy per our doctor's recommendation. 10 hours later, still no labor. The doctor said I had to get labor going due to the risk of infection to the baby. I realize that usually they wait 24 hours before insisting on this, but due to my GBS-positive status, that timeline was bumped up significantly. With God's grace and help, we were still able to deliver without pain relievers while I was on pitocin. Certainly not what I had envisioned happening. But I must admit, I was a hairline away from an epidural if my cervix hadn't dilated to 10 cm by the time that it had. And all my fears of a C-section began to surface as the snowball effect seemed to emerge from all the medical intervention taking place.

So how long could I have safely waited before resorting to the pitocin? I am currently 30 weeks pregnant, and I am concerned about the same scenario again. We are with the same doctor, same hospital. Also my husband and I are seriously contemplating the idea of switching to a midwife for a home birth. Do midwives test for GBS? Do they treat it if it is positive? Should I be concerned about a GBS positive test? One midwife I have spoken with as well as a friend that has had 2 home births said midwives typically treat with more natural/herbal means. Is this proven effective?

A: The Centers for Disease Control's recommendations for GBS diagnosis and treatment say nothing about inducing labor for ruptured membranes in GBS-positive women with full-term pregnancies and recommend against it in women with preterm babies. The key thing is to begin antibiotic treatment within 4 hrs of the birth. By the way, the baby needs no evaluation or antibiotic therapy provided that the baby shows no signs of infection, is at least 35 wks old, and the mother had antibiotics within 4 hrs of birth.

I would support your decision for a home birth. I work in a freestanding birth center and we offer screening to all women at 35-37 weeks per the CDC recommendations. We do have people make an informed decision to decline antibiotics and we are OK with that, however if another risk factor develops (fever during labor, prolonged rupture of membranes, etc.) we insist on antibiotics and/or transfer to the hospital because the baby is at higher risk and not a great candidate for early discharge. As for the PROM situation, we start antibiotics at 18 hours regardless of whether the woman is in labor or not. We require active labor by 24 hours, otherwise our protocols call for hospital induction. We often try castor oil, homeopathic remedies, breast stimulation, etc. to kick start labor. And we definitely avoid vaginal exams in this instance. I will admit that this protocol is not based on any particular evidence and Henci is right that the CDC doesn't comment on the PROM situation.

I have had a home birth (and am pregnant with my second and planning another home birth.) My home birth midwife last time offered screening at 35-37 weeks but many of her clients (including myself) declined testing. There are risk factors you can rely on to pick up many (but statistically speaking, not as many as routine screening) cases where the baby may be at risk and antibiotics may be advised- maternal fever, preterm labor, history of a prior baby with GBS disease, 24+ hrs of ruptured membranes. The CDC guidelines are based on a large study that showed that screening at 35-37 weeks is better than this approach, but it doesn't mean that the risk-based approach is ineffective. With my home birth midwives, regardless of GBS status, it is always the family's decision to choose to use antibiotics or to avoid them (or to use alternatives - none of which have been studied to my knowledge.)

I have major concerns about the liberal use of antibiotics in labor and in the newborn period. There is a lot of research coming out about the role of the newborn gut flora (beneficial bacteria in the intestines) in establishing a healthy immune system. When you disrupt the gut flora with antibiotics (or by introducing pathologic bacteria in a hospital setting) the baby is at higher risk for allergies and asthma. I encourage women who choose antibiotics for GBS to treat themselves and their infants with probiotic supplements after the birth. Probiotic capsules can be opened and the powder mixed with breastmilk and placed on the baby's tongue. There is plenty of research supporting the use of probiotics in preterm infants in the NICU - I'm not sure if there has been research on this issue in healthy term infants. Breastmilk itself is also a great source of probiotics (lactobacillus and bifidobateria) but I think women/babies exposed to antibiotics need supplemental doses.

With all of that said, antibiotics save lives when they are necessary! Unfortunately, we don't have the magic bullet to predict which newborns are going to develop GBS disease and would benefit from antibiotics - the only approaches we have now result in a HUGE number of women and babies being exposed to antibiotics when they never would have gone on to have a newborn GBS infection. GBS disease in the newborn is very rare and some studies have found that high colonization (lots of GBS in the vagina) and/or low immunity (not a lot of antibodies) are the most predictive of which babies will be affected. I think that future methods of screening women to determine who needs preventative antibiotics will focus on these factors, not simply the presence/absence of GBS in the vagina.

