VIM ~ Very Important Message

News Moms Need has posted a critical message today. You can read it here:  MOD

During the holidays expectant moms who are nearing their due dates often want their doctors to induce labor for convenience.  Sometimes the health care providers themselves encourage this due to scheduling concerns, but PLEASE do not succumb to this emotionally and scheduling-driven potential crisis for your baby.  Even if you were "measuring big" - not a reason to change your due date or to push the limits of safety.  The baby's position and mother's body varies.  It is a poor indicator of maturity. 

Later ultrasounds (after the routine 20 week exam) are also not good indicators, as the size of the baby in later weeks, due to genetics and other factors, varies considerably, making it difficult to determine maturity.  This might be an argument against the ultrasound machines that are sometimes found in every office and done at every visit.  For a normal, healthy pregnancy, there is such a thing as excess of procedures since results are not accurate enough. 

These later unltrasound exams which estimate baby's weight are also poor indicator for mom's ability to deliver.  When the baby's size is estimated by one of these late ultrasounds there is a two pound error factor - TWO POUNDS!  Even if the measurement were accurate, you may be underestimating the ability of mom's pelvic bones to move and baby's head to temporaryily mold for birth - you can't beat Mother Nature! 

Starting life in the NICU, if it can be avoided, is most unpleasant and not where you would choose to spend your holidays.  What you want is the safest, healthiest delivery possible for both you and your baby.  We want you to enjoy your holidays, but you'll enjoy them even more if you aren't surprised by an unnecessary preterm birth with all it's complications.

Be a wise consumer of health care and ask the right questions - even around the holidays.  Convenient scheduling or late-term discomfort are poor reasons for increased risks.  One other byproduct of induction without real need is an increased rate of c-section delivery.  Once more - something you don't want around the holidays if you can avoid it.  They mean more pain, longer hospital stays, more complications and greater cost.   Those who benefit from this would only be the hospital and the surgeon.

When intervention is needed for the real safety of the baby or the mom, we're happy to have these options, but please be sure you have researched before you let your emotions decide.

C-section rate is high but IHC in Utah is working on it

Excerpt from the Deseret News:

"SALT LAKE CITY — Cesarean sections have become the most common surgery in U.S. hospitals, increasing more than 50 percent since the 1990s, many of them "unnecessary," according to Intermountain Healthcare physicians.


While cesarean sections may be more convenient, as far as scheduling the birth of a baby and avoiding the last few uncomfortable weeks of a pregnancy, [Dr. Ware] Branch said babies delivered before 39 weeks — the ideal gestational period — are also "more likely to have medical complications."

"We're talking about increased rates of respiratory disorders, elevated bilirubin levels and jaundice, and feeding disorders," he said.

Janie Wilson, a nurse and director of the program, said there is a level of complacency when it comes to available medical care, and mothers believe their babies will be OK regardless of the condition they are in at birth because of the capabilities of modern medicine."

Read the full article in the Deseret News.
Read more from the March of Dimes.

Yay! Breaking news...

In a long overdue press release, the American Congress of Obstetrics and Gynecologists finally steps forward to revise the old guidelines that had once caused so many hospitals and doctors to “ban” VBAC. In a revision released today, The ACOG now states,

“a vaginal birth after cesarean (VBAC) is a safe and appropriate choice for most women who have had a prior cesarean delivery, including for some women who have had two previous cesareans…”

March of Dimes says...

New guidelines on vaginal birth after c-section

Posted: 22 Jul 2010 08:00 AM PDT

It used to be that once you had a c-section, you’d always have a c-section. Now, health experts are rethinking this idea and believe that many women may be able to safely have a vaginal birth after a c-section (called VBAC).

The American College of Obstetricians and Gynecologists today released guidelines to make it easier for more women to have VBACs by encouraging health providers to consider VBACs as an option for healthy pregnant women. In fact, about 6 to 8 out of 10 women who try a VBAC are successful in having a vaginal birth. Even women who are carrying twins and had more than one c-section in the past may be able to have a VBAC safely.

