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
http://www.midwiferytoday.com/enews/enews1220.asp

What do Midwives do if something goes wrong?

This is one of the biggest questions people ask about homebirth. It's based on the fear that is instilled into people from childhood that birth is painful and dangerous and that most women need rescuing from it.

Well, first, that's just not true. True emergencies only occur in about 5%-15% of births where a cesarean is required. I couldn't find an exact statistic for post-birth emergencies, but it's pretty low in general.

Now we're going to disregard pain control in this blog because that's not a part of the question. Women choosing homebirth in the US have already accepted that they wish to give birth without pain medications in most cases. They know that if they need them, a short trip to their nearest hospital can provide them. In the UK, mothers are provided with 'gas and air' (nitrous oxide) that they can control themselves. This option is currently not available to US mothers (despite many women "wishing" for it to be).

So, what happens if something goes wrong in a homebirth?

Now, midwives are not doctors. They are not surgeons. They cannot perform surgery and do not take high risk patients. Only normal pregnancies are taken on in the first place. Midwives watch for the pregnancy to continue normally and if something isn't right (such as placenta previa, pre-eclampsia, toxemia, etc.) then the mother's care will be transferred to an OB.

This works smoothly in countries where midwives are the default caretakers of mothers and homebirth is an easily obtained option. In the US, many midwives do work with OBs as backup to mimic the better model.

Midwives do not induce women with pitocin, artificially rupture their membranes and put them on a clock, either. These are some of the highest risk factors leading to cesarean births. (Some midwives do induce with herbs and sweep membranes, even though the second is shown not to be particularly effective and the first can be nearly as dangerous as pitocin induction.)

So, first, we've eliminated about 4-10% of necessary cesareans right there (approximately).

Now, that does leave some risk to homebirth (studies have shown that the risk of homebirth is no different from hospital birth, except those studies that did not eliminate accidental homebirth and those that included all births occurring outside of a hospital setting--some have even shown that homebirths are actually safer in 90% of normal pregnancies) as to ANY birth. So what happens if one of those risks occurs?

A midwife is there in labor specifically for that (in addition to catching the baby and some postpartum care). She watches the mother and baby for any sign that there is a need to transfer and in the event that she becomes concerned (and the reasons for this do vary by midwife--for type of midwife as well as her personal experience), then mother is transferred to the hospital as quickly as possible. If the hospital is not close by, the midwife may call it sooner than if the hospital is nearby.

Now, many people are afraid of the time that that takes. However, it is not significantly longer than the time it takes for a hospital to call in an anesthesiologist, back-up obstetrician and a neonatologist if necessary. That's right--not all hospitals have all of these staff members available at all times. Any woman in labor is at risk of needing an emergency cesarean when the anesthesiologist has stepped out for lunch (or gone to bed) or her OB doesn't have a second to assist (or no OB is even present in the hospital at the time--why do you think the nurses often page them frantically to get there while urging the woman not to push?).

In the event of an emergency, an ambulance will be called to stabilize mom (and baby if needed) and will call ahead to the hospital to make sure everyone is in place that is needed.

So, basically, the midwife does the same thing at home as she would in a hospital or birth center--only in the comfort of the mother's home.

In the end, homebirth is a safe and should be a valid, legal option for any woman who wishes to have one (just as birth centers and hospitals should be). Making them illegal is what puts women at risk, because they may wait longer to call for help when they need it, for fear of medical bullying or legal reprisal. And midwives are fully capable of recognizing the need to transfer care even during birth or after.

And yes, many midwives are capable of repairing tears and stopping bleeding as well and CNMs usually come with oxygen tanks in the even of the baby needing to be resuscitated or mother needing oxygen. They are also trained to deal with shoulder dystocia, cord prolapse, unresponsive newborns, hemorrhage and nuchal chords (where it's wrapped around the neck). Many are trained in breech birth as well. They are trained to handle most complications that arise and don't require an operating room or specialized equipment.