I wish you lots of strength and joy as you approach the birth of your baby. Let me know if you have more questions about this important issue.

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Q80: Will the estimated size of my baby keep me from having a normal birth?

Q: I recently went to see my OB (at 24.4 weeks) and she measured me at 32 centimeters and predicted that I would have a "very large baby" (she didn't say just how "large"). My question, then, is how out of the ordinary is a 32 centimeter measurement at 24 weeks and what sort of problems might it cause? To give you some background about my health, I've gained 13 lbs (starting pregnancy at 5'5 and 140 lbs) am carrying a boy and have continued to be complication free throughout these past 24 weeks. I haven't yet had the gestational diabetes test yet. I'm getting worried that the estimated size of my baby might keep me from having a normal birth. What advice might you have for me?

A: My advice is to ask your ob her recommendations for women carrying "big babies" in order to minimize problems at the birth. Here are the answers you DON'T want to hear because they are not supported by the research: "I like to induce labor a couple of weeks early so the baby doesn't get too big" or "It may make sense to plan a cesarean."

I also suggest you ask your ob what her cesarean rate is, which I would phrase as: "How often do you find it necessary to perform a cesarean?" If you hear a number over 15%, again, this is not in line with what the research says can be attained in typical populations, that is, some women with problems that increase their likelihood of needing a c/sec but mostly not. If she dances around the issue with responses like "I only do them when they are necessary" or "I'm in the average range" -- which nationally, by the way, is a shocking 29% as of 2004 -- or says she doesn't know, take that as a bad sign too.

If you get any of these "red flag" responses, then I recommend that you seek out a care provider whose practices are more in line with what the research establishes as safe, effective care. Here is a source that can tell you how to do that: How do I choose my caregiver?. My book, the Thinking Woman's Guide to a Better Birth, also has chapters devoted to choosing a caregiver and the place of birth.

Having a care provider on whose judgment you can rely is the most important thing you can do to maximize your chances of a normal birth, but you may also want to surf around this website and find out more about practices that support it.

I thought I'd also offer some tips for helping labor progress with a bigger than average baby. But before I start, let me say that I, too, have birthed a big baby. My 3rd and last child (now 20 yrs old and all of 5"1" tall) weighed 9 lbs 4 oz. I weighed 115 lbs at the start of that pregnancy.

* Hire a doula. The emotional support she can offer both you and your partner and her ideas and suggestions can make a big difference.

* Don't induce labor so that the baby doesn't get "too big." The medical research does not report any benefits from this practice, and it increases the odds of c/sec. For that matter, don't schedule a c/sec either.

* Avoid admission to the hospital until you are established in active labor. The research suggests that women will have more medical intervention if they are admitted early in labor probably because somebody gets impatient because labor seems to be taking so long and decides to "do something." With a 1st baby, this will generally mean at least 1 hour of contractions no more than 5-min apart from the beginning of one to the beginning of the next one, at least 1-min long, and strong enough that you cannot walk or talk while having one. If you aren't sure of where you are and your ob's office is open, drop by and get checked. If it is after hours, go to the hospital but explain that you just want to be checked, not admitted. If you are still not sure whether to stay or go back home, hang around for an hour or two walking the halls and get re-checked.

* Have patience. Expect labor to take longer with a bigger baby. This means having a patient care provider who does not impose arbitrary time limits on how long you have to make progress.

* Plan on staying active in labor and pushing in an upright position. Getting gravity on your side and having mobility maximize your chances of getting the baby into the best position for birth and pushing the baby out on your own.

* Avoid an epidural. It will interfere with your ability to walk and change position, and it interferes with your ability to push effectively.

* Plan on using the "Gaskin Maneuver," the only obstetric technique named after a midwife, with your care provider. Sometimes, especially with bigger babies, the head emerges, but the shoulders hang up behind the pubic bone (shoulder dystocia). The best way to remedy this problem without any ill effects to baby or mother is to either have the woman give birth on her hands and knees or have her turn to her hands and knees should it occur. (This can, by the way, be done with today's modern, lighter epidurals.) Here is the abstract: All-fours maneuver for reducing shoulder dystocia during labor

Here are some resources to help you with these goals:

Books: The Official Lamaze Guide: Giving Birth with Confidence by J Lothian and C DeVries; Ina May's Guide to Childbirth by IM Gaskin; Pregnancy, Childbirth and the Newborn by Simkin, Keppler, and Whalley.

