I’m a mainstream obstetrician. Most of my views about obstetric practice are in line with that of other obstetricians, pediatricians and neonatologists. In one area in particular, though, I am bucking the conventional wisdom, and that is in my oppposition to the hard stop policy banning elective deliveries before 39 weeks gestation.
I realize that the March of Dimes believes strongly that this is an effective and necessary policy (and a lot easier to accomplish than trying to prevent the prematurity that actually kills babies), and I know that the American Congress of OB-GYNs (ACOG) and the American Academy of Pediatrics (AAP) have enthusiasticly climbed on the bandwagon. And almost every time I write about this issue I get emails of other obstetricians (including regular readers of this blog) disagreeing with me.
But I view this issue as a subset of a serious problem plaguing American medical practice: the implementation of “preventive” care guidelines (particularly those that promise to save money) in the absence of evidence to support those guidelines. As I’ve written in the past, I’m afraid of preventive medicine. From routine estrogen replacement therapy to routine use of prostate cancer screening, preventive measures have been implemented without appropriate, large scale, long term studies to determine unanticipated side effects. I’m afraid that the 39 weeks ban will also turn out to have serious side effects, and in this case, we can’t even claim that they were unanticipated.
Why should we anticipate the serious consequences of banning elective deliveries before 39 weeks? Because we know (as demonstrated by the chart below) that each additional week of pregnancy beyond 36 weeks raises the stillbirth rate.
I’m not the only obstetrician to point this out. Indeed two new papers address this issue specifically, one in a theoretical argument, the other using the results of a study.
The first paper is Theoretical and Empirical Justification for Current Rates of Iatrogenic Delivery at Late Preterm Gestation by Joseph and Dalton, published in the most recent issue of Pediatric and Perinatal Epidemiology.
The authors point out that the 39 week ban is based on 3 erroneous beliefs:
1. The erroneous belief that the difference in death rates between babies born at 34 weeks and babies born at 39 weeks is merely due to gestational age.
Numerous studies have quantified the excess morbidity and mortality among late preterm infants compared with term infants. Although such quantification accurately reflects differences between the two groups due to differences in pregnancy duration and pregnancy complications, it is disingenuous to suggest that a pregnancy with evident fetal compromise at 34 weeks gestation could be safely delivered at term.
2. The erroneous belief that “too many” babies are born before 39 weeks.
Expectant management given fetal compromise at late preterm gestation is associated with a potential risk of fetal demise, neonatal death or serious neonatal morbidity (due to progression of the fetal compromise). On the other hand, iatrogenic late preterm birth given fetal compromise is associated with a potential risk of neonatal death or serious neonatal morbidity (especially respiratory morbidity due to lung immaturity). Studies show that recent increases in iatrogenic preterm birth have been associated with declines in perinatal mortality. To our knowledge, no population-based study has demonstrated an increase in rates of neonatal mortality or respiratory morbidity due to the recent increases in iatrogenic late preterm birth.
It is also noteworthy that about one-third of iatrogenic late preterm birth is carried out for maternal indications.Yet no study to date has examined the effects of increases in iatrogenic late preterm birth on maternal health status…
3. The erroneous belief that multiple studies show that unindicated premature deliveries are rampant.
… These studies have been criticised because of their weak retrospective design; two studies were based on retrospective abstraction of medical charts and the third was based on a national database with information from birth certificates (known to overestimate non-indicated labour induction). The lack of detail regarding the clinical context makes judgement regarding the appropriateness of iatrogenic late preterm birth in these studies uncertain. The absence of an indication in the medical chart could imply an elective delivery or could represent a problem with the documentation of a legitimate indication.
So the purported theoretical basis for banning deliveries before 39 weeks is very weak.
What happens to the stillbirth rates if such bans are implemented? That’s the question addressed by the second paper, The risk of fetal death: current concepts of best gestational age for delivery by Mandujano et al., published in this month’s issue of the American Journal of Obstetrics and Gynecology.
According to the authors:
Linked birth and infant death data for the US from the National Center for Health Statistics analyzed nonanomalous singleton pregnancies between 2003 and 2005. Pregnancies were classified as high risk or low risk based on preexisting maternal complications. Out- comes of 8,785,132 live births and 12,777 FDs between 34 and 42 completed weeks’ gestation were examined…
What did they find?
Between 34 and 40 weeks’ gestation, the FD [fetal death] risk of those remaining undelivered for all pregnancies declined and then increased at term. For high risk pregnancies, the FD risk of those remaining undelivered is substantially higher than for low risk pregnancies. The number of FDs that can be avoided by delivery exceeds the neonatal death rate between 37 and 38 weeks’ gestation in low risk pregnancies and at 36 weeks’ gestation in high risk pregnancies.
The inevitable conclusion is:
These findings suggest that delivery at 39 weeks’ gestation in both high and low risk pregnancies would result in an increased number of perinatal deaths. Decisions regarding the “optimal time for delivery” should include the risk of remaining undelivered.
The authors note:
Much of the na- tional conversation and literature on this subject have surrounded the neonatal morbidities associated with a delivery before 39 weeks’ gestation. Although these analyses have demonstrated that delayed delivery reduces neonatal morbidities and the subsequent neonatal mortality from prematurity, they failed to include stillbirth in their analysis. We hope that by directly comparing fetal and neonatal mortality, we highlight what must be considered when determining optimal GA for delivery: both the risk of delivery and the risk of non-delivery. Recommendations that consider only one element should be considered incomplete.
That’s the very point I’ve been striving to make in multiple posts I have written on this issue. The underlying assumption of banning elective delivery before 39 weeks is that morbidity can be reduced without increasing mortality from stillbirths. As these two papers show, that is an assumption that is entirely unjustified. It is probably impossible to reduce morbidity without increasing mortality from stillbirths. As between the two, a short NICU admission is far preferable to a preventable perinatal death.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3719843/
Being born itself imposes the risk of mortality. The fetuses that died and were recorded in these studies never got the chance to be born, so we will never know whether they would have made it or not. That is why fetal death rates during late pregnancy never reached the levels of perinatal or newborn mortality. The fetuses never had to endure birth. That is the problem with comparing fetal deaths with newborn or perinatal deaths – it’s not comparable.
This
is such a good point, and it pervades across the spectrum of women’s
issues, of course. And in some cases, it’s not guideline centered care
so much as it is legislature sanctioned care—the state of SC just
banned elective delivery before 39 weeks for babies whose mothers are on
Medicaid.
Media Monitoring
Again THANK YOU for publishing these articles! As an Obstetrician who has practiced over 16 years I deeply and utterly resent the onerous and coercive 39 week rule being forced upon us by JCAHO and March of Dimes. I have always had a problem with using a NICU admission as an endpoint. Is there an evidence based study with level one or two data showing long term adverse sequelae or morbidity from a NICU admission at term? And why is the Ehrenthal Delaware study so readily dismissed? Sure it was level three data but who is going to do a randomized control study where one end point is fetal demise? I have no doubt that as more and more comparisons of pre and post 39 week rule data come to light we as Obstetricians will ask ourselves how we got to this point when we trade (to use Dr Tuteur’s phrase) morbidity for mortality. I am afraid our complicity and indifference is paving the way for many an unnecessary and preventable tragedy to be suffered by our patients and their families.
THANK YOU! As a practicing OB, I completely agree with you. This is a way that “patient safety” (unclear which patient, mom or baby) concerns get perverted and extended. While it has long been my practice to wait until 39 weeks for truly elective deliveries for low risk women, I think this policy is having a chilling effect on decision-making for others. Of course, all policies say that indicated earlier deliveries are a “judgment call” but the staff has been “educated” to be resistant to any deliveries (and sometimes, allowing women with advanced dilation and prodromal labor etc, to be admitted and delivered) so it puts the Ob in a tight spot. SHould we deliver a live baby that ends up in NICU, we can never prove this baby or mom would have been sicker, or that the baby would have been stillborn. It’s a losing proposition. While I feel that I can stick to my guns if I feel someone needs to be delivered for reasons other than one of the official indications, knowing that you’ll have to undergo peer review (fairly onerous in our institution) adds to the complexity of making the decision. There are so many gray cases in which the exact right time for delivery is not clear, and where I think years of experience are needed to help make the call. The backlash of this policy/movement will be significant, I fear.
DRDEG
OT but why the hell isn’t Zofran avalable OTC? This morning I was convinced I was going to die after being sick for 4 days straight. Now I am keeping down Gatorade and saltines like a boss. Why the hell did I have to go to the ER to procure this drug of the gods?
I LOVED Zofran while pregnant. My insurance only covered four weeks of it, but I didn’t have HG, though I was puking two to three times a day and it was affecting work performance. My OB had no problems prescribing it and basically said I should have asked sooner. I suffered six weeks (from 9w to 15w) before taking the medicine, and within a day felt like a whole new woman.
I hope you feel better soon!
I was given zofran after bad vomiting after a twilight sedation procedure unrelated to pregnancy when I was a teenager and got hives. Nothing is risk free.
Oh, of course not – it made me pretty constipated. But that was much better than spending half my work day at my desk afraid to move lest I throw up.
I am not sure that this is the case in all institutions but at ours any induction prior to 39 weeks is run by the Chief of OB, she is pragmatic and understands that sometimes many “soft” indicators add up to a solid indication.
Some states have instituted a hard stop policy. In my understanding this means no inductions prior to 39 weeks unless the hopitals go through a lot of hassle to justify it.
Why should we trust the conclusion of these two pieces of research, as opposed to the consensus arrived at by the AAP and ACOG? And then why should we trust your explanation of why we should do so? (Yes, I am making a “meta” point here.)
Alan, aka the devils advocate. I missed your credentials again. Your wife is the sole money maker in your relationship, so does that mean you are unemployed? These articles do site findings consistent with other studies, that the relative risk of stillborn is higher with each week after 36-37 weeks, albeit small. Dr Amy feels that relative risk is of concern. ACOG feels the morbidity risk is more of concern. Are you questioning the studies or Dr Amy’s opinion about them? You have read more than just the abstracts and the AAP’s and ACOG’s committee opinions. These two studies are more contemporary, sometimes the AAP and ACOG will change their opinion as new evidence comes to light. How do you know that they won’t change their opinions based on these studies?
I don’t, but until such time I will give their consensus far more weight.
My point though was mainly an arch “meta” commentary that referred back to interaction in other threads.
If I remember correctly the AAP used to endorse circumcisions. Then the AAP did not endorse circumcisions. And now they say there are some potentials benifits to them. Wowza, their consensus changes every 5-10 years.
Also, it is pretty obviously sexist of you to call me unemployed, when you would not say the same I am sure about a SAHM. I have not sought employment for years, therefore I am not unemployed by the government’s definition either.
It’s not sexist to ask what are your credentials or your education background since you are not employed. But I can see that your defense is to make it sexist. Nice one. You may have been laid off or between careers. but i see you’re embarrassed about it or at least defensive about it. Anything to keep yourself in a debate. Both my wife and I are self employed with many kids.
No, I was never laid off, and am not between careers. You are obviously sexist though unless you can link me to a past comment where you called SAHMs unemployed.
You are unemployed. And I don’t need to link you, because anyone who is not employed is unemployed by definition. Even you differentiated the term by stating not according to government definition. So yes, by lay person lingo, you are unemployed. Am I still sexist? You may not have been unemployed, but a medical transcriptionist at home. I didn’t say you were collecting unemployment. You mention your sole money making wife’s salary doesn’t allow you to pay for a hotel when visiting family. And you insult them by declining their hospitality. But you are proud? You can work from home to supplement your family’s income. Just a thought.
I feel confident you have never called a *specific* SAHM “unemployed”, so you are full of shit.
I have a related question for anyone who can answer: is maternal mental health a medical reason that could justify an induction earlier than 39 weeks? Reading these comments, I am struck by how many of us experience anxiety toward the end of our pregnancies due to medical history or conditions that aren’t quite dire but have that potential. Toward the end of my pregnancy I was starting to get more and more anxious that things would go sideways, and I do have a history of depression and general anxiety disorder. In a way I was relieved that the chronic hypertension was a “good enough” reason to induce, but I wondered what would have happened if my blood pressure had been perfect.
