5-1-1, 4-1-1, 3-1-1....Could be a secret code, but most pregnant women towards the end of their pregnancies know exactly what those numbers mean. Contractions every 5 (4, 3) minutes, one minute long, for at least one hour.
TIME TO HEAD TO THE HOSPITAL. (Or, call the midwife, even drive to the birth center.)
Birth partners are prepared for the big day by downloading the best contraction timing app. As soon as the first contraction hits, they excitedly pull out the iPad, or smartphone, and......wait for the next one.
"TELL ME WHEN YOU FEEL ANOTHER ONE!"
"DID IT START YET?"
"Oh no, I forgot to hit the button..."
"How long are they SUPPOSED to be?"
..........and so on.
You might have an idea where I'm going with this. In, "Your Hormones Are Your Helpers", Sarah Buckley draws a comparison between the labor of a cat and that of her human companion. While the human mother packs a bag and anxiously waits for contractions, the cat searches for a comfortable, peaceful, often dark, place to have her babies. Usually she does not have her babies until she is undisturbed, sometimes frustrating the would-be "helpers". In fact, the cat knows how to give birth instinctively with the hormonal processes that she is designed with.
AND SO DO HUMAN MOTHERS. But first a little bit of background information...
Many women learn in childbirth education classes or from friends that oxytocin is the "love hormone", at least partially responsible for beginning the birth process and helping contractions to progressively dilate the cervix and help to move the baby down. They may also be told that Pitocin is exactly the same as oxytocin. It is chemically the same, however oxytocin is produced by the mother's body, along with other hormones in an amazing feedback system between the baby and the mother. In contrast, pitocin is pumped into the mother at a constant and steady pace, with no possible feedback based on how the baby is doing, or how the mother is feeling. This is a VERY IMPORTANT difference.
Especially in early labor, the body's production of oxytocin is a delicate operation that can easily be reduced or even halted by adrenaline. Known as the "fight-or-flight" hormone, adrenaline basically works in opposition to oxytocin, although levels DO increase during the second stage of labor, during pushing. This is why waiting until labor is very well-established can help to keep labor from stalling once you actually leave your home if you are planning on giving birth somewhere else.
SO.....Why ditch the contraction timer?
Because before transition and pushing, a mother desiring a birth with minimal interventions should focus on minimizing the feelings of being "watched", on a clock, meeting a deadline, or having to be on someone else's schedule, to optimize production of oxytocin.
Have you ever had a paper to turn in, or a work assignment due in just a few hours, and you KNOW that it will be completed, but you just don't know HOW by the deadline? Maybe you start sweating, feel shaky, nervous, your mouth feels dry, and you feel "flighty". Maybe if you could just forget about the whole thing it would just go away.
That's adrenaline. And labor doesn't work well under those circumstances. It's not designed to. Although the contraction timer might seem like a fun way to "track" labor progress, it might do more harm that good. Focusing on making sure the contraction timer is being stopped and started and tracked just perfectly....it brings the focus to the mechanical and not the physiological processes of labor. After all, the most "effective" labor contraction is ONE THAT IS WORKING to make the birth process progress.
It does not HAVE to be LONG.
It does not HAVE to be PAINFUL.
It does not HAVE to be VERY FREQUENT.
It might be all of those things, but then again, maybe not! There are NO RULES in labor, because we are all unique.
For instance, in my own first labor I was having contractions every 6 minutes, but with a very mild one in between. My books assured me that I was still in early labor, especially since I had only been having them for a few hours. A few minutes later my contractions were 2 minutes apart, and 1.5 hours later, after some pushing, a lot of belligerent refusals to get in the car, and barely making it to the hospital, my daughter was born!
However, it's also possible to be having strong, frequent contractions, and for labor to be progressing slowly. This is okay! Often in this circumstance women will have to focus quite a bit during contractions, but will not have on their "serious face". Once transition gets close, a woman's facial expression will usually change to one of intense concentration and focus. She also may become more opinionated and "bossy". This is a great sign!
LOOK FOR THE SERIOUS FACE, not the clock face.
Suggestions for laboring women:
Suggestions for birth partners:
As usual, I'm not a medical provider. If you really want to time contractions, go for it! But remember that timing is less important than how you feel! The mother is the only one who can express how she is feeling during labor. Mothers, listen to your intuition, and your baby. Partners, listen to the mother!
Did you have an "unusual" contraction pattern during your labor?
"The Birth Centre of Charlottesville."
"Charlottesville HAS A BIRTH CENTER?!"
YES!!! I would like to say that the birth center run by Janna Grapperhaus, CPM, is the best-kept secret in Charlottesville, but I DON'T WANT it to be a secret!
I would love for every woman in Charlottesville to know that there is an option for giving birth that is safe and beautiful, and is staffed with well-qualified midwives and assistants who really care about each mother and baby. So here are the top 4 reasons why I LOVE the Birth Centre of Charlottesville.