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Q81: My first baby had severe shoulder dystocia – is there anything I can do to increase my chance for a healthy birth?

Q: I am currently 24 weeks pregnant. This is my second pregnancy. My first delivery was a planned induction and my water broken immediately after I arrived at the hospital. I was in labor 15 hrs and pushed for 2 hrs of that time before my daughter was born. She was 8 lbs 4 oz. She had a severe shoulder dystocia. She had 3 broken ribs, her arm was flaacid from the shoulder to the elbow, and she had a facial droop. The nerve damage was, as I was told, was related to brachial plexus damage. The damage reversed itself and she is now 4 1/2 and is fine. The doctor is telling me that the best way to avoid this problem is not to gain too much weight. I have gained 13 lbs so far. I am still extremely concerned about a normal vaginal delivery. The doctor says it is possible but he will be extremely cautious to note how the baby is moving down and how the labor is progressing. Should I be overly concerned from a lamaze standpoint or is it possible that the bony structure of my pelvis has changed enough to deliver an equally sized baby? Am I too concerned? Also, I frequently have Braxton-hicks contractions. They occur with even mild activity (such as walking to the car). They do resolve with rest. Should I be concerned about this? Is this a pre-cursor to premature labor since it occurs so readily?

A: The best and safest way to avoid (or relieve) shoulder dystocia is to give birth on hands and knees, a technique often used by midwives, but few obs seem to know about it. If your ob is not willing to accommodate you in this, I strongly recommend finding a caregiver who will. Bruner JP et al. All-fours maneuver for reducing shoulder dystocia during labor. J Reprod Med 1998;43(5):439-43. Next, while it is possible to give birth on hands and knees with an epidural, you will be much better off if you avoid one in terms of mobility and your ability to push effectively. You should also know that inducing labor for suspected big baby does not improve outcomes and increases the cesarean rate. Go to HenciGoer.com/resources and scroll down to "Labor Induction: When a Big Baby Is Expected." It sounds like your ob may suggest a cesarean either during labor or perhaps even a planned cesarean. I recommend you download What Every Pregnant Woman Needs to Know About Cesarean Section so that you make an informed decision based on knowledge of the potential risks of cesarean surgery as well as the potential benefits. As for weight gain, if you are a high-weight woman, you will want to gain less weight than an average- or low-weight woman, but you do want to gain weight throughout the pregnancy on a sensible, nutritious diet. Regular exercise helps too, not to mention helping build stamina. I also recommend hiring a doula. I think all women benefit from the practical advice and emotional support doulas provide, and their labor companions also benefit from support. However, in your case, I think it is especially important. Your daughter's birth must have been very distressing to you, so you are bound to be more than usually anxious in this labor and in need of a calming, soothing influence. And if you aren't going to use an epidural, you will want someone with you who is knowledgeable about comfort measures and other strategies and techniques for coping with labor pain. Finally, I wouldn't be too concerned about Braxton-Hicks. Most women notice them more the second time around. Check with your care provider on this, but I believe that as long as contractions don't get longer, stronger, and closer together, they aren't a concern. Also, Braxton-Hicks feel like a tightening whereas labor contractions are crampy. Oh, and by the way, I don't know if this is an issue, but you don't need an episiotomy. Shoulder dystocia isn't a soft tissue problem, so an episiotomy does nothing to make the birth easier.

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Q82: What is some information about skin-to-skin right after birth?

Q: I am an older doula who is having a hard time trying to convince hospital staff that mothers and babies should have skin to skin immediately and uninterrupted for an hour or so after birth. Some nurses and doctors are great with this but they are in the minority. My effort to talk about it with nurses leaves me with the emotional equivalent of having a door slammed in my face.

I have been working on developing a handout for parents that is fast and easy to read that would convince them that the research is real. I want to convince them that they can delay learning what the baby weighs and delay calling relatives about the birth until after that first hour.  I am finding this a harder handout to develop than others I have done over the years. 