Maternal mental health was the indication for my c-section AND the indication for my c-section at just over 38 weeks. Thank God, because by 38 weeks I was absolutely wrecked and not lucid anymore at all. I had already known about late prematurity but I had a dating U/S at 6 weeks. I asked my OB to wait until 39+ but she told me to trust her. I was so glad I did because by then I was really, truly mentally ill. That said, I think it would have to be pretty severe circumstances?
OT: Super cool post:
http://jezebel.com/5986200/hospital-live-streams-c+section-on-twitter-and-its-pretty-damn-cool
I had cholestasis with my first two and it got really out of control with my second. Knowing more about the problem, I insisted on getting regular blood work with my third. I had some symptoms but they were only occasionally severe and my blood work looked reasonable because they weren’t tracking the right markers. At 39 weeks, I actually ended up crying in the office that I was afraid to go past 40 weeks because the baby did’t move much at all. The baby passed a non-stress test and so the doc still wouldn’t give me a recommendation for an induction. I spent those last weeks in terror of stillbirth. It was mostly because I was determined to do everything right that I had previously done wrong. In the us, they would’ve induced just o be on the safe side, but due the strict incentives structure in the German health care system, they were happy to let me go past 40 weeks.
I find this interesting to read, especially after having come across the book “Choosing Cesarean: a Natural Birth Plan”. http://www.choosingcesarean.com/
I am all for stopping sections before 39 weeks unless they are medically necessary and letting the pregnancy continue will result in someone’s death.
Mostly, I think it has to do with what was pounded into me about how babies who were born via section tend to have more breathing troubles then vaginally born babies. Then there is the whole issue of how lightly sections are being made out when they carry the same risks as gastric bypass or any other major abdominal surgery (without the stomach bile).
It bothers me to no end how blase’ some people are when I hear them talk about it. Even TEENS! I cannot tell you how shocked I was to overhear a conversation between two girls in their late teens, one wanted a section because she heard natural birth stretched your stuff out and she didn’t want that. The other mentioned how her mother had a horrible scar and how that made her not wear bikini’s again. The other one paused and said “I’m never giving up bikini’s.”
Headache aside there.
The very idea that sections are a acceptable form of birthing even to the point of stating it is ‘Natural’ is baloney! But like others have commented, we do live in a country where women can choose a late term abortion if they wish.
I wonder how they would feel if they were told they were done only by sections………
After all it would be a real shame for a woman to want to protect her sex life….vaginas are made for having babies, and how dare they be used recreationally, and heaven forbid that somebody recognize that vaginal birth is not risk free…..
Or her bowel continence. It’s not like anyone’s life is at stake. – S
Didn’t mean to take away from your point, Mrs. W. If my OB offered me an elective C-section while promising preserved bowel function either way, i’d lean towards the C. One round of vaginal scarring was enough for me.
Also pray tell where you came across your crystal ball that has given you such perfect foresight as to how things will go with respect to birth before it happens?
GDS – the “more breathing problems” of cesarean babies are almost always minor and temporary – as opposed to the greater risk of physical injury or hypoxia from vaginal births. Overall, the outcomes for cesarean babies are better, with a small cost of morbidity to mothers. Please read up on this stuff before making pronouncements. You are on a site where the data in these areas is discussed all the time.
And who “pounded into you” this compelling knowledge? Why don’t you read that site again so you can get a better idea of what actual experts studying the matter are saying about it?
The proper relative risk is not to no surgery, but compared to vaginal birth. Which is not risk-free.
Have you ever had surgery that is not immediately life-or-death? For instance: impacted teeth out, biopsy done, tonsillectomy?
Gratefully I haven’t had to yet. Though I’m sure it is in my future.
Ooooh I had impacted wisdom tooth out (totally easy, Midazolam sedation, almost painless), and then ended up with Stevens Johnson Syndrome from the antibiotic I got. Blisters on all my mucous membranes, couldn’t eat or speak for 10 days because it hurt too much, lost 18 lbs in less than two weeks. And a few weeks before university entrance exams.
Fun times.
Did I mention that my CS was an easy recovery?
Because the tooth extraction was probably my worst.
I had a vaginal birth.
Then I got endometritis. And septic.
And had to be readmitted to hospital for several days. Hubs thought I was dying in the emergency room. Prior to antibiotics, I would have.
they don’t carry the same risks as gastric bypass or other major abdominal surgery.
A c-section is really a pelvic surgery…comparing it to gastric bypass is ignorant. Do you really think it has the same risks as gastric bypass, a liver resection, an open cholecystectomy, a pancreatoduodenectomy, a bowel resection?
Every surgery carries different risks, but it carries the same risks because it is still cutting through layers of skin and muscle as well as into a major organ. Maybe not as major as the heart or as dangerous as the stomach, but it still plays a part. It’s the reattachment of all those layers that is more worrisome. My mother lost a dear friend who had gastric bypass, but she was throwing clots and her incision site never healed completely. She was literally bleeding to death internally before a clot killed her.
It’s not so much the surgery itself, it’s the healing that brings risk.
But I can live without my womb. Living without a liver would be a bit more difficult.. Plus when I had my c-section I was very healthy (as healthy as someone who was 41 weeks pregnant, chronically anemic and with a chronic, undiagnosed inflammatory syndrome could be) – healthy weight gain, healthy diet, good mental health, healthy weight, regular exercise etc etc. Recover wasn’t a problem even with my underlying issues.
In the long run yes, your liver would be missed. But I doubt the side effects from any hormone replacements, if they took everything of course, would be pleasant.
Hormones??” Ïf they took everything”?? In a cesarean?? What on earth are you on about, GDS?
GDS, you’ve clearly never seen any of these surgeries, have very little idea what they involve anatomically, or what the risks are. IIWY I’d stop now.
Being better to remain silent and leave room for doubt than to speak and remove it entirely.
You die within days if your liver isn’t functioning. There is no “long run”.
having done both caesareans and open cholecystectomys in my time – you have no idea what you’re talking about.
I want to add that Choosing Caesarean is a great book. It fully analyzes the different risks of planning a trial of labour vs a pre-labour caesarean in low risk women and summarizes the research in this area. It doesn’t sugar coat the risks of either a TOL or a planned c/s. It allows women to make an informed choice and very plainly states in multiple chapters that the authors don’t believe an elective section is the right choice for all women. Maybe the title is a bit off, but the book itself is a very good read. I would encourage you to read it because it will open your eyes about the true risks of different birth plans.
I will be honest, I was put off by the title, but it is now on my list of books to read this year. I just had a hard time swallowing that there was a book put out about choosing sections. It went along with all of the ‘woo’ warnings about how women are being made to think that sections are a perfectly fine option for birth. I’m glad you said it doesn’t sugar coat things and I’m sure we will have different views on it. 😉
I hope we have the same view on the book…that it is well written and that its central claim (that for healthy low risk women the risks of planning a trial of labour are equivalent in scope and material nature to the risks of planning a prelabour c/s) is well referenced and supported by the medical literature.
Thats the book in a nutshell – that the risks are a wash and the decision comes down to a woman’s values and which set of risks she would rather avoid and hence both prelabour c/s and a trial of labour should be supported after informed consent.
it absolutely does not say one plan is “better” than another, just that for a given woman, either plan could be “better.”
Then I look foreword to reading it. I am not opposed to reading things. I don’t like using the google-verse unless I need a quick answer and even then it’s not always a quick answer. I prefer books, written by people who care enough to do more than blog about something. Anyone can blog or vlog about something and make anyone think they know something. I might sound misguided, but my biggest personal issues are that I have a hard time remembering sources of information. Another reason why I prefer books on my self, I can back track and flip through, make notes and then correct if I quoted something wrong. Don’t get me started on how I get things muddled in with things I’ve seen in documentaries either. Not mystical ‘woo’ ones to rent, but ones I see on PBS. Ones that have evidence to back them up, like Nova or National Geographic. Either way, I appreciate you being honest.
” I might sound misguided, but my biggest personal issues are that I have a hard time remembering sources of information.””
GDS – will you please just stop and draw breath for a moment? YOu clearly need to do a LOT more reading before making pronouncements. And, a pro tip: health professionals learn from textbooks, journal articles and FTF education sessions – not populist books.
Wait, you haven’t even READ THE BOOK? How can you come in here critiquing a book you haven’t read? Oh, yes, because you are from the NCB community. Why can’t you respect the choices of others? I consider my c-section completely natural. There is a post by me floating around here somewhere that details why. To summarize: some of us do not have such a rigid view of “natural” vs. “unnatural”. Technology is a natural adaptation to our environment. To me it was perfectly natural to avoid the unnecessary suffering and trauma of a vaginal birth, when I could have a c-section and control many of the variables. In fact, it seemed quite humane, and safer for baby (but not me) so over all, it seemed quite a natural decision for me. I’m a happy MRCS mama right here (and thankful for Dr. Murphy’s work!) and would do it again. Well, I probably will: one more time. Perhaps you should READ THE BOOK before criticizing it.
Sorry GDS, gastric bypass has a 30 day mortality of 0.1-0.5%.
Orders of magnitude higher than an elective CS. In terms of surgery MRCS is more like an appendicectomy or lap chole than a gastric bypass.
Don’t let the facts get you down though.
In order for the facts to get her down, she would have to read them…
“I’m never giving up bikini’s.” – Actually, I think most normal women would give up a bikini for a healthy child. I’ve had 2-sections. I could still wear a bikini and no one would be pointing at me saying look that woman had a C-SECTION.
I have to say my second c-section was really easy. I had it at 40 weeks and if I had known I would have skipped the 39th week I waited for labor to start so I could “attempt” a vaginal birth. In no way do I regret either of my c-sections. Sometimes I think the NCB crowd is just jealous because for some it can be that easy!
It’s the ignorance in her statement that shocked me. I had to share it because I was so taken aback by it.
I’m happy you had a good experience and I’m not jealous.
My daughter was born in 3 hours, water breaking to holding her, I also healed up quickly with her, my midwives were shocked to see me up and walking around the next day like nothing had happened.
What ignorance? There are risks for a vaginal birth. I have a friend that was terrified of giving birth and was relieved when her OB recommended a C-section. She has a happy and healthy little girl. I personally think her OB half made up the reason for the c-section because she really was that scared of a vaginal birth. I’m sure some people would say her fear was unreasonable and shame on the OB, but her fear was very real to her. I think her OB was her hero, letting her opt out of what might have been a possible, but traumatic vaginal birth when she was already afraid.
BTW – I never said you personally were jealous. You seem so sure that breastfeeding and vaginal births are the way to go that you can’t see the other side. You had a great vaginal birth. Good for you! However, it’s not that easy for all women. I was up and walking around like nothing happen the day after my c-section that doesn’t mean I tell my friends you really should just have a c-section. I let them listen to their doctors and make their own choices based on what is best for them.
I may be wrong, but in your posts you sound young and naive. Life is never as black and white as we like for it to be. We live in a time when technology can and does save lives, why would someone not want to take advantage of it.
I know they are the way to go for me. I have a very good grasp that they aren’t the way for everyone. I must just be an oddity in my own sex to not be afraid of things that everyone else is apparently so scared of or turned off from.
We should take advantage of living in this time, but I really feel there should be a middle ground that is just as firm as either side of the argument. I honestly think every woman should have her first in the hospital, just because it is the first time their body is doing this and no one knows what will happen. I had my first in the hospital and I don’t regret it. But these woman should be able to try doing it naturally first until there is proof of a medical ‘wall'(stalled labor, dropping heartbeat, etc).
I am 33, if that makes me young and naive, so be it. I am someone who has always been sure of how I want my life to be and I am not ashamed of my own thoughts and ideas.
“But these woman should be able to try doing it naturally first until there is proof of a medical ‘wall'(stalled labor, dropping heartbeat, etc).”
