Monday, December 26, 2011
Early tired signs - not colic...
http://breastfeedingqueries.wordpress.com/2011/12/15/gone-with-the-wind/
Saturday, May 7, 2011
Bishop's Score - Induction
http://www.birth.com.au/Induced-labour/Readiness-for-labour-ripe-cervix-Bishop-point-system?p=1
Friday, April 29, 2011
Great "Nuchal Cord" post about how normal they are (1 in 3)
http://midwifethinking.com/2010/07/29/nuchal-cords/
Wednesday, April 27, 2011
Friday, March 25, 2011
GD Link
http://www.ivillage.com/gestational-diabetes-common-sense-approach/6-a-129188?p=1
A great link regarding GD.
A great link regarding GD.
Tuesday, February 15, 2011
Jaundice and Breastfeeding in Full Term Healthy Babies
ORIGINAL POST CAN BE FOUND HERE:
https://sites.google.com/site/problemysdojcenim/jaundice---article-in-english
Jaundice and breastfeeding
Jaundice is a result of many changes that occur in the baby’s body due to the adaptation to the extrauterine life. The main reason is that many red blood cells become abundant and are broken down releasing bilirubin which causes yellowish discoloration of the skin.
Is jaundice a disease or a health problem? Is jaundiced baby in danger? When is it reasonable to intervene and decrease the levels of bilirubin by treatment?
Standard progress of newborn jaundice differs by the food the baby gets
Breastfed babies
Majority of healthy, exclusively breastfed babies who gain weight well has elevated bilirubin levels reaching its maximum in the first week of life and gradually lowering, and lingering in minor degree up to the third month of life or longer.
We like to say that breastfeeding is natural and the breastmilk is considered to be the most suitable food for an infant. If this is really true we should also accept that if majority of breastfed babies are jaundiced, often up to the third month of life, this condition is not a disease, it is normal, even beneficial for the health of the baby. Many studies show that elevated bilirubin levels are important for the newborn as the bilirubin is a powerful antioxidant.
Breastmilk helps the baby to keep the elevated levels of bilirubin which is physiological (natural, normal). That doesn’t mean that breastfeeding and breastmilk make jaundice worse.
Formula fed babies
Majority of healthy term newborns who are partially of fully formula fed are not jaundiced, at least not so much as the breastfed babies. If we believe that the norm is breastfeeding, jaundice in the majority of breastfed babies should not be considered a disease, what should be considered a problem is the absence of newborn jaundice in the formula fed babies. The antioxidative properties of bilirubin help the organism to get rid of free radicals that arise in the body. Formula fed baby has lower levels of bilirubin when compared to the baby receiving natural food (breastmilk). Therefore this phenomenon can be regarded as one of many undesirable side effects of feeding an infant with formula in the period when every baby should not receive anything except breastmilk.
Another issue is that breastfed baby isn’t effectively breastfed just because he is takes the breast. Babies can just pretend to breastfeed and in fact just nibble on the breast most of the time they spend there and drink not enough breastmilk. Unfortunately, this is common in most of the newborns. The cause is not the fact that mother has no milk after birth - a common myth about breastfeeding since almost all mothers produce breastmilk since the 16th week of pregnancy and at the time of birth there is enough colostrum in their breasts. The real cause is that we interfere with the natural start of breastfeeding so much that the baby’s ability to latch correctly is weakened and the baby can’t get enough milk. These babies can have and often have unusually high bilirubin levels which is one of the symptoms of the fact that the baby actually drinks borderline amounts of breastmilk. This is the most common cause of serious newborn jaundice due to which majority of newborns undergoes therapy. Treatment of this problem should not include lowering bilirubin levels but rather fixing the breastfeeding with an experienced lactation consultant.
Even more appropriate approach would be to prevent this problem from happening – by natural birth without unnecessary routine and preventive interventions, by placing the baby on mother’s abdomen skin to skin right after the birth allowing the baby to crawl to the breast all by himself and to breastfeed as long as he wishes, breastfeeding on demand without any routine separation of the mother and baby afterwards and not using any artificial nipples (bottle, pacifier of nipple shields). By preparation for breastfeeding we can help the baby to have a normal, physiological newborn jaundice beneficial for his health.
Does bilirubin really damage baby’s brain?
Not likely. This hypothesis was never tested and proved. On the contrary, there are some proofs that indicate that this assumption is not correct. It is not important to be fixed on the bilirubin levels, what seems to be important is how and why does the bilirubin get to baby’s brain. It is proved that bilirubin can not cross the barrier between blood and brain no matter how high the levels are when this barrier is intact – which it is as long as the baby is healthy. When the health of a baby is compromised by some serious factors, the blood-brain barrier can become impaired and some compounds (also bilirubin) from the blood can enter the brain of this baby. It is likely that the damage of brain cells is caused by some toxic chemicals that cross blood-brain barrier and afterwards bilirubin deposits in the brain cells that are already dead. Which means that bilirubin probably works just as a colourful marker of the fact that the brain cells were previously damaged by some serious health problems. If this theory is truly correct than jaundice never is a problem and should never be treated, and rising levels of bilirubin are just an indicator of the fact that the baby has some health problems which should be treated. However this is just a theory and it probably never will be proved as it is not ethical to test this hypothesis on babies. Therefore therapy is indicated for preventive means when the bilirubin levels exceed the level of 342 µmol/l in healthy and term newborn.
The fear of jaundice comes from the past
Many health professionals still remember terrible complications linked with a massive breakdown of red blood cells that often happened in the past when Rh negative mother had Rh positive child (Rh incompatibility). Rh incompatibility was linked with elevated bilirubin levels and many serious health problems of the baby that caused lifelong health disability (including brain damage) or even death. In the countries with a good health care system this problem almost vanished 30 years ago and currently threatens only a very small percentage of infants. Baby can be endangered if the antenatal care is neglected, if mother’s pregnancy is not observed early and the Rh negative mothers are not monitored. At present, Rh incompatibility can be prevented which is one of the biggest triumphs of medicine.
However, elevated bilirubin levels still do occur as a symptom of some other diseases, just like fever rises when one has flu. Fever (precisely as bilirubin) helps the organism to better cope with the disease. The look on jaundice however remained twisted - the symptom is regarded a cause of the problems.
Another reason why it is common to consider normal newborn jaundice a disease is the fact that the formula fed baby who usually doesn’t display jaundice is considered a norm, a model. Majority of breastfed babies has higher bilirubin levels than the formula fed babies. Instead of considering breastfeeding a norm, many breastfed babies undergo risky therapy in an effort to decrease the amount of bilirubin to the level which is normal in the formula fed babies.
Majority of babies undergoes therapy unnecessarily
Treatment of jaundice is associated with longer hospital stays for mother and child, increased medical and hospital costs, disruption to the early relationship between mother and baby, compromised breastfeeding, and a great deal of anxiety all around. If the approach to jaundice abides by the current scientific knowledge, only a small percentage of newborns will be treated.
Most of the hospitals treat jaundice because of the fear that bilirubin could damage baby’s brain, if the levels of bilirubin are too high. However, the hypothesis about bilirubin being harmful was never tested and there is not a single proof for the accuracy of this theory in scientific studies.
Actually, there is a growing number of evidence that bilirubin is an important antioxidant which has been demonstrated to scavenge potentially toxic free radicals from the body just like vitamin C or E do. With elevated levels of bilirubin the organism of a newborn (and an adult as well) can cope better with some diseases or with stress.
In spite of this, jaundice is feared about as if the elevated bilirubin levels were truly harmful for the health of the baby. Scientific studies however proved clearly that if the newborn is term and healthy bilirubin levels up to 342 µmol/l will not damage brain or the health of the baby.
Safety of the bilirubin levels rising above 342 µmol/l were not studied by any controlled scientific studies. There are only case studies about babies whose bilirubin levels higher exceeded 342 µmol/l even up to 855 µmol/l. If the babies were healthy and term all of them survived these extreme high bilirubin levels without any health problems (in short-term or long-term consequences).