 I talk about skin to skin and the many advantages a lot with my clients ahead of time. They all seem like they want that advantage but when the time comes, a nurse often says, "Let me just take the baby for a minute to _______(fill in the blank with just about anything)."  And then the baby is handed over by the mother who is still feeling dazed by the birth. 

Does anyone have a great handout already prepared? I would be thrilled to see it.

A: The American Academy of Pediatrics (AAP) statement on this topic is:

Healthy infants should be placed and remain in direct skin-to-skin contact with their mothers immediately after delivery until the first feeding is accomplished.156158

The alert, healthy newborn infant is capable of latching on to a breast without specific assistance within the first hour after birth.156 Dry the infant, assign Apgar scores, and perform the initial physical assessment while the infant is with the mother. The mother is an optimal heat source for the infant.159,160 Delay weighing, measuring, bathing, needle-sticks, and eye prophylaxis until after the first feeding is completed. Infants affected by maternal medications may require assistance for effective latch-on.156 Except under unusual circumstances, the newborn infant should remain with the mother throughout the recovery period.161

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Q83: Are there any benefits of placenta encapsulation?

Q: I am a birth doula, currently training through DONA, and am curious about the increasingly popular trend of women having their placentas encapsulated. I know that enthusiasts claim benefits such as regulated hormone levels, more energy, fewer incidents of postpartum depression, and better milk supply, but when I've searched online, I tend to find more opinion pieces than hard science. Have you come across any scientific research about the benefits (or lack of benefits) of consuming the placenta?

A: I ran a search in PubMed, the U.S. National Library of Medicine database, and didn't come up with anything germane. This didn't surprise me because I didn't think placental encapsulation had reached the point where anyone would be conducting research on it yet. In any case, I think that for alternative treatments such as this, there should be a lower bar than "proven effective in experimental trials," namely, safety. If it is safe, then some women will find it helpful simply based on the placebo effect. So the question becomes: Is it safe? I can't think of a reason why it would be any less safe than eating, say, calf or chicken liver. The only danger I can think of is if it replaced more effective treatment, but I don't see that as a big issue either. Presumably if it wasn't helping, a woman would move on to more conventional therapies. Another point to consider is the potential effects of meds used in labor ending up in the placenta. I don't think Pitocin (oxytocin) would be an issue because of its short half-life, but I can't say about the others. Factors that would come into play would be how much would accumulate in the placenta, whether meds would be broken down during digestion, whether they would be absorbed, how much over what time period the woman would consume, and last, but not least, whether they posed any risk even if a meaningful dose were absorbed.

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Q84: Should adoptive parents (present for birth) get skin-to-skin with baby when he/she is born?

Q: My daughter will give birth (as a surrogate) to twin boys in February. The biological parents will be present at the birth to receive their babies. I will be the doula. Here are my questions:

When these babies are born, should they be put "skin to skin" on their biological parents chests or washed and cleaned and then given to the parents?

How do all of you see this birth happening so that the real parents become part of the birth picture?

 What thoughts would you share with the biological parents?

A: My specialty is what the research shows to be safe and healthy birth practices. Among them is putting babies skin-to-skin immediately after birth provided, of course, the baby doesn't require immediate nursery care. The babies' adoptive parents could put them skin-to-skin, no washing necessary--in fact, washing could chill them, although they could be wiped gently to remove blood or other secretions. To preserve modesty, the adopting mom might want to put on one of the hospital gowns like a robe with the opening in the front. 

One more thing: if this isn't already routine practice where your daughter will be delivering, insist on waiting until their umbilical cords stop pulsing before clamping them. Early cord clamping deprives infants of a substantial proportion of their blood supply, which is good for full-term babies and crucial in preemies, which twins are more likely to be.

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Q85: Is breastfeeding not scientifically supported as we believe?

Q: Please tell me, is the author at all correct in her assertions that the scientific literature does not support breastfeeding to the degree that we believe? http://www.theatlantic.com/doc/200904/case-against-breastfeeding

A: I have never developed expertise in the breastfeeding research, but your question was an easy one. Here is a systematic review on the benefits of breastfeeding from the Agency for Healthcare Research and Quality.

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Q86: Is there a postpartum depression treatment that would allow continued breastfeeding?

Q: I am breastfeeding my son who just turned 6 months and I have been diagnosed with post partum depression and have to be put on antidepressants and I have been told that I can't breastfeed which I really wanted to continue until my son Seth is a year or a year and half. I have two other kids that I did breastfeed until a year and half.

