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Jul032008

Post-Dates - Thinking Aloud/Allowed

The article Delaying Childbirth Is Associated With Impaired Contraction of the Uterus and Rising Rates of Cesarean Section reminds me of a phrase I use when discussing post-term pregnancies:

Oftentimes, women who needed help getting pregnant need help getting un-pregnant.

I believe there is a misconception that any length of pregnancy is normal. Yet, if we left all pregnancies to find their natural end, some wouldn't ever be completed and the baby would also not survive.

Lots of caveats:

- Allowance needs to be made for women's cycles

- Some pregnancies do last longer than typical pregnancies (more on that in a moment)

- While I believe some women need to be induced in order to have healthy pregnancies, I do not agree with inducing earlier and earlier in the name of safety.

- I do not believe the definition of post-dates should be changed to 41 weeks or under. (Too many docs even consider over 40 weeks post-dates!)

But, in my experience, when women have hormonal or metabolic issues in their bodies, it isn't uncommon for the body to need a kick-start to get things moving. Maybe the kick-start is homeopathics, Evening Primrose Oil, herbs or even an enema/castor oil or stripping the membranes. Sometimes, the kick-start is prostaglandins or pitocin..

There will always be exceptions - I acknowledge that - but in my limited experience and in talking to loads of women, fat women, women with PCOS (Polycystic Ovary Syndrome), Syndrome X, Gestational Diabetes, older (over 35 or so) primips and women who used technology to get pregnant all seem to have disproportionately high numbers of post-term pregnancies.

Searching "PCOS post-dates pregnancy" comes up with story after story of women 2 weeks "late."

"Post-dates Gestational Diabetes" finds the same information.

(Post-dates is not the same as post-term in my mind. Post-dates is more arbitrary and post-term is a clinical description of the baby and placenta. But, one has to be post-dates in order to determine if the baby is post-term.)

I don't find much information talking about my theories, however, so I really could be way off the mark, missing something. But, I don't think so.

I define post-dates as moving beyond 41 weeks and 3 days with no cervical changes. (I've never written that down before. It feels... um... interesting? Good? Scary?)

It does seem an arbitrary number, doesn't it? What makes me pick that specific day? I admit it... lots of the thinking is "What's are we going to do when we hit 42 weeks?"

(And by 42 weeks, I mean the end of 41 weeks, the beginning of 42. Back in the day, a post-dates pregnancy was at the end of 42 weeks, the beginning of 43.)

Our law states we need to transfer care at 42 weeks. With informed consent, I can avoid what the law says to do, but informed consent is going to include fetal death if the pregnancy is left to go too long.

Starting at 41.3, I need clients to start Biophysical Profile (BPP) testing. I want to know how the baby and placenta are doing. I know it irks some women to hear it, but placentas do have a shelf life.

I have my clients do a BPP every two days while also becoming more aggressive in the "natural," yet active means of getting a cervix softer and hopefully, the uterus doing the work it needs to do.

I do get very antsy once we hit 42 weeks and nothing is happening. Enough research shows a sharp increase in fetal death after 42 weeks and higher and higher the longer the pregnancy goes.

The article mentioned in my opening validates some of what I am saying, although indirectly.

"...they hypothesized that the increased risk of caesarean section among older women is a result of a biological effect of aging on the ability of the muscle of the uterus to contract. They evaluated this hypothesis by examining biopsies from the uteruses of a separate group of 62 women (of mixed parity) undergoing routine elective cesarean delivery in Cambridge. They found that advancing age was associated with impaired uterine function as evidenced by a reduced degree of spontaneous contraction and the type of spontaneous contraction."

The article doesn't directly speak of post-dates or post-term pregnancies, but "impaired uterine function" could certainly be a cause of a post-term pregnancy.

So, I agree the cesarean rate is dramatically inflated for, what would seem to be, causes to do them, but what if women in today's world really were having labor issues and needed to have cesareans because of failed inductions? What if the number of older moms, fatter moms and women with metabolic disorders were some of the reason cesareans aren't in the 5%-10% range most of us think it should be? What if the rate of cesarean really should be higher in our country because of our over-nutrition? Because we are technologically able to conceive babies despite mechanical, hormonal or age issues?

What if we who do natural birth are overlooking information right in front of us? Would this be doing our clients a disservice?

I know it's sometimes hard to digest what the medicos churn out, but what if they're right on some things? How do we decipher the information? Whose spin do we assimilate into our practices?

I look forward to hearing others' thoughts on this topic.

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Reader Comments (66)

Excellent post. I agree with your point about not rolling back the magic "post-dates" limit to permit earlier and earlier inductions. I am also fine with going past 41 weeks (I usually start testing at 41 1/7 at the latest as long as testing looks OK. As a woman approaches 42 weeks, I begin to question the wisdom of waiting much longer. Certainly, if there was any uncertainty about her last menses or cycle length, then I think there is some wiggle room but I really start to chew on my nails at 42 weeks. At 41 4/7 I suggest castor oil, Eve. Primrose, sex, nipple stim, etc. I also strip membranes whenever possible after 40 weeks (with permission of course).

Our practice provides parallel care for home birth clients, and our local HB midwives "risk out" at 42 weeks. I've worked with some of their clients who have waited until 41 6/7 weeks to try the above non-medical kickstarts, only to proceed past 42 weeks which means they will have to come to the hospital to give birth. Sometimes I wonder if these women have some ambivalence about having a HB, but I have never asked them. What has your experience been?

I enjoy your blog very much. Thanks for reading mine.

July 3, 2008 | Unregistered CommenterTheresa

Actually, I have a question for you.

Do you think that so many inductions fail (as in, failure to progress leading in a section), or end up as emergencies because the baby was simply "not ready?"