'What? What is she talking about? Pregnant women should never ever drink alcohol!' (I might be exaggerating a bit there).
No, I'm not talking about alcohol. Who is going to get that into a hospital? I'm talking about water.
'Water?! Oh, water is great. Did you know that if you feel thirsty, you're already dehydrated, and pregnant women ESPECIALLY need to be drinking at least 100 ounces of water a day! And labor is just like a marathon, so keep your water and laboraid close and make sure that you're getting plenty of fluids!!'
Here's the thing though. EVERYTHING in life is about moderation. For some reason, this doesn't seem to apply to water. As I've written about before, this is likely due to misinformation and exaggeration, first on the part of bottled water companies, and then picked up and disseminated by the health industry. Statements like "drink 8, 8 ounce glasses of water a day", or, "drink one half of your body weight in ounces of water a day" may seem harmless even if they aren't based on science, but are they? Can this type of advice be particularly dangerous for pregnant and laboring women? Yes, there is evidence that it can be.
Our cells require a certain balance of nutrients and salts. What happens in hyponatraemia (overhydration/low sodium levels) is that the extracellular fluid becomes too diluted with water and rushes into the body's cells, which causes them to swell and triggers the sympathetic nervous system, or a stress response. That is of course a very simple version; the actual mechanism is way more complicated and also involves the interplay of potassium, calcium, and other minerals in the cells and cell membranes. However along with the stress response comes many symptoms which probably many of us who have taken the mainstream advice on water consumption have experienced:
….sound familiar? Yeah, I thought so. Yet many pregnant women who complain of any of these symptoms during pregnancy will be told…what?
"You're probably dehydrated, drink MORE WATER".
So it's a dangerous cycle. The authors of the study below note that "The maximum capacity of excreting a water load at rest is reported to be approximately 900 ml per hour in healthy women but is reduced by one-third in late pregnancy". So pregnant women are not able to get rid of extra fluid as quickly as a non-pregnant woman, which makes overhydration even more likely. They also note that "no physiologic warning system protects the body against overhydration". (See opening quote for a slightly different perspective on that). This means that once a person starts to become overhydrated, they can no longer trust what their body is telling them, because excessive thirst may not mean that the body needs fluid, but rather, salt. So avoiding that state is important!
Instead, here is what I tell pregnant women (and everyone, really). Drink when you're thirsty, and not a lot more than that. Animals and children know how to do this. Why do we, as adults, think that someone else has to tell us how much to drink to be sufficiently hydrated? And you don't even have to only drink water. There are many nutritious, tasty beverages that contain lots of water, but also minerals, salts, natural sugars, and probiotics. Some that you might consider are grass-fed whole milk, kombucha, water kefir, herbals teas, and even broth (homemade!).
Why This is Especially Important for the Laboring Mother
It's only been recently that hospitals have been "allowing" women to eat and drink during labor. Of course this is a basic human right, and a long time coming. However, it can also be a risk, because there are many women (especially those that are health conscious, who may already starting out labor slightly overhydrated) who have been told that labor is like a marathon, and that staying hydrated is vital to a healthy labor and baby. While part of this is true, and hydration is important, the truth is that labor is NOT like a marathon. Or rather, women's bodies in labor are not acting at all like the body of a marathon runner, or even someone exercising. A simple, crucial fact is missing.
Oxytocin, the "hormone of labor, love hormone", encourages the body to RETAIN water. So a woman that is drinking constantly throughout labor, especially a longer labor, may be in danger of drinking herself and her baby right into hyponatraemia. How can I say that? Not only have I heard of several instances from doulas where a client had a difficult, long labor and ended up with a cesarian birth, but there was enough awareness of it in the medical community to do several studies on it. The most recent is quite compelling.
In, Hyponatremia Complicating Labor: Uncommon or Unrecognized? The authors note that a high total fluid volume (2500 mL or approximately 85 ounces, by mouth and intravenously) taken in by a laboring woman was significantly correlated with overhydration, a longer second stage of labor, and other complications during the birth. Honestly you should really read the whole paper; it's not too long and really fascinating. But here are some key points:
Who are most at risk?
A woman who desires a natural birth and who is giving birth at home or a birth center should be encouraged to drink if she feels like it. Since the body retains more fluid during labor, she likely will need less fluids than normal. If she voluntarily is drinking more than 8 ounces of fluid an hour over the course of several hours, this could be worrisome and she might be encouraged to back off on the fluids. It's been noted before that the symptoms of overhydration often mimic dehydration, so keeping track of fluid intake can be very important.
