VBAC With Multiples IS Possible!

"In women with twins a trial of labor after a previous cesarean section is a safe and effective alternative to routine repeat cesarean delivery."1

(note for those watching video--TTTT is twin-to-twin transfusion and IUGR is intra-uterine growth restriction)

"A French study... suggested that Caesarean delivery more than triples a woman's risk of dying in childbirth compared with a vaginal birth."

http://www.homebirth.org.uk/vbactwins.htm

http://www.radmid.demon.co.uk/twins.htm

"When a cesarean is necessary, it can be a lifesaving technique for both mother and baby, and worth the risks involved. With half the cesareans being performed deemed unnecessary by WHO, the risks these mothers and babies are exposed to are avoidable and costly."

"An analysis in Great Britain revealed that women were 5.5 times more likely to die of an elective cesarean, than a vaginal birth (9 versus 2 per 100,000). A Dutch study found that [ceareans] caused seven times more deaths than vaginal births (28 versus 4 per 100,000)."

"Vaginal delivery when a first twin is vertex and a second is nonvertex (breech) is a safe alternative to cesarean section, according to a study presented at the HGO World Congress of Gynecology and Obstetrics."2

"In selected cases vaginal delivery of triplet gestations can be accomplished without increased maternal or neonatal morbidity and mortality and may significantly decrease maternal hospital stay and postoperative morbidity. (Am J Obstet Gynecol 1998;179:1133-5.)"3

1. http://www.ajog.org/article/S0002-9378%2896%2970274-0/abstract

2. http://www.thefreelibrary.com/If+second+twin+is+breech,+vaginal+delivery+still+safe%3A+study+of+107...-a0112542267 and http://findarticles.com/p/articles/mi_m0CYD/is_1_39/ai_112542267/

3. http://www.ajog.org/article/S0002-9378%2898%2970119-X/abstract

Please remember that I had a cesarean myself and that I do not post this in ignorance to the procedure nor without compassion to those who have undergone it. This is merely informational to present that [attempted] vaginal birth is a viable and safe option for twins and some triplets, even if they are a VBAC. I am not a doctor and this does not substitute for medical advice.

Children Live Here (a poem)

I wrote this this morning while I was lying in bed, trying to decide if I wanted more sleep or wanted to get up. It popped into my head, so my decision was made for me by my muse--get up and write!

image courtesy of stockxchng

Children Live Here

When we welcome you here today
We hope that you enjoy your stay
But one thing we ask you hold dear
Please remember: children live here

There are toys on the floor
Some marks on the door
Clothes scattered in the hall
And marker on the wall
We'll repaint it someday
But we have no time today

There are things in the sink
A Barbie skating rink
This stuff doesn't bother us
And real friends don't raise a fuss
They know the reason is clear
Yes, they know children live here

Instead of cleaning the wall
We went out and learned about Fall
In lieu of the porch being swept
I held the baby who slept
Those clothes were for dress up
While I cleaned a bigger mess up
And the noise tells everyone near
There's no doubt children live here

The happy laughter means more
Than seeing all of the floor
And please respect those kids
For this home is hers and his
We hold our family dear
And you knew children live here.


image courtesy of stockxchng

Since I've been asked many times for permission to print this--anyone may print and share this as they like as long as they give proper credit to me :) My pseudonym is H.S. Hines or H.S. Kallinger for author credit.

Risks To Baby From Cesarean Section Birth

Originally published Nov 6, 2008 at 12:08 AM on Cafemom

So, I read a surprising comment today--someone believing the risk of amniocentesis outweighs the risk of a cesarean to the baby. She said that a cesarean has its risks, but amnio could be the end of the world.

Do people really think a cesarean is that SAFE? I'm sorry, but it's not. And while, yes, the risks to mom are higher than risks to baby, just because those risks are frightening and include horrific infections, infertility, death, etc. does not make the risks to baby insignificant (and they are still greater than to a baby born vaginally and include a 3x increase in risk in death).

Here's just the short list, so you don't have to drag through all the papers and sources I have.

image courtesy of stockxchng

Risks to baby from cesarean section birth

Breathing problems^[1]

weakened immune system^[2]

digestive problems^[3]

fetal injury^[4]

diabetes (risk is 20% greater for babies born by c-birth)^[5]

asthma (risk is 50% greater)^[6]

neonatal depression (from anesthesia)^[7]

hospital borne infections (rate is higher due to the longer stay after a c-birth)^[8]

neonatal mortality (risk rises from .62 to 1.77)^[9]

and increased risk of SIDS^[10]

Low APGARS^[11]

There's the list of the most common side effects. I know that most people aren't aware of them, so that's why I compiled a list here. I couldn't find a comprehensive list anywhere else. I may expand this journal with a short synopsis of each condition at a later date.

My daughter was born by cesarean, beautifully, APGARS of 9, no side effects that we know of. But that doesn't negate that these risks are real and any baby born by cesarean could be affected in one of the ways above. It's important to be informed about the potential risks in any procedure being performed on you or your baby.

image courtesy of stockxchng

^[8]Pai, Madhukar. 2000. “Medical Interventions: Caesareans Sections as a Case Study.” Economic and Political Weekly 35 (31): 2755-2761.

What You Should Know About Shoulder Dystocia

Photo courtesy of stockxchng

This is something that my doctor loved to threaten me with when I was carrying Lilly. It was ridiculous because 1. my daughter was perfectly normal sized and 2. I had no intention of birthing on my back, which is the primary cause of problems, and my doctor knew this and had agreed to it. She was just angry that I wouldn't consent to an unnecessary induction for her convenience.

What is Shoulder Dystocia? It's a very rare and serious complication in which baby's shoulders get stuck that affects babies of all sizes, though it occurs slightly more frequently in babies that are over 9lbs. It's still rare, however, and not something that you should spend time worrying about. There is no way to accurately predict it ahead of time and any provider talking about it is likely looking for the bigger paycheck that comes with a cesarean birth (the difference? vaginal birth: $10K, cesarean birth: $25K and a VBAC costs more than a regular vaginal birth, thus, it's always in an OBs best financial interest to go for a cesarean--though it's NOT in mom's OR baby's, as mom is 5.5 times more likely to die and baby is 3 times more likely to die and complications of less serious natures are far more frequent as well).

So, doctors love to say, "Your baby is too big," (usually based on faulty ultrasound data, despite the fact that ultrasounds can be wrong by 2lbs or even more and become useless in determining size after week 20). The reason is usually shoulder dystocia. Many techniques have been used over the years, including just killing the baby, though the most success has been found in the easiest technique to date--the Gaskin Maneuver. The Gaskin Maneuver consists of having mom roll onto all fours (or assisting if necessary). During the process, many babies become dislodged and pop right out. If this doesn't happen, then the doctor actually has better access to help wiggle the baby around until the shoulder releases and the rest of baby is born (Woods or Rubin maneuver).