And finally, the difference between OBs and midwives:

An Obstetrician is a surgeon and a fully licensed doctor. Decades ago, they were taught to handle many more births vaginally than they now know how. Many forms of breech babies could be birthed vaginally and women would transfer to an OB for this service. Now, most OBs are no longer trained in this and are primarily trained in surgery.

There are different types of midwives.

First is the DEM or Direct Entry Midwife. "An independent practitioner who has learned midwifery through study, apprenticeship, a midwifery school, or a college program that is not a nursing program."

Then there are Licensed Midwives. "Midwives licensed to practice midwifery in a particular area. Normally a state. "

Next is the CPM or Certified Professional Midwife. "A midwife who has passed rigorous competency testing by the North American Registry of Midwives (NARM) is awarded a CPM certificate."

Finally, we have the CNM or Certified Nurse Midwife. "These women are trained as nurses and have done additional study in midwifery. Many are graduate students. They often offer complete prenatal care as well as attending births. "

CPMs and DEMs typically attend homebirth and though CNMs can, most work in hospital settings. CPMs also attend birth center births, as do CNMs.

So now you know a little more about what happens in a real emergency during a homebirth. It's still very rare, but protocols are in place and most women don't die even if they require a transfer, any more than they do in a hospital.

Reversal

Jerry went into work that morning bursting with news. He wanted to shout to the sky--his wife and he were expecting a baby! But he kept it inside, knowing that it was clear on his face anyway. Several of his coworkers asked him why he was in such a good mood that day, but he knew he couldn't tell them. After all, if he talked about being married at work, he could lose his job.

It was really hard thinking about how if he had chosen any other work but the military, he might be able to tell all his friends at work that he had a wife and that he loved her and the best part of getting up every morning was seeing her sleeping next to him.

But talking about love where he worked was taboo. Today, that was very hard and slowly, the excitement dimmed until, instead, a depression set in that he couldn't share his joy. His work was rewarding, yes, but it was still work and it was draining that he couldn't share his personal life without fear.

It ruined the whole rest of his day, but he steadfastly concentrated on work. After all, he was a soldier, his feelings didn't matter wherein they did not interfere with his ability to follow orders. He would continue to protect the people of his fine nation, even while not able to enjoy the same liberties that he was fighting for.


Sounds ridiculous, doesn't it? But that's the story that all of our soldiers who are GLBT experience because of Don't Ask, Don't Tell. People ask, "Why repeal it? Why does it matter? Why do they have to talk about it? It's no one's business but their own." That last line is from GLBT supporters. Yeah.

Imagine you were unable to talk about falling in love, getting married, starting a family--worse, you couldn't get married (even though it's legal for anyone else) because it could lose you your career!

I reverse the question: "Why should it matter who the people fighting and dying for our rights are in love with? Why should it matter who is waiting for them at home?"

With the Don't Ask, Don't Tell reversal going through, we need to support the change, support the troops and remember that this is supposed to be a nation where "...all Men are created equal, that they are endowed by their Creator with certain unalienable Rights, that among these are Life, Liberty and the pursuit of Happiness."

Who can pursue happiness when their safety is in jeopardy and freedom of religion is considered lesser than that of another (as several religions accept GLBT relationships, including branches of Christianity and it is only the adherents of certain religions that says GLBT is not a valid way of life)? Thus, any person denying the right of GLBT soldiers to talk about their families the same as heterosexual soldiers is violating the constitution of the United States of America. And that's exactly what the court decision repealing DADT decided.


Hooray for reversal! Support the Troops! All of them.

Stock image from FantasyStock at Deviant Art. Used with Permission.

Weaning and the Ways it Happens

So, the World Health Organisation (WHO) and UNICEF recommend a minimum of two years of nursing 'or beyond'. A lot of people don't know that. The American Academy of Pediatricians (AAP) and American Academy of Family Physicians (AAFP) recommend a minimum of one year and then 'as long thereafter as mother and child desire.' Both recommend no other substances in the first six months of life.