I did some research on how much fluid a woman laboring in the hospital might be given if she requires an induction, antibiotics for Group B Strep, or an epidural. It's likely that if an IV of fluids is hooked up, the laboring mother will receive at least 1000 mL total, at 125 mL per hour (4.2 ounces) or sometimes even 250 mL (8.45 ounces) per hour. These women are likely most at risk, especially if they are also taking in oral fluids. Women who are continuously receiving IV fluids should be very careful with how much they add to that by drinking, and birth partners and doulas probably shouldn't be encouraging the mother to drink extra fluids. Remember, 26% of women who received more than 2500 mL (about 84 ounces), developed hyponatraemia, so it wasn't a rare occurrence by any means.
What is the Bottom Line?
Basically, all humans have the ability to tell when they're thirsty and when they need to drink. Sometimes we get so used to people telling us what to do, that we forget how to listen to our bodies, but pregnancy is a wonderful time to start really tuning in and trusting your body and instincts.
Despite the common advice to drink at least 64 ounces of water a day, and even more during pregnancy, there is no scientific proof to back this up. Each person is different and has varied fluid intake needs. During labor, a woman should be able to drink when she's thirsty, and not encouraged to keep hydrating unless there is clear indication of dehydration. However, thirst can't always be trusted as a sign of this, since excessive thirst is also a sign of being overhydrated. If a mother is receiving IV fluids AND oral hydration, especially over the course of a long labor, the care providers (or family and friends) should be especially careful to make a note of the total fluid volume, since these women are most at risk of overhydration.
To Be Continued....Implications for Baby
What do you think? Is overhydration more common or less common than the evidence suggests?
My Mom used to tell me about how she craved jello when she was pregnant with my sister and I (twins). In fact, she craved it so much that she would wait until my Dad went to work, then make a package the "quick-set" way, and then eat the whole thing herself. I could tell that this seemed really strange to her...almost like she was guilty about it! But the more I started learning about the nutritional needs of pregnant women, the more I understood how WISE her body was!
Building babies takes a LOT of nutrients, including proteins and fats (she was building two!) Personally, I craved eggs during my first pregnancy, which isn't surprising now considering that I ate a mostly vegetarian diet. My body knew that I needed more protein than I was getting, and it told me so. Now that I know more about how helpful probiotics are for a healthy immune system and pregnancy, I'm sharing a recipe that has quality protein and probiotics in a tasty package.
Water Kefir Jello
I've made this one with apple cinnamon flavored water kefir, but you can use any flavor. Water kefir is a mild, broad-spectrum probiotic beverage that can be flavored in myriads of ways. Probiotics help to populate and balance the microbiome, which strengthens the immune system of mother and baby. For directions on how to make water kefir, see here.
You will Need:
That's All! Simple and protein-packed. My kids love this also. Some individuals don't like the taste of the gelatin, so you might substitute some of the water kefir for a stronger organic juice. Just play around with it, and enjoy!
In Part One of this (admittedly rather short) saga, I found myself in a position that I hadn't expected as a doula, and it was leading to quite a few conflicting emotions. Most who know me in real life probably know how I strongly dislike hypocrisy...yet here I was, attempting to self-induce labor for a reason which many may not even feel is particularly valid (short answer...mainly financial).
Many midwives and doulas feel that negative emotions or doubts surrounding birth can hinder the birth process, and since I had experienced two pretty fast and uncomplicated births, I was also concerned that I was setting myself up for a more difficult labor by inducing labor, not to mention during the day. Both of my other labors had started at night, and I just felt that was when I was "supposed" to be in labor.
Back to the induction...
Still, when my mom arrived with the castor oil and root beer, I promised her that I would take it at 11:00 am, 41 weeks and 4 days pregnant. Before then, I called my midwife to get some final directions on preparation. She was so sure that this would work, she said that she was going to take a nap to make sure that she would be well-rested for that night! I still had my doubts.
At 11:00, I took 1 tablespoon of castor oil, mixed it with some vanilla ice cream, poured in some root beer, mixed it again, and then added more root beer. (If you're looking for more exact measurements, you won't find them here. This is just the way I prepare everything. It drives my husband crazy). At this point, I didn't even bother with all natural, organic root beer. I'm already compromising my ideals, so why bother? *insert sad ironic laughter*
It actually wasn't that bad. And so we waited. At 2:00 pm I took another dose, which is pretty common from what I've read, especially with the low-dose castor oil induction. I tried to go about my day as normally as possible, but the frustration was slightly setting in.
NOTHING WAS HAPPENING. And I do mean nothing. No extra bathroom trips, no nausea, contractions....nada.
At 4:45 I sent my midwife a text message lamenting the fact that nothing was happening and I really had hoped that I wouldn't have to make dinner. Selfish, I know. But then....
I felt the familiar, although mild, sensation of a contraction. In my three births they have always started out the same way and just gotten progressively stronger. Really low, tightening sensation, pretty much like a menstrual cramp. 6 minutes later, I had another one. BINGO! Since my previous births were fast, I went ahead and told my midwife, and she said that she would meet us at the birth center at 6:15.