Most obstetricians don't even know that this maneuver exists, though most midwives are trained in it. In one study, it was shown to be effective in 83% of use without any further maneuvers. 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%).

Many doctors use traction (pulling on baby's head) or fundal pressure (where the nurse climbs on the bed and jumps down onto your stomach) before anything else and these are not only the least effective techniques, but dangerous to mother and baby.

The McRoberts maneuver (where mom's legs are brought up as far back toward her stomach as possible, which realigns the pubic bone and can slip baby's shoulder out) should be tried first and if failing, suprapubic pressure (where the doctor or nurse makes a fist and pushes hard on the baby's shoulder just above the pubic bone) can be applied. Next, the Gaskin maneuver should be performed and if that fails, then Woods and Rubin maneuvers can be tried.

McRoberts is effective in 39.5% of cases and in 58% with the addition of the suprapubic pressure. These methods can cause serious injury to the mother (McRoberts can injure mom's legs, particularly the femur and hips), but are typically safe to the baby. Woods does not have an available statistic for effectiveness and can break the baby's humerus. The Rubin maneuver is the opposite of Woods and requires less traction and causes significantly less injury.

Australia is currently training doctors in fracture of the clavicle, which has been dismissed until now as so dangerous to the baby and difficult to perform that it should not be used. However, it is used in some cases and can be lifesaving for baby. It's a severe emergency procedure that should not be attempted until all others have failed.

The Gaskin maneuver is most criticized due to it requiring the mother to be able to roll over and support herself on her hands and knees--something that is difficult, if not impossible, to do with a normal epidural. That's the only criticism, however, that is keeping it from being more widely studied and implemented.

The evidence from the literature on shoulder dystocia shows clearly that shoulder dystocia cannot be predicted with any degree of accuracy and it cannot be prevented by any specific strategies or maneuvers. Half of the babies in the Gaskin study were not larger than average and many were in the 5lb range. The worst outcomes did occur in the 'macrosomic' (larger than 10lbs) category. However, 'macrosmia' is not a sole cause nor does it always lead to shoulder dystocia. In fact, over 90% of macrosomic babies can be delivered vaginally without incident.

Perhaps in those "birth plan creators" that are available all over the internet that include sections on emergency births, preferences on maneuvers should be included in the event of shoulder dystocia. It's unlikely that doctors would be open to this, however, despite evidence of effectiveness and safety of the procedure, simply because they have no experience with it.

The best thing you can do as a pregnant woman is to be educated and if your doctor brings up the issue, discuss it with him/her. Eve if they don't, it might be useful to know their typical management of shoulder dystocia in case of emergency and their willingness to attempt maneuvers with less risk to mother and baby, even if unconventional, before the more dangerous, riskier maneuvers. It's also important to stay calm and follow your care provider's direction if the complication does arise.

Maneuver illustrations:

Traction:



McRoberts:


suprapubic pressure:


Woods Screw Maneuver:


Rubin Maneuver:

Gaskin Maneuver:

Musing on Gestational Diabetes

For all intents and purposes, this blog refers to Type A1 gestational diabetes only: "abnormal oral glucose tolerance test (OGTT) but normal blood glucose levels during fasting and 2 hours after meals; diet modification is sufficient to control glucose levels"1

photo courtesy stockxchng

So, you're in the sixth month of pregnancy and the doctor says that at your next appointment, you are going to be tested for gestational diabetes. She explains that you are going to be given a drink an hour before blood is drawn to see if you have GD. She doesn't give you much other information. At some offices, you will be sent home with the glucola (sometimes you even get to pick your flavor), while at others, you go in the day of testing, an hour before, and are given the drink.

Let's say you're in the second group, like I was the first time. So, on the day of, you get up and have breakfast as usual. A couple hours later, you go in and you get your drink. You choke it down (I thought it tasted fine, but many women complain of the taste) and then go sit in the chairs to wait for your test. You go to the phlebotomist's chair and she either draws a vial of blood or pricks your finger, depending on the office. You get your bandaid and go home (probably craving something high in protein or a lot of water).

You go in for your next appointment to find out you failed the test. Next, you are told that you'll have to take the fasting three hour test. You are given a date and you fret and worry about what this means. Your doctor assures you that many women who fail the one hour test pass the three hour test.

So, on the day of, you go in, your stomach growling, possibly having a return of the dreaded morning sickness because your blood sugar is so low. They take your blood and send you off with your drink. You choke it down (it's even worse this time) and are informed that if you throw up or consume anything else, you automatically fail and have to do it again. You can have as much water as you want, though.

You go sit in the chairs and read a book or magazine for the next hour, or watch a movie on a portable DVD player. You get your blood taken again. Then back to the chairs. At this point, you may be feeling dizzy and faint. You reach your chair gratefully and try hard to distract yourself against how crummy you're feeling. The second hour takes forever to pass, but you get there and have your blood drawn again. At this point, you may feel irritable and nauseated. You don't want to do this again, though, so you desperately try to not throw up. Just one more hour. Maybe you have some water. You probably need to pee. The baby's hyper and the rolling around and elbowing you in the stomach is not helping your nausea. You pick up your book or movie and put it down, unable to concentrate. You space off. You finally get back to reading or watching and find out that you made it. One last poke and the vampire is done with you.

You bolt from the office right for the nearest fast food to appease the baby, who is sucking all the nutrients from your starved body. Food at last!! You find out at the follow up appointment that you failed. You're told your numbers: 80, 195, 156, 120. These numbers probably don't mean a lot to you, especially since you're devastated and wondering what this all means to you. No more crackers in the morning? No cake at your baby shower?

You're told that you just need to monitor your sugar and diet and see a nutritionist and that there is no reason to worry. You are now high risk and will probably have a huge baby who will need bottles to stabilize him after he's born, but it's okay. The doctor will perform a cesarean to save you from this all if she needs to. You should probably try to pump some milk to prepare if you don't want the hospital to give your baby a bottle.

Now, let's examine what you should have questioned in the above scenario.

"...you get up and have breakfast as usual."

The day of your one hour test, you should be careful about your breakfast. Avoid carbohydrates as much as you can--absolutely no juice or soda pop! If you drink coffee, it should be black. If you drink tea, the same thing. The absolute best thing for you is to only drink water. Even milk is full of sugar. No bananas! They may seem like an innocent fruit, but they are a sugar-spiking fiend in the least diabetic of people! Have some eggs and bacon. Not the healthiest breakfast, no, but you need protein to break down blood sugar in your body. Have a handful of raw almonds, too (or any natural nut of your choice).

"You go sit in the chairs and read a book or magazine for the next hour, or watch a movie on a portable DVD player."

Don't sit! If you have a long drive to the doctor after drinking your glucola, then go an hour early and drink it there. Walk around the office. Jog. Do some light exercise that you would normally do. But whatever you do, don't just sit there. Your body won't burn the carbs properly just by sitting. Don't worry about what other people think about it, lead by example or at least just protect your own body.