Isn't there a very sensitive and very crucial mix of hormones between mom and baby that makes labor begin and natural birth take place? If we mess with that medically, and it fails to make productive labor happen, aren't we basically setting these women up for c-sections?

Or is it more important with post-term mom and babies that the birth takes place because the pregnancy has gone on too long, for health and safety reasons, no matter what type of birth it is?

July 4, 2008 | Unregistered CommenterMommy Dearest

Although I haven't read the article, not having access, there is an article I keep running into suggesting that obese women do not take up enough calcium in their uterus during pregnancy to add in contractions during labor. (Lipid rafts, the sarcoplasmic reticulum and uterine calcium signalling: an integrated approach
Karen Noble, Jie Zhang, and Susan Wray J Physiol. 2006 January 1; 570(Pt 1): 29–35. )

And there are other calls for studies in obese pregnant gals to administer cholesterol lowering drugs to try to increase the calcium absorption (Contractility and Calcium Signaling of Human Myometrium Are Profoundly Affected by Cholesterol Manipulation: Implications for Labor?
Jie Zhang, MBBS University of Liverpool Annabelle Kendrick, MBBS Liverpool Women's Hospital Liverpool, UK Siobhan Quenby, MD University of Liverpool Susan Wray, PhD University of Liverpool, s.wray@liv.ac.uk, Reproductive Sciences, Vol. 14, No. 5, 456-466 (2007)).

I do think that lowering cholesterol during pregnancy is a bad idea, we know that cholesterol rises during pregnancy, and then will fall due to nursing after the pregnancy and I am no convinced that cholesterol is implicated in a decreased ability to retain calcium - a poor diet might be though. Cholesterol is so critical to brain development and seems to be something that babies need, and the rise is true for all women regardless of size. Then again where you start out is important.

Sorry I'm taking up so much space, I'm not a midwife, a biochemist and someone who is obese and delivers late. I never thought much of it, my mother's children came in her 41-42+ weeks (4 babies), and she was NOT obese at the time. I delivered at 41.1 and 41.5 weeks, to babies who were healthy and not over-ripe. To me it's just when we (my family) delivers, and it's our norm. I do think humans have a lot more variability in our physiological norms then doctors want to allow for.

Anyway, hope I gave you some food for thought.

July 4, 2008 | Unregistered CommenterEthel

So, Ethel, how about this?

Fat women sit inside more and don't get enough vitamin D which DOES have a huge hand in calcium absorption... and the lack of calcium could be the cause of minimal/absent uterine contractibility.

How's that for a non-scientic leap to conclusions?

Because of my own extremely low Vit D, I have been hearing and reading so much about women's (and children's and infants') Vit D deficiencies... even those of us who live where there is plenty of sun. I know that as a fat woman, I am outside in the sun SO much less than even my getting-less-overweight partner. I know that the fatter I was, the less outside - especially during the day - I wanted to be. It wasn't fun being made fun of for being so fat. And it's hot and sweaty or cold and having to pile on too many clothes (which hinders the sun, too).

Another piece of information I am learning is newborns and infants are having decreasing amounts of Vit D in their bodies. Not that breastfed babies naturally have less, but they are having measurably less every year.

(Another leap.)

I wonder if, because of mothers' lessening Vit D intake from the sun, the babies themselves are also having their levels lowered.

Could Vit D be the panacea to all things Calcium/Labor/Newborn health related?

I should write a post on Vit D.

Thanks, Ethel... great insight.

July 4, 2008 | Unregistered CommenterNavelgazing Midwife

I have not commented in ages though have been reading always. I knew you from Empowered Childbirth and you helped "debrief" my birth stories a few years back. I'm in Ireland, if that jogs your memory. ;-)

And I apologise in advance- this comment will be a long one.

With my second child I was planning UC after a traumatic c-section for "failure to wait" with my first, and eight years of unexplained infertility after his birth. I was 30 years old and obese (250lbs+). Tough I had prenatal care, blood sugar status unknown as GD is not routinely tested here. I went to 42w5d with the second pregnancy.

I had no stress testing, but fetal movement started to decrease noticeably (enough to worry me) at 41w. I was still devoted to UC and tried all the gentle measures (aromatherapy, homeopathics, herbs, walking, prayer, etc) but was so desperate to birth my baby as the days passed that I became literally suicidal. I chose to try castor oil at 41w6d (over the strong objections of the EC ladies!) And got nothing more than a night of painful unproductive contractions and severe diarrhoea.

I went into labour at 42w4d- if you can really call it "labour". Contractions 2mins apart from the start but no stronger than very bad menstrual cramps. Coped for about 16-18 hours of this before I got fed up. Had my DH attempt a cervical check- my cervix was so high that he couldn't find it (despite having "practise checked" earlier the pregnancy- he knew what he was feeling for). So we went to hospital.

Hospital midwife checked my cervix- which she declared was high, long, and less than 1cm dilated. I was devastated. They rushed me into the OR for a c/s. My daughter was healthy with no sign of postmaturity. No mec either, but had two true knots in the cord (which is probably irrelevant as the cord was plenty long). I was not told the state of my placenta though I asked.

Docs said scarring to cervix from botched first section may have been an issue. I've long suspected that my pendulous belly was an issue- baby's head not putting proper pressure on the cervix. But reading this entry has me thinking- maybe a metabolic issue, too? Maybe poor uterine tone?

Who knows? I hate to play the "my baby could have died" card, but had I continued my devotion to the concept of UC and gone on to 43 weeks or beyond- yes, she could have died.

As a matter of fact, in my gut I think that her time was running short, which is why I went to hospital. Not truly because of "fear", but because of a deep gut feeling that something was not right.

We were lucky. I'm glad I listened to my gut in the end and got help before it was too late.

For any UCers reading, my intent is not to spread fear. This was my body and my birth, and the decisions made were mine, never coerced. I'm only sharing my experience.