I was pretty happy that SOMETHING was changing, but I still felt really strange. This wasn't supposed to be how my labor started. I had imagined waking up in the middle of the night or early morning with contractions. The daylight was throwing me off, the crazy children were jumping on the couch, the sun was still streaming through the windows. Not surprisingly, my contractions nearly stopped in the hour before we got to the birth center.
As we arrived, I honestly felt silly that we were even there. I wasn't feeling much of anything other than some really spaced-out, weak contractions. But, my midwife didn't seem concerned. My husband encouraged me to think of the whole experience as a night at the spa..which was actually a really great idea. He prayed with me, the kids went to play with Thomas the Train (and Friends, of course), and I was left in the "birth cave" room with the diffuser, a birth ball, my chosen music, and, OBVIOUSLY, twinkle lights.
10 MINUTES LATER (around 6:30) I walk into the kitchen at the birth center. "Okay, I want to get in the tub now". The tub has a curtain; how amazing is that?! Contractions were 2-3 minutes apart, at least a minute long. Not too bad, though. (I took a LOT of RRL tea and ate pounds of dates throughout my pregnancy.)
Time gets really fuzzy after this, but about 15 minutes in my husband left to get food. Maybe 30 minutes later I mentioned to my midwife that she might want to send him a message and tell him to come back. I wasn't feeling pushy yet, but I could tell that each contraction was getting me closer to that point. The midwife was sitting quietly in the corner, and we were both pretending like she wasn't there. I started to get that desperate, "I need to get this over with" feeling, AKA, transition.
My husband walked in, and I started pushing. Pushing is just a crazy, disconcerting feeling to me. I would love to be like those women that I've seen with the calm, controlled demeanor while squeezing a (not so) tiny human out of their bodies, but that isn't me. I guess it never will be. Like my two others labors, my water broke right as I started pushing. A few minutes later, at 7:34 PM, Corbin was born, all 8.5 pounds of him. He was almost 1.5 pounds bigger than his younger brother, and I believed it.
So much for my spa experience; we were at the birth center a total of 3 hours! (Even with delayed clamping, skin-to-skin, immediate breastfeeding and being pooped on three times...)
The only way that the castor oil changed my experience of labor was by making it happen a bit earlier than it would have. I didn't have any negative side effects, and my labor, which was about 1 hour from regular contractions, felt basically the same as my others, just faster. As much as I would have liked to go into labor on my own with this baby, I would likely make the same decision again if in similar circumstances.
I wonder if the low dose makes taking castor oil less likely to produce a negative laxative effect, or if perhaps what the castor oil is taken with makes a difference. Most of the recipes that I have seen or heard of used 2-4 ounces of castor oil, often with juice. Not only was I only using one tablespoon at a time, but I took it with ice cream. Downing several ounces of straight fat with orange juice sounds like a recipe for vomiting to me, induction or not.
Conventional wisdom, and even published medical papers like this one, say that castor oil works because it stimulates smooth muscles in the intestines (producing a laxative effect) and the uterus (causing contractions). Or, as the scientists put it: "Thus, the castor oil metabolite ricinoleic acid activates intestinal and uterine smooth-muscle cells via EP3 prostanoid receptors." But, if that is truly what induces labor, how can contractions start but no intestinal effects? I don't know the answer; I'm just thinking out loud. But it seems to me that it should be studied MORE. There are actually not that many human studies on labor induction with castor oil that I could find. WHY NOT? What are the possible side effects of castor oil induction, vs the alternatives?
Castor oil- May cause nausea, vomiting, or diarrhea (Yet, my midwife swears that almost no one gets sick when they stick to the root beer float recipe.) Maybe dehydration.
Pitocin, Cytotec, Cervadil- May cause uterine hyperstimulation, fetal distress, or hemorrhage.
Again, I am not actually a fan of inducing labor. I really do feel that babies generally know when they should be born, and that if they are happy in the uterus, then it's likely a safe place for them to be. But...we don't live in a perfect world, and sometimes we, as mothers, have to make tough choices. At least I wanted to share my choice and experience. Even when we do have to make those choices, it's best to know ALL of your options, and choose the risks that you are most comfortable accepting.
What do you think, would you use castor oil over a medical induction?
I have a confession to make. And an apology. First things first.
I induced labor with my third baby. I am a birth doula who has been pretty (mostly silently) judgemental of women who have done the same thing.
I'm sorry for my negativity, even if I never vocalized my disagreement. I did probably say things like this:
"Your baby will come when it's ready!"
"If you're not in labor, your baby/body isn't supposed to be in labor!"
"Babies don't have calendars!"
"Get a new provider if they won't let you go past 40/41/42 weeks!"