Jaundice experts Jeffrey Maisels and Tom Newman elaborated a review considering all the data available on this topic and they found out that as long as the infant is healthy and term, the fear of bilirubin, no matter how high it rises, is not supported by any evidence. Maisels and Newman recommend changing the traditional approach to jaundice treatment since according to their review there is no proof about the efficiency of the treatment and the treatment is not without risks. They recommend that a healthy and term infant should not be examined for jaundice routinely. Only when there is a suspicion that the baby has abnormal bilirubin levels, check up is in place and the treatment is recommended only in case that the bilirubin levels exceed 342 µmol/l and are still rising. The aim of the treatment of otherwise healthy and term newborn should be to keep bilirubin below 500-400 µmol/l.
According to the available data, bilirubin levels close to 342 µmol/l is observed in 0.5-1 % of the babies. However, treatment of jaundice is recommended when the bilirubin levels are lower than 342 µmol/l in large number of infants. What benefits should provide these interventions when it is clearly proved that bilirubin levels up to 342 µmol/l are not harmful for the brain of a healthy baby is not clear.
Therapy of jaundice
Don’t stop breastfeeding because of jaundice!
Some interventions should never be used for jaundice treatment – no matter how high the bilirubin levels are, whether the children are healthy or ill, term or preterm. This includes all interventions for which breastfeeding is stopped and the baby is given formula, boiled breastmilk or any other food instead of breastmilk. Efficiency as well as safety of these methods were not proved by scientific studies. What’s more, these interventions can seriously jeopardize the success of breastfeeding making them potentially harmful for the health of the baby.
Almost always are these interventions recommended for the babies of which bilirubin levels do not reach the 342 µmol/l. However, safety of these levels of bilirubin for healthy and term newborn is proved babies just like the risks of unsuccessful breastfeeding and feeding newborn with formula to baby’s health. Therefore, the risks of using these methods without any doubt outweigh their positive effects – there are none.
These methods are misused due to incorrect interpretation of the fact why they actually decrease the levels of bilirubin
These methods started to be recommended when some studies were published which stated that elevated bilirubin levels are seen more often in breastfed babies and that the decrease of bilirubin levels occurred faster when the babies were temporarily fed formula by bottle. This led to incorrect conclusion that breastfeeding makes jaundice worse. The reality however is completely different:
Abnormal bilirubin levels for which therapy is considered occur most commonly when the baby gets not enough milk by breastfeeding – when the baby mostly nibbles on the breast without sufficient milk intake.
How can it happen that the baby gets not enough milk by breastfeeding?
Many mothers think that breastfeeding as a natural source of food for their babies is successful all by itself, that they just put the baby to the breast and that’s it. This notion is basically correct so long as the birth and the start of breastfeeding are not influenced by routine and preventive interventions that can weaken the baby’s ability to latch on well. Too many babies have difficulties with breastfeeding after the baby is not given a chance to crawl to his mother’s breast and latch on by himself. Rooming-in for 24 hours a day is also not available in many hospitals and artificial nipples (pacifier, bottle or nipple shields) are misused without considering how badly it affects breastfeeding.
Baby is not born with the ability to breastfeed. Baby only has a sucking reflex. For successful breastfeeding from day one after birth a correct latch is necessary and these negative interventions weaken the ability of the baby to latch on well. The baby is willing to take the breast but sucks just the nipple and he gets only borderline amounts of colostrum. It can hardly be said that this baby is breastfed. More proper would be to say that the baby is nothing-fed. Baby soon becomes hungry, dehydrated and exhausted and thereupon extremely sleepy.
Mothers try to do their best to wake the baby up and when they do, baby takes the breast, nibbles few times and falls asleep again. The only way to wake up a sleepy newborn is the flow of milk and when the baby is not latched on well, he will not get enough colostrum especially in the first few days when the mother’s milk supply is not abundant (there is enough colostrum in the breasts, but the only way to get it in the first three or four days is a correct latch). Poor milk intake becomes evident when the baby still passes black stool (meconium) on the 4th day after birth. If breastfeeding was not fixed by that time, this issue becomes emergency at this point. Problems with breastfeeding can be fixed but the mother has to get a good help from lactation consultant who can show her the difference between good drinking and nibbling, who can help her by better positioning of both baby and the mother (preferably in a cross-cradle hold) and better asymmetric latch to increase the milk intake. Lactation consultant should also be able to show the mother how the baby can get even more breastmilk by compressing the breast when the baby no longer drinks on his own and how to supplement the baby at the breast when necessary.
How can the inefficient milk intake be related with the elevated bilrubin levels?
If the baby does not get enough colostrum in the first days of life, his body is not able to get rid of bilirubin that has already been processed by liver and is meant to be excreted by stool. It is quite common that the baby still passes meconium on day four or five when breastfeeding is not efficient. Bilirubin is excreted to gut but the guts are not emptied properly. Bilirubin is reabsorbed to the blood stream again thereby increasing the levels of bilirubin.
The elevated bilirubin levels are just a symptom of a more serious problem – that the baby is actually starving and not getting enough colostrum. This is where supplementing with anything (boiled breastmilk, formula or even mouse milk) can help and truly decrease the bilirubin levels because most mothers would supplement their babies with a bottle. And the baby who did not get enough colostrum from the breast eventually starts to feed, because finally he starts to get his food from the bottle.
Mother who plans to breastfeed however has another possibility how to solve this problem. Bottle can be an answer to treat the symptom - elevated bilirubin levels, but it doesn’t fix inefficient breastfeeding – the real cause of this situation.
Therefore the only legitimate intervention for jaundice when the baby is healthy and term is to check the breastfeeding and fix potential problems with the lactation consultant.
Only when breastfeeding is okay and the bilirubin levels are above 342 µmol/l and are still rising, it is reasonable to decrease the bilirubin levels since the safety of bilirubin levels that exceeded 342 µmol/l is not sufficiently proved by scientific studies.
The most suitable intervention in this case is phototherapy. If it does not work fast enough, medicamentous treatment or the exchange transfusion are other possibilities.
Phototherapy
Baby’s skin is exposed to a special light that breaks down bilirubin and helps to get rid of it faster. If phototherapy is used for healthy and term newborn whose bilirubin levels are under 342 µmol/l (which according to statistics is true for 99 % of healthy and term newborns), the benefits of this treatment are none since these levels of bilirubin are not dangerous. Phototherapy however brings some risks.
According to current trends in jaundice treatment, phototherapy in healthy and term newborn should be used in order to decrease the levels of bilirubin below 500 – 400 µmol/l. This is approach is probably the least dangerous for jaundice treatment. It should be used when the levels of bilirubin exceed 342 µmol/l, do not decrease after improving the milk intake and still rise.
When it is really necessary to use phototherapy, mother has to get a qualified help with breastfeeding. Often the baby is treated in a special room separated from mother. Breastfeeding on demand is therefore hindered. In addition, baby treated with phototherapy sometimes requires more fluids, which means that efficient breastfeeding with sufficient milk intake is absolutely necessary. Sometimes even with the abundant milk intake, the baby can get dehydrated and needs some extra fluids. If supplementing is not to jeopardize the success of breastfeeding it is essential to avoid using a bottle. Mother can learn how to use a little tube (the so-called lactation aid) that is put into the baby’s mouth and the baby sucks this extra fluid when breastfeeding.
Medicamentous treatment
The baby is given drugs that degrade bilirubin. Most frequently, phenobarbital and black coal are used. Their usage (especially phenobarbital) should be considered thoroughly. Levels of bilirubin that do not exceed 342 µmol/l are proved to be safe for healthy and term newborn, the medicamentous treatment however brings some undesirable side effects.
Many jaundice experts warn against phenobarbital for jaundice treatment since there are serious doubts whether this is a safe drug. Its usage is linked with many serious side effects – sedation, increase of the risk of haemorrhagic disease and it is potentially addictive. It influences the synthesis of some hormones and the hormonal homeostasis heavily.