July 4, 2008 | Unregistered CommenterLili

By the way- I should note- I was absolutely, 100% sure of my dates- it;s impossible to get it wrong when you've only had penetrative sex once in a six-month period.

July 4, 2008 | Unregistered CommenterLili

Hmm. Some thoughts on postdates - probably all in a jumble.
I agree that using postdates as an argument for earlier and earlier inductions is not great. I've even heard the diagnosis of "impending postdates" used to justify a 39+ wk induction which is just nuts.
I do think that the best available data does show a slow rise in the spontaneous stillbirth rate over time - but it actually looks like the rise starts earlier and only goes up more steeply after 42 weeks. That makes it more puzzling for me to decide what to do.
I don't think a fair amount of the iatrogenic prematurity rate is attributed to postdates inductions. I do think it's very important to establish good dating early in the pregnancy. I'm content with a certain LMP, knowledge of the woman's cylce length, some discussion of when they think conception occurred, etc - I don't mean everyone needs an early dating ultrasound - but I also don't want to be trying to find a few more days at 41 wks 4 days. The true rate of pregnancies going over 42 weeks is pretty darn low, so establishing good dating should help with the need to decide what to do at postdates.
I personally start monitoring at 41 completed weeks (41 0/7) and do an initial BPP, then decide on monitoring from there. For a healthy woman, especially a primip, with a normal BPP, I usually do a NST at 41 3/7, and another BPP at 41 6/7. If there is more concern for some reason, I individualize it.
After 42 certain weeks, I feel the only risk of induction are the risks of induction if that makes any sense. In my practice, I'm not worrying about an iatrogenic preemie at 42 weeks because I am very careful about dating early on (and in my experience, it is more common for me to move someone's dating later than earlier, meaning I'm not calling someone "late" who isn't even due.) So that leaves the risks of prolonged labor, failed induction, cesarean section. I don't personally have a huge failed induction rate, because I am very patient, and I set my clients up to understand that we are in for the long haul and it may be a while before we get things moving, so not to get discouraged, and I rarely AROM unless we are certain things are going well (and then only for a specific reason, not just because the water bag is still there!) and so that leaves me the option of calling off an induction that is failing and trying again another day. When that happens, we usually have the benefit of having had prolonged reassuring monitoring of the fetus, too (a prolonged CST usually) so I've even more reassured that babe is well and can wait a couple more days.
I haven't noticed the issue with obese women somehow. I do, however, see a connection between persistently posterior babies and both postdates and failed inductions - I always wonder if those babies would have eventually wiggled their way into decent position when I have a failed induction go to cesarean for persistent posterior/FTP or whatever. I don't think there is any significant benefit to the baby of waiting after 42 weeks, there might be small risk, and often my clients are anxious to hold a baby already, so it's rare for me have someone want to wait after 42, but occasionaly I do have someone, and I'm comfortable with that with good informed decision making. I had one such client have a great birth at 42 3/7 weeks, and I've never had a bad fetal outcome by waiting.
About cesarean rates - I'm a family doc, but I do a wide range of clients risk levels - I care for chronic hypertensive pregnant women, pre-e, gestational DMs even on insulin, have older clients, a lot of teen moms, plenty of obesity, etc. I do 60-70 births a year. My cesarean rate over the 7 years of my practice has consistently hung around 10-11%, and this is in an entirely hospital practice with a lot of clients who are not the least bit interested in a midwifery model of care (although they get stuck with it anyway if they come to me!) Except practices with really high risk clients (like a recent lupus client with renal failure I referred out) I think my rate is reasonable for standard US practices. And I do some of the things that might inflate my cesarean rate some (some elective inductions, about 1/3 epidural rate, caring for clients with more risk factors) so I do think it's possible to have a practice with good outcomes with a cesarean rate within that rate "most of us think it should be."

July 4, 2008 | Unregistered Commenterdoctorjen

Let's see...

I *can't* "prove" anything. That's why we're talking here, isn't it?

We all know we can find studies that show our points of view and it is up to our educated minds to decipher which ones we accept. I appreciate your thoughts and the studies you pointed out, mystic, but I have read too many other studies (well, overview of studies) that show a sharp increase in fetal demise after 42 weeks. As Dr. Jen says, the rise actually begins at 40 weeks, but goes up sharply after 42.

I feel as long as my clients know what's in my head and I have them research and they make *informed* decisions regarding continuing the pregnancy, we are on the same page. Post-term/post-dates certainly needs to be a topic of conversation earlier than 41 weeks, though, right?

(The more I write, the more I think I should write a book of consents that clients should read before we begin prenatal care together!)

I love, love, love what Dr. Jen has to say.

So interesting, Jen that you haven't seen the obesity correlation. I don't see the posterior one! I wonder why. Maybe it is what we expect/have seen that colors the incidences? Something for me to ponder.

You definitely move through the path towards induction as I would. I don't have the opportunity to utilize the pit to do an OCT the way you do, though. I would have to send a woman in for an OCT and around here, the likelihood of her leaving with the baby still in her uterus are nil.

I rupture membranes for post-term baby-having only if mom is 3-4 cm. I wouldn't feel comfortable with her cervix less than that. I had one mom who was 5-6 and 41.6 weeks. At midnight, she was going to go to the hospital (her choice), so I ruptured her membranes and she delivered 3 hours later. We'd done all the standard at-home induction ideas... several times, but only AROM tipped her over the edge into labor. She wasn't fat, but did have a baby that looked as if she (mom) had GDM (baby over 10 pounds and massive amounts of vernix). An undiagnosed metabolic issue? Hmmm.

I look forward to what you have to say, Dr. Jen, about the next post I am writing about Vitamin D. Your input is always welcome.

(Everyone's is!)