If you fail the one hour test still, there isn't a lot you can do for the three hour test, except to remain active throughout, no matter how crappy you feel. You can avoid a lot of carbs the day before it, but you need to keep your blood sugar as level as possible.

Next, know your numbers! The list of numbers I gave before indicates someone who does not have diabetes. In fact, they were almost exactly my numbers. The first is a normal fasting glucose number, then the second is a high spike that isn't an abnormal reaction to the amount of glucola that they give you. The third is one point above fail, which is a faster sugar drop than they are looking for, but they look solely at numbers, not at pattern. The final number is more than just a passing number--it's a pass with flying colors. Again, this pattern should be seen as a sign of insulin working pretty well, but it's a definite fail. If the numbers had looked like this:

95, 200, 165, 145

Then you most definitely have a problem.

Now, it's not a bad thing to follow a healthy diabetic diet with a failed test and to monitor your sugar, particularly if you've had symptoms (extreme thirst, dizziness, nausea) to identify problem areas. Me, I found out that I was waking up borderline hypoglycemic (70mg/dl) if I didn't have a chocolate cake at bedtime each night. Yes, Little Debbie and I had a standing appointment. She didn't spike me and I didn't feel like crap when I woke up in the morning. Win-win. Medicinal chocolate, lol.

Now, where it is dangerous is the assumption that any level of glucose intolerance (including just being intolerant to the stupid test) will negatively impact the baby. Let's start with "big baby".

First, as recently as the early 1900s, a 10lb baby received congratulations to the mother for growing such a 'healthy baby' and a 6lb baby was received in hushed tones and worries about such a small baby being born. Sometimes the mother was even scolded for 'starving' her baby (even though 6lbs is a valid weight, as is 10lbs). Now, the average is 7.5lbs, but that's hardly a cutoff. After all, women can birth nearly 14lb babies naturally.2 Many women that I've known report that their bigger, 9-11lb babies were actually easier than their smaller (6-8lb) ones! Not always, of course--my best friend's mom had problems with her nearly 12lb baby in that she tore six ways to Sunday, but her others were 11-something, 10-something and a couple of 9lbers and she didn't have problems.

A lot of the worry about big babies comes from shoulder dystocia. This is a very rare complication that can occur in babies of any size, but is considered higher risk in babies of larger sizes. The true risks of shoulder dystocia include: malpositioned baby, mother in the lithotomy position or otherwise on her back and/or tailbone and any monitoring or drugs that limit mother's movement (if you're going to get an epidural, make sure it's the lowest dose they can do or that it's turned off long before pushing!). If you suspect a large baby, it's important to have a provider who knows the Gaskin Maneuver,3 which has been shown quite successful and is pretty easy--just roll mom onto all fours. From that position, if baby is not released by the act of rolling over, some otherwise difficult maneuvers become much easier to perform to attempt to dislodge baby. If unsuccessful, mom can be rolled back and the usual "nurse jumps on the fundus" maneuver that most OBs use exclusively, can be performed. This is very dangerous for the baby, so it should be left as a last resort. However, a cesarean is not needed in most cases and never to just prevent the possibility of a rare incidence.

If you're worried about a big baby and tearing--let me tell you, as someone who's had both a cesarean and a terrible, messy tear with my VBAC, that a tear is preferable to recovering from abdominal surgery. Especially with a dependent infant!

The next risk for a baby in regards to gestational diabetes is elevated blood sugar leading to crash at birth. If mom's sugars are well-regulated, this isn't actually a risk. Some researchers believe that much of the elevated sugar accompanied by no symptoms is actually natural stores in the maternal bloodstream as backup for the baby and doesn't actually go to the baby.4 However, in cases of controlled sugars, there is no excess to cause the spike that leads to the crash and it's more likely that the fasting during labor may be a bigger risk to the baby (eat during labor, ladies, regardless of 'hospital policy' or diabetes status! It matters!), leaving baby born with low blood sugar. Bring baby straight to breast from birth to help with this.

The real risk of being diagnosed with gestational diabetes is that your chances of cesarean skyrocket because management may lead to risk factors for pre-eclampsia. Also, many women are not properly counseled or are told to "avoid carbs" (very dangerous for both mom and baby! Diabetics take in more carbs than you are probably aware!) or go straight on insulin (also dangerous, as taking insulin with no need can lead to an insulin coma).

So, before you just blindly consent to the test, ask your doctor or midwife what options are available. If you are in a low risk category, request being allowed to skip. If you cannot, ask what other forms of testing are available that would be easier on your body and your baby if you fail the one hour test (and do not consent to the fasting one hour test--it's outdated). Find out how your practitioner will respond if you fail the tests and if they start talking about cesareans--get another doctor. I still, to this day, regret not following that advice. Also find out hospital policy as to what they will do to your baby, particularly if you plan on breastfeeding.

In the end, non-insulin-dependent gestational diabetes is really not a cause for concern--at least not regarding birth. Don't freak out and don't let yourself be 'managed' into unnecessary surgery.

Like many women, after I was diagnosed with gestational diabetes, I never showed any symptoms and my sugar never spiked into the danger zone. The worst it got was after my baby shower, where I had ice cream cake, fruit pizza and bread rolls. It was no higher than expected in a non-diabetic after that fair, either! My baby was the exact same weight at 42 weeks as her sister at 39weeks, 6 days (who I did not have GD with).

Knowing this is important as well to know that not all women diagnosed with GD are at risk for Type 2 diabetes, despite the media hype to the contrary.

If you'd like to avoid the risk altogether, you might consider Dr. Brewer's Diet which is available for many dietary needs.



1.Gabbe S.G., Niebyl J.R., Simpson J.L. OBSTETRICS: Normal and Problem Pregnancies. Fourth edition. Churchill Livingstone, New York, 2002
2. CTV News: B.C. Family Welcomes Very Big Bundle of Joy
3. The Gaskin Maneuver and The Farm Midwives: Dystocia
4. "Gestational Diabetes: Myth or Metabolism?" by Joy Jones, RN (p. 59)

You're Doing It Wrong!

Men aren't as helpless as most women think. And the helplessness they display is not imprinted on the Y chromosome, no matter how much we've convinced ourselves otherwise. The fact is that men are trained to be helpless--usually by the very people who most want their help: women.

I'm not talking about domestic duties (although many men act like the trash magically gathers itself and that they might blow up the washing machine if they have to try to use it) but in being an equal partner in parenting.

Now the defeatism usually starts in that first year when most babies are programmed to automatically want Mommy for everything. If Mom's breastfeeding, this typically means that when it comes to feeding (which, in the first two months, seems to be every waking moment!) Daddy IS helpless. The things he can do at those times promote more of a bond with Mom than Junior (and is that a bad thing? Staying bonded with Mom?). However, feeding is hardly the end-all of parenting a new baby and most women don't breastfeed or at least don't do it exclusively. Dirty diapers are not the only other thing that babies need taken care of, either.