The black coal brings risks by the fact that it is mostly given in a powder form mixed with water by bottle. In some babies even one bottle can jeopardize breastfeeding seriously. If it is really necessary to give this drug to a baby, the least dangerous way is to give it to the baby by cup or a small tube placed on mother’s finger (finger feeding) or with a syringe or spoon.
Some babies are also given substances that should protect the liver (hepatoprotectives) because of an incorrect assumption that newborns’ liver is immature and it is extremely loaded by bilirubin. These substances are really not necessary for any jaundiced baby.
Exchange transfusion
This intervention brings some really serious risks and it is used rarely. It should only be used in a situation when the bilirubin levels are really high (much more than 342 µmol/l) that do not decrease after increasing the milk intake and phototherapy. This baby is seriously ill and the cause of this condition is to be seeked intensely. If the cause is found and started to be cured, the bilirubin levels should decrease also.
https://sites.google.com/site/problemysdojcenim/jaundice---article-in-english
Jaundice and breastfeeding
Jaundice is a result of many changes that occur in the baby’s body due to the adaptation to the extrauterine life. The main reason is that many red blood cells become abundant and are broken down releasing bilirubin which causes yellowish discoloration of the skin.
Is jaundice a disease or a health problem? Is jaundiced baby in danger? When is it reasonable to intervene and decrease the levels of bilirubin by treatment?
Standard progress of newborn jaundice differs by the food the baby gets
Breastfed babies
Majority of healthy, exclusively breastfed babies who gain weight well has elevated bilirubin levels reaching its maximum in the first week of life and gradually lowering, and lingering in minor degree up to the third month of life or longer.
We like to say that breastfeeding is natural and the breastmilk is considered to be the most suitable food for an infant. If this is really true we should also accept that if majority of breastfed babies are jaundiced, often up to the third month of life, this condition is not a disease, it is normal, even beneficial for the health of the baby. Many studies show that elevated bilirubin levels are important for the newborn as the bilirubin is a powerful antioxidant.
Breastmilk helps the baby to keep the elevated levels of bilirubin which is physiological (natural, normal). That doesn’t mean that breastfeeding and breastmilk make jaundice worse.
Formula fed babies
Majority of healthy term newborns who are partially of fully formula fed are not jaundiced, at least not so much as the breastfed babies. If we believe that the norm is breastfeeding, jaundice in the majority of breastfed babies should not be considered a disease, what should be considered a problem is the absence of newborn jaundice in the formula fed babies. The antioxidative properties of bilirubin help the organism to get rid of free radicals that arise in the body. Formula fed baby has lower levels of bilirubin when compared to the baby receiving natural food (breastmilk). Therefore this phenomenon can be regarded as one of many undesirable side effects of feeding an infant with formula in the period when every baby should not receive anything except breastmilk.
Another issue is that breastfed baby isn’t effectively breastfed just because he is takes the breast. Babies can just pretend to breastfeed and in fact just nibble on the breast most of the time they spend there and drink not enough breastmilk. Unfortunately, this is common in most of the newborns. The cause is not the fact that mother has no milk after birth - a common myth about breastfeeding since almost all mothers produce breastmilk since the 16th week of pregnancy and at the time of birth there is enough colostrum in their breasts. The real cause is that we interfere with the natural start of breastfeeding so much that the baby’s ability to latch correctly is weakened and the baby can’t get enough milk. These babies can have and often have unusually high bilirubin levels which is one of the symptoms of the fact that the baby actually drinks borderline amounts of breastmilk. This is the most common cause of serious newborn jaundice due to which majority of newborns undergoes therapy. Treatment of this problem should not include lowering bilirubin levels but rather fixing the breastfeeding with an experienced lactation consultant.
Even more appropriate approach would be to prevent this problem from happening – by natural birth without unnecessary routine and preventive interventions, by placing the baby on mother’s abdomen skin to skin right after the birth allowing the baby to crawl to the breast all by himself and to breastfeed as long as he wishes, breastfeeding on demand without any routine separation of the mother and baby afterwards and not using any artificial nipples (bottle, pacifier of nipple shields). By preparation for breastfeeding we can help the baby to have a normal, physiological newborn jaundice beneficial for his health.
Does bilirubin really damage baby’s brain?
Not likely. This hypothesis was never tested and proved. On the contrary, there are some proofs that indicate that this assumption is not correct. It is not important to be fixed on the bilirubin levels, what seems to be important is how and why does the bilirubin get to baby’s brain. It is proved that bilirubin can not cross the barrier between blood and brain no matter how high the levels are when this barrier is intact – which it is as long as the baby is healthy. When the health of a baby is compromised by some serious factors, the blood-brain barrier can become impaired and some compounds (also bilirubin) from the blood can enter the brain of this baby. It is likely that the damage of brain cells is caused by some toxic chemicals that cross blood-brain barrier and afterwards bilirubin deposits in the brain cells that are already dead. Which means that bilirubin probably works just as a colourful marker of the fact that the brain cells were previously damaged by some serious health problems. If this theory is truly correct than jaundice never is a problem and should never be treated, and rising levels of bilirubin are just an indicator of the fact that the baby has some health problems which should be treated. However this is just a theory and it probably never will be proved as it is not ethical to test this hypothesis on babies. Therefore therapy is indicated for preventive means when the bilirubin levels exceed the level of 342 µmol/l in healthy and term newborn.
The fear of jaundice comes from the past
Many health professionals still remember terrible complications linked with a massive breakdown of red blood cells that often happened in the past when Rh negative mother had Rh positive child (Rh incompatibility). Rh incompatibility was linked with elevated bilirubin levels and many serious health problems of the baby that caused lifelong health disability (including brain damage) or even death. In the countries with a good health care system this problem almost vanished 30 years ago and currently threatens only a very small percentage of infants. Baby can be endangered if the antenatal care is neglected, if mother’s pregnancy is not observed early and the Rh negative mothers are not monitored. At present, Rh incompatibility can be prevented which is one of the biggest triumphs of medicine.
However, elevated bilirubin levels still do occur as a symptom of some other diseases, just like fever rises when one has flu. Fever (precisely as bilirubin) helps the organism to better cope with the disease. The look on jaundice however remained twisted - the symptom is regarded a cause of the problems.
Another reason why it is common to consider normal newborn jaundice a disease is the fact that the formula fed baby who usually doesn’t display jaundice is considered a norm, a model. Majority of breastfed babies has higher bilirubin levels than the formula fed babies. Instead of considering breastfeeding a norm, many breastfed babies undergo risky therapy in an effort to decrease the amount of bilirubin to the level which is normal in the formula fed babies.
Majority of babies undergoes therapy unnecessarily
Treatment of jaundice is associated with longer hospital stays for mother and child, increased medical and hospital costs, disruption to the early relationship between mother and baby, compromised breastfeeding, and a great deal of anxiety all around. If the approach to jaundice abides by the current scientific knowledge, only a small percentage of newborns will be treated.
Most of the hospitals treat jaundice because of the fear that bilirubin could damage baby’s brain, if the levels of bilirubin are too high. However, the hypothesis about bilirubin being harmful was never tested and there is not a single proof for the accuracy of this theory in scientific studies.
Actually, there is a growing number of evidence that bilirubin is an important antioxidant which has been demonstrated to scavenge potentially toxic free radicals from the body just like vitamin C or E do. With elevated levels of bilirubin the organism of a newborn (and an adult as well) can cope better with some diseases or with stress.
In spite of this, jaundice is feared about as if the elevated bilirubin levels were truly harmful for the health of the baby. Scientific studies however proved clearly that if the newborn is term and healthy bilirubin levels up to 342 µmol/l will not damage brain or the health of the baby.
Safety of the bilirubin levels rising above 342 µmol/l were not studied by any controlled scientific studies. There are only case studies about babies whose bilirubin levels higher exceeded 342 µmol/l even up to 855 µmol/l. If the babies were healthy and term all of them survived these extreme high bilirubin levels without any health problems (in short-term or long-term consequences).