I really hope you meant to put the ‘able’ in there. Yes- should be able to do try it – if they want to, and it’s safe to do so. But what about those women that don’t want to – they deserve as much advocacy and support – they’re trying to do what is best for them and their babe.
I disagree mightily with the ‘medical’ requirement. Maternal exhaustion, justifiable fear of adverse side effects, these are completely valid. And why wait for a dropping heart rate and a compromised baby?
“I really hope you meant to put the ‘able’ in there. Yes- should be able to do try it – if they want to, and it’s safe to do so. But what about those women that don’t want to – they deserve as much advocacy and support – they’re trying to do what is best for them and their babe.
I disagree mightily with the ‘medical’ requirement. Maternal exhaustion, justifiable fear of adverse side effects, these are completely valid. And why wait for a dropping heart rate and a compromised baby?”
Amen!
Why would they be surprised? Most people I know are up and walking around before the next day. My SIL was up and walking around the day after her C-section. I guess they have not seen many births.
I was up and walking as soon as I got feeling in my legs again after my csection. Moving around asap even though it can be painful helps me get off pain meds a lot sooner. I didn’t even need them when leaving the hospital with my third son but took some home just in case. I had staples with my 4th and that made thing hurt more and longer but even then I was off them soon after I left the hospital.
Because I was normal. No slow steady pacing, no wincing, no stopping for breaths. Not like how it was with my son, I’ll tell you that.
You do realize that in the US, late-term abortions are only done in cases where A) the mother’s life is in danger and/or B) the baby has a condition which is incompatible with life? Don’t quote me on this but I believe there are only 4 doctors left in the COUNTRY that perform them. Your comparison makes as much sense as saying, “We live in a country where people can choose to take a relative off life support, so murder should be OK.” The two situations are COMPLETELY different.
What is it that makes sections “unacceptable” as a form of birthing to you?
I guess I’m just one of the people who view any kind of operation as something that is needed to fix something that is broken. If it is necessary, sure that’s fine. But to opt for it because you are (excuse the expression) to posh to push? I only link the two together because the risks are the same when it comes to healing. Stitches can be popped, wounds can weep, bacterial infections can creep in and all of those can result in death, sometimes quickly and silently. It’s just not a risk I would take unless it were necessary.
I’ve had elective cosmetic surgery. Since those complications are rare, I didn’t have any of them, and I am so, so glad I did it. I am sorry you are so afraid of operations, but your fear is irrationally disproportionate to the risk.
Well, vaginal delivery does not mean you are sure to escape stitches. I had a c-section, but mmy SIL had 4th degree tear. I think she had it worse.
So why aren’t people like you more honest about the complications caused by vaginal birth, GDS? I had no idea that it was possible for the cervix to be torn during a vaginal birth, so imagine my surprise when it happened to me! No one really told me about urinary and fecal incontinence either, and I had a hard time finding a pelvic floor therapist in a major metropolitan area! At least I didn’t have prolapse, which is another complication of vaginal birth.
“Stitches can be popped, wounds can weep, bacterial infections can creep in and all of those can result in death, sometimes quickly and silently” Yes, so that is why doctors have to tell you about those things before you sign the form that says you have been made aware of the possibility of those things happening. But I wish someone could find the link to the post about informed consent about the risks of vaginal birth-something few people think about when they make arguments against C-sections.
Something you should think about when you make a comment like “too posh to push” is that there are women who are survivors of terrible things like incest, molestation and rape. They might be absolutely low risk and have no medical reason for wanting that C-section, but for their own mental health opt NOT to be terrified and triggered.
I am not sure why you read so much into the attitudes of teenagers…they are really trying to figure out who they are, their opinions are likely to change 5 times prior to adulthood and they can chose opinions and courses of action purely out of a desire to be oppositional.
The only things that remain from my teenage years are a) that I identify as heterosexual b) that I still want to be a doctor (am one) and c) one good friend and d) that I still like root beer more than cola. Everything else is different – my religious affiliation, how I feel about abortion, most of my friends, my relationship with my parents, my preferred diet, my taste in music, my style of dress…
It just took me by surprise. That she seemed so sure that that was the thing for her. When I was that age, anything that involved me being cut open was horrifying.
I’m not that much different than I was in school, though others may argue I am. Truth is I’m just actually going down the path I was starting on. I still like the same style of music, I still dress the same, I still enjoy helping others and yes I was that crazy girl arguing with my classmates about breastfeeding. Guess I always will be arguing for what I feel to be right, even if I word it wrong.
By that age I had had 4 surgeries and had recovered fine. Some friends had had many more surgeries. I’m NOT horrified at the thought of being cut open, though I don’t randomly schedule having surgery just to have something to do on a boring day.
I have never had a surgery in my life. I’m not horrified at the thought of being cut open, I am scared speechless at how my body will metabolize the medications given to me during.
GDS – these are strange attitudes from someone who gives health advice to new mothers.
I don’t think GDS attitudes are all that strange – in the sense of uncommon – unfortunately.
This is the “It stands to reason” thinking of those who cannot actually distinguish to well between facts and opinions, or prejudices. And it accounts for a lot of the popularity of NCB.
I do rather optimistically believe that with better information, GDS might change her views – which is more than you can say for those who really ought to know better. And at least she is not insisting that the rest of us are wrong.
I’m sorry you are scared, and glad you avoided unwanted surgery. Yet you don’t seem to see that you are like an agoraphobe claiming that your concerns are right, proper and moral and furthermore that claustrophobia is a moral failing and all claustrophobes should be shoved in dark closets for their own health.
“I’m scared speechless at how my body will metabolize the medications given to me during”
That’s because you aren’t sure how the liver works:
“In the long run yes, your liver would be missed.”
In the long run? How about in a day or two? GDS, if you went and got a proper education wrt physiology and pathophysiology and just a wee bit of statistical training, you would see that about 80-90% of your opinions (maybe more, would have to collect all your comments and start a spreadsheet to tell for sure) are due to ignorance-based fear.
This single post explains a LOT.
Honey, I’ve had a lot of surgeries. Some with good recoveries, so not so good. Of all of them, the CS was by far the quickest and easiest.
What on earth do you think your body will metabolise the medications into?
Is this why you think pain is good, because pain medications scare you?
The thought that people like you may be working in a hospital with women who just had c-sections horrifies me. If I manage to have a baby, I will try to breastfeed and would like some help if I need it. But if the help needs to come from someone who lacks the medical expertise to understand why I had a c-section or who sees herself as having a place in assessing for herself the quality or rationale for my care, then I would rather have no help. I would formula feed off the bat before I let someone like you get into my space right after I just had a baby. I am having a c-section for valid medical reasons and it is between me and my doctor, not some self-appointed, ignorant busybody llike you. You are hurting your profession, because I’m now suspicious of just who the “lactation consultant” at my hospital might be…
Why does it horrify you? I don’t pass any judgment on to them. I don’t sit there and berate them for failing at their births. I have been more vocal here than I have ever been to anyone else but my husband. I keep my mouth shut on everything that doesn’t have to do with the task at hand and that is to get that baby to latch on, give the mother comfort that she is doing a good job and that it will get easier. The most medical talk I ever do with section mothers, is informing them that some of the pain medication may pass through the milk to their infant. Emphasis on the may, because every woman’s breasts work differently.
I’m sure the one where you work has their own thoughts and speculations, but they probably won’t say anything about it to you. Because the matter is not what just happened in the delivery room, it’s about getting the new baby to eat.
Failing at their births? You have got to think about your words here – if they have a baby that might be latching etc then they have a live, healthy baby and that is not a failed birth.
I don’t sit there and berate them for failing at their births. — What?? Why would this even be something you would think. Yeah, I agree would not have wanted you for my LC.
GDS – if you are really a health service provider, your knowledge about pregnancy and delivery leave a lot to be desired.
And “ëvery woman’s breasts work differently?” The way medications are metabolised and excreted is not determined by the breasts. Are you not trained in the health sciences? What is the basis of the advice you give?
Oh good, yet another example of a bad lactation counselor! What do you do when a mom simply doesn’t have supply? Do you tell her to just keep trying? Do you recommend medications or supplements that are unproven or may have very severe side effects? Because that was my experience with the LC after my first was born, and if I hadn’t done my own research, I might have caused a severe asthma flare-up (cause that’s a potential side effect of fenugreek). Do you understand that a woman with IGT is NOT EVER going to have adequate supply, no matter how much she pumps?
Wow, you seriously have suggested that women who are getting late-term abortions–all of whom are dealing with serious health issues or with fetuses with serious health issues–would decide against abortion if they had to get a c-section?
Are you insane?
Late-term abortion in this country is pretty damned serious and pretty damned rare. Women getting those abortions aren’t thinking about bikini scars. They’re thinking about cancer diagnoses, or anacephaly, or HELLP syndrome, and are often carrying very wanted babies. They’re in a world of pain. Show some compassion.
Thank you, Starling. I was so busy being offended for my own c-section that I forgot how even more horrible the implications are for women who have suffered in the circumstances you describe.
It was a hypothetical question.
I know there are a lot of women who are heartbroken at the very mention of it having to be done, but also keep in mind there are some who want to have it done.
No I’m not insane, just apparently still learning that I can’t speak my mind the way others seem to be able to.
You’re perfectly entitled to speak your mind, and others are perfectly entitled to tell you what they think about it. It’s not carte blanche to vomit up whatever pops into your head with no expectation of criticism. If it’s universal approval and applause you’re after, then you are in the wrong place and judged your audience particularly poorly with those statements.
How are not you able to “speak your mind”?
Sorry what is “it”?
Late term abortion?
I don’t think anyone “wants” to have a late term abortion “has been unfortunate enough to need” is more accurate.
Opting to terminate a pregnancy is not the same as “wanting” a termination.
CS?
Because yep, some of us want those. Want, desire, plan for, hope for, ask for, prefer CS.
Some of us have been unfortunate enough to need them too, and had planned something else.
Not the same.
Really not.
GDS-since they are teenagers and have yet to be exposed to the joys and pain of being responsible adults, don’t put too much weight in anything they say about big life decisions. They probably had just gotten done with the life skills class where they watch a video of a baby being born-which if I remember correctly had 1 boy in our class vomiting, 2 getting into position because they thought they were going to faint and every girl in the class insisting she was going to become a nun.
Very rarely second and third trimester abortions DO have to be performed through uterine incisions, for example if there is a large tumour in the uterus, vagina or cervix, or if there is complete placenta praevia. It is called hysterotomy.
If you have to choose to sacrifice your child to save your life, I don’t really think that that being told it will require this type of surgery is the sole thing likely to change your mind.
The biggest thing that bothers me about this is the obvious circumvention of a woman’s right to choose. If a woman can legally decide when a pregnancy is going to end by choosing abortion, why can’t she decide when it’s going to end by choosing elective c-section or induction? I, for one, believe totally in the doctrine of “my body, my choice.” A doctor has no right to supersede a patient’s right to make decision about their body except in cases of obvious mental impairment. Just because YOU believe that such-and-such choice is “in their best interest” doesn’t (or at least SHOULDN’T) give you the right to overrule their decision.
Yes, I have a really hard time accepting this as well. It is a total affront to patient autonomy, especially when the patient is being forced into expectant management and it has its own risks. In that case, it is not risk neutral and a woman should have the right to make a decision about her baby and her body. It is like forcing everyone woman to attempt an TOLAC, when she wants an ERCS. I hear this is happening more and more now. How dare they? As patients, we have a right to weigh the evidence and make an informed choice, especially in circumstances where the risk/benefit is murky.
I have been thinking about this a lot since the birth of my daughter last year. My pregnancy had various complications toward the end, including gestational diabetes and a blood pressure that was inching upward, but not meeting the definition of pre-eclampsia. My obstetrician even described me as “a bit of a ticking time bomb”, and clearly would have liked to induce at 37 weeks (the blood pressure issues began toward the end of week 36, the baby was on the 90% percentile for weight, with a head in the 98th percentile – and, although I had had a previous vaginal birth, that was a much smaller baby). Hospital policy, though, was to require a clear trigger for induction before 39 weeks.