However, the really defeating thing comes when Mom says, "Here, let me do it." There's a learning curve, ladies! We had to do it, so does he! Also, guess what? There's not just one single way to do everything.

I know that's hard to hear. It's hard for me to deal with, personally. I hear my husband taking care of the kids and I want to run in and correct this or that and despite what he'd say to the contrary, I actually have been practicing restraint lately and letting him just do it.

Now, some things, he's always been a pro at--like diapers and dressing the kiddos--but he had an advantage: a baby sister. I was the last born in my immediate family and until I was holding my own, I never touched a new born baby. My sister called me in to help out with her second and I loved it, but she was already a few weeks old before I actually held her. I did learn some tricks to colic, though, that were nice and useful! But for real baby care, of course she did most of it and mainly when I wasn't there.

My husband, however, was right there with his little sister for it all. He even did his share, since he was an older child when she was born. So he came with more confidence and expereience than the average man--and yet, he was just as nervous as any new father and felt just as clueless as to what to do with himself.

Now, I'm not going to sacrifice the baby by just leaving her with him (she was a nursing maniac and wanted nothing to do with him, poor guy--it's no wonder he ended up feeling helpless!), so he didn't get thrown into the deep end like many men who become baby pros do.

It was really later, though, as he was building up his confidence because she started wanting to spend time with him (as everyone had assured that she would!) that I started breaking it down. Correcting small little things, "Oh, I don't do it that way." "You're taking too long, let me do it." "Oh, no, you're doing it wrong!" I don't know why. I just don't seem to know how to walk away and let him do it, so I hover and watch, (which, let's admit, is like watching someone with a different video game style playing--you want to take over and show them how it's really done). Instead, lately, I've started forcing myself to find other things to do when I've asked him to help out or if the kids have asked him.

But it doesn't start when baby comes home. It starts long before that, when our husbands were boys and somebody's sons. First, the gender boxing. "Boys can't wear pink." "Boys can't play with dolls (and if they do, we must call them action figures)." Boys even often get kicked out of playing house in pretty much all forms. They might wander their way into a play kitchen.

Now I don't know if this attitude is as widespread as it was when I was a kid, because I live in this neat little bubble where the vast majority of my friends are against gender boxing. I still have some that were raised with and cling to the idea of boys toys vs. girls toys, but they are the minority now.

This continues later as boys grow into young men. Girls in the family are often sent to look after siblings and do domestic duties while boys are sent to look after cars and do yard maintenance (which leads to the feminine version of helplessness where women think they can't change a tire or mow the lawn). It's becoming more popular to let boys in on the domestic duties (especially since most major chefs are men and men need to pick up after themselves, too) and teach girls car care, but mainly, boys are still not included in the child care development.

This discrepancy can really be seen in one of the first teen jobs: babysitting. Now, while I know parents who'd take a boy babysitter who's known to be responsible, this isn't true in most homes. Even most homes who say they'd hire a boy to babysit, if offered the choice between two inexperienced teens, one male and one female, they are going to pick the girl. Women are just identified as more nurturing and boys are held with the misandrist view that they're unpredictable and dangerous.

I happen to know someone who's first husband lost his virginity to his babysitter when he was 10. So, uh, yeah... nurturing... And yet, more people would be horrified if the gender was reversed--somehow, it's okay for a 10 year old boy to decide to have sex with a 16 year old girl, but the other way around? They're both statutory and they're both just as harmful for the 10 year old.

But that's beside the point. This all leads to men having less training when the kids get in in a lot of homes, but certainly not all! I've seen homes where the women had less experience, most definitely. Sometimes even in these, though, the men are made helpless by that mama bear instinct.

It bothers me a lot when a group of women is talking about their husbands and one brings up a situation she wants to change where the group response is, "What do you expect? He's a man!"

That is just as wrong as a woman going into a new profession, stumbling and having the men say, "What do you expect? She's a woman!" Oh, there the tempers fly! Misogyny cannot be let go, but blaming a gender for the inefficiencies of its individuals who happen to have a Y chromosome? That's fine. Actually, that's called misandry and it's not fine.

It's damaging. It damages the men who are just left to flounder, unaware that they could learn the very skills they have been told men just aren't any good at. It damages our sons, who hear this garbage and grow up believing that's just how it is. It damages marriages who crumble because women have been taught that they're supposed to do everything. It damages women who really are left to carry more burden than they can handle and don't know that it's okay to ask their husband for help and to let him learn and let him make mistakes. We made them, too.

Yes, sometimes we had our mothers, sisters, aunts, random other women in our lives standing over us and correcting us. But most of us have the strength to say, "I'm glad that worked for you, but this is what works for me." Men aren't taught to communicate that way. Most end up angry, hurt, resentful and not knowing how to express that in a way that doesn't blow up in their faces or just assuming that they really can't do it.

Obviously, not all men are like this, just as not all women are. But this is the average family. And it doesn't have to be.

Men can wear their babies, dress them, bathe them, give them solids when they're six months or older, play with them, do tummy time and Gymboree with them. Oh, yes, they can! They can hold them close and make rumbling noises in their chest that we can't and that babies find soothing. He can take Junior to the potty in a super-hurry because she's got to go NOW! He can gather up toys and decide how the playroom is arranged and pick out the kids' clothes (and it's not the end of the world if his fashion sense is different from ours). He can wipe their face differently, he can put their socks on after their pants and their hat on before their shirt and it still all ends up on there. He can brush their teeth and play video games with them, etc.

Dad can do it. And if we're lucky enough to have a husband who wants to (even if just to try), or even is just willing to try, we darn well need to let him.

Breastfeeding Isn't Easy

I see comments all the time about how "it was just too hard" as though the mothers who continued breastfeeding had it easy. Because sore nipples, plugged ducts, mastitis, feedings every 1-2 hours, dealing with flow issues and upset tummies as a result, worrying about supply because there's no ounce markers, having to change one's diet to adjust for baby's intolerance(s) or allergies, feeding sessions lasting up to three hours, cracked nipples, bleeding nipples and blood blisters, scathing remarks/glares if we dare feed our babies out of our own house and in some cases, supplemental feeding systems... are easy?

Honestly, though, who said parenting was easy? And taking shortcuts may not be cheating in the traditional sense, but it cheats baby out of the benefits of the standard of care. Not just nursing, but in all aspects of parenting. "You aren't managing a convenience, you're raising a human being."

I'm not looking for your story about why it was so much harder for you than my friend who doesn't make 50% of the supply she needs to exclusively nurse and yet doesn't use bottles. Or me, who had a baby who screamed at the sight of my breast, weak suck, latch issues, one side preference, etc. Or blood blisters, choking from overactive letdown, living in horrible pain postponing surgery to get to a point where my baby would have enough of my milk to get through it... Or the mom friends I have with PCOS. Or those who've had to adjust their medications for breastfeeding-friendly ones. Those who live in daily pain trying to reach a minimum goal of nursing before going on medications or having surgery that would make it all better.