Jaundice experts Jeffrey Maisels and Tom Newman elaborated a review considering all the data available on this topic and they found out that as long as the infant is healthy and term, the fear of bilirubin, no matter how high it rises, is not supported by any evidence. Maisels and Newman recommend changing the traditional approach to jaundice treatment since according to their review there is no proof about the efficiency of the treatment and the treatment is not without risks. They recommend that a healthy and term infant should not be examined for jaundice routinely. Only when there is a suspicion that the baby has abnormal bilirubin levels, check up is in place and the treatment is recommended only in case that the bilirubin levels exceed 342 µmol/l and are still rising. The aim of the treatment of otherwise healthy and term newborn should be to keep bilirubin below 500-400 µmol/l.
According to the available data, bilirubin levels close to 342 µmol/l is observed in 0.5-1 % of the babies. However, treatment of jaundice is recommended when the bilirubin levels are lower than 342 µmol/l in large number of infants. What benefits should provide these interventions when it is clearly proved that bilirubin levels up to 342 µmol/l are not harmful for the brain of a healthy baby is not clear.
Therapy of jaundice
Don’t stop breastfeeding because of jaundice!
Some interventions should never be used for jaundice treatment – no matter how high the bilirubin levels are, whether the children are healthy or ill, term or preterm. This includes all interventions for which breastfeeding is stopped and the baby is given formula, boiled breastmilk or any other food instead of breastmilk. Efficiency as well as safety of these methods were not proved by scientific studies. What’s more, these interventions can seriously jeopardize the success of breastfeeding making them potentially harmful for the health of the baby.
Almost always are these interventions recommended for the babies of which bilirubin levels do not reach the 342 µmol/l. However, safety of these levels of bilirubin for healthy and term newborn is proved babies just like the risks of unsuccessful breastfeeding and feeding newborn with formula to baby’s health. Therefore, the risks of using these methods without any doubt outweigh their positive effects – there are none.
These methods are misused due to incorrect interpretation of the fact why they actually decrease the levels of bilirubin
These methods started to be recommended when some studies were published which stated that elevated bilirubin levels are seen more often in breastfed babies and that the decrease of bilirubin levels occurred faster when the babies were temporarily fed formula by bottle. This led to incorrect conclusion that breastfeeding makes jaundice worse. The reality however is completely different:
Abnormal bilirubin levels for which therapy is considered occur most commonly when the baby gets not enough milk by breastfeeding – when the baby mostly nibbles on the breast without sufficient milk intake.
How can it happen that the baby gets not enough milk by breastfeeding?
Many mothers think that breastfeeding as a natural source of food for their babies is successful all by itself, that they just put the baby to the breast and that’s it. This notion is basically correct so long as the birth and the start of breastfeeding are not influenced by routine and preventive interventions that can weaken the baby’s ability to latch on well. Too many babies have difficulties with breastfeeding after the baby is not given a chance to crawl to his mother’s breast and latch on by himself. Rooming-in for 24 hours a day is also not available in many hospitals and artificial nipples (pacifier, bottle or nipple shields) are misused without considering how badly it affects breastfeeding.
Baby is not born with the ability to breastfeed. Baby only has a sucking reflex. For successful breastfeeding from day one after birth a correct latch is necessary and these negative interventions weaken the ability of the baby to latch on well. The baby is willing to take the breast but sucks just the nipple and he gets only borderline amounts of colostrum. It can hardly be said that this baby is breastfed. More proper would be to say that the baby is nothing-fed. Baby soon becomes hungry, dehydrated and exhausted and thereupon extremely sleepy.
Mothers try to do their best to wake the baby up and when they do, baby takes the breast, nibbles few times and falls asleep again. The only way to wake up a sleepy newborn is the flow of milk and when the baby is not latched on well, he will not get enough colostrum especially in the first few days when the mother’s milk supply is not abundant (there is enough colostrum in the breasts, but the only way to get it in the first three or four days is a correct latch). Poor milk intake becomes evident when the baby still passes black stool (meconium) on the 4th day after birth. If breastfeeding was not fixed by that time, this issue becomes emergency at this point. Problems with breastfeeding can be fixed but the mother has to get a good help from lactation consultant who can show her the difference between good drinking and nibbling, who can help her by better positioning of both baby and the mother (preferably in a cross-cradle hold) and better asymmetric latch to increase the milk intake. Lactation consultant should also be able to show the mother how the baby can get even more breastmilk by compressing the breast when the baby no longer drinks on his own and how to supplement the baby at the breast when necessary.
How can the inefficient milk intake be related with the elevated bilrubin levels?
If the baby does not get enough colostrum in the first days of life, his body is not able to get rid of bilirubin that has already been processed by liver and is meant to be excreted by stool. It is quite common that the baby still passes meconium on day four or five when breastfeeding is not efficient. Bilirubin is excreted to gut but the guts are not emptied properly. Bilirubin is reabsorbed to the blood stream again thereby increasing the levels of bilirubin.
The elevated bilirubin levels are just a symptom of a more serious problem – that the baby is actually starving and not getting enough colostrum. This is where supplementing with anything (boiled breastmilk, formula or even mouse milk) can help and truly decrease the bilirubin levels because most mothers would supplement their babies with a bottle. And the baby who did not get enough colostrum from the breast eventually starts to feed, because finally he starts to get his food from the bottle.
Mother who plans to breastfeed however has another possibility how to solve this problem. Bottle can be an answer to treat the symptom - elevated bilirubin levels, but it doesn’t fix inefficient breastfeeding – the real cause of this situation.
Therefore the only legitimate intervention for jaundice when the baby is healthy and term is to check the breastfeeding and fix potential problems with the lactation consultant.
Only when breastfeeding is okay and the bilirubin levels are above 342 µmol/l and are still rising, it is reasonable to decrease the bilirubin levels since the safety of bilirubin levels that exceeded 342 µmol/l is not sufficiently proved by scientific studies.
The most suitable intervention in this case is phototherapy. If it does not work fast enough, medicamentous treatment or the exchange transfusion are other possibilities.
Phototherapy
Baby’s skin is exposed to a special light that breaks down bilirubin and helps to get rid of it faster. If phototherapy is used for healthy and term newborn whose bilirubin levels are under 342 µmol/l (which according to statistics is true for 99 % of healthy and term newborns), the benefits of this treatment are none since these levels of bilirubin are not dangerous. Phototherapy however brings some risks.
According to current trends in jaundice treatment, phototherapy in healthy and term newborn should be used in order to decrease the levels of bilirubin below 500 – 400 µmol/l. This is approach is probably the least dangerous for jaundice treatment. It should be used when the levels of bilirubin exceed 342 µmol/l, do not decrease after improving the milk intake and still rise.
When it is really necessary to use phototherapy, mother has to get a qualified help with breastfeeding. Often the baby is treated in a special room separated from mother. Breastfeeding on demand is therefore hindered. In addition, baby treated with phototherapy sometimes requires more fluids, which means that efficient breastfeeding with sufficient milk intake is absolutely necessary. Sometimes even with the abundant milk intake, the baby can get dehydrated and needs some extra fluids. If supplementing is not to jeopardize the success of breastfeeding it is essential to avoid using a bottle. Mother can learn how to use a little tube (the so-called lactation aid) that is put into the baby’s mouth and the baby sucks this extra fluid when breastfeeding.
Medicamentous treatment
The baby is given drugs that degrade bilirubin. Most frequently, phenobarbital and black coal are used. Their usage (especially phenobarbital) should be considered thoroughly. Levels of bilirubin that do not exceed 342 µmol/l are proved to be safe for healthy and term newborn, the medicamentous treatment however brings some undesirable side effects.
Many jaundice experts warn against phenobarbital for jaundice treatment since there are serious doubts whether this is a safe drug. Its usage is linked with many serious side effects – sedation, increase of the risk of haemorrhagic disease and it is potentially addictive. It influences the synthesis of some hormones and the hormonal homeostasis heavily.