July 4, 2008 | Unregistered CommenterNavelgazing Midwife

LILY!!!!!!!!!

I had your records, but now don't know if I still have them.

How wonderful to hear from you.

Thank you for sharing your story. I know a lot of people poo poo anecdotes, but I believe stories can bring studies to life. I really appreciate your telling me you are still here!

*loving hugs*

July 4, 2008 | Unregistered CommenterNavelgazing Midwife

I'm curious about what you think of sweeping (or striping) the membranes as a more "natural" way of getting labor going? Do you do it for your post dates clients? Does it work well? I am biased as it worked super well for me - I had a favorable cervix and went into labor ~18 hours after the procedure.

July 4, 2008 | Unregistered CommenterCindy

This is obviously not a broad range study but from the women around me:

2 that are overweight with PCOS and GD went over their due date by 2 weeks

1 with GD went a day over

2 with PCOS (1 overweight) neither with GD birthed before due date by more than a week with a total of 4 children between them

July 4, 2008 | Unregistered CommenterMegan

Just for fun, thought you might enjoy the story of the last heavier woman I attended. She's 5 ft tall and 250 lbs approximately. She has very irregular periods due to likely PCOS, but did conceive spontaneously. Her first births 2 1/2 years ago with an OB in town was a cesarean at full dilation for a combination of fetal distress and failure to descend - reading her records it looked like she had some questionable fetal heart tones and wasn't pushing the baby out quickly (but she was a first time mom with an epidural) and she pushed for less than an hour before going to cesarean. The official diagnosis on her operative report was actually CPD - for a 7 lb 1 oz baby. Anyway, she switched to me for the second baby because she heard I was the doc to go to for a VBAC. Which used to be true. Unfortunately, my small community hospital changed its policy in the last 6 mos due to not have 24 hr in house OB and anesthesia all the time that we only do VBACs if everyone is in house, including a free surgery team (scrub tech and circulator nurse). My OB backup is not interested in sitting in house for even his own potential VBAC clients, let alone mine, so I can no longer do VBACs since I can't do surgery and therefore can't meet the new policy. There is no OB in my town that will attend a VBAC either on purpose. So, my client had the option to travel for a VBAC or schedule a repeat with me and my back up, and she reluctantly chose to do that rather than travel.
On the morning of her scheduled cesarean at 39 weeks, she arrived at 4:30 am saying she'd been having irregular contractions through the night, and now was having more painful contractions. She was 4 cms dilated. I talked to her about whether she wanted to go through with the cesarean or decline it, and she was now very unsure what to do. She was very worried that if she refused a cesarean at present, she'd still need one later, and of course, I couldn't guarantee her either outcome. While we were talking, it became obvious that her labor was really picking up. She asked for another exam, and by now was 7 cms dilated - only 1/2 hour after arrival! My OB backup arrived, anesthesia was in house, the surgery team was available. Client was still waffling, and really wanting pain meds. OB insists we move to the OR - although he is willing to let client do whatever she wants, he says he feels safer in the operating room (insert eye rolling here.) Off we go to OR. As my client slid over to the OR table, OB wants me to check her again - now 9 cms. At this point, he says he does not want to do a cesarean, he really wants client to try vaginally first, he insists that I break her water, waits until he sees that the water is clear, and he vanishes.
Now, client is stuck in the stranded beetle position on an operating table - pissed because pain meds are no longer available, and in serious transition labor. A few minutes later, though, she is pushing spontaneously. Luckily, we have a great anesthesiologist who, except for inexplicably hooking her up to a full cardiac monitor and continuous pulse ox, basically stood around and said encouraging things to the client. The circulator nurse and scrub tech are thrilled to get to see a normal birth, and the labor nurse has had a VBAC herself. OB pops his head back in briefly and tells the circulator nurse to find me some stirrups - and she shows back up with the candy cane stirrups - were the client's legs would basically dangle in loops of cloth. I said no way, as no one can possibly push a baby out with their legs suspended and flapping in the air! The nurse and I figure out we can at least roll her from side to side, so client pushes and we keep helping her move side to side. Her poor befuddled dh (his first child) sat on a stool by her head and tried hard to be supportive, but looked scared out of his mind. Shortly, she ends up partly on her right side, partly semi-sitting, with her arms wrapped around a trainee nurse, and her upper foot on my shoulder, and the regular labor nurse holding a doppler and keeping her bottom leg from falling off the table, and I am sitting on end of this narrow OR table, trying not to fall off as she keeps pushing her foot hard into my shoulder. Babe was shortly born in this position - a gorgeous little fellow, with a nice round head - 7 lbs 8 oz, and 36 1/2 cm head (7 oz and 2 1/2 cm bigger than her "CPD" baby.) Babe was born at 6:18 am, less than 2 hours after she arrived, and a little more than an hour before her scheduled cesarean.
Of course anecdote is not data - but at least in this case there was certainly no issue with obesity or hormonal issues! It was nice to squeak in one more illegal VBAC at least!

July 4, 2008 | Unregistered Commenterdoctorjen

I feel like I am looking at myself in your blog tonight. Emotional...very emotional. I am glad Lily's baby made it, mind did not. Sad sad sad. I wish I could comment more effectively, but do want to say, thank you for this post. I hope all that read it are gently reminded that babies do die from post dates.
Much love.

July 4, 2008 | Unregistered CommenterDebstmomy

Curiously, in the studies that reflect a sharp increase in fetal demise after 42 weeks, what percentage of those pregnancies were left alone to gestate unfettered, and what percentage were managed with induction and other intervention (including frequent testing--and how proven is testing in preventing poor outcomes?). Since the standard to not allow post-42 weeks was already in place by the time these studies were done, it seems they would be forced to consider it medically unethical to not intervene with induction. So can we be certain that the sharp increase in demise really reflects dangers in post-dates pregnancies or the dangers in inductions?