While there may be some risks in doing a VBAC (as with childbirth in general), it can be safe for many healthy women and their babies. The benefits of having a VBAC include a lower chance of infection, blood loss or other health complications associated with c-sections as well as a shorter recovery time after giving birth. You’re more likely to have a successful VBAC if:
• Your c-section cut was made in the lower part of the uterus
• Your health and baby’s health are well during pregnancy.
• Your labor starts on its own and continues naturally at 37 to 40 weeks of pregnancy.

If you had a c-section and are pregnant again, talk to your health provider to see if a VBAC is the right choice for you.

A little history (from the FeministBreeder) who said, "They confirmed what we already knew."

"... they didn’t come to this decision on their own. Back in March, the National Institutes of Health held a conference on Vaginal Birth After Cesarean – a conference that I attended, wrote about, and was even featured in during the "Mother's Stories." I was so proud to see that at that conference, birth activists from all walks of life – doctors, researchers, midwives, and mothers – gathered to help try to convince the panel to see what we’ve all been seeing, which is that women’s rights are being trampled on when they are denied the safe option of vaginal birth. The ACOG President himself sat in a theatre listening to stories of doctors who couldn’t help their patients because their hands were tied. They heard stories from mothers who had to battle hospitals for the right to birth vaginally, or instead birthed unassisted at home because they could not find a provider able to help them. And they listened to highly respected doctors and researchers present the latest available evidence, which is that VBAC is a safe option, and in fact, it is a safer option than a repeat cesarean for most women.

They were also shown a slide listing grassroots organizations and activists who tirelessly battle to preserve patient autonomy and protect the rights of childbearing women. Thanks to those women who stood up and demanded that this was a human right’s issue, the ACOG also included this in their statement:

“restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will if, for example, a woman in labor presents for care and declines a repeat cesarean delivery at a center that does not support TOLAC.”

Do they know how long we’ve waited to hear those words?

I know many of us don’t care what the ACOG says, and we’d be VBAC’ing whether they got on board or not. But this statement could actually change maternity care in this country. They have now admitted that women are being “forced” into surgeries they do not want or need. They now admit that cesareans have risks, and that the risks of vaginal birth are much lower than previously implied. They are now admitting that despite their claim as the authority on All Things Obstetric, it took a government panel to investigate this issue for the Truth about VBAC to be exposed.

http://thefeministbreeder.com/jules-michael-birth-story/

Preterm Births - The magic of 40 weeks

According to the March of Dimes Utah gets a "C" grade in preterm births, which are on the rise throughout the country. There was only one "B" grade (Vermont) and no "A"s.

Late preterm birth (defined as 34-37 weeks) is on the rise in the U.S., now making up 71% of all preterm births. Many of these are preventable, but they are associated with increased problems.

In some cases this early delivery is a necessary prevention of problems. Pregnancy dating difficulty often results in elective induction or cesarean section births because these aren't always accurate, especially those estimates and ultrasounds done later in pregnancy. An early dating ultrasound in the first few weeks is considered most accurate and measurement of the mother's abdomen and by ultrasound are notoriously wrong.

The healthiest babies with the lowest risks (even for the first year of life) are born between 39 and 41 weeks completed gestation. Anything earlier increases their odds for a myriad of problems including breathing difficulties, feeding problems and jaundice. These babies are also at increased risk for readmission to the hospital. Breastfeeding is often interrupted, sometimes resulting in a baby being deprived of the best nourishment out there at a time when they need it most. Many of these late preterm babies require NICU or special stay nursery care which can cost 10 times the charges in a normal, uncomplicated delivery at term.

As an example of what is happening during those last few weeks of gestation, the baby's brain at 35 weeks weighs only2/3 of what it will weigh at39-40 weeks. See more here.