The black coal brings risks by the fact that it is mostly given in a powder form mixed with water by bottle. In some babies even one bottle can jeopardize breastfeeding seriously. If it is really necessary to give this drug to a baby, the least dangerous way is to give it to the baby by cup or a small tube placed on mother’s finger (finger feeding) or with a syringe or spoon.
Some babies are also given substances that should protect the liver (hepatoprotectives) because of an incorrect assumption that newborns’ liver is immature and it is extremely loaded by bilirubin. These substances are really not necessary for any jaundiced baby.
Exchange transfusion
This intervention brings some really serious risks and it is used rarely. It should only be used in a situation when the bilirubin levels are really high (much more than 342 µmol/l) that do not decrease after increasing the milk intake and phototherapy. This baby is seriously ill and the cause of this condition is to be seeked intensely. If the cause is found and started to be cured, the bilirubin levels should decrease also.
Waiting for birth or inducing found equally effective for women with IUGR
ORIGINAL POST CAN BE FOUND HERE:
http://www.eurekalert.org/pub_releases/2010-02/sfmm-wfb011510.php
CHICAGO, Ill. (February 4, 2010) — In a study to be presented today at the Society for Maternal-Fetal Medicine's (SMFM) annual meeting, The Pregnancy Meeting ™, in Chicago, researchers will unveil findings that show that waiting for birth is as effective as inducing labor in cases of intrauterine growth restriction (IUGR).
Intrauterine growth restriction means that the fetus is substantially smaller than normal. The condition affects about 10% of pregnant women.
At birth the babies are more likely to have low blood sugar, trouble maintaining their body temperature, and an abnormally high red blood cell count. They're also prone to jaundice, infections, and Cerebral Palsy. Later in life growth restricted babies may be prone to executive and behavioral disorders, obesity, heart disease, type II diabetes, and high blood pressure.
Because of lack of evidence, obstetricians follow two main policies for pregnancies with suspected fetal growth restriction at term. Some doctors may induce labor out of concern for complications, while others will await spontaneous delivery to prevent higher operative delivery rates. Researchers in the obstetric research consortium in the Netherlands conducted a randomized controlled trial of 650 women in 52 hospitals to compare both strategies.
Pregnant women with a singleton pregnancy suspected of IUGR beyond 36 weeks of gestation were randomly allocated to either induction of labor or expectant monitoring using a web-based allocation system. Median birth weight was significantly lower in the induction group; 2420 grams, vs. 2560 grams in the group that waited. Adverse neonatal outcomes occurred at similar rates in both groups (difference of 0.9 %). The results show that waiting is an equally effective strategy to inducing labor.
"We now have an evidence based reason to individualize care and to allow women to do what they are most comfortable with when deciding whether to induce labor or wait, although long term outcomes have to be awaited" said Dr. Kim Boers the study's author from Leiden University Medical Center in the Netherlands.
http://www.eurekalert.org/pub_releases/2010-02/sfmm-wfb011510.php
CHICAGO, Ill. (February 4, 2010) — In a study to be presented today at the Society for Maternal-Fetal Medicine's (SMFM) annual meeting, The Pregnancy Meeting ™, in Chicago, researchers will unveil findings that show that waiting for birth is as effective as inducing labor in cases of intrauterine growth restriction (IUGR).
Intrauterine growth restriction means that the fetus is substantially smaller than normal. The condition affects about 10% of pregnant women.
At birth the babies are more likely to have low blood sugar, trouble maintaining their body temperature, and an abnormally high red blood cell count. They're also prone to jaundice, infections, and Cerebral Palsy. Later in life growth restricted babies may be prone to executive and behavioral disorders, obesity, heart disease, type II diabetes, and high blood pressure.
Because of lack of evidence, obstetricians follow two main policies for pregnancies with suspected fetal growth restriction at term. Some doctors may induce labor out of concern for complications, while others will await spontaneous delivery to prevent higher operative delivery rates. Researchers in the obstetric research consortium in the Netherlands conducted a randomized controlled trial of 650 women in 52 hospitals to compare both strategies.
Pregnant women with a singleton pregnancy suspected of IUGR beyond 36 weeks of gestation were randomly allocated to either induction of labor or expectant monitoring using a web-based allocation system. Median birth weight was significantly lower in the induction group; 2420 grams, vs. 2560 grams in the group that waited. Adverse neonatal outcomes occurred at similar rates in both groups (difference of 0.9 %). The results show that waiting is an equally effective strategy to inducing labor.
"We now have an evidence based reason to individualize care and to allow women to do what they are most comfortable with when deciding whether to induce labor or wait, although long term outcomes have to be awaited" said Dr. Kim Boers the study's author from Leiden University Medical Center in the Netherlands.
Are you really "overdue"?
Original Post Available HERE:
http://www.facebook.com/note.php?note_id=152890514765371&id=110067179067769
Are you really "overdue"?
The chances are that you will not actually reach 42 weeks anyway, as when the date of conception is known, this is quite unusual. Many pregnancies which are thought to be "overdue" are just inaccurately dated.
Standard pregnancy dating based on your last period date (LMP) is only accurate if you have a 28-day cycle and you ovulated on day 14. If your cycles are sometimes longer than this then there is a good chance that your due date is actually later than the 'standard' one.
Conception has to happen in the 24 hours after ovulation - you cannot conceive before your egg has been released, but the egg dies if unfertilized 12-24 hours later. So your most accurate way of dating the pregnancy is knowing when you ovulated. This is not necessarily on a day when you had sex; sperm can survive for up to four days, possibly longer, so the intercourse which resulted in conception could have occurred several days before the actual conception. If you have been charting your cycles or practising natural family planning you will know all about this - if not, see the links on dating your pregnancy for more info.
One very thorough study of over 24,000 pregnant women in the UK who had dating scans which were compared with their LMP date [1], found that:
"Most pregnancies undergoing post-term induction are not post-term when assessed by ultrasound dates"
A review of the study noted that:
"If we look at how many women end up going 2 weeks over their due date, it is 9.5% according to dating by LMP but only 1.5% when dated by scan. This suggests that the dating of pregnancy by LMP tends to overestimate the gestation. Therefore if scan information is available, it is preferable to use this for dating a pregnancy (presuming it was carried out during the first half of pregnancy, when dating is most accurate)." [2]
Ultrasound scans for dating are pretty accurate in the first trimester, but get less and less accurate as time goes on.
Sometimes a scan will suggest that your due date is actually later than the LMP date, but the revised date may not have been entered on your notes as your 'new' due date. Check that any recommendations for induction are based on the most accurate assessment of your due date, not on LMP dating.
Even if you are genuinely post-dates, your chances of going into labour naturally increase with every day which passes:
"of women at 40 weeks, 65% labour spontaneously within the next week. Of those at 10 days over their dates, 60% will enter spontaneous labour within the next 3 days." [2]
But what if you really are "overdue"?
It is undeniable that the rate of stillbirths and neonatal deaths does rise as pregnancy becomes more and more prolonged. However, many of these deaths are due to congenital abnormalities, or occur in babies with intra-uterine growth restriction. It is not clear how much the death rate rises for normal babies who do not show any signs of being growth-restricted. It can be alarming to hear that the death rate for pregnancies over 42 weeks doubles, but it is perhaps more informative to let people know the figures rather than the relative chance. Some sources suggest that the death rate for apparently normal babies, ie those without detected abnormalities, may rise from around 1 in 1,000 to 2 in 1,000. See the US Midwife Archive detailed paper on post-dates pregnancy.
Can you be induced at home?
The methods of induction of labour normally offered by medical staff are membrane sweeping, prostaglandin gel or pessaries which are inserted into the vagina (or occasionally given orally), artificial rupture of the membranes ('breaking the waters'), and an oxytocin drip, which is given in the synthetic forms of Syntocinon (in the UK) and Pitocin (in the USA).
Membrane sweeping can be performed at home or in an antenatal clinic, and there is no reason why you cannot have a home birth after it has been carried out. However, it is not as effective at inducing labour as other methods.