July 5, 2008 | Unregistered CommenterAnonymous

What a great story!

Question: How old is she?

My own anecdote:

I was 180, 220 and 280 when I spontaneously conceived 3 babies. I went into labor, but with all three had SROM long before labor (3rd was 7 days before labor commenced)... I feel because of poor nutrition (over-nutrition). Kids were 10 days, 10 days and 2 days post-dates.

Back then, however, I didn't have the spotty periods I got a few years after the births. I believe I had some insulin resistance, but didn't get the PCOS until I was about 30 years old. Dx with Diabetes at 34.

So, wondering if the women with PCOS/insulin resistance issues might not have serious issues with conception/labor/breastfeeding until they are over (insert arbitrary age here) years old.

Maybe I am grasping at straws and making up a whole lot of gobblety gook.

July 5, 2008 | Unregistered CommenterNavelgazing Midwife

*loving hugs*

Yes, you are reading about yourself.

Much love.

July 5, 2008 | Unregistered CommenterNavelgazing Midwife

Re: stripping membranes

I do this rarely, but it is a tool in the arsenal of interventions.

I believe stripping/sweeping membranes isn't a very natural way to stimulate labor... it's one of the more invasive ones. Anything that carries the risk of a prolapsed cord (via accidental rupture of membranes) isn't very "natural."

My apprentice Donna is wont to say, "NO induction is natural... even if it is with herbs or homeopathy." And I agree with her. There might be a *spectrum* of induction methods, some more gentle than others, but provoking labor isn't very natural.

Doesn't mean Nature doesn't need a hand, however.

We're born in a day and age where we have a plethora of tools to help keep our babies and ourselves safe.

While it's important to keep perspective of *when* to use things, it behooves us TO use them when needed.

July 5, 2008 | Unregistered CommenterNavelgazing Midwife

On vitamin D:

My son takes a high quality Essential Fatty Acid, or fish oil, for verbal apraxia. This is supposedly a hefty life long diagnosis, but since he has been taking fish oil, only 2 months later he was talking, and 6 months later he tested out of speech therapy.

I knew that vitamin D was in his fish oil, and I also have learned that every man, woman, and child is EFA deficient since our diets don't include them anymore (or the balance of both of them anyway). In fact high quality EFA's, or fish oil, have been known to help kids with apraxia, autism, and ADHD, which are all on the same spectrum of neurological issues.

Anyway, I wondered if what you were talking about here, a vitamin D deficiency, was actually an essential fatty acid deficiency, since I know that humans in general are deficient in this, and taking it helps multiple systems in the body; including brain, heart, cancer, asthma, and depression.

Anyway, I typed in 'essential fatty acid vitamin D' in google, and came up with this;

http://www.springerlink.com/content/qq24686036117h58/fulltext.pdf

I'm not entirely sure what it means, but it talks about vitamin D deficiency and calcium absorption. From what I can gather, essential fatty acids help with vitamin D absorption, which in turn helps with calcium absorption.

Hope this helps.

July 5, 2008 | Unregistered CommenterJennifer

I am enjoying your blog but thought I'd send soemthing else out for you to think about. I conceived spontaneously at 28yrs old weight 260 height 5.5. Diagnosed with PCOS at age 20. 12 wks told one baby. 22 wks told 2 babies. Bed rest at 28 weeks due to pre-term labor. Spent as much time outside as I could regardless of how hot I was. Thankfully we were having a cool summer. Gestation went to 40 wks 5 days. Spontaneous contractions start labor. Labor started at 1:30, baby a born at 9:45 baby B born at 10:11. Was not regularly taking prenates (I kept forgetting. At 6 -8 months really craved milk and was drinking a gallon in a day and a half. So sorry for the length but thought you'd like to have another piece of data, granting that we are all different and there fore all pregnancies and deliveries are different.

Sarah

July 5, 2008 | Unregistered CommenterSarah

I get antsy when moms complete 41 weeks with no signs of impending labor. I recommend striping membranes at 41. At 41 3/7 I recommend castor oil. My protocols are 42 weeks before transferring/risking out.
I’ve had only one mom, G1 P0, in my private practice who has gone past 42 weeks, she
was also one mom who needed help getting pregnant the reasoning was insulin resistance. At the end of 42 weeks (on a Friday) we started talking about transfer she insisted on waiting it out through the weekend. SROM on Sunday morning, a regular labor pattern never was established and we transported at 5cm and 24+or- hr post rupture with mom unable to keep any thing down. 16 hrs of pit and 2 hrs pushing with little advancement resulted in a section. Baby was scored 41- 42 weeks gestation with very little molding. In hindsight I believe that it was hormonal and had an induction occurred earlier it might have been more likely to result in a vaginal birth.
Second interesting case was a G2 P1 whose babies are born at 37-38 weeks term and whose second baby was born with cranial stenosis. With baby number 3 she had SROM at 38 weeks and no labor despite having attempted every thing within a legal means to establish labor prior to transport at 41 hrs post rupture. The entire time I’m thinking this is a hormone issue. The OB, upon reviewing her history, stated that thyroid imbalance in moms have been linked to cranial stenosis in infants. Both of these moms where overweight, which might possibly have been the result of boarder line hypothyroidism.
It would be interesting to research the impact of mild to moderate thyroid hormones imbalances and their associated effects on spontaneous labor.
In most cases I do believe that women grow their babies to term at an individual rate some where between 37 and 42 weeks.
I myself have had everyone of my children go beyond the 40 week mark, being 40 +5 41, 41+4, 41 +3, 41 up to 42. It has also been my experience that women are generally consistent in regards to the weeks gestation and the onset of labor. So I pose this question.
If you had a client G4 P3 with reliable dates who consistently experienced spontaneous labor at 38+-5 days, then with this pregnancy she is closing the 40 week window, or the opposite where she goes to 41+-5days now she is in labor at 38+-5days would you be lifting an eyebrow? I would certainly be lifting an eyebrow maybe two.