I spent the last couple of weeks of my pregnancy in frank terror. I was spending half a day in the hospital, twice a week, for monitoring – but had a long weekend gap with no monitoring between Friday morning and Tuesday. I was petrified of something going wrong. Clearly the situation was deteriorating – my blood sugars suddenly actually became really easy to control, which my obstetrician felt could be a sign the placenta was beginning to fail, my blood pressure was creeping up, but hadn’t hit the magical diagnostic number. I was beginning to twitch with exaggerated reflexes… But no one would pull the trigger…
Finally, I’ll confess, in the middle of week 38, I told them I felt the baby was moving less. That gave them, I guess, something firm to tick the boxes needed to justify the induction. Even so, I heard the midwives discussing tut-tutting with each other when they reviewed the file as the induction was being est up, with the senior midwife saying there was really no clear indication, just a lot of small things, and that someone “had a loss of nerve”…
The birth was long, difficult, seemed several times likely to fail to progress. Obstetrical staff kept coming in and saying they were about to schedule a c-section. We tried to be clear that we were /fine/ with that, but each time, a bit like before the birth, the baby would progress /just/ enough that they’d pass the issue off to the next shift. The baby was doing worse and worse as the labour stretched out. But everyone seemed to assume that a vaginal birth should be a really high priority in the reasoning about how to proceed. It ultimately turned out okay, but my catheter was red with blood by the end, the baby came out in a really weird position (the most senior obstetrician actually burst out laughing, said she’d never seen it before in her whole career, and my room suddenly filled with medical students wanting to see the unusual presentation… I was beyond caring at that point…) Afterwards, they said if they’d known, they would have just scheduled a c-section from the get-go, as the chances of its having been a successful vaginal birth were regarded as quite low. I guess I could see this, from a “natural birth” perspective, as an example of how vaginal births are possible even in circumstances where c-sections are routinely scheduled. But personally I’d have rather traded less damage to my pelvic floor…
At any rate, five days after the birth, the day they would have induced if we’d waiting to hospital policy, I came down with post-partum pre-eclampsia, was extremely ill, and had to be booked back into the hospital for several more days. I don’t know if it works this way, but I keep wondering whether, if I hadn’t tipped the balance into getting them to induce “early”, I might have been that ill during labour itself, making the birth much more of an emergency than it had actually been?
I won’t even get into the horrible “home visit” midwife who, when I called to tell them I wouldn’t be at home for their visit because I’d been readmitted to the hospital, decided to drop into my hospital room – and proceeded to lecture me for not having brought a breast pump with me (when I raced to emergency with sky-high blood pressure and a falling pulse!) so that I could continue to express between every feed. My daughter was readmitted with me, and I was breastfeeding her every two hours while I was ill! No way was I going to get even less sleep by expressing too! And when I asked whether she needed formula supplementation, I got treated like a monster… I filed a complaint…
((Hugs)) I am glad that you are doing better and that everything turned out fine with the baby.
Thanks 🙂 Weirdly, in spite of all the complications, it all went better in many ways than the birth of my son either years prior – when I was in a midwife-run unit in a different (non-tertiary) public hospital, and I requested an epidural. I got it – but within an hour after the anaesthetist left, the midwife responsible for topping up the anaesthetic told me I was very close to pushing, and it should now be allowed to wear off – and stopped topping it up.
I was in labour for half a day from there – in agony (why I’d requested the epidural in the first place…). They told me epidurals were no longer effective once the baby had descended so low, and that there was no point in calling the anaesthetist back. I stupidly assumed they were telling the truth and just suffered through it. They also allowed me to push for a ridiculous amount of time, and allowed my son to basically stay put for almost an hour after crowning, with no progress and no interventions to get him out. He did eventually get pushed out, but was born with a very low APGAR, low blood sugars, had to spend a few days in the neonatal unit (with the midwives constantly telling me to distrust the NICU staff and contest their recommendations for intervention!). Today has some reasonably fine motor skills issues – no idea if it’s related to the birth, or if he would been this way regardless. But he’s a brilliant kid and I feel very much like we dodged several bullets from the woo-filled – but professionally-trained, hospital-affiliated – staff of the midwife unit.
I had flashbacks to the pain from that particular labour for over a year, which would randomly stop me in my tracks at unpredictable moments. It never occurred to me to complain about it until far too long after the fact for the complaint to be effective… But the experience – and realising very belatedly that they had just flat-out lied to me because of their own mumbo-jumbo about pain relief – certainly affected my decision to choose a tertiary centre, and to refuse from the outset to be managed in a widwife-run unit, this time around…
zomg.
I’m sorry, but NICU staff know more about neonatology than any RN or CNM. Any midwife or RN who contests the recommendations from the NICU staff should be told off. Good grief!
It was just infuriating! It also wasn’t as though the NICU staff were proposing anything extreme: he was a term baby, and basically in okay shape – he was just worn out from a long, difficult labour and delivery, his blood sugars were unstable, and they needed to supplement him with formula for the first few days while that settled down.
They let me be in the NICU as often as I wanted, holding and breastfeeding him. They did the formula supplementations via a nasogastric tube – presumably feeling that this would cause less “confusion” around breastfeeding. He was a greedy guts and nursed nonstop no matter how much they were supplementing, so it had zero effect on breastfeeding (and, indeed, didn’t wean until he was almost three…).
But the midwives in the postnatal ward were just horrendous about it – they told me the NICU staff would keep him for weeks and weeks once I let them “take him”, and wanted me to fight the original recommendation. They scared me enough that I did ask for a second opinion – the poor doctor, I still remember, looked at me with genuine fear in his eyes, explained what my son’s blood sugar numbers were, and went through the possible consequences. I was ashamed I’d let myself be talked into asking for this, as it delayed the supplementation… 🙁
When we were due to be discharged (just three days later), the midwives tried to tell me that, because I’d “given in” on supplementation, my son’s blood sugars might remain unstable once we came home and he might have a seizure. (As far as I can tell, this was just nonsense – certainly the NICU staff had said nothing about it – but it was a terrifying thing to be told at the time.) I asked if that meant I should continue to supplement formula at home to make sure that didn’t happen, and asked for some advice about formula feeding. They said they couldn’t advise on formula.
I still find this baffling – as it is, we went home, breastfed, and everything was fine. But I was on hyper-alert for the first couple weeks as a result, and felt terrible uncertainty and guilt over whether perhaps I ought to still be supplementing (I have no problems with supplementing, but my son was gaining comical amounts of weight while breastfeeding so, aside from this scary story on discharge, there didn’t otherwise seem to be a need).
But since they were clearly hostile to formula feeding, I’m unclear why they would say something whose major effect was to make me worried that my breastmilk wouldn’t be enough. The only thing I can figure, is that they were so committed to the notion that the littlest bit of formula would undermine breastfeeding, that they were – consciously or not – doing their bit to ensure that anyone who supplemented in the hospital also had problems breastfeeding at home. Sort of like generating the evidence for one’s own confirmation bias…
With a couple of my babies I asked the nursery staff to take my babies for the night after their births so that I could sleep. I assumed they’d give them formula or sugar water or whatever. I also knew that they would be exclusively breastfed babies when we got home and they were. Perhaps I just got “lucky” several times or common sense and logic really do rule the day.
I could have done this with my daughter – they didn’t have a nursery as such unless babies were ill, but one of the midwives in the postnatal area noticed she was unsettled one night, and offered to keep her by the desk if I needed sleep. With my son, the midwives were just bizarrely militant about it, and very critical of me for allowing the NICU to keep him instead of having him room in…
Even at the second hospital, though, they were hugely anti-formula supplementation. It took a while for my milk to come in properly – presumably because I was ill – and my daughter lost almost 10% of her weight and was becoming jaundiced: I asked repeatedly if we should supplement with formula. If nothing else, my experience with my son hadn’t suggested that supplementing in the early days wouldn’t cause any issues with future breastfeeding.
But everyone was categorically opposed to it – I was getting really nervous about it until her weight finally began to turn around… To be honest, I regret not ignoring them and just supplementing without official approval… I feel like she had a pretty miserable first week as a result, and that I could have prevented that…
Pepper, I’m sorry to hear you had so much trouble. I have IGT and major supply issues. Similar attitude from the midwives, as well as going against paed’s recommendations. The regret that you (and I) feel, for not just supplementing and not preventing a miserable first week, is a difficult thing to deal with, but I don’t think we can blame ourselves. We’re not supposed to be the experts, we’re supposed to be able to trust our HCP’s to do the right thing and give us the right advice, not just adhere to their own party line at all costs, regardless of the evidence.
Sorry you had a similar experience… 🙁 I agree, of course, about the guilt thing. But I still feel stupid for listening to them… ;-P
You should notify the hospital.
The story just above is about my son – who’s now 9 🙂 At the time it happened, I didn’t process how egregious the whole thing was – I was relieved to have a healthy child (still am), and just shrugged off the hospital experience.
It was only when we decided to try to conceive again that I went back through my old medical records. In the interim, I’d earned a PhD, received a position teaching and consulting in research design, and had institutional access to academic journals – and it was only really when I looked back at the old medical records, with that experience, that I realised just how many risks the midwife unit had taken with me and my son.
It’s not that I was anti-science during that first birth. Far from it: I had an MA, and was applying for PhD programs during my pregnancy… But the midwives talked a talk of “evidence-based practice” – and even handed me printouts of articles from medical journals. Where I was naive was in not realising how cherry-picked those articles were. I should have guessed, because they were also pushing Gaskin – who I thought was just nutty – and Goer, who struck me as hugely problematic. But I had no institutional access to go digging around in medical journals on my own – and, to be honest, it might not have occurred to me to do it: they were the medical professionals, right?
This is the thing that really gets me about the space of tolerance for woo-based alternative medical systems: I don’t have any issue if people, fully informed, decide to roll the dice. But I had no desire – absolutely none – to take these kinds of risks at all. But because this stuff had percolated into what really should have been a very mainstream medical institution, I exposed my child to risks I would never have voluntarily chosen. It’s completely unacceptable…
But it was so long ago, I have no way of knowing if this hospital still operates the same way – nine years is a lot of time for internal reform.
Good for you for having the courage to complain! I’m so sorry that you were treated that way by people who were supposed to help and support you. So much for respecting a woman’s choice! This (like the post from the woman who talked about her horrible experiences in the “baby-friendly” hospital) is a perfect example of what a lie it is for these mockwives to say they are there “for the mother” to “support her”. I don’t even care if they were actual CNMs. If you’re standing over a woman’s hospital bed questioning and belittling her choices at the VERY MOMENT she’s trying to exercise her right to make decisions about HER body and HER baby, you are not “with woman”. They should be ashamed of themselves!
You are obviously a strong and brave woman. Your daughter is a very lucky girl to have you for a mother. And you are lucky to have her after the misogynistic incompetence of your “care” providers!
I have to admit, when I got back home, and the day rolled around when the next home visit midwife was scheduled, my husband and I quite seriously sat around that morning debating whether we should just not answer the door – so I’m not sure “brave” is the word I’d use… ;-P
(We ultimately decided we’d better let her in, as we weren’t sure what they might do if we pretended not to be home… As it happened, it wasn’t a “normal” home visit midwife, but instead the head of the home visit program, who had decided to come in person to apologise after seeing my complaint. She was both extremely competent and very apologetic, and said she would work better on training to keep something like this from happening in the future.)
But we were very relieved it all worked out okay. It was incredibly rough to watch the obstetrical staff (this was in a public hospital – a tertiary one with a great track record on the books, which is why we’d chosen it) clearly think I should be induced, but unable to work out a way to justify it according to the paperwork required. I really didn’t want to be in the position of, effectively, making the call myself… 🙁 But it also seemed that the obstetrical staff were just not allowed to use their own clinical judgement that this was a pregnancy clearly heading south… The staff were hinting that they needed us to say very specific things, so ultimately that’s what we did…
It’s an odd thing for a care provider to, in a rather sly way, “coach” a patient on what to say to get the medical action they need. A smart nurse or doctor will figure out what questions to ask and facial expressions to use to get the patients own words documented to proceed with appropriate care in the face of rigid hospital protocols. This is the art of medicine. I am very glad everything turned out well for both of you, but am very sorry for how hard it all was. And let me say as well, “Bravo!” for complaining. I am happy to hear that the senior person in charge of the home visit program personally came to apologize on behalf of the insensitive midwife who berated you before. I am quite confident that she got a good “talking to” and will probably be much more careful in the future. Thank you for sharing your story. Enjoy your little girl!