Artificial Rupture of Membranes is sometimes carried out to induce labour at home, but nowadays this is uncommon as it can place the baby under stress and increases the risk of infection. Used carefully, though, it can be highly successful - for instance see Danielle's story. For more about breaking the waters in general, see the UK Midwifery Archives (www.radmid.demon.co.uk/arm.htm)
Induction with drugs, using prostaglandins or oxytocin drips, is not carried out at home as it significantly increases the risk of foetal distress, and can cause hyperstimulation of the uterus. It is usual to have continuous electronic foetal monitoring after these drugs are given in hospital, to watch for signs of distress. Many women also find contractions significantly more painful after drug induction and an epidural may be needed.
There are also various Do-It-Yourself methods of inducing labour which you can try at home.
What if you refuse induction of labour?
It is, of course, your right to refuse any medical treatment which is proposed, including induction of labour. It is up to you to make the decision which is right for your family. The vast majority of women who decline induction of labour will go on to have healthy babies. See for example the stories about "Ten Month Mamas" on birthlove.com.
You can ask for monitoring to check your baby's wellbeing, instead of choosing induction. There is a very small risk of foetal death occurring suddenly despite reassuring monitoring, but this can happen at any stage of pregnancy - and as the sources above show, it is extremely rare. Some women feel that it is not appropriate to accept induction on the basis of a one-in-a-thousand risk.
The UK's National Institute of Clinical Excellence and the Royal College of Obstetricians and Gynaecologists offer this information to pregnant women and their families [3]:
If your pregnancy is more than 41 weeks
Even if you have had a healthy trouble free pregnancy, you should be offered induction of labour after 41 weeks because from this stage the risk of your baby developing health problems increases. An induction because you are overdue does not increase the chance of you needing a caesarean section.
If you choose not to be induced at this stage then from 42 weeks you should be offered:
Twice weekly checks of your baby's heartbeat using a piece of equipment called an electronic fetal heart rate monitor.
A single ultrasound test to check the depth of amniotic fluid (or "waters") surrounding your baby.
An ultrasound scan in early pregnancy (before 20 weeks) can help to determine your baby's due date more accurately. This reduces your chances of unnecessary induction.
If you find yourself under pressure to accept induction at 42 weeks and you are not happy with this, then it may help to discuss these guidelines with your doctor or midwives; the Royal College of Obstetricians and Gynaecologists (RCOG) does make clear that monitoring beyond 42 weeks is an alternative to induction.[4]
The full Guidelines on Induction of Labour from the RCOG emphasise that:
Women must be able to make informed choices regarding their care or treatment via access to evidence based information. These choices should be recognised by health professionals as an integral part of the process. [5]
You can still have a home birth if your pregnancy is over 42 weeks gestation. This may involve some negotiation with your caregivers as different midwives and obstetricians have different views on the risks of post-dates pregnancy. Some are relaxed about it while others will be very concerned. However, the bottom line is that nobody can force you to go into hospital to give birth. See 'Birth Stories about long pregnancies' for some case studies of women who have decided to stay home.
If you are told that you 'cannot' have a home birth beyond a certain point in your pregnancy, it may be worth taking a "we'll cross that bridge if we come to it" approach. There is little point in putting yourself in stressful situations and having conflicts with your midwives, when the situation may well not arise. Such debates have their place, but maybe campaigning is better carried out when you are not at the end of your pregnancy! However, if you do find yourself 'overdue' and your midwives say that you 'cannot' have a home birth, you may have little choice but to argue your corner.
One approach which many people find helpful is to write a polite, no-nonsense letter to the Supervisor of Midwives. If you put things in writing then your position is made clear and it will usually be taken seriously. Here is an example of a letter you might use:
Dear Supervisor of Midwives,
I am expecting a baby, and my due date was ........ I would like to inform you that I am continuing with my plans to give birth at home. I appreciate that your advice is to give birth in hospital post 42 weeks, but I have made an informed decision to decline this offer of hospital admission at present.
I will of course transfer to hospital if my baby's condition, or my own, makes it necessary, but for the time being I would appreciate your continued support of my informed decision.
Many thanks for your help,
Yours....
If you find yourself under continuing pressure to accept hospital admission, you may need to be more forceful. Contact the Association for Improvements in the Maternity Services (www.aims.org.uk) for advice as they are very experienced in helping women in this situation.
Meconium-Stained Liquor
One issue to be aware of if you do stay at home for a post-dates pregnancy is meconium-stained liquor. This is where the baby has passed meconium (done its first poo) while still in your womb, and when your waters break, they are found to be stained brown or green. It becomes more and more likely as pregnancy progresses beyond 40 weeks. Many health authorities will request that you transfer to hospital whenever meconium-staining is found as it can be an indicator that the baby is, or has been, in distress. It can also lead to Meconium Aspiration Syndrome, a dangerous condition which can occur if the baby breathes in meconium while still inside the womb.
In post-term pregnancies, many midwives believe that passing meconium does not necessarily indicate that the baby has been in distress, as it is also often simply an indicator that the baby's gut is mature. It is sometimes said that meconium-stained liquor before 40 weeks is far more significant than it is in post-dates pregnancy, and for this reason some mothers choose not to transfer to hospital for meconium staining if the meconium is not thick. It is a difficult issue and controversial issue, and one which you are more likely to have to deal with in a post-dates pregnancy. I am still searching for good sources of information on this, but have been doing so for five years without much success!
Membrane Sweeping
The RCOG Guidelines on Induction of Labour emphasise that a membrane sweep should be offered before other forms of induction are considered. Sweeping the membranes does not seem to put babies under any additional stress, so there is no reason why you should not have a home birth after your membranes have been swept. Here is some info on membrane sweeping from the NICE/RCOG patient information document on induction of labour:
Membrane sweeping
This has been shown to increase the chances of labour starting naturally within the next 48 hours and can reduce the need for other methods of induction of labour.
Membrane sweeping involves your midwife or doctor placing a finger just inside your cervix and making a circular, sweeping movement to separate the membranes from the cervix. It can be carried out at home, at an outpatient appointment or in hospital.
If you have agreed to induction of labour, you should be offered membrane sweeping before other methods are used. The procedure may cause some discomfort or bleeding, but will not cause any harm to your baby and it will not increase the chance of you or your baby getting an infection. Membrane sweeping is not recommended if your membranes have ruptured (waters broken).
Possible Disadvantages
Women's experiences of membrane sweeping vary widely. Some find it mildly uncomfortable, while others find it extremely painful.
There is a risk that your waters could be accidentally broken, which then increases the risk of your baby contracting an infection. Because of this, if your waters break, you will normally be put under pressure to give birth within 96 hours (NICE guidelines) or less, with induction offered if your labour does not progress that fast naturally. You can, of course, refuse such induction, but you'd need to consider your individual infection risk first.
There is a risk that a weak, stop-start labour could be triggered, because your body or baby was not really ready for labour - see the discussion about DIY induction methods, below. If this happens, you may find yourself exhausted in the early stages of labour, and transfer to hospital for an epidural for rest, and to have your labour artificially speeded up. I am not aware of any research on the rates of induction or augmentation of labour after membrane sweeping, so this is speculation rather than evidence-based.
DIY alternatives to induction
If you are desperate to see your baby, or are finding it hard to decline offers of hospital induction, then you may be considering ways to bring on labour yourself. There are plenty of links and suggestions on the UK Midwifery archives page on complementary therapies.
It might be worth thinking through exactly you do not want induction in hospital. If you would not accept medical treatment to bring on labour, what is different about using complementary therapies? Fine, if your intention is just to avoid hospital - but if you are concerned about interfering with your body's ability to give birth, then DIY methods might not be right for you.
If your baby is not ready to be born, in a difficult position, or your body is not ready to go into labour, then DIY induction might bring on a weak pre-labour which peters out. If this happens, and you have already informed your midwives, then you might find yourself under pressure to go into hospital for acceleration of labour, or you might find yourself tired out by the time true labour begins.