I am very upset about this. Does it really have to be one or the other? Do I have to really choose? Are there any anti-depressants I can take that is safe for breastfeeding?

A: I copied your post to a friend who is a licensed psychotherapist specializing in perinatal mood disorders and asked her if she could advise you on options for treatment that can help with your depression without requiring you to quit breastfeeding. Aside from your preference to continue, you don't want to quit breastfeeding unless you absolutely have to because it can worsen depression. I'm pasting in her response below:

I'm so sorry that you are finding the transition after your 3rd birth to be so difficult. I am aflutter with questions, none of which you need to answer to me directly. The questions are more in line with keeping us both open to options. If it is interesting to you to continue a conversation with me by email, you are so, so welcome to do so. It is very common for me to have these sorts of conversations, and I quite enjoy the contacts I make.

So, question #1 - are you SURE you are experiencing postpartum depression? The term "postpartum depression" is SO vague. PPD is not a specific diagnosis. It's a general category that describes anything from a normal response to challenging life situations (financial stressors, traumatic childbirth experiences, significant stressors in the couple relationship, etc) to anxiety disorders (posttraumatic stress disorder from birth itself, or from childhood and/or domestic abuse) to actual major depressive disorders. Whew! That's quite a list! Very often, if the source of the stress is the birth itself, it is the childbirth professional providing the care who also makes the diagnosis of "depression." I'm sure you can imagine how this can be problematic. The mother and/or physician/midwife may not be comfortable asking or answering questions around trauma. Few ask about household tensions, whether this was a planned or unplanned pregnancy, and so forth. The diagnosis of depression is fast, centers the problem in the mother, and allows for a speedy treatment plan.

The most common diagnostic inventory used to discover postpartum "depression" is the Edinburgh Postnatal Depression Inventory. It's one of the few free and easily-available tools out there, so it is used by most providers. Per the authors' own caution, the inventory was never designed to discover anything outside of depression - but *everything* outside of expected limits is marked as such.

Acquiring a diagnosis of depression sets into motion a whole protocol for treatment. SSRIs (selective serotonin reuptake inhibitors) are currently the most popular option. As prescription drugs, they are covered by most insurance plans, have a reduced social stigma (as compared with counseling), and are easy on the provider's time. Interestingly, there is relatively little data on the efficacy of these drugs in the postpartum period when all the factors I discussed above are controlled for. Some, such as zoloft, are very commonly prescribed to breastfeeding women, and the data seem to suggest that there is little to no long-term consequence for the infant. Most mothers, however, prefer not to take prescription drugs while breastfeeding and will, therefore, forgo treatment or breastfeeding in the mix. Rapid weaning can have physical and emotional consequences, which actually worsen the depression. In my private practice, the cessation of breastfeeding at the suggestion of other providers is the most common source of tears, as mothers describe their grief and guilt.

So what are other options? Well, first - properly assess the situation you find in front of you. There is an Alpha Antenatal Inventory out of Canada that looks at life stressors relative to mood disorders in the perinatal period. If you work through to the end of this article, you will find the inventory: http://www.cmaj.ca/cgi/reprint/173/3/253.pdf

Unfortunately, at this time, there are no proper inventories for doing a "differential diagnosis" in the postpartum period. This means, essentially, asking the question, "What are we REALLY seeing here?" You will need to find a mental health clinician who is a bit sophisticated on that sort of work. Or at the very least, open-minded! Peer resources such as International Cesarean Awareness Network and/or Solace for Mothers can help to connect you with providers near to you - if you are in the US or Canada. Further afield takes other resources, however, I do have a list from which you can begin if you have an interest along those lines.

Have your healthcare provider thoroughly check your thyroid and your iron levels. Imbalances in those areas can cause symptoms that mimic PPD. After that, acupuncture, group support, individual psychotherapy, and naturopathic remedies have all been studies as effective for the treatment of postpartum mood and anxiety disorders.

A technique such as EMDR has been helpful for some around the resolution of trauma. This period of time is NOT, in my opinion, a time to engage in long-term therapies of any kind. This is a "crisis counseling" situation, and should be brief and very focused on finding you relief ASAP. That's why a proper assessment is the right place to start, as you can only be brief if you are pointed in the right direction to begin with!