Right on ^^^^^^ YES! And Pepper, what a harrowing experience!
a blood pressure that was inching upward, but not meeting the definition of pre-eclampsia.
Yours is the kind of story I find quite horrifying. And I can certainly sympathise with your terror! Maybe it is the definition of pre-eclampsia that needs to be re-considered, and the failure of nerve that leads to action may not be popular with NCB, but stuff that.
Both me and my daughter were the same kind of ticking time bomb. In more primitive times, I was sent home for a week between week 34-35, with vague instructions to come back if I saw flashing lights. Test results that showed up in my absence clearly indicated this was not a great idea – my baby did stop moving, and a rapid re-call and emergency CS was unfortunately too late to save her brain. My daughter’s high blood pressure was ignored – and she too had post-natal problems – though thankfully not as severe as yours. Her baby, like yours, did well. Born at 35 weeks, and bright as a button. If the hospital had been less chaotic, she might have been sent to NICU – but she didn’t need it. My daughter DID need better care, but didn’t get it.
That’s just horrifying – I’m so sorry you had to go through that… 🙁 And your daughter as well… 🙁 I remember very keenly the sense that there wasn’t much they could do once I was readmitted, but wait it out, let it run its course, and see how bad it ended up being…
One thing that I found very very difficult in the final weeks of my pregnancy is this sense that I was, effectively, needing to make a call myself – without medical training – that my doctors felt too intimidated to make. I knew there were some risks with inducing before the due date, but was mainly of course petrified that the situation would suddenly become urgent when I wasn’t at the hospital… But how to weigh the relative odds of these things? A chance of some impairment due to slightly early induction vs. the chance of something absolutely catastrophic…
I felt unexpectedly responsible for making the call on what should have been a specialised medical decision – and I really didn’t want to be in that position.
I can really sympathize with your story. I’m so glad you were able to advocate for yourself and your baby.
What I hate about this 39 week rule is that it places all the responsibility on the mother for ensuring the safety of her baby; and the stakes are so high.
I’ve had crummy CNM care- and good care as well- but I can and do sympathize. I don’t blame you at all for not wanting to answer the door! Like you as a new Mommy don’t have enough other things to focus on than judgmental crappy care. I wish all that stuff would just fade but I think there is something about how vulnerable we are surrounding birth that those silly attitudes and judgments of others can stick with us.
But the NICU stay costs money; health insurance doesn’t have to pay for infant funerals. Therefore, postponing delivery to 39, 40, 41, 42 weeks is more cost effective. Or something like that. (hmph!)
Sort of OT – but I work with an intern at the moment who has different colored eyes and unequal pupil size – he has Horner’s syndrome incurred during chidlbirth. Put that in your complication list for “natural”.
(Interestingly, he thinks that his different eye colors relate to the role of nerve supply in the pigmentation process when newborn eyes develop color – his Horner’s eye (loss of sympathetic nerve supply) is blue – didn’t change from neonatal color) and his normal eye is dark brown. Anyone know about this stuff?)
Never heard of Horner’s syndrome but will look it up with interest.
My daughter has different coloured eyes one blue, one blue and green. It is quite subtle, and rather attractive. (I once knew someone with one very blue, and one brown, and that was not so attractive – rather distracting) Her second daughter has spectacularly multi-coloured eyes – blue and dark brown in segments. This has been put down to Wardenberg’s Syndrome, a genetic problem with pigmentation, which MAY account for my prematurely grey hair, and in my granddaughter’s case has also caused sensorineural deafness in one ear, which fortunately she is coping with very well so far.
Where are the NCBers and anticesareanists with their own data and graphs, form their own clinical research, coming in to debate the science? Or are they still stuck at “babies aren’t library books”?
“babies aren’t library books”
Most people return their books before the due date, in good condition. Books returned after the due date have often been lost behind the couch or used as coffee cup holders, chewed on by the dog, left behind at a bus station or otherwise maltreated. Whenever I hear this stupid analogy trotted out as an excuse for going ridiculously post-dates, I always get a mental picture of a confused-looking baby being found under the bed, covered in dust bunnies.
“babies aren’t library books.”
I always want to respond, “no, babies can die.” But that might be too bitchy, even for me.
The people who throw out “babies aren’t library books” would dismiss that response as “playing the dead baby card.” Even though it’s true.
I said something like that to a preceptor…and you wonder why I never got to be a full blown CPM.
anticesareanist!!
wtf?
dammit! sorry. this is S, failing at disqus.
I think babies are more like fruit in a fruit bowl. If they stay there too long, things might start getting ooky.
I don’t know that much about fetal and neonatal mortality and what can go wrong if you are born a couple weeks early, but what is the big deal about being born at 37 or 38 weeks? Most babies born then are just fine right? Why did this guideline get started in the first place?
It was all about reducing NICU admissions, period. Early term babies do tend to have minor breathing issues (my oldest was born at 38 + 3 and spent two days in the NICU because he was grunting; he didn’t require oxygen or intubation, just close observation). I’m sure that my insurer didn’t love the extra cost, but I’d far rather have a NICU stay than be buying a tiny coffin..
That just seems counterintuitive! I am not a scientist, took one stat course in college, and even I can understand that trading NICU admissions for tiny coffins is not desirable. 🙁 I am glad your baby was fine!
Sounds like TTN. But they probably was watching for PPHN, RDS, pneumonia, pneumothorax, and sepsis.
And I’m glad that they were, Captain Obvious! For clarity, I should note that my delivery was not induced. I had SROM at 6 am, contraction started in earnest around noon, and son was born at 5:44 pm.
NICU care is expensive, and dead babies are cheap – especially in the UK, where there is little point in suiing. No pain and suffering here, only financial loss counts.
I was for quite a long time haunted by the idea that there was a certain ambivalence about rescuing mine, given the high expense of disability, and the uncertainty of success in saving babies in trouble. It was only the rapid decline in my state that galvanised action – couple of days, or maybe hours, too late to save my daughter from the stroke that did the worst of the damage. Those who take a pragmatic view, who are not “sentimental” about babies, would have no problem with considering that acceptable.
Transient tachypnea of the newborn (TTN) and persistent pulmonary hypertension (PPHN) are not too uncommon in 36-37 weekers. PPHN can be fatal. Increased risks for RDS, jaundice needing bili lights, feeding issues, temperature regulation, and hypogycemia do occur in 36-37 weekers more than 39-40 weekers.
I’m a neonatal NP and I can tell you why! We very often admitted babies at 37-38 weeks with respiratory distress before the guidelines. The OB’s and parents were always shocked. Nothing messes up a planned social delivery like a stay in the NICU. Some babies are simply not ready. This problem has pretty much been eliminated. Personally, I’ve had 3 inductions- at 41 wks, 31 weeks(stillbirth) and 36 weeks for oligo. There is a time and place for each.
1. No-one is arguing for social deliveries. 2. “very often” is not terribly scientific. 3. There are NICU stays and NICU stays. A couple of days as a precaution or for a relatively easily managed complication is not quite the same as the kind of care a baby allowed to get into serious trouble might need.
I scheduled my repeat c-section with the OB a few days ago, maternal request due to previous traumatic birth. He said that he wasn’t allowed to book me in before 39 weeks, due to policy, then booked me in for 38 weeks anyway, since I’m high risk. I’m pretty happy with that 🙂
A good friend of mine just had a baby by scheduled repeat c-section. She was scheduled just after 39 weeks, but she started having contractions almost a week before. Poor thing was miserable, she was having fairly strong contractions as often as 6-8 minutes apart. But her doctors wouldn’t do a thing until her scheduled date because they wouldn’t do an elective c-section before 39 weeks. So she got a week of prodromal labor and then finally a c-section.
That was me too! Thank God my OB/GYN seemed to have crystal ball and saw that one coming. I did about 4 days of prodromal labour with contractions on my couch before my scheduled c-section. All the women in my family deliver good sized babies in the 38th week. I was am so glad I wasn’t forced to go to 39 weeks because I would’ve had him before the c-section. I was in so much pain with those early labour/prelabour contractions I just held on and screamed into a pillow. Ugh. I should have had my OB tie my tubes while she was in there. Haha. I can’t even believe I want to do that again…
congrats – may everything go smoothly.
Thanks!
Can I ask why 39 weeks and not ” less than 37 completed weeks” ? If you are wanting not to trade a prem baby in the nursery for a stillbirth then a 38 weeker isn’t prem and most 37 plus weekers seem to manage nicely without need to go to NICU! So why the ban before 39 weeks?
Because neonatal morbidity is higher before 39 weeks. http://www2.cfpc.ca/local/user/files/%7B12DC1DBB-10B6-4998-9598-A5091C118AAA%7D/induction%20Am%20J.pdf
There is also some sign of longer term differences in babies born before 39 weeks, http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000289
with babies born before 39 weeks being more likely to need special education in elementary school.
Aha, I see I should have scrolled down before I asked my question above!
Could there be something confounding the likelihood, like a baby with complications necessitating an earlier delivery might be more likely to have problems stemming from the complications? I just glanced at the second link you posted, but didn’t see anything about accounting for necessary deliveries or elective early deliveries? Would that make a difference?
Thanks for that , I read this in the first linked article
“the “normalization of deviance,” a term used to describe an un- sound practice that continues because of anecdotally derived favorable experience” they use it in this article to say that most individual obstetricians would have observed as I have that babies born between 37 and 39 weeks seem to do well but that you really need quite large numbers such as this study used before you see that a higher proportion end up in the nursery.
I also think that using the “normalization of deviance” is a perfect counter to the “variation of normal” statement. Claiming that breech, twins VBACs etc are variations of normal is “normalization of deviance” ….new term….I like it!
I’m sure that there could be confounding factors, but this study said that this correlation held for both spontaneous and induced delivery, which might eliminate or minimize some of those factors. I’ve been told that the brain is growing rapidly in the last few weeks of pregnancy, but I don’t know how accurate that is.
I’ve struggled my way quickly through the second of these – but don’t know what to make of it. Could anyone who is better at the statistics amplify, at all? Can one imply that if the percentage of children born at 37-39 weeks who turn out to have SEN would NOT have had them if they had stayed in utero to 40?
It is late, and it has been a long day. – but I can’t see that that makes a lot of sense. Some of these children apparently were growth restricted, not a whole lot seems to be given about why they were born early. It looks like a good study – but what conclusions can be drawn, exactly?
OT, but I just read on a crunchy facebook page that parents should not wash their son’s intact penis. They claim that cleaning and “messing with it” in infancy is unnatural what causes infections later in life, not that you let years of awful gunk collect under the foreskin. I guess personal hygiene is unnatural.
Well you’re not supposed to retract the foreskin before it retracts on its own (I believe in late toddlerhood/preschool age) from my understanding. However, it would be weird not to wash that area at all…it can get fecal material/diaper cream/pee sitting on it for extended periods of time – it really needs to be cleaned. That’s disgusting.
Of course i fully admit I could be completely wrong because it’s not easy to get non-woo info on dealing with intact penises in babies/toddlers/children, sigh. But our pediatrician has never complained and she gives my son a thorough going over at every checkup.
Ok, lol, the non-woo on the intact penis (there are a lot of them in Canada– most people no longer circumcise here) is that you do not retract the foreskin and just rash the penis like you would a finger or any other body part. Not washing it at all is insane.
You can wash a penis, but you do NOT need to try and retract a physiologically adherent foreskin to clean under it.
Seriously, foreskins don’t retract for a long time, and you don’t need to wash under them until they do.
By all means wash, but don’t try to force a foreskin back.
It is perfectly fine if the foreskin doesn’t retract until puberty.