ACOG (American College of Obstetrics and Gynecology) advises against any elective deliveries prior to that time without clear risks which must be circumvented such as maternal or fetal well-being (high blood pressure, pre-eclampsia, congenital malformations, cord or placental insufficiency, etc.) . Because of dating errors sometimes when we think we are dealing with a baby at 37 - 38 weeks, it could be that the baby is actually 35 - 36 weeks and behavior is like that of a preemie as opposed to a term baby.

Consequences of Late Preterm Delivery
• Temperature instability
• Hypoglycemia
• Breathing difficulties
• Feeding difficulties
• Jaundice
• Sepsis
• Increased neonatal and infant mortality
• Increased NICU use and readmission
• Increased cost

No pregnant woman enjoys the last few weeks of pregnancy and most would jump at the chance to deliver early if they feel the baby would be OK. And, in many cases, the baby is OK, but in far too many, the baby is not ready for life outside the womb. Cesarean delivery rates are also increased when an elective induction is performed because once the membranes are ruptured, infection risks necessitate delivery one way or another. The first c-section often determines future deliveries. This could mean increased risks because multiple c-sections and VBAC deliveries are both associated with more complications than vaginal deliveries. So this first one is a critical decision not to be entered into lightly, even when sorely tempted. Asking a pregnant woman if she wants to have the baby at her (or her doctor's) convenience is not the best way to make a decision with possible long-term adverse consequences.

The March of Dimes suggests asking hard but important questions.

If your doctor or CNM recommends delivery before 39 completed weeks, ask these questions about induction or elective c-section:

• Is there a problem with my health or the health of my baby that may make me need to have my baby early?
• Can I wait to have my baby until I'm closer to 40 weeks?
• Why do you need to induce my labor?
• How will you induce my labor?
• Will inducing labor increase the chance that I'll need to have a c-section?
• Why do I need to have a c-section (if applicable)?
• What problems can a c-section cause for me and my baby?
• Will I need to have a c-section in future pregnancies?
• If I want more children beyond one or two, how will a c-section now affect this?

Sometimes women mistakenly believe that c-sections are safer and they request this surgery. The truth is, risks are inherent in any birth, but c-sections are major surgeries and except when they are truly needed, the risk is greater than in normal vaginal deliveries. C-sections should be the rare exception when the benefits outweigh the risks. Unnecessary c-sections also contribute to the high cost of health care since they cost 2-3 times that of a vaginal delivery even without other complications resulting from the surgery. For a time it was believed that future problems with urinary stress incontinence might be prevented if a vaginal delivery is bypassed but this has not proven to be the case. This problem occurs in women who have never had children and in women with c-sections. The studies concluded that this should not be a consideration in deciding mode of delivery.

If you are the one pushing for an early delivery due to discomfort, false labor pain, family concerns, grandma coming to town, etc. try to keep perspective about what is most important. The convenience now could be completely consumed by the inconvenience, stress and worry that comes when the baby ends up in trouble because he/she was just not quite "done" yet. Even grandma will be happier with a healthy grandchild and baby's mom, even if it is a little bit inconvenient.

More thoughts on induction here.

Ultrasound Guestimates

Be careful when determining the size of your baby by ultrasounds, often used to get an idea of a baby's size. What the practitioner may fail to tell the mother is that third-trimester ultrasounds which attempt to guess the weight of the baby are considered accurate within two pounds (plus or minus). In baby size, that is a huge variation. Because of this I'm always a bit skeptical when someone reports that the technician told them their baby was 6 lbs. 6 oz. (in utero according to ultrasound). This is a calculation based on averages and it would be much more accurate if they would say "your baby is between 4 lbs. 6 oz and 8 lb. 6 oz" to allow for the normal variation - quite a difference! But, that would not sound very scientific and we do like to believe that our high-tech society really can predict this accurately.

It can be a bit risky when critical decisions such as elective inductions or planned c-sections are made based on this kind of information.