Basically, all of those "don't worry your pretty little head about that" kind of comments. And you know, I still believe all of those statements. I might even use them again, depending on the circumstances. But....I also have a little more empathy for women who feel like it's necessary to get the ball rolling, so to speak. Because I became that woman. It was distressing, to say the least. I felt like I was betraying my conviction that babies KNOW when to be born as long as everyone was healthy (which we were). But.....
I DON'T REGRET MY DECISION. Let me explain. No, let me sum up. (Please someone get that reference)..
I knew going into the home stretch of my third pregnancy that I would likely go past my EDD. My second was born at 41 weeks, and I just felt like this one would be the same or longer. I was right! At my 41 week appointment my care provider commented that it was apparent that I and the baby were doing well and healthy, and she was perfectly happy if I wanted to keep waiting, but that I needed to schedule a biophysical profile for 42 weeks in the event that I got that far. I was content to comply with this request (and find it a very reasonable one), however I realized rather quickly that the out-of-pocket expense is very high for this test. Like, really really high.
She gave me another option, one which she only mentions (unless there is a clear medical indication) to mothers who are past 41 weeks. She said that I could take a root beer float with a small amount of castor oil in it.
Castor oil! No way! I had basically heard two versions of castor oil inductions. These probably sound familiar to you also.
Scenario #1- Nausea, vomiting, diarrhea, but you have a baby.
Scenario #2- Nausea, vomiting, diarrhea, and no baby.
Hmm...I think I'll take NEITHER. Also, it just felt wrong. I needed to give us more time. I couldn't betray my convictions that easily. However, I was assured that this method would NOT make me sick. I would just start having contractions or not. I wasn't sure if that was possible, but I trust my care provider, so I kept it on the back burner as an option. I felt like this baby was bigger than my last two, but that didn't scare me.
Each morning, I woke up still pregnant. No labor. Actually, no signs even of impending labor. I knew I'd have to schedule the test by Friday to get in, so Thursday morning, at 41 weeks and 4 days, still conflicted and feeling like a complete doula hypocrite, I called my mom.
"Pick up the castor oil and some root beer. I've got the ice cream."
....to be continued.
Many women are aware that babies can be vertex (head-down), or breech (head-up), but few understand that even if the baby's head is down, this doesn't guarantee that the baby is in an optimal position for birth. Labor will generally speaking be shorter and "easier" if the baby is in an ANTERIOR position. This means that the back of the baby's head is facing away from mom's back. It's possible for you as the mother to observe your baby's position as the baby grows bigger and movements can be clearly felt. Feel free to contact me if you would like some simple tips on how to identify what position your baby is in.
If you suspect that your baby is in a POSTERIOR position, you can choose to do exercises that may help baby to turn into a more optimal position, or you might try chiropractic care to help balance the mother's body and therefore the baby's position. Nothing is guaranteed to help turn the baby, but if you do go into labor with a baby in the posterior position, you will at least know that labor may very well be longer than "average" and even perhaps more intense. Once baby turns, though, it will likely progress quickly!
Information is power! Here are a few things to know about posterior labors:
Disclaimer: I am not a medical professional. I encourage everyone to read, examine the evidence, use their own mind, examine what their intuition is telling them, and find a care provider that they can trust before making medical decisions for themselves or their babies.
First of all, I think it's worthwhile to evaluate some medical and obstetrical practices that SEEMED to make sense when they were devised, but, in retrospect, and sometimes after several years or even decades of practice, have been thoroughly debunked as downright useless, or, even worse, harmful to numerous mothers and babies. There are many, so I'm just going to pick on one for a minute.
How about routine episiotomy? An episiotomy is when the doctor or midwife, during the second stage of labor (pushing), makes a small cut to the perineum to make more space for the baby. As recently as 1979, episiotomies were performed on 62.5% of women in the US, and 80% of women having their first baby. It's not too difficult to see the "logic" in helping make the vaginal opening a little bit bigger, faster. Proponents felt that it reduced trauma to the baby, helped the baby to be born faster, and reduced the chance of severe maternal tearing.
But does it? Surely, a surgical procedure which scarred millions of women must have SOME backing in "science"? Actually...not really. Until 1921 episiotomies were almost always only performed on women with severe health issues to speed up the birth of their babies. Then an OB wrote an opinion piece on how wonderful it was for women to have episiotomies cut and their babies pulled out with forceps....ALL women. He thought it was easier to stitch up and made birth less stressful for babies. By 1938, a survey of obstetricians found that most supported the routine cutting of women's bodies during labor, and that it was beneficial and needed "no defense". Decades later, it's now fairly common knowledge among midwives and obstetricians that episiotomy almost never "helps" the baby unless there is truly an emergency situation where the baby must be born quickly (often with vacuum or forceps). Otherwise, the mother often tears worse during an episiotomy and needs MORE stitches or a more extensive repair than if she had torn naturally. (Here is an extensive review of the evidence against episiotomy). In my area, the episiotomy rate, even with obstetricians, is between 5 and 10%, a far cry from just a few decades ago.
