Due Dates & Inductions

The average length of pregnancy is 280 days from the first day of the last menstrual period. Most babies are born between 38-42 weeks gestation with very few arriving on their estimated due date.
Studies show that monitoring pregnancy while waiting for spontaneous labor results in fewer cesareans without any rise in the stillbirth rate. It is true that the stillbirth and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no signs).
Post-term isn’t until after 42 weeks. ACOG states:  “Health risks for the baby and mother increase if a pregnancy is prolonged. The more prolonged the pregnancy, the greater the risks. But problems occur in only a small portion of postterm pregnancies. Most women who give birth after the due date have healthy newborns. After 42 weeks, the placenta may not work as well as it did earlier in pregnancy. Also, as the baby grows, the amount of amniotic fluid may begin to decrease. Less fluid may cause the umbilical cord to become pinched as the baby moves or as the uterus contracts. For these reasons your doctor may recommend delivery before 42 weeks of pregnancy.”
The risks of inductions include hyper-stimulation of the uterus (where the uterus contracts too frequently, decreasing blood flow to the baby), the use of extra interventions such as continuous fetal monitoring and the need for additional pain relief, and a failed induction leading to a Cesarean (NICE Guidelines, 2008). Induction multiplies the risk of cesarean section, forceps-assisted delivery, shoulder dystocia, hemorrhage, fetal distress and meconium aspiration. Inductions should only be given as an option when the benefits outweigh the risks involved.
As with anything it is a discussion you should have with your provider. Everyone has a unique situation and medical history so there isn’t one blanket course of action that will be right for everyone. The important thing is to ask questions and ensure you are making an informed decision regarding your options for delivery if labor doesn’t start on it’s own before 40 weeks what the next steps for you would be.
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Planning and the Unexpected

Many expectant women think about how their pregnancy and birth will go. They may read books or blogs, researching the latest fads, new research or what has been historically done for years. Most will talk to friends or family who have been there before, seeking advice on what to expect. Some will dream about the environment they want to welcome their child into, and others will focus on what life will be like after baby arrives.

Most women will be faced with an overwhelming amount of decisions regarding the birth of their child. Where do they want to give birth, where is plan B located, who will be there, how will I handle labor pains, what if I don’t go into labor on my own, what happens if labor starts too early, etc.? So many decisions to be made over the course of 9 months and for some not much has been explained why they would choose one over the other. How do you decided and who’s opinion do you trust? And all of this just gets you to the point of welcoming that child into the world, not to mention becoming parents and everything that happens after delivery. It is hard for some to navigate the web of information that surrounds pregnancy, childbirth and parenting.

I have learned that making a plan helps to alleviate some stress. Having time to research options and come up with a course of action when you are not pressed for an immediate decision is the best. But what happens when things veer off course? That’s where plan B comes in! It’s important to not only think about your ideal birth and create a plan in which everything goes ideally, and every option is still an option, but also to decide, if some options are taken away, what is still very important to you. Birth is not predictable and it’s important to be flexible in some areas when necessary. For example, options are limited when you are faced with a cesarean birth. Can you still have skin to skin contact once baby is out and you are still in surgery? Can you have your arms free to hold your baby instead of being strapped down?  You can talk with your provider about what options you may still have, given the situation.

There are interventions that are scary so some people don’t want to think about or plan for. It’s important though to familiarize yourself with what possibilities are out there so you can decide ahead of time what you would do given the situation. Take a childbirth class and learn all about the birthing process and what options are out there.  I encourage you to have a discussion with your provider if you have any questions about some of the possible interventions and situations surrounding birth.

Benefits of upright pushing in labor

Evidence shows that women should be allowed to make choices about the birth positions in which they might want to assume for the birth of their baby. Frequent position changes in the second stage may reduce the length of the second stage. (Golara. 2002) Researchers hypothesize that pushing in an upright position is beneficial for multiple reasons. In an upright position, gravity can assist in engaging the baby down and out. Also, when a woman is upright there is less risk of compressing the mother’s aorta and therefore a better oxygen supply to the baby. Upright positioning also helps the uterus contract more strongly and efficiently and helps the baby get in a better position to pass through the pelvis. Finally, X-ray evidence has shown that the pelvic outlet becomes wider in the squatting and kneeling positions. (Gupta. 2012)

Upright positions are defined as sitting (on a birthing stool or cushion), kneeling, and squatting. Non-upright positions are defined as side-lying, semi-sitting, and supine (back-lying with feet up in stirrups or supported by care givers hands). Research confirms that giving birth in a supine position has distinct disadvantages without demonstrable benefits to either mother or infant. Squatting can be the most exhausting position and is frequently combined with side-lying, semi-sitting and kneeling with resting between contractions. Even though positions such as side-lying, kneeling, and semi-reclining lose the advantages associated with gravity, other benefits include heightened relaxation and the opportunity to rest more effectively between contractions. Throughout the course of labor women benefit from frequent position chances and ideally, should be free to select or reject them at will.

The use of epidural frequently limits the ability of the laboring woman to change position without assistance. Even distribution of the pain medication is best achieved when the woman remains supine or semi-reclined. (Roberts & Hanson. 2007) Maternal movement is also complication by the need for iv fluids, continuous monitoring, and the use of urinary catheters. These common practices do not prevent women from using a variety of positions during labor and birth but may not be achievable without a great deal of assistance. Almost three-quarters of women in the U.S. (71%) receive an epidural during childbirth (Declercq. 2007). There have been only two randomized, controlled trials that compared upright versus non-upright pushing positions in women with epidurals.  Results from both studies show that being upright during the second stage of labor shortens labor in women with epidurals.