I've heard all the stories and I know moms who really couldn't do it (I have friends that even I would have/did encourage to stop for both mom and baby's sanity/health) and moms who did it when no one else believed they could--because they refused to take "no" for an answer.

The whole point of this is that it's NOT always easy with floods of happy hormones. I don't enjoy nursing. I enjoy the benefits, sure, and how deliriously happy it makes my kids. I don't notice any "special bond" or go to la la happy hormone land. I don't do it for me.

Inspired by HeidiLJ

Less than 2% of women don't make enough milk to exclusively breastfeed. That doesn't mean they shouldn't breastfeed at all, just that they need to supplement. Even that can be done at the breast now. Less than 5% can't do that for other reasons (mastectomy, medications, psychological trauma, etc.). But the number of mothers who bottle feed is closer to 40% that goes up the closer to a year you get. The number of women who nurse to the recommended 2 year minimum is only like 12%.So those who even make it half way (one year) is only like 35%. So all of those women have a reason to be proud--out of the 93%-95% that should have nursed that long, they were the ones who did. I'm not saying that bottle feeding is never okay or even necessary! I'm just saying that parenting isn't easy and there are more options than most people even know!

One Becomes Many

Every one counts. Sometimes, when we try to share the information we've learned, even if it's lifesaving (such as simply sliding up the chest clip on an infant in his car seat or pulling the straps tight), it's rejected. And sometimes, someone thanks you because they just didn't know. Other times, you receive no thanks, or even get cursed. Some of those people think angry thoughts about you for a little while and forget you forever after. Others are angry until they realize that what you said is not only true, but that you only meant to help.

Dr. Martin Luther King, Jr. once said, 'The first question which the priest and the Levite asked was: "If I stop to help this man, what will happen to me?" But... the good Samaritan reversed the question: "If I do not stop to help this man, what will happen to him?"'

Recommending "first do no harm" is so often met with disdain, sarcasm, dismissal, defensiveness ("Well, that's the way it was for me and I'M fine!"--often from people who are anything but) and outright hostility. It makes no sense and it's discouraging. Sometimes one wonders why to even keep trying. Well, with much thanks to Danielle at Peaceful Parenting for sharing a story that explains why we do keep trying, I'm passing this story along:

Image courtesy ~foureyestock

From The Star Thrower by anthropologist and writer, Loren Eiseley (1907-1977)


Once upon a time, there was a wise man who used to go to the ocean to do his writing. He had a habit of walking on the beach before he began his work.

One day, as he was walking along the shore, he looked down the beach and saw a human figure moving like a dancer. He smiled to himself at the thought of someone who would dance to the day, and so, he walked faster to catch up.

As he got closer, he noticed that the figure was that of a young man, and that what he was doing was not dancing at all. The young man was reaching down to the shore, picking up small objects, and throwing them into the ocean.

He came closer still and called out, "Good morning! May I ask what it is that you are doing?"

The young man paused, looked up, and replied, "Throwing starfish into the ocean."

"I must ask, then, why are you throwing starfish into the ocean?" asked the somewhat startled wise man.

To this, the young man replied, "The sun is up and the tide is going out. If I don't throw them in, they will die."

Upon hearing this, the wise man commented, "But, young man, do you not realize that there are miles and miles of beach and there are starfish all along every mile? You can't possibly make a difference!"

At this, the young man bent down, picked up yet another starfish, and threw it into the ocean. As it met the water, he said, "It made a difference for that one."



Note: This is a true story that Eiseley wrote about. He was the 'wise man' walking the beach before his morning writing session. He encountered this young man throwing starfish back into the ocean and was forever impacted by the experience. His story is told in many forms, in many places - but rarely is credit given to Eiseley as the original author and subject of the narrative.



Another discouraging thought many people have is: "How does my voice matter? I'm only one person." This is from anything in life that we want to see change. Yes, you are one person. Just as the person who shared their knowledge with me was just one person. Now we're two. From there, many hear our words and if just one person listens to each of us, we are four. Then eight. Sixteen. Thirty-two. I think you can continue the math. Rarely, though, does one person only affect one person.

Look at a teacher in a classroom--a typical classroom of an average of 20 students. Every year or even twice a year if high school. For twenty years of teaching, that is 400-800 kids. I had a microbiology teacher who imparted life wisdom that was actually usable in addition to the science. He taught me about Shettles and delayed cord clamping and the importance of avoiding debt (except for home ownership) because he thought it would be interesting to us. I don't know how many of my classmates listened, but I did. I pass that information along to people who pass it along.

One person is only one person when their voice is silent. Gandhi said, "Nearly everything you do is of no importance, but it is important that you do it," and "Non-cooperation with evil is as much a duty as is cooperation with good." Voltaire said, "Stand upright, speak thy thoughts, declare The truth thou hast, that all may share; Be bold, proclaim it everywhere: They only live who dare." As well as, "The instruction we find in books is like fire. We fetch it from our neighbours, kindle it at home, communicate it to others, and it becomes the property of all." Dr. King said, "History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people."

They were all "one person." I'm not saying that we will become famous for spreading the information, just that "one person" doesn't mean a lot, because all groups are made up of a lot of "one person".

"Almost always, the creative dedicated minority has made the world better." -Dr. MLK, Jr.

"Be the change you wish to see in the world." -Mohandas Gandhi

Anniversary!

Today is my 6th year wedding anniversary with my husband. We have been a couple for 9 years now.

When I met his home for the first time (don't seem to have any scans of us together when we first met):

a pic of him when we first met, before the one above:

When I brought him back here:

Our wedding (handfasting):

guest book:

The altar (each bowl had one of each element: air, earth, fire, water):

water, fire, earth, air:

Me, the bride (that's a parrot play gym we built from PVC in the background, lol):

The women of the wedding (back: two bridesmaids, me, my maid of honor. front: my nieces: jr. bridesmaid and flower girl)

The men (and female groomsman--DH's little sister) of the wedding: Groomsmen, best man (DH was his best man, too) and groom:

fire's moment in the ceremony:

our hands, tied (how many people actually 'tie the knot?' LOL):

The kiss:

and the cake:

cards:

Happy Halloween! (Ghost Stories)

image courtesy of my husband's pumpkin carving skillz

I originally posted this as a contest entry for Halloween stories. Everything here is completely true to the best of my knowledge and represents paranormal experiences I've had--just in time for Halloween!



My experience with the paranormal began as a child. I was always 'sensitive' to unseen things and was good at predicting small events, like phone calls and things that people were going to say.

When I was 12, I had a best friend (who was basically my ONLY friend at the time) and we both became sick and missed school. We saw each other at the Boys and Girls club and she asked me to come home with her. Afraid of getting in trouble (and afraid of going a new place without anyone knowing where I was), I begged off and went home.