But it took close to 80 years for episiotomy to start to fall out of favor, despite the initial lack of evidence, and then subsequent evidence against it. Directed "purple" pushing, supine pushing, continuous fetal monitoring, denying women food and drink during labor....these are just a few more interventions that are common to birth in the developed world that seemed like a good idea, yet the evidence has shown that these practices may be necessary for a small minority of women, but are generally not helpful and often cause significant of collateral damage to a majority of mothers.
That was a really long-winded way of saying, 'Hey, let's take a step back and think critically about ALL interventions...even if they SEEM like they might be based on "common sense". I believe that the management of intrauterine growth restriction (IUGR) is a perfect example of this, and for whatever reason, it seems to be coming up more and more lately.
As a doula I love to help women to do their own research. However, I often feel frustrated when discussing IUGR with clients or even other doulas, because I hear this SO often:
"If the baby isn't growing, it's better off out than in!" There almost is the feeling that it's okay to question all of these other interventions, but NOT a diagnosis of IUGR, because surely the doctor must know what is best at that point.
Now....I understand the thought process behind that, and indeed, often women who are carrying babies who are suspected to have IUGR are either induced early (some even as early as 36-37 weeks), or their babies are delivered by cesarean. It's truly BELIEVED that these babies are in imminent danger and will be better off in the capable hands of the medical staff. BUT....is that evidence-based? How is IUGR diagnosed? What babies are truly at risk? Does early induction improve outcomes, or is watchful waiting a reasonable choice? What are risk factors for a false diagnosis of a growth-restricted baby?
Let me also be clear that this article is mainly addressing "late onset IUGR", which is usually diagnosed in a third-trimester ultrasound right around or after 36 weeks gestation. Early onset IUGR has a much higher mortality rate and babies who are diagnosed before 28-30 weeks, using the same criteria that will be discussed, have a much higher risk of stillbirth. (I've seen numbers from 2.5% to 14% in various studies, and the majority are born preterm). Most researchers note that they wish there was more information available on how to help these babies, but unfortunately the data is not conclusive.
How is IUGR traditionally diagnosed?
Approximately 5-8% of women will have a baby diagnosed with IUGR, but this percentage is higher and lower in distinct populations. Some fetal abnormalities, like congenital heart defects, trisomy genetic disorders, multiple gestation (twins or more) pregnancies, or pregnancy complications such as pre-eclampsia and diabetes increase the risk of growth restriction for the baby. Smoking may also be a risk factor. The classical diagnosis involves a fundal height (for the mother) behind by 4cm, an ultrasound weight estimation below the 10th percentile, and abdominal circumference that falls below the 2.5th percentile. However, these criteria have been recently questioned. The tricky part is identifying babies who are "constitutionally small" from those that are truly growth restricted.
This study examined babies who were suspected to be SGA (small for gestational age) and compared outcomes to those that were not suspected, but had weight below the 10th percentile. Babies in the suspected group were born much sooner due to elective induction or cesarean, and had lower birthweight than those in the non-suspected group. Admissions to the NICU past 7 days were about the same in both groups. So basically, if care providers thought that the babies weren't growing, they delivered them sooner, performed more surgery, but babies that were left alone gained more weight and didn't die at a higher rate. Which group would you rather be in if you were the baby? This, and other research, calls into question the wisdom of automatically delivering babies who are suspected to be small just because it seems like they would be better off "outside".
What have recent studies suggested are risk factors for true IUGR and adverse outcomes, including death?
Weight below the 3rd percentile (NOT 10th)
Poor umbilical artery results
Amniotic fluid volume (via ultrasound estimation) less than 5cm.
Combinations of these factors seem to be most concerning. In one study of over 1,000 babies, all of the deaths (8) occurred in babies who had weight below the 3rd percentile. Abnormal umbilical artery doppler was also strongly associated with admission to the NICU and other adverse outcomes, likely because this can be a symptom of poor placental function.
The authors of this study note, "Our data call into question the current definitions of IUGR used. Future studies may address whether using stricter IUGR cutoffs comparing various definitions and management strategies has implications on resource allocation and pregnancy outcome."
What is the evidence for management of a pregnancy where baby is suspected to have IUGR after 36 weeks?
Actual management is quite varied, and often doesn't rely on the most recent evidence. Several surveys of physicians have found wide variation in the diagnosis and management of IUGR pregnancies. In this survey, the ONLY question that all of the obstetricians agreed on was that none of them informed mothers of the reoccurrence rate of IUGR in subsequent pregnancies!