July 5, 2008 | Unregistered Commenternadahfmidwife

Actually, as I was showering after commenting I did think about vitamin D also. And too, I think that a lot of women are undiagnosed celiac disease (as I was with first and I did not respond to pitocin after premature rupture) which interferes with calcium absorption. And while I was thinking about vit. D I was thinking about how it's a steroid too (fat soluble molecule), and that our fat ingestion would interfere with that availability of vitamin D to do it's work (a drop in a bucket of vit. D vs. a usable dose).

Basically, vit. D is an agonist and anti-agonist at some protein sites but if there is enough steroid like molecules like Vit. D. interfering with vit. D's ability to seat in the appropriate active site of proteins, it's not going to do it's job.

I will say, I am a fat ass myself (330lbs and 6'... ideal I was told is 210 for me). I spend a lot of time thinking, and I have been thinking about this one. Indeed with my second staying on a gluten free diet certainly might have helped with my VBAC since I responded to my own body and the extra pitocin my doc was giving me (no worries, it was a small amount and she's a VBAC warrior). It's a lot to think about.

July 5, 2008 | Unregistered CommenterEthel

FWIW, NHS guidelines say you're postdates (risked out of midwife care) at 40+12. I don't think they're as big on NSTs/BPPs here (you'd have to go to a hospital ultrasound department). They are big on membrane sweeping and stripping--they tried it on me (I can't remember which, I think strip) and it hurt like hell because my cervix was high and tight (38+3). Had a caesarean later that night.

July 5, 2008 | Unregistered CommenterAlexis

This in response to Jennifer about EPA's. This is a response from Chris Masterjohn(http://www.cholesterol-and-health.com/Vegetarianism.html) in a discussion about EFAs and prostaglanding:


***
"I just wanted to let all of the mommies out there that while cod liver oil
is great, it is a known fact that omega fatty oils suppress prostaglandins
(these are needed to go into labor), so you may want to stop cod liver and
other omegas at the beginning of third trimester. By then you will have
built up enough of the good stuff and you will have an easier birth."

There is some truth to it.

Just to clear up terminology first, there is no such thing as an
"omega fatty oil." Fatty acids are either omega-3, omega-6, omega-7,
omega-9, etc, not just "omega." The "omega" refers to the tail end of
the molecule and the number refers to the first carbon in where you
find the first double bond. All fatty acids have omega ends but not
all of them have double bonds.

Induction of labor is dependent on prostaglandins, which are formed
from the omega-6 fatty acid arachidonic acid. This is the one that
everyone calls "inflammatory" and is the most important essential
fatty acid in the body.

Cod liver oil is very useful during pregnancy because it supplies DHA.
The fetal brain takes up huge amounts of DHA in the third trimester.

The downside to cod liver oil is that it also contains EPA, which can
interfere with arachidonic acid metabolism, and thus could interfere
with labor induction.

There are a few ways you could address this:

-- Try to eat a diet very low in total PUFA by excluding all of the
PUFA-rich vegetable oils and poultry fats and using olive oil and lard
only in moderation, while primarily using butter, coconut oil, lamb
and beef fat, and so on. Eat a diet rich in vitamin B6 from bananas,
liver, and meats that are not overcooked. These practices will help
you convert the EPA in the cod liver oil to DHA.

-- Eat liver and large amounts of egg yolks. This will provide plenty
of arachidonic acid to balance the EPA. Pastured egg yolks are a
decent source of DHA as well, so if you eat a lot of them you could
reduce your CLO somewhat.

It is traditional to eat a diet high in omega-3 fatty acids during
pregnancy. One group I've read of used flax seed. Most of the
groups Price looked at used fish eggs if they had access. These are
high in EPA and DHA. It might be the case, however, that they are
high in arachidonic acid (unlike CLO), but this is not clear because
nutritiondata lists a 20-carbon 4-double bond fatty acid that is
usually arachidonic acid but in this case could be a different omega-3
fatty acid, because they don't say whether it is n-6 or n-3. So
anyway, I think in conclusion you want to make sure to get a source of
omega-3, ideally DHA, but you also want to make sure to get plenty of
arachidonic acid.

I don't know if cutting the CLO for the last week will help, since
your membranes will be influenced by what you've been eating through
pregnancy and the cell membranes are where the arachidonic acid is
stored, but I suppose it couldn't hurt to replace the CLO with extra
pastured egg yolks for that time period.

Chris

***

To add information about fatty acids and labor.
maria

July 6, 2008 | Unregistered CommenterAnonymous

But, pregnant women are not supposed to eat beef or poultry liver because of the toxins they hold.

Pregnant and nursing women are also not supposed to eat flax seeds or use flaxseed oil because of the (possible) estrogen issues and the possibility of reducing clotting abilities. I've also read flax (in its incarnations) can delay the start of labor.

This is good/interesting information, but folks need to read the available information for themselves and discuss things with their care providers before adding suggestions to their diets. (How's that for a CYA!?)

I am really enjoying the discussion. Thank you so much for adding to it.

July 7, 2008 | Unregistered CommenterNavelgazing Midwife

anonymous,

Interesting. This person you quote from though is a vegetarian, so this may cloud his views on "cod liver oil". Do you have any studies or anything else that backs up what you are saying?

Also, I wasn't speaking specifically about 'cod liver oil', in fact, I take salmon oil myself. The thing about Essential Fatty Acids that is important to keep in mind is that they should be balanced properly. For example, with my sons condition of Apraxia, his EFA's need to be balanced properly with EPA's and DHA's, which only a few high quality brands do (Vital Choice, Nordic Naturals, Carlson's). If he were to take any old generic brand that was not properly balanced, it would have little effect on him (yes we did try this, it had an effect, but not that much), it is the proper balance and the higher quality fish oil that fills the nutritional void that we all have.