DIY labour induction has worked well for many women, and may work for you - but do be aware that it is an intervention, albeit usually a gentler one than hospital induction, and it may well alter the course of your labour.
Is your baby in the right position?
It may be that there is a very good reason why you have not gone into spontaneous labour so far. If your baby is not in a good position to pass through your pelvis, then it may not be exerting enough pressure on your cervix to trigger labour. The ideal position for labour is with the occiput - the back of the baby's head - towards the front ('occiput anterior' or OA). The position is normally further described according to which side the baby is leaning towards, ie Left Occiput Anterior or LOA when the occiput and back is towards your left side, which is most common, and Right Occiput Anterior or ROA when the baby's occiput and back is towards your right side.
As well as the baby's position being 'anterior', the baby's chin should be tucked down on its chest so that the occiput is nearest to your cervix. This ensures that the baby's head has the best chance of fitting through your pelvis. Babies normally try to get themselves into this 'ideal' position for birth, but sometimes they may take their time doing so.
If your baby is in the occiput posterior position (facing outwards, its back against your spine) then you may not go into spontaneous labour until it has moved around to face the other way. There is a very good reason for this - labour with the baby in the posterior position may be harder than usual for first-time mothers (although often no problem if this is not your first baby), and vaginal birth is sometimes impossible as the baby's head may get stuck as it attempts to turn in your pelvis. For more information, see 'Get your baby lined up'.
Similarly, if your baby is positioned so that its face, forehead or ear is nearest to your cervix at the moment, then vaginal birth could be very difficult or impossible, and labour will often not start on its own until the baby has moved.
If you are induced when the baby is malpresented, then the result could be a very difficult labour or a caesarean section. This is one of the reasons why many women prefer to avoid induction - we usually just don't know why labour hasn't started yet, and there may be a very good reason for it.
If you are considering induction, you can first of all ask your midwife to check your baby's position, and do so yourself (see 'Get your baby lined up'). It is not possible to identify all malpresentations before labour, and some babies start labour in a good position and then decide to move to a worse one! However, you should at least be able to check whether your baby is anterior or posterior.
ITS YOUR CHOICE
Essentially, its youre body, and your choice. Arming yourself with as many of the facts and research as possible can help you make an informed decision, and make the right choice for you and your baby. It can also make those awkward discussions with medical care-givers A LOT EASIER when you know the facts risks and benefits of what you are proposing.
http://www.facebook.com/note.php?note_id=152890514765371&id=110067179067769
Are you really "overdue"?
The chances are that you will not actually reach 42 weeks anyway, as when the date of conception is known, this is quite unusual. Many pregnancies which are thought to be "overdue" are just inaccurately dated.
Standard pregnancy dating based on your last period date (LMP) is only accurate if you have a 28-day cycle and you ovulated on day 14. If your cycles are sometimes longer than this then there is a good chance that your due date is actually later than the 'standard' one.
Conception has to happen in the 24 hours after ovulation - you cannot conceive before your egg has been released, but the egg dies if unfertilized 12-24 hours later. So your most accurate way of dating the pregnancy is knowing when you ovulated. This is not necessarily on a day when you had sex; sperm can survive for up to four days, possibly longer, so the intercourse which resulted in conception could have occurred several days before the actual conception. If you have been charting your cycles or practising natural family planning you will know all about this - if not, see the links on dating your pregnancy for more info.
One very thorough study of over 24,000 pregnant women in the UK who had dating scans which were compared with their LMP date [1], found that:
"Most pregnancies undergoing post-term induction are not post-term when assessed by ultrasound dates"
A review of the study noted that:
"If we look at how many women end up going 2 weeks over their due date, it is 9.5% according to dating by LMP but only 1.5% when dated by scan. This suggests that the dating of pregnancy by LMP tends to overestimate the gestation. Therefore if scan information is available, it is preferable to use this for dating a pregnancy (presuming it was carried out during the first half of pregnancy, when dating is most accurate)." [2]
Ultrasound scans for dating are pretty accurate in the first trimester, but get less and less accurate as time goes on.
Sometimes a scan will suggest that your due date is actually later than the LMP date, but the revised date may not have been entered on your notes as your 'new' due date. Check that any recommendations for induction are based on the most accurate assessment of your due date, not on LMP dating.
Even if you are genuinely post-dates, your chances of going into labour naturally increase with every day which passes:
"of women at 40 weeks, 65% labour spontaneously within the next week. Of those at 10 days over their dates, 60% will enter spontaneous labour within the next 3 days." [2]
But what if you really are "overdue"?
It is undeniable that the rate of stillbirths and neonatal deaths does rise as pregnancy becomes more and more prolonged. However, many of these deaths are due to congenital abnormalities, or occur in babies with intra-uterine growth restriction. It is not clear how much the death rate rises for normal babies who do not show any signs of being growth-restricted. It can be alarming to hear that the death rate for pregnancies over 42 weeks doubles, but it is perhaps more informative to let people know the figures rather than the relative chance. Some sources suggest that the death rate for apparently normal babies, ie those without detected abnormalities, may rise from around 1 in 1,000 to 2 in 1,000. See the US Midwife Archive detailed paper on post-dates pregnancy.
Can you be induced at home?
The methods of induction of labour normally offered by medical staff are membrane sweeping, prostaglandin gel or pessaries which are inserted into the vagina (or occasionally given orally), artificial rupture of the membranes ('breaking the waters'), and an oxytocin drip, which is given in the synthetic forms of Syntocinon (in the UK) and Pitocin (in the USA).
Membrane sweeping can be performed at home or in an antenatal clinic, and there is no reason why you cannot have a home birth after it has been carried out. However, it is not as effective at inducing labour as other methods.
Artificial Rupture of Membranes is sometimes carried out to induce labour at home, but nowadays this is uncommon as it can place the baby under stress and increases the risk of infection. Used carefully, though, it can be highly successful - for instance see Danielle's story. For more about breaking the waters in general, see the UK Midwifery Archives (www.radmid.demon.co.uk/arm.htm)
Induction with drugs, using prostaglandins or oxytocin drips, is not carried out at home as it significantly increases the risk of foetal distress, and can cause hyperstimulation of the uterus. It is usual to have continuous electronic foetal monitoring after these drugs are given in hospital, to watch for signs of distress. Many women also find contractions significantly more painful after drug induction and an epidural may be needed.
There are also various Do-It-Yourself methods of inducing labour which you can try at home.
What if you refuse induction of labour?
It is, of course, your right to refuse any medical treatment which is proposed, including induction of labour. It is up to you to make the decision which is right for your family. The vast majority of women who decline induction of labour will go on to have healthy babies. See for example the stories about "Ten Month Mamas" on birthlove.com.
You can ask for monitoring to check your baby's wellbeing, instead of choosing induction. There is a very small risk of foetal death occurring suddenly despite reassuring monitoring, but this can happen at any stage of pregnancy - and as the sources above show, it is extremely rare. Some women feel that it is not appropriate to accept induction on the basis of a one-in-a-thousand risk.
The UK's National Institute of Clinical Excellence and the Royal College of Obstetricians and Gynaecologists offer this information to pregnant women and their families [3]:
If your pregnancy is more than 41 weeks
Even if you have had a healthy trouble free pregnancy, you should be offered induction of labour after 41 weeks because from this stage the risk of your baby developing health problems increases. An induction because you are overdue does not increase the chance of you needing a caesarean section.
If you choose not to be induced at this stage then from 42 weeks you should be offered:
Twice weekly checks of your baby's heartbeat using a piece of equipment called an electronic fetal heart rate monitor.
A single ultrasound test to check the depth of amniotic fluid (or "waters") surrounding your baby.
An ultrasound scan in early pregnancy (before 20 weeks) can help to determine your baby's due date more accurately. This reduces your chances of unnecessary induction.