I stopped going to a pediatrician because he forcibly retracted my son’s foreskin. I about jumped out of my skin it was so awful looking. Now I just always ask for the younger, female pediatrician who does not do this to my son. At the time, I didn’t even know what he did was wrong, but it looked so awful I did some research on it. I had always just cleaned my son like I cleaned my daughter, the outside only. And he has always been fine.
In a similar practice outcomes but for high risk twins, planned earlier delivery has better outcomes. Decades ago twins would be allowed to goto near term before being induced/delivered. Now diamnio dichorio twins have better outcomes if delivered between 38-39 weeks with some studies saying maybe as early as 37-38 weeks. Diamnio Monochorio twins should be delivered sooner. If twins are allowed to go longer much worse outcomes happen. So much for these woo wanting to deliver their twins at home at 42 weeks, huh. Evidence base my a$$.
We do them at 37-38.
Even more interesting is the stuff I heard at a conference recently about mums over 40. The presenter was showing stillbirth data being much higher, and indicating that we should really be considering induction at 38-39 weeks with 42 being completely out of the question.
What are the risks of stillbirth in a woman over 40 who goes to 42 weeks?
I was a month away from turning 40 and my son was born at 41 weeks. This was sixteen years ago, and I realized at the time I dodged a bullet since he aspirated mec and my some of my placenta had to be manually removed. (painful but just a few seconds). Now that I read this blog, I’ve become even more convinced! So thankful my son was born in a hospital with a pediatrician summoned to be there for him immediately.
It was my last pregnancy and I was happy to keep enjoying that special feeling of my baby inside me. Reasoned that it just as many babies were born after the due date as before. We are grateful it turned out okay.
But still, what are the odds that someone turning 40 will have a baby that aspirates meconium? Is it really that commone?
This is totally OT, but if one has a couple of hospitals they want to look into to decide whether or not it’s a ‘good’ hospital to give birth at, what sorts of facts and stats do you look for, and where do you find them?
My first question would be what kind of backup is available there. Do they have a level 3 NICU? 24 hour in house anesthesia and OBs? MICU/SICUs with critical care attendings?
My first question would be to ask if everyone in the delivery room has had NRP training.
and their flu shot/TDAP
My first question was the same as TCAMN’s. I wanted 24hr in house OBs and Anesthesia and an adult ICU. I didn’t care as much about the NICU because if there is something wrong with the baby you generally know about it prior to labour based on a detailed anatomy scan and can transfer your care and delivery to a hosp with a level 3 NICU. In my humble experience, it is easier to stabilize and transport a baby that sustained an injury during birth than it is to stabilize and transport a mother who is septic, or after hemorrhagic shock.
With in house OB and anesthesia if there is badness, the baby can be out surgically within 5-10 minutes. With offsite OB and Anes you are looking at 20-30 min, best case scenario.
Otherwise you’ll have to figure out what else is important to you…rooming in? night nursery available? private rooms?
I personally wouldn’t put too much emphasis on published quality indicators…they might be non-risk adjusted and difficult to interpret. Instead I would look for a place that does some active QI – and you can ask the OB or CNM when you interview them what their quality monitoring and improvement program looks like, how adverse events are investigated etc. I would just want a place that takes it seriously and continually strives to be better. If they spout off about their program to lower the c/s rate…I would personally go to another hospital because I don’t care about the c/s rate as much as I care about the intrapartum death and disability rate. Cut me at the first sign of trouble was what I told my OB.
Thanks all the good suggestions TAM. My nephew’s life was most likely saved by a 5 minute section. My sister was at a community hospital where if she had needed the section at 3am it’s possible he’d be dead.
“In my humble experience, it is easier to stabilize and transport a baby that sustained an injury during birth”
In my humble experience too. Onsite neonatology/ peds (where I am all the peds are able to prepare a sick neonate for transfer including umbilical lines, resus, intubation, surf etc).
I agree with the other posts. I would want 24 hours in house OB and anesthesia and I would want an NICU. It depends on what sort of town or city you live in what your choices will be. Where I live it makes a pretty huge difference (IMO) where you deliver regarding the skill at neonatal resuscitation. People aren’t good at skills they rarely use, so having a NICU means usually that if there is a need for neonatal resuscitation the staff should be better at it. Where I live you would not have a choice to get some of this ( the in house OB and anesthesia) they are called in at night or on weekends. But I would pick the hospital with the NICU and Maternal Fetal Medicine over the hospital that bases it’s reputation more on being baby friendly and it’s comfort amenitities. You can ask too about the staffing for nurses if you are in a state that doesn’t have laws about staffing ratios. Also there are still hospitals without a C/S suite on the OB unit. That would matter to me a lot. Those things are the most important. After you have decided about safety ( if both are equal ) then look into creature comforts!
we are in a silly situation where i live because the hosp that has the level three NICU and MFM doesn’t have an adult blood bank or adult ICU. The other hosp in town that also has 24 hr OB and anesthesia has those things, but only a level 2 nicu. I think a level 2 nicu is good enough for term babies that have trouble at birth. If I had found myself in labour prior to 32 weeks I would have gone to the level 3 NICU hospital.
When you are a health care provider you have the privlege of making decisions based on better information than what other patients have….on the flipside you get treated weird by your colleagues when you are a patient.
I think the answers here are pretty interesting. Do most women really want a low resource setting to give birth in (ie home, birth center or community hospital with LDR?) or does more actual (not NCB) education about birth lead women to seek a higher resource center? The provincial govts here keep pushing home birth and are creating birth centers and making fussy noises about the c/s rate. Myself, and my friends, we want OB in house, easy and quick access to anesthesia and epidurals and pediatricians to resusc our newborns should it be required. We also want a NICU in house so that there is NO question of the baby going to another hospital and leaving us behind. Maybe the people here are self-selected to be very risk adverse or maybe not. What do you guys think?
Having seen maternal mortality, intrapartum mortality, late term FD etc and lots of transfers to the NICU and adult ICU, I find myself very wary of the entire birthing process.
I gave birth to my first two at a community hospital with low resources. I didn’t know any better really and just picked the hospital that was closest to me. Both kids had to be transferred to a place with a NICU. After having lightening strike twice I had my other two were born at big hospitals with NICUs even though with my last one I had to travel an hour each way for appointments. Neither needed the NICU but I was so glad it was there.
I had a choice of two.
One sent Dads home over night and had no night nursery, so if you wanted assistance with breastfeeding or anything over night you had to buzz for a nurse to come and help.
The other allowed Dads to stay if you were in a single room and also had a night nursery where they encouraged you to come and feed there in the night (especially if breastfeeding to get assistance) and would also let you leave the baby in the nursery to get a meal with your partner.
Both practiced rooming in.
I chose the second because it was closer and because I wanted better assistance over night with a new baby. Also the nurses seemed a lot less rushed and my obgyn preferred working with the midwives at that one.
Did something happen to the comments you are referring to. I only see my original OT comment and this reply. I know you’d had a much longer reply about what to look at and there was at least one other commenter with suggestions on how to make the choice when I last looked.
The reason I ask is I’ve been going through fertility treatment with an OB who isn’t my regular OB. We’ve got somethings worked out and are officially back to trying after two losses. In the mean time it’s occurred to me that if I ever get pregnant and stay pregnant (which now seems likely) I will have to go back to my old OB to go to the hospital I want, or go to the other hospital that my new doctor delivers at. Or … I guess find another new one would be an option. I also worry that since this new doctor will have done the ‘work’ to get me pregnant it seems wrong to not give him the ‘business’ of my prenatal care and delivery? I worry about going back to my old doctor and things being uncomfortable.
I think it is so intensley personal. I was always into ‘safe’; 13 years ago my research led me to beleive ‘safe’ was low/no interventions. Now, my definition of safe is as you describe; I drove an hour to my last hospital for visits and delivery becuase I wanted that level of resources available. Anesthesia, high level NICU, the works.
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I can’t remember who, but somebody posted recently about a friend with complete placenta previa who was being forced to wait til 39 weeks for a caesarean, which is against everything I’d ever heard of for previa management. The problem is not only the rule but fear of repercussions of not following it, which leads to insanely strict application of it.
39 week rule is for low risk patients.
That’s how it is intended, but that’s not how it is being implemented in many places. Even the study showing an increase in stillbirths with an implementation of this policy found that most of these happened in women who DID have a medical indication for an earlier induction.
It’s not uncommon for evidence-based guidelines to be misapplied (generally too simplistically) to bash clinicians. The guidelines should summarise the relevant current research findings and give advice based on those. The whole idea of having medical specialists is to be able to add a more sophisticated layer to the management – otherwise, why not just have technicians following guidelines?
The other thing that happens is that governance systems and regulators may try to “measure” their system by taking an indicator like “number of elective deliveries occurring before 39 weeks” and using that as a performance indicator rather than an audit filter. If the cases are audited and found to be appropriate management, then the total number is not the issue.
This happens with all sorts of things. For example, the drive to minimise the negative laparotomy rate has led to more abdominal CT scans – OK for the elderly, but not for kids or young people.
Just like homebirth is for strictly “low risk” mothers. Just like bullying women into breastfeeding in the hospital is “baby friendly”. Somehow that’s never the whole truth. Seems like drawing a really hard line this way is very unwise. I mean really, how often were people getting approved for an elective induction at 37 weeks? I find it almost impossible to believe the situation was common enough to warrant this change.
Very common actually. One doctor at my hospital did it quite often and babies were not uncommonly transferred to the university NICU. The 39 week rule, like many ACOG protocols, are just that, guidelines.
I really, really hope that most hospitals are maintaining some sort of happy medium, then. A lot of them certainly aren’t with the “baby-friendly hospital” thing, although I realize those two things are separate matters.
Unfortunately I have to echo Becky05- my most recent experience at a University Hospital was very stressful; I had several ‘soft’ indications for induction at 38 weeks and ran againt the wall of expectant managment. I ended up getting the induction but it took a lot of self advocacy on my part, and even Dr. Amy was kind enough to review my reasons for wanting an induction. In my scenario it should not have been an issue at all, but there was the 39 week policy. (I have a history of precipitous birth- from 4 hours at 37.5 weeks with #1, ‘silent’ dilation with #2- I was at 6cm at my 37.0 check, after they broke my water it was a couple of hours until birth, and again ‘silent’ dilation with #3- 7cm at my 38.0 week check, GBS+ so after my antibiotics they broke my water and had my baby 45 minutes later, and with #4 at 38 weeks I was sitting at 4cm with a low baby, again GBS+, knowing full well if labor started on its own I’d be hard pressed to make it to the hospital an hour away, and that there would be no chance of getting the antibiotics)
I wish doctors really felt their judgment on when to induce was enough, but I think it is easier and safer for them to ‘tow the party line’ in the current climate.
Your situation is not low risk. It justifies induction so antibiotics can be given and so that you deliver in the hospital. Precipitous deliveries are not low risk, even a risk factor for PPH.
This whole comment string reminded me of my friend who gave birth about four weeks after I did. Spontaneous delivery at 41w2d, 2 hours from first contraction to delivery, baby 10lbs4oz, with some respiratory problems and low blood sugar right after birth (my friend passed her GD screening, but I wonder if she didn’t have late onset GD). She was thrilled to have avoided an induction and epidural. Her husband’s first remark? “Next time we could do this at home!”
Respiratory problems and hypoglycemia at home. Next time may be GDM and SD.
Too right. I am not a doctor but why did I have to be that annoying patient who would not take ‘wait until 39 weeks’ for an answer. Why did I have to go through two attendings, a resident, and then they had to ‘pull some strings’ just to get the induction? Not appropriate care, I’d say, and I blame it on the 39 week rule.