At home, I talked with her on the phone for a while and taught her "American Pie" ("This will be the day that I die") after "Paint It Black" and some other oldies. She loved them. At the end of the call, she had to go take her medicine and we sang American Pie one last time.

That night, I had terrible dreams about fire and trying to find her.

The next day, my mom came home and said, "Heather, it's April..."

I just looked up and said, "Is she dead?"

There had been a fire and because of the cough medicine she took, she never woke up. Her mother lost both her daughters that night (her sons survived) partly because of the burglar bars on their windows. April was 12, like me and her sister was in high school.

Then there was the terribly haunted house I lived in in high school (a toaster once flew across the kitchen at my mom's head while I was in the living room, coming to the kitchen--it flew outward by about 2' right at her from on top of the fridge to where she was cooking at the stove and there were people who absolutely refused to set foot in our house--they would get to the threshold and freeze, uncomfortable and then leave... amongst too many other stories). My best friend was the only person comfortable with being downstairs alone at night there. There was one ghost on the stairs that kept any others from coming up.

On to when my husband and I first met in person (we met online months before). He flew here and then flew us down to New Orleans to meet with more friends from our online group. While there, we stayed in an Inn in Geismar. We had one jacket and hung it on the single coat rod. Randomly, it would slide back and forth along the totally level rod. We checked everywhere and there was no draft, no airflow at all to move it. And it slid both ways.

Going back a way, I was on a family vacation with a friend, coming back from Colorado (to Missouri) when it became late and we pulled into this small town to find a place to sleep. I could see shapes moving out in the darkness and this pervasive sense of Wrong filled me with terror and the need to leave. Immediately.

I started telling my friend we couldn't stay there, we had to get away, get away now. Her walkie talkie buzzed on and her parents (in a separate vehicle) said, "Your sister is freaking out and says we have to leave. We're thinking we might want to find another town to stay in tonight."

My friend confirmed that I was acting the exact same way and thankfully her parents were spiritual people who believed us. I don't remember what town it was, just a small one in KS before we got to Salina, which is where we ended up staying. But in two separate vehicles, her little sister and I saw and felt the exact same thing. She described exactly what I had.

And for my last ghost story... In the last house we lived in before this one, there was one night where I felt this incredibly disturbing feeling. I felt sick and terrified and knew exactly where it was coming from--like hearing a sound, only with a completely different sense.

I felt it moving around the house and locked the doors in fear. Then this scratching sound started on the back porch door (enclosed porch--the door was non-functional--we used it as a library). I was freaking out and staring at the source of the sound and then a banging started against it. I touched the glass of the door with my left hand that led to the porch and jerked my hand back. There were scratches up and down my left arm. I started praying frantically and it faded away.

When my husband (then fiance) got home, I had him look and there were scratches on my arm and my shoulder where I couldn't see.

I warded the house after that. In this one, there's some disturbing negative sense that both I and my youngest feel toward the back porch/back yard, but the house is basically neutral.

Well, there's a short summary of many of the ghost stories I've lived personally. Happy Halloween!

image again courtesy of my husband's pumpkin carving skillz

Cosleeping

Two things inspired this: One, a trip to the pediatrician where she was nosier than she's ever been and one of her questions was to ask if Lilly had her own room (yes, she does--no, she doesn't sleep in it and no, we didn't say that because it's none of her business and I don't appreciate having another person's culture and family structure preferences pushed on me, which is what I suspect would have followed). Two, there was a Carnival of Breastfeeding on nursing and sleep, so a bunch of posts about sleep popped up. Since I nurse while cosleeping, that's what this entry is going to be about.

So, I went into parenting with a different perspective than most Americans on the issue of sleep. To me, the idea of having a baby in another room, where you aren't aware of what's happening to them, if they're truly safe or even alive, is disturbing. I would never trust a mechanical monitor to tell me that my baby is breathing, nor would I trust that my baby is not being injured like hundreds are every year by their cribs. Hell, SIDS used to be called crib/cot death.

I coslept with my mom as a baby, toddler and child. Like many Japanese children (the culture which held a special place in my mother's heart and influenced such parenting practices as cosleeping, breastfeeding for two years and baby wearing), I was in my mother's bed until I was about 8 (the average age for a Japanese child is actually 10 before they begin sleeping alone--if another baby is born, usually they sleep with another family member), which is roughly when I was ready to sleep on my own... to a certain extent. There were extenuating circumstances and I probably would have stuck around longer if I'd had the choice--but I'm glad I had the time I did and that my mom followed my cues on where to sleep, more or less.

It's not normal for humans to sleep alone. 1/4th of American couples sleep in separate beds, however, and the vast majority of American children sleep alone. Some are lucky enough to share a room or even bed with a sibling and a few are lucky enough to have access to a family bed as long as they want.

It's a cycle. In infancy (or early childhood), the baby is isolated, being forced to learn to sleep alone, being denied the human contact that they need (24/7--parenting is not a 6am-8pm job) and it continues through childhood. This creates a need for an artificial sleeping environment that is not conducive to bed sharing at any point in life. In fact, most couples have to learn to sleep together and many are just incapable in the end.

Throw in a healthy baby, who moves, wriggles, snores, coos, wakes and needs all. night. long. and it can be something that a Western-reared parent just can not handle. They can't sleep and so they fall back into the cycle that they were raised to fall into--by sending the baby off to sleep alone so that they can get their stimulating-sensory-event-free sleep.

Cosleeping doesn't have to be bed sharing. It includes just having the crib in the parents' room (which is actually recommended by the AAP for the first 6 months of life--which very few people seem to know) and then the toddler bed and kid's bed until they're ready to be alone. It doesn't have to be an intrusion into mom and dad's space--there are healthier compromises. But this, too, can be very hard for the parent who has been conditioned to sleep only in total darkness and silence.

A white noise machine (or a fan) can help many people get past the little noises in the night, but if baby's not in bed, that can defeat the 'mom wakes at the smallest sound' safety that's built in to protect our babies and keep their natural biorhythms going (which are attuned to our own).

It's not for everyone. People who smoke, drink, do drugs or take prescription sleep aids should never have baby in their bed (and if you smoke in the house, you shouldn't have a baby in the house at all--it's the number two direct cause of SIDS). That crib in the room can still be an option, however. People who are addicted to big, fluffy pillows and miles of bedding should not have baby in the bed. People who are exceptionally deep sleepers--same deal (and if you're drop dead exhausted from a sleep situation that's not working, that's not particularly safe, either!). Obesity? Well, that's a crock. The whole "overlying" thing makes it sound like fat people have no sense of touch. Without a secondary problem, that's just not the case. Secondary conditions that may cause dangerous sleeping habits that afflict obese people also affect thin people and should be taken into consideration with anyone before sharing bed with a baby.