The proper balance is what we are missing in our diets. Our species evolved as carnivores who ate foods such as fish with EFA's. We are now missing these things in our diets as we don't eat enough fish anymore. Pregnant women may not eat any fish as they are afraid of the mercury in them. So EFA supplements are very important, in my opinion anyway. And from the study I posted it seems as if they may have something to do with vitamin D absorption and the way our body deals with calcium. I think that is an important clue in relation to what Barb was talking about earlier with vitamin D. Especially since pregnant women shun fish, so they aren't even getting their normal amount of EFA's.

July 7, 2008 | Unregistered CommenterJennifer

I'm so happy with this post, because it is so timely for me!

I've got a client planning a (first) homebirth for her fourth baby, due later this week. She has PCOS and weighs about 260 at 5'3" or so. First two babies were just under 42 weeks gestation, third was a few days past her due date. First two babies were Pit inductions, third was Pit augmentation after SROM and ineffectual contractions. Blessedly, all were vaginal births.

SVE last week (her request) showed a typical multip cervix - 1cm, 50%, floating head.

I've been on her case to walk, walk walk! Studies have shown that the more regular exercise a woman gets, the more likely she is to give birth close to her due date, so I've been trying to get her to take a brisk 30-minute walk every day. She's been mostly compliant.

But, I'm also thinking there may be a hormonal component to the way her labors went--like, how can I get more of her own Oxytocin flowing to help her uterus contract better? She needed Pit for all of her other labors and I'd to not have to go that route if we don't need to.

So, your thoughts about Calcium and Vitamin D are very well taken. I've had her doing a Cal/Mag supplement for her whole pregnancy, but I'm thinking of upping it now, and having her include Vitamin D. Can't hurt, might help, eh?

Thanks for such a lovely blog!

July 7, 2008 | Unregistered CommenterKaren

In my bit of Britain, they won't offer you an induction before 41 w 3 days, and even then, you'll be offered a stretch-and-sweep first. I was offered one at 41 w 1 day, and then after the midwife investigated, she refused to do one because she felt that my cervix wasn't close to ready. I suppose that I appreciate it now, but at the time, I went home and bawled. I finally went into labour naturally at 41 w 3 days exactly, and delivered an average-sized baby with parchment skin and ridiculously long fingernails. I get a bit horrified at stories from American friends and family about docs inducing at 39 weeks because they don't 'do overdue babies'.

Interestingly, I'm a 43 weeker myself (and yes, my mother's quite sure of her dates!) They just don't let you go that late anymore, even over here.

(PSA: DON'T eat a vast, hot curry in the attempt to bring on 'real' labour. You and your midwives will regret it when you projectile-vomit said curry across the room later on...)

July 7, 2008 | Unregistered CommenterTamsyn

You're not "risked out" of midwife care at 40+12 in the UK. Prolonged pregnancy (from whence monitoring starts) is from 42 weeks (at least in NICE guidelines, and I don't think many units offer monitoring before 42 weeks). The standard things for monitoring every 2-3 days after 42 weeks are: CTG trace and ultrasound to measure fluid depth - and yes, you'd have have to attend a day assessment unit w/sonography for that.

Sweeping and Stripping membranes are two terms for the same thing (think stripping is just the US term?) It's actually physically impossible to sweep the membranes when the cervix is closed, because you've got to be able to get your finger through the internal os to do it. However, some of the research studies show that it 'works' on an unfavourable cervix - which I take to mean, giving a closed cervix a 'vigorous massage' is effective in the same way as an actual sweep. Which begs the question why sexual intercourse hasn't been shown to be effective - which you would think was the same thing?

I'm totally against castor oil. Horrible for the mum, horrible for the baby, horrible for the care providers too! Yes, studies (and experience) show effective, but also show increased meconium in utero - presumably it does cross the placenta, or maybe the induced contractions cause distress.

I'm suprised that anyone is doing inductions with AROM at home. If it doesn't work, what is your plan B? You then have ruptured membranes (and not from a SROM, but using an instrument, which will inevitably push some bugs from vagina into the uterus, no matter how aseptic your technique).

Certainly it would be regarded as outside midwifery practice here. (Not the fact of doing an ARM - all too common - but doing one at home for purpose of induction).

July 7, 2008 | Unregistered CommenterYehudit

p.s. I don't think that sweeping of membranes carries a risk of accidentally rupturing the membranes. Some bleeding, discomfort and possible triggering of demoralising false labour that doesn't go anywhere and then just stops. But you'd have to have some fabulous falsies to rupture membranes with your finger nails through a latex glove - unless the membranes were bulging through a very dilated multips os?

July 7, 2008 | Unregistered CommenterYehudit

Plan B is move into the hospital.

As a solo homebirth midwife the last 3 years and an intern 3 years before that, I have done AROM for induction the once. At Casa, we did it much more often - and it almost always worked - but we also didn't do it unless the woman was more than 3cm dilated and the head well into the pelvis (at least engaged).

Interesting you can't AROM in the home. I hadn't thought of it being that controversial, actually. Not *needed* in most cases, but controversial between midwives? Didn't expect that.

July 7, 2008 | Unregistered CommenterNavelgazing Midwife

Oh, and yes, "sweeping" and "stripping" are the same - meant to mention that earlier. Thanks, Yehundit for saying so. The medical term is "stripping" and the more gentle, natural term is "sweeping," but both are typically very uncomfortable. In fact, unless my client gets tears in her eyes and I get blood on the glove, I wouldn't consider it a decent job.