My post sounds so mean. Sorry. It ended up being the most amazing experience- and I really do have a lot of respect for my doctors, I just found that particular aspect frustrating. Being induced was awe-some. First time I ever had the luxury of an epidural, my husband was actually present (we’re military and he’s missed 2 of 4), one of the nurses was so nice she came and attended the birth even though her shift was over… they let me give my baby his first bath- it was a bit of a crowd being a teaching university hospital, but, overall, my care was exemplary and I felt so safe. I did get ‘in trouble’ for being a breast mom who asked for a bottle; thank goodness I am more confident in my old age. I explained that since my baby was coombs+ and my last coombs+ baby spent a week in the NICU with scary jaundice that I wanted to get a jump on getting this one’s system moving until my milk came in… but got a lecture anyway… oh well. I still did what I wanted and gave him a bottle until my milk came in- luckily this time the jaundice was mild.
I have a history of precip deliveries, too, and have GBS. With my last baby, my 6th, I lived a 1/2 hour away from the hospital without traffic. Double that time with traffic. My last baby was optimally positioned for a quick delivery, unlike my last two posterior babies. So I was more than willing to get induced at 39 !/2 weeks as I considered myself to have some risk factors. I did get my antibiotics and was glad to do so. And it was a quick delivery with a surprise shoulder dystocia that got quickly resolved.
Can’t remember exactly how long my daughter’s first labour was – I think it was about 6 hours – very short for a first baby. GBS+ the second time round, she was completely paranoid about getting to the hospital in time for antibiotics, and was not pleased to be told that induction would not be considered before 42 weeks. (Neither of us had got to term in our other pregnancies 35, 37,35 was our previous experience.) As it happens, her waters broke pre-labour, and as she was leaking light meconium, she was admitted and got the antibiotics – though she did have to pester, her midwives were disdainful. (And I wasn’t that happy about their attitude to the mec, either. No signs of distress on the monitor thankfully, and everyone very blase.) Active labour again short, and preciptious at the end – 7cms to out in a very brief time, with rather more sensible midwife panicking.
That’s ridiculous and indefensible. Placenta previa is an indication for delivery at term, at the latest. Otherwise, it’s a gruesome accident waiting to happen.
(I delivered my daughter at 32w gestation, after a hemorrhage from placenta previa. A hemorrhage that happened at night, at home – pretty much the worst time and place. I hope she’s at least doing the waiting in a hospital.)
So, I have seen (online only) pregnant woo people saying they are so opposed to delivery before 39wk. They insist that any baby born before 39wk is premature (37/38wk). They seem to be very worked up over the potential problems of iatrogenic prematurity, but ignoring or unaware of stillbirth as a potential problem of waiting until at least 39w. The MDC type people seem to glorify going post-dates.
I don’t understand this mindset. Of course no one wants a micropreemie, but most preemies born 34w and later survive and do very well. I know I would rather have a living child, even with the risks of issues related to prematurity, than a dead baby.
I remember the story that was here a few months ago, about that poor woman whose labor at 36?wk was stopped/stalled on purpose and her baby died. That is horrifying. I hope that most OBs actually practice whatever is most beneficial for the patient and the baby.
Would an OB practicing in a hospital with a “no elective delivery before 39w” always be sure to find an acceptable medical reason to deliver a baby earlier if said OB wasn’t comfortable with the pregnancy continuing? And where is the line drawn with regard to “elective?” Off the top of my head, I can think of a few reasons why a baby should/could be delivered earlier than 39wk: Pre-e in Mom, GD-baby thought to be macrosomic, Baby not responding well during BBP/NST, placenta previa, some other condition where Mom is in danger if she stays pregnant, etc. Would all of those count as valid medical reasons? Or would most hospitals attempt to stall or deny those deliveries?
I doubt many women would ask for a delivery at 36w just for the hell of it. Certainly no one WANTS a preemie and no one would want to be delivered weeks before term for fun.
I would hope that at most hospitals Pre-E, GD, failed BPP/NST, placenta previa, etc. are clear indications for delivery before 39w. What seems to get the ire of most people online is the 38w induction because a growth ultrasound measured baby at 8lbs and the doctor is warning of a baby that’s too large to deliver or because mom is just tired of being pregnant.
Well, if she really is just tired of being pregnant, but she and the baby are both in perfect health, there isn’t a medical reason to deliver before 39w. But concerns about the baby’s size seems on the line, mostly I think, due to the fact that u/s late in pregnancy may not be super accurate wrt to predicting weight. I would err on the side of caution myself, but I can see how that could be considered “elective” vs. “medically necessary” by people who are violently opposed to babies being born a second before 39w.
They gave me weight estimates for my twins shortly before they were born—they had Twin A spot on, but Twin B was 0.5lb smaller than predicted.
What I see cited is the ACOG statement that suspected macrosomia is not an indication for induction before 39w.
And you’re right – ultrasounds are not always accurate at predicting weight. At 37w6d my son was estimated to weigh 8lbs 1oz. He was born at 39w3d and weighed 7lbs 14oz.
Oh thanks, I hadn’t read the ACOG statement. Ha! Nice that your son was smaller than predicted–probably easier on you!
Yeah my kid was 6 lbs3oz, but measured 7lbs on US. Not engaged in my pelvis at 38weeks.
My mother ended up with CS at 42w for me. I weighed 6lbs 5oz, and didn’t engage in her pelvis either, and she doesn’t have my dodgy cyborg pelvis and spine.
I opted for CS . Nobody can convince me I made the wrong choice.
I absolutely think macrosomia should be reason to opt for IOL or CS. It isn’t as if macrosomia is risk free.
Does anyone know if having a vaginal birth with a large baby makes you less likely to have issues with macrosomia in the future? Or is it impossible to predict?
If I had pushed out one large baby without too many serious problems I would be less anxious about doing it again – but as macrosomia is only one of the problems that might crop up, I wouldn’t be less anxious about THOSE.
Why is it that second babies tend to be bigger anyway?
I was told that a second CS was likely to be easier than the first, – and it was. That doesn’t make a whole lot of sense to me either.
In my head, the only thing you can be sure about in birth is that you can’t be sure of anything.
Thanks! I was just wondering if there were any evidence anywhere that I am more likely to have a crazy 13lb baby the next time, or if my next one would be likely to be similar in size to my son.
Well said. I think there are a few reasons why the second c section is easier. First of all, it makes a huge difference when you know what to expect and you’ve been there before. The ‘unknown’ has a way of making things harder on us. Also, a lot of women have their first c section after a long labor that’s not gone well. That makes for an exhausted patient having surgery. Elective c section for the second, skipping the labor makes for a faster, easier recovery.
My first never engaged either. Even after being in labour for 8 hours, even though my waters broke spontaneously at home about half way through that 8 hours. Baby was head down and well positioned so I’m not sure why she didn’t fit. She was average sized (50th percentile) but did have a large head circumference (90th percentile) so maybe that was it? I didn’t even bother with number two and went straight to c-section. His head circ was even bigger.
I am glad that I had my second son before this was put in place because my OB moved his csection date back a week (38 weeks) because of suspected macrosomia and he was 11 pounds. I was extremely tired of being pregnant at that point and very glad to be done with it.
My daughter was estimated at 4000g at 41 weeks. At 41 weeks, 2 days, she was 4765g at birth. The error can go both ways.
Ultrasounds are off in both directions! In as many cases that an actual weight is less than the ultrasound predicted weight, the actual weight can be HIGHER than the ultrasound predicted weight. Decisions are based on what evidence we have, 1) how big the mom feels compared to previous pregnancies, 2) how big or small you measure by fundal height or Leopolds, 3) the size predicted by ultrasound, 4) the difference between AC and HC by ultrasound, even 5) what was the biggest baby you have delivered so far or 6) have your mother or sisters delivered by CS or not. If you have delivered a previous nine pound kid and this one is the same or smaller, no problem. If you haven’t delivered a kid yet and the baby is measuring big and worse the AC is bigger than the HC, than consider alternatives.
You never hear anyone ask whether your mother or sister(s) delivered by csection. My mom had 2 easy vaginal births and my sister had 2 vaginal births. Then I went on to have 2 easy vaginal births. I have always wondered about the genetic side of how women give birth. Is a woman who comes from a history of csections in the family more likely to give birth by csection?
I don’t know about the c-section question, but I always remembered a quote I read from a fairly competent CNM, who said “A woman will labor more like her sisters than her mother.” I found that observation very intriguing, since it speaks loudly (albeit anecdotally) to the influence of genetics on birthing.
not sure this follows…
I don’t have any sisters but my pregnancies and labour were completely different from my mother’s. Her deliveries were a vaginal birth after SROM 3 weeks early and an emergency c/s after a 4 week hospital stay, also before due date. Both babies around 6 pounds. I’ve had 3 inductions, all past due date and size range from 7 pounds 12 to 9 pounds.
My mom was in labor for a while with me, and needed pit, but did give birth vaginally. Her labor with my sister (second child) was a lot easier and faster. I had a pretty fast, easy labor. My sister doesn’t have any kids, so no data points there. Then again, my 2 grandmothers, between them, had 4 babies born 3+ weeks early, and my mom didn’t go to her due date with either of us, so I figured I’d go early, but nope! Had her at 40w4d.
I was induced at 39.5w (unsuccessfully, and my OB was given crap for it) and then again at 40w for macrosomia. U/S estimates were 10lbs. He was 11lbs. So you are right, they are not always accurate.
Sometimes I wonder about the women who are ‘tired of being pregnant.’ I can’t help but think if there really is such thing as ‘being in tune with your health’ or having some sort of ‘intuition’, that maybe some percentage of those women actually do have trouble brewing that can’t be pin pointed by the tests we currently do. I’m not doctor, so maybe I’m just crazy and thinking with my feelings instead of my brain. But it seems possible to me.
I wonder if that’s not also an excuse when an OB feels that a pregnancy has gone on long enough but can’t quite justify the induction by the rules. S/he might say “maternal preference” in order to justify an induction that s/he thinks is likely medically necessary, but can’t explain the need adequately to an insurance company.
Also, isn’t the NCB movement all about instinct and “listening to your body”? Shouldn’t they be for maternal request induction and even c-section? Why isn’t that mother’s intuition about what’s needed?
Even though we’re not talking about late late term, the possibility of post dates is real if pregnancy is deliberately allowed to continue. I’ve never liked the look of post dates babies, they’ve often obviously lost weight as the placenta craps out (it’s not an infinitely magically growing organ, NCB dummies!), and they’re wrinkly, without subcutaneous fat, all leggy. I don’t understand why it’s better to let a baby struggle in utero and use up its fat stores, than to let it be born all lovely and chubby with plenty of reserve.
The NCBers never talk about what a post term baby looks like. I’d heard there are differences, but probably couldn’t explain them well myself. The nurses at my son’s delivery remarked that he looked older than a 39w3d baby, I think due to some dryish looking skin, which has made me wonder since if the chronic hypertension was beginning to affect the placenta, though amniotic fluid levels were still good.
Technical term ” craps out” ? LOL
my placenta crapped out with my 1st baby and he almost died…
My son was 5 days late, a hair under 10lbs and perfectly chubby and lovely; I was also 5 days late as a baby, just over 9lbs and pretty lovely, though not particularly chubby. 🙂
That said, I was scared as hell every day after 40 weeks, and would absolutely not have gone past 41. (had a scheduled induction for 41wks on the dot, but didn’t make it, fortunately!)
They argue that studies show that induction for suspected macrosomia doesn’t improve outcomes. Technically true, but the studies are quite small. http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000938/abstract?systemMessage=Wiley+Online+Library+will+be+disrupted+on+23+February+from+10%3A00-12%3A00+BST+%2805%3A00-07%3A00+EDT%29+for+essential+maintenance&userIsAuthenticated=false&deniedAccessCustomisedMessage=
I’ll take ultrasound over fundal height any day of the week, and twice on Sundays — particularly if the tech is very good at what he/she does. My primary RM estimated via Leopold’s and fundal height that my daughter would be between 6 and 7 lbs, and closer to 7. Ultrasound tech said 9.2 lbs, the very same day. My RMs used the ultrasound results as leverage to get me to induce (I was 41+4, narrow pelvis, first time mother) and I’m glad they did. She was born the next day at 8.8 lbs.