One of the largest studies yet published in 2010 compared 650 women with a pregnancy suspected to be complicated by IUGR at 36 weeks or above and randomly assigned them to induction or watchful waiting, with increased surveillance of their babies. The results were surprising! The induction group was delivered an average of 10 days earlier and, not surprisingly, these babies averaged about 4.6 ounces lighter than babies in the watchful waiting group. No babies were stillborn in either group, and the cesarean rate was about the same (14 and 13.7%, respectively). The authors summarized their findings this way-
"In women with suspected intrauterine growth restriction at term, we found no important differences in adverse outcomes between induction of labour and expectant monitoring. Patients who are keen on non-intervention can safely choose expectant management with intensive maternal and fetal monitoring..."
Watchful waiting generally includes weekly or bi-weekly non-stress tests or bio-physical profiles for the baby. Since induction increases risks of fetal distress and cesarean, particularly in first-time mothers, watchful waiting seems to be no more risky for babies than induction. Another analysis of this study found that NICU admissions were lower after 38 weeks, and concluded that delaying induction until at least that point was likely to decrease NICU stays and the associated risks to babies.
Is elective cesarean recommended for suspected IUGR at term?
No, unless there is clear evidence of fetal distress in the form of abnormal doppler artery flow and low amniotic fluid. In this study, elective cesarean birth significantly affected morbidity (injury or adverse outcomes) for mothers, but did not significantly improve outcomes for babies. "After 36 weeks of gestation, IUGR due to suspected placental insufficiency can be managed equally effectively by early delivery or delayed delivery with increased fetal surveillance." (Practice bulletin from SCOG). Elective cesarean delivery is not recommended by ACOG or SCOG.
What are risk factors for a false diagnosis of IUGR?
Researchers examined the records of women who had been suspected of carrying a baby with IUGR, but the diagnosis was not confirmed at birth. They found a few common denominators. In the majority (over 60%), the fundal height was normal. Nearly 30% had been subjected to 2-6 ultrasounds before 32 weeks of pregnancy. Also importantly, over 50% of babies had at least one ultrasound measurement over the 10th percentile. They summed up their findings in this way: "The false diagnosis of IUGR involves high hospital costs and higher demand for specialists. The symphysis-fundal height measurement must be valued, and the diagnosis of IUGR must be confirmed with ultrasonography in the last weeks of pregnancy before any obstetric management is taken."
I would add that the cost is not only to the hospital and care providers, but also to parents and babies. Instead of the last few weeks being a time to treasure and keep as a safe space for the baby, parents with babies who are given a diagnosis of IUGR, false or not, often spend those last weeks with their baby stressed, anxious, and worried. They may also have to bear a heavier financial burden by the end of the process. Parents and babies deserve evidence-based care, NOT fear-based.
Here is what I would wish to convey, in a nutshell.
Medical and obstetric history is filled with practices that seemed helpful, but actually are either not supported by evidence or have even been proven to be downright dangerous.
It's difficult to identify before birth babies that are simply small versus growth-restricted. Babies who are small for gestational age do not have the increased risk of stillbirth, NICU admissions, and breathing difficulties that IUGR babies do.
The most current evidence suggests that diagnosis of IUGR is most accurate when taking into consideration multiple parameters: Estimated fetal weight below 3rd percentile, abnormal umbilical artery doppler, and low amniotic fluid levels. Fundal height may also be a consideration.
Current management of pregnancies suspected to be complicated by IUGR is extremely varied and often fear-based, yet recent evidence suggests that in the majority of cases after 36 weeks, watchful waiting is just as reasonable as induction, and may result in babies who weigh more at birth.
Parents deserve to be partners in evidence-based care, and to be informed of all risks. Inductions and cesareans come with their own set of potential complications, and these need to be weighed with the risks of early delivery of the baby. It's also reasonable to ask for a second opinion!
Have you ever had a baby diagnosed with IUGR before or after birth? What options were presented to you? I'd love to hear from you!
As the birth of mystery baby number three grows more imminent, I find myself reflecting on the arrival of my first child. First of all, I feel that I must make a confession.
I never planned to have children. I was never a "baby person". I never, ever asked women about their birth stories, and not once had I held a newborn in my arms. I had never imagined myself with children, or picked out names. One of my friends had asked me what I would do if I became pregnant, and I said, "I would cry". Yeah. Sorry future children!
Yet...I was about to have a baby. And so I did what I always had. I researched. And read birth stories, and midwife blogs, and medical studies. And, of course, Ina May Gaskin. I needed to know the truth about what was possible with birth. Partly I was spurred on by a real problem with needles...no one wants to pass out during labor! That can't be good for the baby.
As I approached my estimated due date, I felt quite positive and confident about what birth would be like. Let me make it clear that I had NO idea what my pain tolerance would be like...in fact I still consider myself to be a bit of a wimp in that regard. My primary activity for the first 20 years of my life was reading books, and although I had been exercising for the previous 5 years, I had never broken a bone or really hurt myself seriously in any way. So this whole idea of labor should have been a bit worrying.