For instance, if a woman had a history of delivering a large baby with difficulty, the doctor may advise an early c-section or induction to prevent the baby from "getting too big" but with the two weeks' variation in ultrasound pregnancy dating, there is the potential of delivering a baby that is actually preterm, with accompanying problems. If a planned induction fails because mom's cervix was not actually ready a c-section is likely. So major surgery is another possible risky complication. If the baby is actually a bit premature on top of that (again because of variability of dates), this kind of decision could mean danger for both mother and baby.

Sometimes a baby needs to be delivered early. The goal here is just to be sure you are informed if the only reason you are planning to intervene is because of the ultrasound size measurement. Any baby born by elective induction or c-section more than a week early in the absence of complications that might put the baby or mom in danger to continue the pregnancy to term, should only be done with a lung maturity assessment to be sure the baby is ready. Read what the March of Dimes says about elective inductions and what you should ask your doctor here .

In addition, they have made this statement:

"Clinicians weigh the risk for the mother and the fetus of continuing a medically complicated pregnancy, versus the risks associated with earlier delivery. For some high-risk pregnancies, early delivery may promote better outcomes for both the mother and the baby. The availability of more data on the outcomes of late preterm births will better inform providers and the public about potentially preventable risks. Pregnancies should continue to term if medically and obstetrically advisable, thereby avoiding unnecessary preterm inductions and c-sections. (Source)

Click the post title to see some mothers' experiences with weight guesstimates and the accuracy of them.

The woman's pelvis also has an amazing ability to move and allow delivery, in most cases even of a large baby, so baby and pelvis size do not necessarily mean normal vaginal delivery is impossible. The baby born full-term (ideally 39-40 weeks) has the best chance at good health. It's important not to rush things simply for convenience or avoidance of another few weeks of discomfort.

Want more information about this topic? Click here to learn about the history of ultrasound in obstetrics. And, if you want to see some cool 3-D ultrasound pictures, click here.

Added later - On elective inductions, this is from the Deseret News:

"Some hospitals — including Intermountain Healthcare in Utah — are tightening the rules for elective deliveries because some babies are being delivered too early.

Recent research shows a troubling link between elective inductions and so-called "late preemies" who are at higher risk of breathing disorders and other problems than babies who finish their very last weeks in the womb.

"It was an 'aha' moment for me," recalls Dr. Bryan Oshiro of his visit to a Utah intensive care nursery several years ago, where neonatologists pointed to babies there simply because they'd been induced too soon."

C/S Awareness Month

The U.S.hit a record 31.8% C-section rate. While cesarean is a life-saving event when it is necessary, it is not without its risks and often these risks are downplayed, leaving women with the impression that it is a safer way to give birth. Not true! It is safer in some instances, but our high rate of cesarean deliveries reflects liability concerns, convenience, impatience, and more risk in many instances.

International Cesarean Awareness Network (ICAN) states:

"The Cesarean Awareness Ribbon debuted in April of 2004 for Cesarean Awareness Month. The burgundy color of the ribbons represents birth and the wearing of the ribbon upside down symbolizes the state of distress many pregnant women find themselves in when their birthing choices are limited. The loop of the inverted ribbon represents a pregnant belly and the tails are the arms of a woman outstretched in a cry for help."

Check her out for VBAC info too (Vaginal Birth After Cesarean). Good source of information here.

Risks in Pregnancy - short video clip

American Pregnancy Association posted this short video that addresses rising rates of complications in pregnancy. It appears that the increased cesarean rate has also caused an increased in some serious complications. It is major surgery so it's not too surprising this would be the case. I guess we get the ad along with the free service...click here to view it: American Pregnancy

Something to think about...
On average, a c-section brings in twice the revenue of a vaginal birth. Today, the c-section is the single most common surgical procedure performed in the United States. The first hospitals to adopt controls on early elective inductions have been nonprofits. Early inductions often lead to cesarean births because the mother's body is not ready for delivery and the result is "failed induction" and c-section birth. Cesareans are necessary at times, but too often they are not needed.