But you have to be careful with the ultrasounds too. I had what felt like a million ultrasounds during my pregnancy, and by 34 weeks the tech was estimating my daughter as a potential 10 lb baby. At 38w6 she was estimated at 9.5 lbs. My OB was confident she would be in the 7-8 lb range. I was induced due to PIH at 39w3 and after 26 hours of labor and god knows how many bags of IV fluids she was born at 8 lbs 4oz with an off the charts head so large she’d gotten stuck in my birth canal (seriously, it took 30 minutes for her to come out during the c-section. She was really wedged in there). The head was what was throwing off the measurements and making her look so large on the ultrasounds; my ob was spot on in her estimates.
As I recall, it seemed like the OB in baby Jacob’s story had taken the hospital’s policy and ran a little too far with it; that their policy of not electively delivering before 39 weeks meant that he was required to stop a naturally occuring labor at 36 weeks.
At my 36 week appointment, I was told, “You’re 36 weeks now, so if you go into labor, we won’t try to stop it, so don’t call unless your water breaks or contractions are 5 minutes apart.” I immediately remembered Jacob’s story and was relieved that my practitioner’s office wouldn’t put my full-term baby at risk.
Yes, I had pre term labor issues, and was in the hospital from 30w-34w. I was still pregnant, but they sent me home because after 34w (in my situation)they wouldn’t try to stop labor. The babies held out to 36w which was good and I’m glad my OB wouldn’t have dreamed of attempting to stop labor at that point.
My daughter was born at 38 weeks (no problems, that’s just when I went into labor). She was born perfectly healthy. I was induced on my due date with my second because I didn’t want to go past 40 weeks. My OB said nothing good is gained by going past your due date, and it’s pretty obvious from many of the sad stories I’ve read here and online that she was right. I didn’t necessarily want to be induced since I wasn’t the first time, but I really wasn’t comfortable going past 40 weeks. And the induction wasn’t bad at all. I knew I’d probably get another epidural, and I did. So much fuss is made over being induced, epidurals, etc. I just don’t get it. I have 2 healthy, happy kids. How they got here just doesn’t matter to me.
Has to do with likelihood of success of an elective non-medical reason induction. An old 1985 study by Arulkumaran ( didn’t use cervical ripeners) showed primips with a low Bishops score unripe cervix had as high as a 45% failed induction rate which would lead to a cesarean.
Bishop Primip Multip.
0-3 45% 7.7%
4-6. 10% 3.9%
7-10 1.4% 0.9%
One modest way of decreasing the cesarean rate now is to prevent elective inductions of low risk primips with unripe cervixes. Antenatal testing once or twice weekly with NST/BPP/Dopplers can allow some patients 1-2 weeks of close follow up in hopes that the cervix becomes more ripe with delivery by 41 weeks. Low risk primiparous patients who have a closed or 1 cm open cervix should be given informed consent of a higher failed induction rate with cs risk versus the slight higher increased stillborn rate. Now remember, the failed induction rate is much much higher than the stillborn rate, I know the stillborn risk is much more grave, but the absolute risk is small. Letting a woman continue the pregnancy from 39 weeks to 40 or 41 weeks is doable. Past 41 weeks is of more concern. And once you have delivered successfully vaginally, inducing at 39 weeks, even with a less favorable cervix is an option since the failed induction risk is smaller.
That is pretty much exactly what my doctor said … only in much more simple terms that I could understand. She basically said, since I had an easy vaginal birth with the first baby, it would probably be no problem to induce with the second baby. And she was completely correct. Induced at 6 a.m., baby out by 1:30 p.m. She even said the risk of CS with an induction with your first baby was much higher.
39 week rule is to prevent elective inductions in low risk patients, not to stop active labor in patients after 35 weeks.
I think the problem is that it began as a guideline and then some insurance companies started wanting it to be policy. Any time you get insurance companies involved in medical decisions it is trouble.
LOL! Then I had two “preemies,” 38w3d and 37w1d respectively. Both robustly healthy. What is the cutoff for “late pre-term” versus “full term,” anyway? I thought anything after 37 weeks was kosher…
There is an official list of reasons the Joint Commission considers acceptable, table 11.07. It covers a very broad range of possible issues.
https://manual.jointcommission.org/releases/TJC2013A/AppendixATJC.html#Table_Number_11_07_Conditions_Po
I have had growing anxiety about this and will have to talk to my ob about it at my apt on Monday. At my first appt my ob asked if my kids had been premature, I said they were full term at 37 and 38 weeks, and he corrected me that 39 weeks is full term. My second labor was augmented with pit after contractions started getting wonky. I’m really worried he wouldn’t admit me/augment if I went into labor at 36-38 weeks, and could have a tragedy if labor goes wonky. On the other hand I think the baby will come early whether I like it or not. Due in July in a climate where it is 110 everyday. I feel doomed to dehydration based preterm labor.
I went into labor with my first in 2008 and I was 38 weeks. No one made a big deal out of the fact that she was 2 weeks early, and everyone called her full term. I was induced with #2 at 40 weeks, but I am nervous when I have another one. I would be very upset if anyone tried to stop labor after 37-38 weeks. My daughter was perfectly healthy at 38 weeks. And if the estimated due date can be off 2 weeks in either direction, who’s to say 38 weeks isn’t full term for that particular baby?
Let’s see – risk of 1 -2 weeks “prematurity” vs risk of stillbirth….any sort of balance here?
post dates are dangerous. I went 4 weeks overdue with my fist child, my GP was taking care of me and honestly I dont think he cared, he was Pissed off because I was a teenaged mother (16) My son was born via emergency C/S at 43-44 weeks, He was covered with Meconium and had respiratory problems, he was sent to the NICU. This was in 1979. He is now grown, health etc. However He is unable to father children.
Why is he unable to father children?
Mostly it has to do with the idea that the baby is not finished developing until they hit full term or when spontaneous birth happens. If you are overdue, it’s because either something isn’t finished yet or the dd was wrong. Which I can see as a real concern since most, not all, babies who are born before 39weeks have to spend time in the NICU and could have some other condition from being born too early.
My issue is that we don’t know the true fetal age, despite our technology. Ultrasounds might be accurate, but we know they are not 100% accurate and yet some rely on them so heavily to be. It’s all an estimate. Yet, my son was one of the rare who was born on his estimated due date. No one believed me when I told them that while being admitted. My daughter came a week early.
I understand the fear of still borns, but I guess it’s hard for me to put myself in the shoes of a mother who doesn’t pay attention to whether or not the baby moved today. I was very aware and sometimes actively poking my belly to get the baby to move to make sure they were alive.
I would hope that the hospitals would do what is necessary in medical emergency situations and hopefully this ban doesn’t stop the life saving procedures and only the desires of an impatient mother.
Is it accurate that “most” babies born after 37, but before 39, weeks have to stay in NICU? (Saying “most babies born before 39 weeks” must do so presumably counts heaps of quite premature babies, for whom a NICU stay is a foregone conclusion: that’s not the population being discussed in this post.) And, if it is, what is the clinical significance of this beyond that stay?
Most babies are not expected to have a stay in the NICU from 37 weeks on. Ours were, thankfully, fine; two in the 37th week and the other 2 at 38.0. In fact, I had my #2 at (an accredited) birth center and that did not risk her out for delivery there. Our son did have scary jaundice and an NICU stay, but that was due to a blood reaction (he was coombs +) Also, (@Gooddaysunshine) I think with early ultrasounds that dating a gestation these days is pretty accurate.
” If you are overdue, it’s because either something isn’t finished yet”
How, then, GDS, do you explain the over-mature baby who arrives with a degenerate placenta, thick dry skin and long fingernails?
Or one that’s dead.
Really. By the time I hit term, my baby’s head wouldn’t fit into my pelvis.
And how dare you insinuate that stillbirths can be prevented by paying attention to if the baby moves?
Tell that to my sister, who’s first was stillborn at over 41 weeks.
Just hope my BIL doesn’t go half-cocked on your ass.
Pretty bloody insulting. Tell me, what do you think my nephew wasn’t “finished” with yet that he wasn’t born at 40 weeks? Besides dying, that is.
I’m sorry that your family had to suffer through a stillbirth.
Oh, come on, GDS, you don’t seriously think that mothers of stillborns are in this position because they weren’t paying attention? That your “awareness” somehow protected you? I pay plenty of attention to my baby’s movements, I poke my belly if she’s a bit quiet and I want to get her moving, but kick counts are meant to alert you and your caregivers to potential trouble, they aren’t bloody preventative.
You really, really need to start thinking before you speak, since you don’t seem to be able to post without saying something highly offensive or completely untrue. I just hope that you’re not very good at expressing yourself effectively, since the implication that stillbirths are the fault of a “mother who doesn’t pay attention” is just unbelievably offensive to those of us who have suffered through infant loss and miscarriage, even though we’ve done all we could and should do to ensure our baby’s health.
Good Grief. Talk about taking something way more seriously than it was meant. I was stating that I, just me, was very aware of my babies movements. I didn’t stand and point saying “Your baby died because you failed to count kicks.” But then again, tone cannot be placed in type, so of course everyone is taking me the wrong way.
In what way did you intend the comment to be read? I took it seriously, since it seemed to be a fairly obvious statement that you equated stillborns with mothers who didn’t pay attention to fetal movement. As I said, that statement is unbelievably offensive, whether seriously made or not and I’m going to have a strong emotive response, and say so, since I’ve got a looooooong history of miscarriage and a couple of close family members and friends who have had stillborns.
If you were airing a passing random thought, that you can’t understand why mothers wouldn’t pay any attention to fetal movement, fine, no-one’s going to argue with that, but the way you said it came across very, very differently, in content, not just tone and my response was to the content.
Mine wasn’t an estimate–I planned my pregnancy and tracked my ovulation. I know the exact day of conception.
Then you are one of the few. I have tracked my cycle, but could never pinpoint my ovulation because it was never at the same time.
There are simple urine tests to track ovulation – much like pregnancy tests.
Let me put you in their shoes: You go to sleep, wake up and notice less movement, go to the doctor immediately, and find no heartbeat. Your much loved baby has been dead for four hours. And because… what? This woman just didn’t have your special type of good-Mommy self-knowledge to know to wake up in the middle of the night?
“I was very aware and sometimes actively poking my belly to get the baby to move to make sure they were alive.”
You and virtually every pregnant woman. Were you doing this while you were asleep, too?
How dare you lay the blame for such an event on someone who has done everything right and more? You think you’re so different from the millions of women who have experienced this that you would magically wake up in the middle of the night?
People like you seem to revel in a false sense of control over their lives that makes them think that they’re actually better people, morally, than those who are so unfortunate as to experience one of the very worst things that can happen to anyone. Keep it up, if it makes you happy and comfortable. But I am personally repulsed by your smugness, your sanctimony, and your sweeping generalizations on complex topics of which you obviously know very little.
The drive away from patient centred care to guideline centred care is maddening! Unfortunately, at this point in time it seems to be gaining steam particularly as ACO’s are formed and performance is measured and paid for….of course if you measure the wrong things, well it is quite possible that an undesirable trade off (in this case short term morbidity for mortality)….
Guidelines should be just that…guidelines. Not policy, not universally implemented protocols, just guidelines to help direct care. There are always exceptions to the rules and trying to make a guideline that fits every patient is simply not going to work. In the end, the individual patient’s needs must be considered carefully and, of course, come first.
This is such a good point, and it pervades across the spectrum of women’s issues, of course. And in some cases, it’s not guideline centered care so much as it is legislature sanctioned care—the state of SC just banned elective delivery before 39 weeks for babies whose mothers are on Medicaid.
Someday legislators will figure out that they aren’t doctors.
Wow. That’s insulting…
IMHO all performance measures that are based on guidelnes need to have opt-outs to account for patient preference. In this regard I agree with the ACC/AHA so I’m in good company.
Agreed – as I said elsewhere, there is confusion between audit filters and performance indicators.
Great analysis, thank you for the article. Way to make some noise. I fully support your efforts to have this issue looked at in a sensible way. I am grateful for the studies you mentioned and hope that this issue will continue to be studied and addressed by the obstetric community.