But, it just wasn't. My mantra to myself was, "birth is going to be awesome". I didn't even really contemplate complication, although I think this is more of a personality thing. I tend to live in the moment, which can be advantageous, but sometimes works against me. I also made the choice to decline all cervical checks at the end of my pregnancy, so I was blissfully unaware of what was "going on" with my cervix. (Having made a different decision the second time, I can honestly say that I feel strongly that NOT knowing is the way to go).
In any case, I felt like my baby was going to be "late", so when January 21 arrived, I wasn't concerned. I felt normal and actually pretty great for 40 weeks pregnant! I went to work, to the gym, and then we ordered Chinese food, watched some TV, and went to bed. Here's what happened next.
Claire's Birth Story as It happened in My Head
11:30 PM: Hmm....what is that crampy feeling? It just felt like menstrual cramps, but definitely different than anything else I had felt. 10 minutes go by...and another one. Maybe I should time these. So for about and hour I notice that they are coming 10 minutes apart. I KNOW, I KNOW....everyone says to try to sleep through those early contractions...but especially when it's your first, how can you? I started to get excited, so I get up, go into the living room, and get out my birth books to see what they say.
12:30 am: Bummer. According to my books....I'm not really in labor. But who can sleep? I guess I shouldn't call anyone, because it's really late, and this is probably going to last a while. First-time mother and all that. I'll just sit here on my couch with the books.
1:30 am: Wow maybe that Chinese food wasn't the best idea....it's going right through me! Back to the bathroom I guess. Good thing it's not in the bedroom; I wouldn't want to wake my husband up. Looks like contractions are getting a bit closer now, though. 8 minutes apart. But they just aren't that BAD. I'll just let everyone sleep and keep reading my books.
2:45 am: Still 7 minutes apart...maybe I'll take a shower to be close to the toilet. I LOVE hot water.
3:15 am: Running out of hot water...I'll just lay in the tub for a while and call my friend/doula who has had three unmedicated births. Maybe she will have something to tell me. "Hi! So, I think I might be in labor. I'm just hanging out in my tub. Chad? Oh, he's asleep. Contractions are about 6 minutes apart, but not that bad. There's one. Oh it's over. My parents? I haven't called them....I don't want to wake them up if it's nothing. Oh you think I should call my parents and wake up Chad? Okay....talk to you soon."
3:30 am: "Mom, I think I'm in labor. Yep, but it's not that bad. I guess you can start coming this way, though. See you soon! (They live about 1.5 hours away).
3:40 am: I'll just get up and wake up my husband. Let me get out of the tub. OH CRAP. What on earth just happened?! (Maybe my water broke). Okay now it's a lot more intense. Contractions were just 6 minutes apart...now what is happening?! Stumble into the bedroom and tell my husband that I'm in labor, then head back to the tub ASAP. Ask my husband to time contractions. 2 minutes apart. THIS IS NOT NORMAL. WHAT IS HAPPENING?
4:00 am: (Husband calls the OB office, but gets the answering machine. He then calls my friend/doula back who tells him to get me in the car and she'll meet us at the hospital.)
4:30 am: Wow these are really intense. I think I'll get on the toilet again. OMG is that a head?! Don't tell him, don't tell him. NO I CAN'T GET IN THE CAR. Why? I just can't get in the car. Getting back in the tub. I understand why women get epidurals now....
4:45 am: Oh there's my brother. Great, I'm in my sleepshirt, no shoes, and there's my brother. You two are going to carry me out to the car? Okay fine. Not pushing, not pushing.
5:00 am: Okay there's my friend and there's the hospital. We made it. NO YOU DO NOT NEED TO WEIGH ME. "I'm pushing!" " I don't want to push on my back". I'll just close my eyes now. Nurse to doctor- "Hurry doctor!"
5:05 am: Ugh I'm on my back anyway, oh well. This all seems really fast. What tray is the doctor moving over here? Oh HECK NO it has scissors. "NO CUTTING!" Oh good he moved it back. No I'm not moving my hands; yes, I'd like to catch my baby.
5:20 am: Claire is born. She's so beautiful! What JUST HAPPENED?!
Looked at my friend and said, "I have to do that again".
After 6 months of planning, my daughter's birth lasted a whopping 5 hours or so and I missed most of it. I had a newborn in my arms for the first time ever. It was pretty incredible but also anti-climactic. I still had no shoes, and left about 36 hours after she was born, still shoeless. I learned a lot about birth from Claire's unexpectedly fast arrival, though. I'll write more about that next time.
Rest assured, I do love my children and I feel like they have made me a better person. Less selfish and self-absorbed. Children change you for the better if you let them. I never imagined myself a mother, or a doula, but now I am both! My personality of 6 years ago probably wouldn't recognize me now! 26 months later our son was born, but that's a story for another day.
I look at birth from the perspective that our bodies are wonderfully made, and if we really believe that and work with the birth process and nourish our bodies properly, they will function optimally, most of the time!