So, according to the experts, babies should be nursed at least a year. We all know that this isn't usually the case in the US, though in other countries, the time varies both in modern times and historically. In UK Europe, nursing only through infancy has been a pattern for quite a while, while in Japan the norm was 2 years and China was recorded as children nursing until up to 5 years. The worldwide average for weaning is 2.8-4.2 years (depending on the study and if the US is included--it drags the worldwide average down due to its low breastfeeding rate, premature weaning tradition and large population).

Okay, so that's all the recommendations and the average and yada yada. Now, one question I was once asked as my still non-verbal toddler nursed was, "Don't you have to wean soon?"

It was asked in complete innocence and I answered honestly, "No. Children will wean on their own. I don't actually have to do so."

It's true! While rarely, children will nurse 6-7 years, the average age of children weaning on their own is much earlier--about the range of the worldwide averages, actually. Somewhere between ages 2 and 5. Children will not typically wean without some sort of encouragement (even if not deliberate) before 18 months of age.

Does that mean every family has to wait until their child is ready? Of course not! Waiting at least the minimum 2 years is best for baby and mom, but people wean in many different ways for many different reasons. Some women wean earlier than they would like due to work, lack of support, medical conditions, peer pressure, etc. Some women nurse longer than they actually want because they aren't sure how to wean; and some women are simply "done" before their children. Nursing IS a two way street.

I'm not going to tell you how to wean. I have no clue. It's not something I'm interested in. But I will now tell you about the different kinds of weaning. Oh, and a child after the age of 6 months who nurses, starts eating food just like bottle fed babies between 6-14 months and eats the same stuff ;) They drink from cups (mine started drinking water from cups at 6 months with my first taking pumped milk as early as 4 months in a Nuby Softspout--we mostly skipped sippies and went with straw cups for better oral development--until my second decided that they were more fun upside down, so we switched back to sippy cups for her--though she and her sister both can drink from open cups easily... I even prefer straw cups for me for minimizing spills) at the same ages and nothing changes except that they still take nourishment from their mother directly.

Parent-led weaning: This is the most common. This is when the mother chooses to wean and institutes a weaning strategy, such as "Don't offer/don't refuse," gently replacing nursing sessions, going out of town, pretending her breasts are broken, etc.

Influenced weaning: This one isn't talked about very much and is one of the main reasons that I'm writing this entry. Influenced weaning is when a child is weaned due to circumstances such as milk drying up, accidental parent-led weaning (such as a mother instituting "Don't offer/don't refuse" without knowing that it's a weaning technique, refusing to nurse so often that the child gives up or giving cues that they don't want to nurse anymore which the child picks up on), or societal pressure (such as the father or a nosey grandparent or auntie making rude comments that shame the child or parent, disparage the nursing relationship or attempt to make the child feel bad for nursing--like saying 'Big girls don't nurse! Don't you want to be a big girl?'). Nursing strikes would also fall into this category (more explanation on this later).

Mutual weaning: This is pretty rare and comes from the mother and child making a deal that they will stop nursing at a certain point. This is usually in a full-term nursing relationship (2+ years) when the child is old enough to be reasoned with and the parent no longer desires to nurse.

Child-led weaning: This is when the child is given support to nurse but slowly and gradually stops doing so on their own time.

Sudden cessation of nursing is not child-led weaning, it's a nursing strike. Nursing strikes happen for a variety of reasons and at different ages in life, but usually in the first two years. Nursing strikes are often used to wean children without trauma, but if they occur in the first year of life, they should be reversed if at all possible, unless the mother needs to stop nursing for some reason.


So there you have it. The different ways that children wean. For extensive information on weaning, "How Weaning Happens" by Diane Bengson is considered the best book by all the friends I know, on explaining the subject (warning: this is NOT a book on how to wean!).