The ideal situation for cosleeping is the biggest bed you can afford with the firmest mattress, on the floor (no frame and no headboard/footboard for baby to get caught in) with a parent/parents who is/are not under the influence of any substances, including prescription substances, with no pillows around the baby and no heavy blanket (baby does best in a sleep sack or something similar).

We do a family bed and sleep great. I know where my kids are (so no horror movie scenarios for me, thanks), they know where we are (no monsters to keep us coming back in so they don't feel lonely, scared, etc.) and when they're ready to have their own beds, that will be up to them. That's what works for our family. Like I said, I was raised to see the whole thing completely different from the culture I am surrounded by. I would never ask of my children what I wouldn't want for my own life. And in this case, that is to be alone while they sleep. Finally, it facilitates nursing as well as our connection. Never do I feel as at peace as those last moments of looking at my sleeping family before I let myself succumb to sleep.

Welfare Drug Testing: Why I'm Against It

Photo used with Creative Commons permission © Pink Sherbet Photography / Flickr

So, I'm constantly seeing, "If I have to get drug tested for a job, welfare recipients should be tested for drugs," and it makes me cringe. The first time I heard it, it made sense and I agreed (after all, I'm a prohibitionist). Then I actually thought about it.

Let's start with what Welfare is. In my state, it's a pittance of less than $300 that only goes to needy parents. If you don't have children, you do not qualify. There is a 5 year limit on this assistance--for life. Meaning that once the 5 years of assistance has been reached, you can never get it again.

The ONLY people truly hurt by this would be the children. Suddenly, kids who were already barely getting enough to get by wouldn't even have that. Would that make their parents clean up and get help? No. It's not even doubtful, but history shows that it would do the opposite. The further stressed parents (who couldn't even keep clean long enough for a damn drug test they'd have KNOWN was coming) would just delve deeper into drugs to deal with their problems (because if they're on drugs in the first place, then they have no coping skills in the first place). If you are rejected for a job because you tested positive for drugs, then that's all that happens. The children would receive no help by having their parents cleaned up AND they wouldn't have food or necessities that the money was going to bring them.

Drug testing would add $6 million to the cost of Welfare per year for new users of the program. To put that in perspective, new users cost about $2.3 million on their own. So it would triple the additional money each year--in a state that spends less on its poor than any other in the country. The bill that was brought up to force this didn't go through because it was primarily a publicity stunt.

However, in Florida, they made the recipients, who make less than $80/week to feed their kids, pay for it out of pocket. Then, when they pass (as 98% did), the State had to repay them. Assuming they could afford half a week's money to prove that they are in the majority of people--those who don't use drugs. 70% of illegal drug users are employed full-time.

Now, why it isn't comparable to job drug testing. Why do you get tested for drugs for a job? Because if you are on drugs, then your job performance is going to be impeded. You aren't going to be able to perform the duties of your job--which is going to pay far, far more than Welfare, even if you're working as a waitress at half minimum wage. It has nothing to do with the law and once you've been rejected for the job for drugs, that's the end of the story.

So, this would cost the state more money, only cause harm to children who are already in a horrible position and doesn't serve a purpose like drug testing for employment does. What's more, it's already been ruled unconstitutional by federal court in 1999 when Michigan instituted the program and was slapped with a restraining order to cease and desist immediately (Marchwinski v. Howard, in the U.S. Court of Appeals for the Sixth Circuit ruled this unconstitutional).

The main proponents of such an act are people who constantly quote the Constitution. Well, you can't have it both ways! Either the Constitution is valid for EVERY citizen or it's not valid at all. You don't get to pick and choose which parts of the Constitution you want to uphold, either.

Now, the MO bill did address two key issues: the purposelessness of the bill and the food taken out of the children's mouths (the second by allowing third party benefits--but this might not apply to all children). They would have required testing only for those who the caseworker felt there was "reasonable suspicion" to suspect drug use and be given drug treatment assistance. Also, assuming that "reasonable suspicion" didn't include simply showing up at the office or being poor, it would avoid violating the constitutional bit about unreasonable search and seizure. Although I have my doubts about 1. Case worker bias and 2. training.

Now, none of this would affect me much because 1. I've never used and never will use drugs and 2. I'm not on Welfare. I hope to God I'm never that poor. I'd definitely be tested because my disability makes my behavior strange in stressful situations and I wouldn't care, but this isn't about my personal situation. It's about children who are living in terrible conditions who would be punished for their parents' poor decisions on top of the crappy circumstances they're already living in. It could also cause prideful people who are letting their families suffer because they don't want to ask for help, to be less inclined to get that help because their personal privacy was being violated (even though these kinds of people are very unlikely to fail a drug test).

It's just a mess. If the whole purpose were to get help for the families with drug problems, I'd be for it, possibly. But that's not why people go off about it. People are going off like children seeing another kid with a different toy. It doesn't matter that it's a dirty used water bottle and they have a shiny new doll, they are throwing a fit because the other child, after going through a humiliating trial and being teased constantly for their toy, was just given it when they had to spend their chore money on their toy. Because 'outrage' is all the rage.

And I'll close on a quote:

“A nation that continues year after year to spend more money on military defense than on programs of social uplift is approaching spiritual death.” ~Dr. Martin Luther King, Jr.


Further recommended reading:

http://m.nwfdailynews.com/opinion/florida-40819-drug-fox.html
www.aclu.org/blog/criminal-law-reform-racial-justice/just-we-suspected-florida-saved-nothing-drug-testing-welfare
http://www.aclu.org/drug-law-reform/drug-testing-public-assistance-recipients-condition-eligibility

This blog entry was updated 3-10-13

Why Rock the Boat? Quotes

A collection of my favorite quotes:

A 'No' uttered from the deepest conviction is better than a 'Yes' merely uttered to please, or worse, to avoid trouble.
Mohandas Gandhi

Man must evolve for all human conflict a method which rejects revenge, aggression and retaliation. The foundation of such a method is love.
Martin Luther King, Jr.

Nearly everything you do is of no importance, but it is important that you do it.
Mohandas Gandhi

The hope of a secure and livable world lies with disciplined nonconformists who are dedicated to justice, peace and brotherhood.
Martin Luther King, Jr.

Power is of two kinds. One is obtained by the fear of punishment and the other by acts of love. Power based on love is a thousand times more effective and permanent then the one derived from fear of punishment.
Mohandas Gandhi

Almost always, the creative dedicated minority has made the world better.
Martin Luther King, Jr.

You must not lose faith in humanity. Humanity is an ocean; if a few drops of the ocean are dirty, the ocean does not become dirty.
Mohandas Gandhi

He who passively accepts evil is as much involved in it as he who helps to perpetrate it. He who accepts evil without protesting against it is really cooperating with it.
Martin Luther King, Jr.

Stand upright, speak thy thoughts, declare The truth thou hast, that all may share; Be bold, proclaim it everywhere: They only live who dare.
Voltaire

We who engage in nonviolent direct action are not the creators of tension. We merely bring to the surface the hidden tension that is already alive.
Martin Luther King, Jr.