Families should understand the benefits of approaching birth with an evidence-based approach that allows for self-determined positions throughout the second stage of labor. Understanding that the length of second stage is variable and may be prolonged without adverse effects. Continuous labor support aids in this approach by helping the birthing person and partner feel knowledgeable and supported about their birthing decisions and recognizing that they have choices in their birth. Women should be allowed to give birth in whatever position they are comfortable in.

 

Labor Positions

“Research suggests that certain positions can also enhance the progress of labor.”

Mayo Clinic: Labor Position Slide Show

Changing your position often during labor can improve the progress of your labor. Upright positions use gravity to help bring the baby down. In addition, moving around allows your uterus to labor more efficiently. High risk complications and certain medical interventions restrict movements for some mothers. A doula can help with labor positions to aid in coping well with early labor as well as active labor support once you are at your place of birth.

Freedom of movement is important in making the birth of your baby easier. It is the best way for you to use gravity to help your baby come down and to increase the size and shape of your pelvis. It allows you to respond to pain in an active way, and it may speed up the labor process (Simkin & Ancheta, 2005).

Researchers who examined all of the published studies on freedom of movement in labor found that, when compared with policies restricting movement, policies that encourage women to walk or change position in labor may result in the following outcomes:

  • shorter labors,
  • more efficient contractions,
  • greater comfort, and
  • less need for pain medicine in labor

(Simkin & Bolding, 2004Simkin & O’Hara, 2002).

 

What is a Baby-Friendly hospital?

Have you heard of baby-friendly hospitals but never really understood what that meant?

According to their website: ” The Baby-Friendly Hospital Initiative (BFHI) is a global program that was launched by the World Health Organization (WHO) and the United Nations Children’s Fund (UNICEF) in 1991 to encourage and recognize hospitals and birthing centers that offer an optimal level of care for infant feeding and mother/baby bonding. “

Hospitals have go through several steps to receive the BFHI designation. Most importantly they train their staff  on how to give mothers the information, confidence and skills to successfully initiate breastfeeding. The staff has more training compared to hospitals that aren’t a part of the program. This additional training helps them better prepare mothers on  how to safely feed their newborn. While breastfeeding is one of the main platforms of the BFHI there are several other aspects to the accreditation that are beneficial to all mothers and babies. The full list is listed here:

The U.S. BFHI Guidelines and Evaluation Criteria and the assessment and accreditation processes are predicated on the following tenets:

  1. Well-constructed, comprehensive policies effectively guide staff to deliver evidence-based care.
  2. Well-trained staff provide current, evidence-based care.
  3. Monitoring of practice is required to assure adherence to policy.
  4. Breastfeeding has been recognized by scientific authorities as the optimal method of infant feeding and should be promoted as the norm within all maternal and child health care facilities.
  5. The most sound and effective procedural approaches to supporting breastfeeding and human lactation in the birthing environment that have been documented in the scientific literature to date should be followed by the health facility.
  6. The health care delivery environment should be neither restrictive nor punitive and should facilitate informed health care decisions on the part of the mother and her family.
  7. The health care delivery environment should be sensitive to cultural and social diversity.
  8. The mother and her family should be protected within the health care setting from false or misleading product promotion and/or advertising which interferes with or undermines informed choices regarding infant health care practices.
  9. When a mother has chosen not to breastfeed, when supplementation of breastfeeding is medically indicated, or when supplementation is chosen by the breastfeeding mother (after appropriate counseling and education), it is crucial that safe and appropriate methods of formula mixing, handling, storage, and feeding are taught to the parents.
  10. Recognition as a Baby-Friendly institution should have both national and international credibility and prestige, so that it is marketable to the community, increases demand, and thereby improves motivation among facilities to participate in the Initiative.
  11. Participation of any facility in the U.S. BFHI is entirely voluntary and is available to any institution providing birthing services. Each participating facility assumes full responsibility for assuring that its implementation of the BFHI is consistent with all of its safety protocols.

To find if your hospital is a part of the Baby-Friendly Hospital Initiative check out their website. Baby-Friendly USA

ACOG recommends Doulas

There has been buzz about a study produced by The American Congress of Obstetricians and Gynecologists (ACOG) in 2014 and reaffirmed in 2016 about the benefits of continuous labor support during labor.

“Increasing women’s access to nonmedical interventions during labor, such as continuous labor support, also has been shown to reduce cesarean birth rates.”

These new guidelines encourage birth providers to re-examine some standard practices that might not benefit low risk mothers. It is important that ACOG is publishing information that supports more individualized labor care and re-examining practices that might impede more than aid labor. Working relationships improve as studies show doctors and other birth professionals that doulas have a positive impact during labor and delivery. More mothers hear about and hire doulas which means more mothers receive the benefits of having a supportive birth experience.

 

To read the statement from the American Congress of Obstetricians and Gynecologists click here

 

Birth Plans 101

A birth plan is a way to communicate your expectations and preferences for labor, delivery, postpartum recovery, and newborn care. Birth is unpredictable so you need to have flexibility in your birth plan. But a printed document gives you a place to make your wishes clear.

You should do your research and be very educated about your choices regarding your birth. Knowing what the standard procedures are at your place of birth is important when creating your birth plan. Plan on discussing your birth plan with your provider during your third trimester. Discussing your wishes for birth with your provider will ensure that you are both on the same page and gives you a realistic view of what your options are for birth given your specific medical history.

Plan for the unexpected. No one goes into birth desiring things to go off plan. But it is helpful to have a plan incase the situation changes.

Include sections for infant care and postpartum recovery. Your desires for care after delivery are important.

As a doula I help my clients gather their wishes into an easy to read document that clearly expresses their wishes for their birth.