Whew! A long-winded answer to be sure. If you have any further questions, please feel free to send back a note. I'm happy to support you as you discern your options. Very best wishes, Sharon Storton

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Q87: Are there any resources or readings to assist with the loss of a ‘normal birth’ dream?

Q: I received an email from a member of a group I used to be the leader of, and she was asking for information or suggestions on dealing with her lingering sadness over the loss of her dream of a normal birth. I met her when she was pregnant with her second child, so I am not sure what her first birth was like. Her second involved an OB who cut an insane episiotomy and it extended, and then did a botched repair. She had painful sex and some other issues from the rectal tear for a LONG time until finally she had to see another doctor and have the repair repaired. Things were still not "fixed" then but were much better. Anyway, the second birth was a really awful experience that lingered on for about two years in its effects.

Fast forward a year after that, she was expecting again and was so glad to get a chance to have a different birth. She was "doing everything she could" - she chose midwives so that she could have the midwifery model of care, interviewing doulas, etc.

Then she realized that the baby wasn't moving one day- listened to her instincts, which saved the baby's life. Her daughter has heart problems and they thought she was going to die. (I believe my friend was ~28 weeks at the point that she realized there was a problem.) She spent a lot of time in various hospitals for the rest of her pregnancy, trying to walk the delicate balance of giving enough heart medicine that the baby would receive and be able to to survive, while not causing damage to my friend, whose heart was fine. It was quite touch-and-go and a stressful couple of months. Eventually, no matter how much tinkering with the dosages that they did, they couldn't give my friend enough of the drug for what the baby needed without the effects on my friend being too toxic, and it truly did become a case of the baby being safer out rather than in, and she ended up born by cesarean prematurely but much less prematurely than she almost was.

My friend did her research, feels good about her decisions and grateful that her daughter is alive and doing pretty well with a pacemaker- she is quite delayed so far but cute as a button and such a joy to their family. They hope that she lives a long life, although I believe she is still at some risk of not living to adulthood due to a variety of problems. Still, for today she is doing well, and they have learned to appreciate each day as it comes and not borrow trouble. They have plenty to deal with on a daily basis without looking for more!

But even so- the cesarean of a preemie was not the healing experience that my friend was hoping for and working for, and she is still mourning it (even as she rejoices at her daughter's life and considers the sacrifices to have been well worth making, etc.) and people basically telling her she shouldn't be doing so, that she should just be grateful she has her daughter (which of course she IS) and that she's ungrateful to be anything other than happy... and that c/s is no big deal... etc. isn't helping. Instead it makes her feel guilty that she still feels kind of cheated of her chance to try again.

So it seems to me that maybe this is a big unmet need, with the climate of birth there is in our country right now. There must be many more women who are dealing with the grief and pain of not getting to have a normal birth when they so urgently desire one. Are there any resources or readings to assist with the loss of a ‘normal birth’ dream?

A: This story is heartbreaking on so many levels. It is often true that by listening and *truly* hearing this lovely woman's distress, you are providing a salve toward healing. Too frequently, we are shamed into believing that we are ungrateful if we admit to "negative" feelings, and that love and sadness are somehow mutually exclusive. She is so blessed to know you!

In my practice, I am often with women who have had dramatic and traumatic experiences. Trauma is possible whenever a person experiences fear, horror, or revulsion. No one else needs to objectively validate that experience: the experience is in the eye of the beholder. Certainly finding onself in the hospital, hanging on moment by moment for your unborn child's life, not knowing all the while if your own healthy is also in jeopardy, can be horrifying to say the least. Understanding the grief involved in this trauma, and working through the adjustment from expectations to current reality is important. A very fine book in this regard is *Shattered Assumptions* by Janoff-Bulman.

When working through the trauma itself, I often use "EMDR" as a tool for healing. A good book on that particular form of help is *Transforming Trauma: EMDR* by Parnell.

Looking at the possibility of a residual experience of either depression, anxiety, or PTSD (post-traumatic stress disorder), two very good books spring to mind: *The Hidden Feelings of Motherood* by Kendall-Tackett, and *Rebounding from Childbirth* by Madsen. Each has a section on stress and dealing with the unexpected.