The instruction we find in books is like fire. We fetch it from our neighbours, kindle it at home, communicate it to others, and it becomes the property of all.
Voltaire (this can be applies to the internet as well)

First they ignore you, then they laugh at you, then they fight you, then you win.
Mohandas Gandhi

Human progress is neither automatic nor inevitable... Every step toward the goal of justice requires sacrifice, suffering, and struggle; the tireless exertions and passionate concern of dedicated individuals.
Martin Luther King, Jr.

I object to violence because when it appears to do good, the good is only temporary; the evil it does is permanent.
Mohandas Gandhi

History will have to record that the greatest tragedy of this period of social transition was not the strident clamor of the bad people, but the appalling silence of the good people.
Martin Luther King, Jr.

Man becomes great exactly in the degree in which he works for the welfare of his fellow-men.
Mohandas Gandhi

In the End, we will remember not the words of our enemies, but the silence of our friends.
Martin Luther King, Jr.

Non-cooperation with evil is as much a duty as is cooperation with good.
Mohandas Gandhi

Nonviolence is a powerful and just weapon. which cuts without wounding and ennobles the man who wields it. It is a sword that heals.
Martin Luther King, Jr.

We may encounter many defeats but we must not be defeated.
Maya Angelou

The first question which the priest and the Levite asked was: "If I stop to help this man, what will happen to me?" But... the good Samaritan reversed the question: "If I do not stop to help this man, what will happen to him?"
Martin Luther King, Jr.

Satisfaction lies in the effort, not in the attainment, full effort is full victory.
Mohandas Gandhi

Our lives begin to end the day we become silent about things that matter.
Martin Luther King, Jr.

All great achievements require time. --Maya Angelou

Every man is guilty of all the good he did not do. --Voltaire

Keep love in your heart. A life without it is like a sunless garden when the flowers are dead. --Oscar Wilde

I've learned that people will forget what you said, people will forget what you did, but people will never forget how you made them feel. --Maya Angelou

Means we use must be as pure as the ends we seek. --Martin Luther King, Jr.

Be the change that you want to see in the world. --Mohandas Ghandi

It is time for parents to teach young people early on that in diversity there is beauty and there is strength. --Maya Angelou

We allow our ignorance to prevail upon us and make us think we can survive alone, alone in patches, alone in groups, alone in races, even alone in genders. --Maya Angelou

Live as if you were to die tomorrow. Learn as if you were to live forever. (Ghandi)

42 Weeks Is As Good As 40 weeks For Infant Outcomes

My first daughter was born at 42 weeks, perfectly healthy and in the same state as her sister born at 39 weeks, 6 days. A lot of people asked "Why are they letting you go so long?" I can't tell you how angry that question makes me. It devalues me as a thinking adult--like I'm a child who needs permission to continue a pregnancy. The implication is that I'm incapable of making an intelligent, educated decision (which, according to studies, induction is NOT) and that I should be 'stopped' from continuing a healthy, normal-term pregnancy!

However, while the wording leaves much to be desired (and isn't meant as the insult that it is), I understand their concern. Most people are still only informed of the last major study done on infant outcomes at gestational ages--from 60 years ago. That's right, from the 1950s, when people still had black and white television and weren't aware x-rays caused cancer.

The fact is that we don't live in the 50s anymore and the technology and the times have changed--and so have mortality rates. Women's have gone up with inductions and unnecessary cesareans and so have infants'. But they are still FAR lower than in the 1950s! Especially when you remember that women were advised to eat very little back then so that they would not gain too much weight--after all, they needed to please their husbands above all else!

The concern for later weeks in pregnancy is the placenta. It is an organ unlike any other: it forms to perform one temporary function and is then expelled from the body. In that time, though, it requires the same care you would give any other organ: specialized care and nutrition for its optimal health. Placentas crave protein and most women just don't get enough.

Also, most people seem unaware that 42 weeks is as normal as 40 weeks. 41 weeks is actually more "average" than either of those weeks. And babies born anywhere from 38-42 weeks (spontaneously) have roughly the same outcomes today. You aren't even "overdue" medically until 42+1 days.

The following is an excerpt from Midwifery today:

A Timely Birth

Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or postdates in conjunction with poor fetal growth or developmental abnormalities does show an increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43 weeks. The primary “evidence” of a sharp rise in stillbirth after 40 weeks—often misquoted as “double at 42 weeks and triple at 43 weeks”—seems to come from one study based on data collected in 1958.(1)

The first question one should ask is whether neonatal mortality statistics from the 1950s should be compared to modern statistics, since labor anesthetics and forceps rates were very different. Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks. Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten times the modern mortality rate. Either modern delivery methods are vastly different or something is wrong with the data collection. This study should be updated by research conducted at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to 42, with a slight rise at 43 weeks (all numbers being close to 1/1,000).(2)

There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41 weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the due date but does not start on the due date. And the risks need to be compared to the risks of interventions. Induction, as already noted, is not risk free. In addition to the risks of prematurity, induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous amniotic fluid embolism.

Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1,800 post-term (past 42 weeks) pregnancies with reliable dates compared this group with a matched group delivering “on time” (between 37 and 41 weeks). The perinatal mortality was similar in both groups (0.56 /1,000 in the post-term and 0.75/1,000 in the on-time group). The rates of meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress, instrumental delivery and low Apgar were actually lower in the postdate group than in the on-time group.(3) This is only one of several studies showing postdate pregnancies can be monitored safely until delivery or until indications arise for induction. Even the famous Canadian Multicenter Post-term Pregnancy Trial Group (Hannah) of 1,700 postdates women showed no difference in perinatal outcome among women who were monitored past their due date, as compared with those who were induced at term.(4)

In some studies, post-term births have shown a higher cesarean rate for suspected fetal distress. However, when a group of researchers conducted a case-matched review of nearly 300 postdates pregnancies they concluded that the increased rate of obstetric and neonatal interventions “does not appear to be a result of underlying pathology associated with post-term pregnancy.” They suggest that “a lower threshold for clinical intervention in pregnancies perceived to be ‘at-risk’ may be a significant contributing factor.” In other words, the perceived risk is greater than the actual risk and can become a self-fulfilling prophecy!(5) When monitoring demonstrates that fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40 weeks.

References:

1. McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational age through the past three decades. Am J Obstet Gynecol 85: 573–82.
2. Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies. Obstet Gynecol 69(3 Pt.1): 296–99.
3. Weinstein, D., et al. 1996. Expectant management of post-term patients: observations and outcome. J Matern Fetal Med 5(5): 293–97.
4. Hannah, M.E., et al. 1992. Induction of labor as compared with serial antenatal monitoring in post-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92.
5. Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79.

— Gail Hart
Excerpted from "A Timely Birth," Midwifery Today, Issue 72
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