If you find yourself under pressure to accept induction at 42 weeks and you are not happy with this, then it may help to discuss these guidelines with your doctor or midwives; the Royal College of Obstetricians and Gynaecologists (RCOG) does make clear that monitoring beyond 42 weeks is an alternative to induction.[4]
The full Guidelines on Induction of Labour from the RCOG emphasise that:
Women must be able to make informed choices regarding their care or treatment via access to evidence based information. These choices should be recognised by health professionals as an integral part of the process. [5]
You can still have a home birth if your pregnancy is over 42 weeks gestation. This may involve some negotiation with your caregivers as different midwives and obstetricians have different views on the risks of post-dates pregnancy. Some are relaxed about it while others will be very concerned. However, the bottom line is that nobody can force you to go into hospital to give birth. See 'Birth Stories about long pregnancies' for some case studies of women who have decided to stay home.
If you are told that you 'cannot' have a home birth beyond a certain point in your pregnancy, it may be worth taking a "we'll cross that bridge if we come to it" approach. There is little point in putting yourself in stressful situations and having conflicts with your midwives, when the situation may well not arise. Such debates have their place, but maybe campaigning is better carried out when you are not at the end of your pregnancy! However, if you do find yourself 'overdue' and your midwives say that you 'cannot' have a home birth, you may have little choice but to argue your corner.
One approach which many people find helpful is to write a polite, no-nonsense letter to the Supervisor of Midwives. If you put things in writing then your position is made clear and it will usually be taken seriously. Here is an example of a letter you might use:
Dear Supervisor of Midwives,
I am expecting a baby, and my due date was ........ I would like to inform you that I am continuing with my plans to give birth at home. I appreciate that your advice is to give birth in hospital post 42 weeks, but I have made an informed decision to decline this offer of hospital admission at present.
I will of course transfer to hospital if my baby's condition, or my own, makes it necessary, but for the time being I would appreciate your continued support of my informed decision.
Many thanks for your help,
Yours....
If you find yourself under continuing pressure to accept hospital admission, you may need to be more forceful. Contact the Association for Improvements in the Maternity Services (www.aims.org.uk) for advice as they are very experienced in helping women in this situation.
Meconium-Stained Liquor
One issue to be aware of if you do stay at home for a post-dates pregnancy is meconium-stained liquor. This is where the baby has passed meconium (done its first poo) while still in your womb, and when your waters break, they are found to be stained brown or green. It becomes more and more likely as pregnancy progresses beyond 40 weeks. Many health authorities will request that you transfer to hospital whenever meconium-staining is found as it can be an indicator that the baby is, or has been, in distress. It can also lead to Meconium Aspiration Syndrome, a dangerous condition which can occur if the baby breathes in meconium while still inside the womb.
In post-term pregnancies, many midwives believe that passing meconium does not necessarily indicate that the baby has been in distress, as it is also often simply an indicator that the baby's gut is mature. It is sometimes said that meconium-stained liquor before 40 weeks is far more significant than it is in post-dates pregnancy, and for this reason some mothers choose not to transfer to hospital for meconium staining if the meconium is not thick. It is a difficult issue and controversial issue, and one which you are more likely to have to deal with in a post-dates pregnancy. I am still searching for good sources of information on this, but have been doing so for five years without much success!
Membrane Sweeping
The RCOG Guidelines on Induction of Labour emphasise that a membrane sweep should be offered before other forms of induction are considered. Sweeping the membranes does not seem to put babies under any additional stress, so there is no reason why you should not have a home birth after your membranes have been swept. Here is some info on membrane sweeping from the NICE/RCOG patient information document on induction of labour:
Membrane sweeping
This has been shown to increase the chances of labour starting naturally within the next 48 hours and can reduce the need for other methods of induction of labour.
Membrane sweeping involves your midwife or doctor placing a finger just inside your cervix and making a circular, sweeping movement to separate the membranes from the cervix. It can be carried out at home, at an outpatient appointment or in hospital.
If you have agreed to induction of labour, you should be offered membrane sweeping before other methods are used. The procedure may cause some discomfort or bleeding, but will not cause any harm to your baby and it will not increase the chance of you or your baby getting an infection. Membrane sweeping is not recommended if your membranes have ruptured (waters broken).
Possible Disadvantages
Women's experiences of membrane sweeping vary widely. Some find it mildly uncomfortable, while others find it extremely painful.
There is a risk that your waters could be accidentally broken, which then increases the risk of your baby contracting an infection. Because of this, if your waters break, you will normally be put under pressure to give birth within 96 hours (NICE guidelines) or less, with induction offered if your labour does not progress that fast naturally. You can, of course, refuse such induction, but you'd need to consider your individual infection risk first.
There is a risk that a weak, stop-start labour could be triggered, because your body or baby was not really ready for labour - see the discussion about DIY induction methods, below. If this happens, you may find yourself exhausted in the early stages of labour, and transfer to hospital for an epidural for rest, and to have your labour artificially speeded up. I am not aware of any research on the rates of induction or augmentation of labour after membrane sweeping, so this is speculation rather than evidence-based.
DIY alternatives to induction
If you are desperate to see your baby, or are finding it hard to decline offers of hospital induction, then you may be considering ways to bring on labour yourself. There are plenty of links and suggestions on the UK Midwifery archives page on complementary therapies.
It might be worth thinking through exactly you do not want induction in hospital. If you would not accept medical treatment to bring on labour, what is different about using complementary therapies? Fine, if your intention is just to avoid hospital - but if you are concerned about interfering with your body's ability to give birth, then DIY methods might not be right for you.
If your baby is not ready to be born, in a difficult position, or your body is not ready to go into labour, then DIY induction might bring on a weak pre-labour which peters out. If this happens, and you have already informed your midwives, then you might find yourself under pressure to go into hospital for acceleration of labour, or you might find yourself tired out by the time true labour begins.
DIY labour induction has worked well for many women, and may work for you - but do be aware that it is an intervention, albeit usually a gentler one than hospital induction, and it may well alter the course of your labour.
Is your baby in the right position?
It may be that there is a very good reason why you have not gone into spontaneous labour so far. If your baby is not in a good position to pass through your pelvis, then it may not be exerting enough pressure on your cervix to trigger labour. The ideal position for labour is with the occiput - the back of the baby's head - towards the front ('occiput anterior' or OA). The position is normally further described according to which side the baby is leaning towards, ie Left Occiput Anterior or LOA when the occiput and back is towards your left side, which is most common, and Right Occiput Anterior or ROA when the baby's occiput and back is towards your right side.
As well as the baby's position being 'anterior', the baby's chin should be tucked down on its chest so that the occiput is nearest to your cervix. This ensures that the baby's head has the best chance of fitting through your pelvis. Babies normally try to get themselves into this 'ideal' position for birth, but sometimes they may take their time doing so.
If your baby is in the occiput posterior position (facing outwards, its back against your spine) then you may not go into spontaneous labour until it has moved around to face the other way. There is a very good reason for this - labour with the baby in the posterior position may be harder than usual for first-time mothers (although often no problem if this is not your first baby), and vaginal birth is sometimes impossible as the baby's head may get stuck as it attempts to turn in your pelvis. For more information, see 'Get your baby lined up'.
Similarly, if your baby is positioned so that its face, forehead or ear is nearest to your cervix at the moment, then vaginal birth could be very difficult or impossible, and labour will often not start on its own until the baby has moved.
If you are induced when the baby is malpresented, then the result could be a very difficult labour or a caesarean section. This is one of the reasons why many women prefer to avoid induction - we usually just don't know why labour hasn't started yet, and there may be a very good reason for it.
If you are considering induction, you can first of all ask your midwife to check your baby's position, and do so yourself (see 'Get your baby lined up'). It is not possible to identify all malpresentations before labour, and some babies start labour in a good position and then decide to move to a worse one! However, you should at least be able to check whether your baby is anterior or posterior.
ITS YOUR CHOICE
Essentially, its youre body, and your choice. Arming yourself with as many of the facts and research as possible can help you make an informed decision, and make the right choice for you and your baby. It can also make those awkward discussions with medical care-givers A LOT EASIER when you know the facts risks and benefits of what you are proposing.
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