An excellent organization supporting women who have experienced birth-related trauma is hosted by the organization called "TABS" (Trauma and Birth Stress) out of New Zealand. Their site can be found at http://www.tabs.org.nz/home.htm. In the US and Canada, an organization called "Postpartum Support International" (PSI) can be found at http://www.postpartum.net. On the PSI site, you can find a list of mental health therapists trained to support women in the perinatal period, as well as list of support groups by region.

Not all therapists are equipped to work with trauma, and that would certainly be a screening question I would ask before making an appointment. My experience is that this type of therapy is relative short term (as little as 2-3 sessions! and commonly around 5-6 if the therapist is well trained and experienced, and the subject of counseling is confined to the perinatal experience). When you do locate the appropriate support, relief is often very rapid in coming.

I wish you and this mom all the very best, and hope for a peaceful resolution to her experience. It sounds like you are a very active resource for your local area. What a gift you must be to the mothers you meet. Now go solicit a hug - you've earned it!

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Q88: Is there any help for stress incontinence around the time of ovulation?

Q: I am working with a mother who has had several children (more than 5 - all vaginally) and she is suffering with stress incontinence. She notices that it gets worse around the time of ovulation and knows other women for whom this is also the case.

Why would this be and is there any recommendation about what to do about it?

A: I haven't researched this issue, but it would not surprise me to hear that incontinence fluctuates with hormones. I can tell you that one of the surprise findings of the Hormone Replacement Therapy trial was that women on HRT were more likely to have urinary incontinence. As to what to do about it, I would give her the same advice that I would give to any woman experiencing problems with urinary stress incontinence (involuntary loss of urine when sudden pressure is put on the pelvic floor such as when sneezing, laughing, coughing, or lifting a heavy object):

-- Contract the pelvic floor in anticipation of activities that cause loss of urine.

-- Maintain healthy body weight: the extra weight on the pelvic floor increases pressure

-- Avoid smoking: the cough smokers often develop is the likely culprit.

-- Continue pelvic floor muscle exercises: more intensive programs have been shown to produce better results than less intensive ones.

-- Avoid hysterectomy, when possible: this is probably because removing the uterus removes some of the support structures of the pelvic floor.

-- Avoid HRT, when possible: it's unclear why, but the association was found in a random assignment trial, which means it is probably real.

Of course, I'm assuming that her problem is stress incontinence, the type associated with childbirth. There is another type of incontinence called "urge incontinence" where a person leaks urine during a sudden urge to void. This is more of an irritability issue. We've all seen the commercials on this one, and as they make clear, there are medications for this type.

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Q89: What is pelvic floor and vaginal recovery after childbirth?

A: You are least likely to experience injury or pelvic floor weakness if:

* Your caregiver has a high "intact perineum" rate. This means either no injury or just little "skid marks" that don't need stitching.

* You don't have a vaginal instrumental delivery. Epidurals, BTW, increase your likelihood of having a vacuum extraction or forceps delivery.

* You don't have an episiotomy. Anal sphincter injuries almost never occur except as extensions of midline episiotomies. Women have stronger pelvic floors even after perineal tears that need stitching compared with episiotomy of whatever type.

* You push according to your natural urges, breathing and making noise spontaneously. This is another reason to avoid epidurals. They numb you so you will almost certainly need coached pushing.

* You push and give birth in whatever positions you find comfortable and effective. You avoid pushing, and especially giving birth while lying flat on your back or nearly flat on your back or with your legs in stirrups. You give birth with your legs comfortably apart.

* You birth the head gently and in a controlled manner in between contractions.

* You practice your pelvic floor contractions (also called "Kegel" contractions after the ob who thought he invented them) in pregnancy and especially in the weeks and months after the birth. (If you don't know what this is, most good "how to" childbirth books such as The Official Lamaze Guide: Giving Birth with Confidence will tell you how to do these, and I'll bet you could also find instructions on the 'net.)

* You get regular exercise. It will take several months to recover completely, so be patient. Also, know that the notion being promoted by many obstetricians that elective cesarean surgery will protect your pelvic floor is not true. First of all, studies concluding this do not take into account all the injurious practices and policies common to obstetric management of vaginal birth. Even so, by 6 mos or more after the birth, differences between women birthing vaginally and women delivering by c/sec have almost disappeared. Finally, no study finds any differences after age 50 or so. Problems with incontinence in later life are due to other factors.

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The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.