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.

Induction?

This is a week for lots of inductions and planned c-sections as people try to avoid Thanksgiving for the birth of their babies. But, before rushing in to this, it would be wise to consider the risks as well as the benefits (which of course are obvious!). Induction can be a positive experience with a good outcome if considered carefully and if you and the baby really are ready.

Some things to consider...

The March of Dimes says, "More than 70 percent of premature babies are born between 34 and 36 weeks gestation. These are called late-preterm births. Late-preterm babies account for most of the increase in the premature birth rate in this country. A 2008 study found that cesarean sections (c-sections) account for nearly all of the increase in U.S. singleton premature births, and this group had the largest increase in c-section deliveries."

What this means is that "late-preterm births" are the most preventable of all preterm deliveries. Much stress and risk can be avoided if the baby can go home with mom rather than going to a NICU (Newborn Intensive Care Unit). In addition to the emotional trauma, a special care nursery with its restrictions, wires, machines, treatments and feeding requirements associated with preterm babies can interfere with breastfeeding success and the health care costs skyrocket. We are very fortunate to have excellent NICU care, but a healthy, closer-to-term infant is ideal.

There is some confusion about why these preterm infants are preventable. If the induction is based on calculated dates, it would seem they would be at term. The problem arises that calculations have an error factor and can be off by a couple of weeks. Thus a "term" baby of 37 completed weeks gestation could actually be 35 weeks by physiological exam at birth. This happens often enough that the stats could be improved greatly by not delivering prior to 39 completed weeks' gestation, unless there is a serious medical concern with the mother or baby necessitating an early delivery. This would be in such cases as pre-eclampsia (where the blood pressure gets too high and can't be brought down with traditional means - bedrest and meds) or when the baby has a placenta or cord problem keeping it from receiving adequate nourishment.

There are other situations as well, but a few reasons that really aren't wise for an earlier delivery include:

• The doctor is going out of town
• The baby's grandmother is coming to town
• The mother is tired of being pregnant
• The mother is having lots of "false" labor and is uncomfortable
• The doctor said the baby will be healthy at this point (this is hard to ascertain)
• The ultrasound said my baby is too big (ultrasound exam estimates of weight in late pregnancy may be off by one whole pound)
• A friend/relative had a baby born early and was just fine
• Big babies run in the family

It is also dangerous to assume that induction assures a safe vaginal delivery. If your body is not ready for induction there is a higher than usual chance you could end up with a surgical delivery because once the membranes have been ruptured (often artificially in the case of labor induction), there is a risk of infection so the clock is ticking. Delivery is best accomplished within 24 hours or less. Risks of c-section include the usual surgical risks, anesthesia, a more difficult recovery, potential rupture of repaired incision, bladder or uterine injury, infection and postpartum depression related to complications and delayed return to activity, pain, etc. It can also affect your future childbearing plans as following deliveries mean either a VBAC delivery or repeat c-section (increasing risks with each).

You may be a candidate for induction if:

• Your cervix is ready (soft, dilating and effaced) and the baby in low, correct position. A bishop's score is often used to predict readiness.
  
• You have completed 39 weeks or more of gestation with accurate date estimates by last menstrual period and/or early ultrasound dating. The closer you are to your due date, the higher the likelihood of a successful induction.
  
• You have discussed pros and cons of induction with your doctor or midwife, including how long induction will last before other interventions occur, such as c-section. There are a lot of 5:00 pm c-sections performed following early morning inductions - sometimes due to "failure to progress" which may just mean not enough time to progress yet. It is not unusual for labor to take 12-14 hours and the initial dilation can be slow, especially if the cervix is less favorable).
• You are OK with having an IV from the onset and for the duration of labor and delivery. Usually continuous monitoring is also required, thus restricting movement and mobility to a degree, possibly earlier than desired.
• You are able to be objective about what is best for you and your baby. It is easy when you are nearing nine months pregnancy to let your emotions make your decisions. Try to remember that even though each day feels like a week, adequate time in utero is critical to the health of your baby.
• You can be flexible since some procedures may be required that aren't part of your birth plan. However, you can have an unmedicated (limited or no anesthesia) birth even with induction if you want, particularly if you have prepared for that.
  

To improve your odds, talk frankly with your health care provider and be sure you know all your options, risks and benefits - including c-section delivery possibility before committing to a scheduled induction. Inductions can be good when all factors are considered and sometimes it is the best option for you and your baby's health and safety.

Tomorrow I will post a 16 minute video for your enjoyment, celebrating the first birthday of one late preterm baby. He is very healthy now but he got a rough start.

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."