Happy nursing (and weaning)!



Some resources I used (outside of several books):

http://aappolicy.aappublications.org/cgi/content/full/pediatrics;115/2/496
http://www.aafp.org/online/en/home/policy/policies/b/breastfeedingpolicy.html
http://www.wpro.who.int/media_centre/fact_sheets/fs_20070801.htm
http://www.amazon.com/How-Weaning-Happens-Diane-Bengson/dp/0912500549

Why txt spk bugs the hell out of me

It hurts my eyes. Plain and simple. It's almost a physical pain. I understand being in a hurry, having limited space (twitter, text messages on a T9, that sort of thing) but if you have a full keyboard at your arsenal and unlimited space/messages, then there is absolutely no reason to write out this sentence:

I hope you're having a great day.

as:

hope ur having a gr8 day

You had damn well better have only 5 seconds to type if you're sending that message. It makes you look not only stupid, but either 13-16 or 30+ Yes, either so young you're new to the scene or so old that you learned to text with a T9.

In IM or on forums, I'm flexible. If a phrase/group of words is being said a lot, acronyms don't bother me, nor do some abbreviations. Acronyms don't even really bother me in general, it's the mutilation of words, particularly by including numbers in place of letters. That's for license plates, people, not communication. I. DESPISE. THAT.

If I'm using words like 'ur' then I'm either in a crisis or I am typing so furiously on my phone that you're glad you're not in front of me, because I'd be shouting or hitting you with my phone. Or my hand is cramping from using that tiny damn qwerty board and we're trying to have a conversation that is too long for texting.

In short, if you have a real keyboard, use real words. PLEASE. Use them correctly.

Thank you.

Supply Issues Without Bottles

Okay, so when we have serious supply issues, what's our first thought to do? Supplement. Sometimes it's with breast milk, sometimes with formula, but no matter which, the typical method of giving this supplement is counterproductive to breastfeeding: bottles.

So I'm going to show you another option, that will bring your supply up if you need to supplement. It's not as easy to feed as with a bottle, maybe, but it will not only make certain your infant is getting everything she or he needs, but also will raise your supply and cannot cause nipple confusion or nipple preference.

The Lact-aid. I've suggested this in the past, but it sounds complicated to people and really, it's not.

(image is of the Medela SNS from their site)

What is a lact-aid? It's a thin tube that supplies milk to the baby while he or she is latched onto the breast and suckling. What's at the other end of the tube varies. It can be a bottle with the nipple cut off or the hole enlarged, or it can be thawed bags of breast milk. The lact-aid tube can be held or taped to the chest for the Mommy-on-the-go (who is breastfeeding while doing other things--usually accomplished by having baby in a sling) or the Mommy who has a baby who might pull the tube out of his/her mouth.

How is it used? You simply get baby latched on, then slip the tube into the mouth, towards the roof of the mouth until the milk gets sucked up.

Here's a video of a lact-aid being introduced. (it will open a video download window).

Lact-aids (or supplemental nurser systems, SNS for short) can be obtained through lactation consultants or a few websites, including through Medela.

I hope this offers another option to moms who are worried about their supplies, but don't want to introduce bottles, have had issues with nipple confusion/preference already or have babies who won't TAKE a bottle. And, with a little practice, it is just as easy as using a bottle--or easier if you're using pumped milk, as you don't have to transfer it from the bag you froze it in!

This is also a way that moms who just can't produce milk can give their babies formula and have the bonding and skin-to-skin contact that breastfeeding brings and babies need. In fact, it may stimulate a mom who had trouble making milk into making milk. Maybe not enough to fully feed off of (although that's a possibility) but every drop counts!

This is also an option for moms choosing to relactate to build up their supply faster than just pumping.

Here is a site with a few images of the lact-aid in use (and instructions how): http://lact-aid.com/rpt022.htm#positioning

And a site with SNS in use: http://www.breastfeed-essentials.com/accessories.html#SNS