*That* said (and I have explained this before), I have my client hold my left hand above her head and squeeze it as hard as I hurt her cervix. At *any* time, she can tell me to stop and I will stop moving. If she wants me to get out, I do so immediately (but gently). It isn't uncommon for women to take a breath every 30 seconds or so and I wouldn't stretch and strip longer than a minute, minute and a half. The cervix is a small area to manipulate; it shouldn't take too long to do what needs to be done.

Of course there is a risk of ROM! You even just said, "unless the membranes were bulging through...." It doesn't even have to be a very very dilated cervix. While I haven't accidently had ROM, I have seen it happen in the birth centers and certainly during vigorous vaginal exams in the hospital.

July 7, 2008 | Unregistered CommenterNavelgazing Midwife

Wouldn't say "can't" AROM, so much as feel induction of labour (though sweeping membranes is a gray area, I guess - since that is done at home - go figure) is outside remit. It wasn't meant as a criticism, just expression of surpise.

The remit of the midwife here is normal pregnancy and birth. Induction of labour is regarded as an obstetric procedure (of course, not in history - with all the herbal preparations etc...but today, yes, essentially an obstetric procedure) - because by definition women are being induced for an indication, right? Of course, midwives actually do amniotomy for induction (and insert prostin and put up syntocinon and all the rest) but very much as implementation of an obstetric-led multi-disciplinary team thing going on. Not as midwifery-led care, as such.

ARM at home for augmentation during labour for slow progress, if the head was well down - certainly (but then, if it's slow progress, arguably that's outside midwifery remit too! I didn't say I was consistent! Maybe I mean slow but still normal - I guess it depends how slow and why you want to speed it up).

Personally, I detest ARM for "low-risk" induction - it's crossing the rubicon and there is no turning back if labour doesn't kick in (and sometimes the reason why labour doesn't kick in is the same as the reason why she hasn't gone into labour spontaneously - she's just very difficult to get into labour). And then you are looking at the clock ticking because of ruptured membranes.

July 7, 2008 | Unregistered CommenterYehudit

Really a risk of accidental ARM with a woman not in labour (and why would anyone sweep a woman already in labour?) I've never ever heard of it happening to anyone here (anecdotal) - nor seen reference to it as a risk of membrane sweeping in the research literature (less anecdotal). (Of course, theoretically I can see it can happen, as could causing haemorrhage of previously undiagnosed placenta praevia/vasa praevia - yikes!) and you've seen it happen so it must be possible. But honestly, I've never thought of it as anything other than a theoretical risk. It is practised absolutely routinely at home by community midwives in the UK (and recommended in NICE guidelines for prevention of formal induction) and the risk of ROM is not considered (presumably as no research evidence/bank of experience to suggest that it is a risk?) Perhaps we do gentler (and less effective?) sweeps here?

July 7, 2008 | Unregistered CommenterYehudit

The liver filters the toxins but the toxins are not
*stored* in the liver. They are only filtered there. So actually the liver
is extremely clean. They are filtered to the bile or the blood, then
excreted via urine or feces. Excess toxins are stored in fat and other
cells.

"The liver eliminates toxins from the body by breaking them down and
converting them. These are then excreted to the bile or blood. Bile waste
substances enter the intestine via the duodenum and are eliminated from the
body as feces. Blood waste substances are filtered from the blood by the
kidneys and are eliminated from the body as urine.

Many of the toxins that are consumed and stored in the body fat and other
tissues, derive from the residues of medications. Still, other toxins
originate in foods, from the air we breathe and the water we drink. Most of
these toxins are lipophilic (fat-soluble) and are stored in our fatty
tissues and cells, where they may survive for many years, wreaking all
manner of havoc to the health of your body. This process of the conversion
of toxins and waste material from lipophilic to hydrophilic (water-soluble)
substances is called glucuronidation."
http://common-patient-ailments.suite101.com/article.cfm/the_liver_an_overview


Also, no, Chris is not a vegetarian as you see if you peruse his site. His articles are published on pubmed and contain references to studies, yes.

And indeed, the balance is important. However, most people lack Omega 3's because they either do not eat fish and eggs, eat only olive oil and nut (butters) for instance. The ratio needs to be O3:O6+O9 =1:1 and this should half of the fat intake. The other half should be sat fat. And the total amount of fat needs to be around 1/3 of total food intake (these are broad guidelines however.

So, this why, not speaking about your son per se, but for most people, the natural high vitamin cod liver, with naturallu occuring synergetic A and D, is a good start. Most people should def. add fish oil and/or a balanced supplement.

maria.

July 7, 2008 | Unregistered CommenterAnonymous

I had two different midwives for my two pregnancies, and they both recommended groud flax seed every day during the pregnancy for the omega-3 fatty acids. In fact, I was gently nagged when I complained about disliking the taste and texture. I believe that most Québec midwives recommend flax seed during pregnancy. I've never heard of bleeding issues before from flax seed.

July 7, 2008 | Unregistered CommenterElisabeth

Maria,

I think we agree then for the most part. The balance is what people are lacking, and the balance may not be struck by supplementation alone. I don't have the answers for what a pregnant woman should take or eat as far as EFA's, but I do believe she should get them in somehow, as they affect a lot of things, including the babies brain development.

July 8, 2008 | Unregistered CommenterJennifer

(((HUGS))) to Debstmomy

My mom lost a child to MAP secondary to postmaturity syndrome in 1970.

Yehudit - Sorry, 40+12 is my local trust criteria for midwife-led birth:
http://www.bcf.nhs.uk/our_services/womens_services/maternity_services/midwifery_led_acceptance_criteria.pdf

I thought (or so I was told!) that they base their guidelines on NICE recommendations.

July 9, 2008 | Unregistered CommenterAlexis

Curious why it is called 40+12 and not 41.5?

July 9, 2008 | Unregistered CommenterNavelgazing Midwife

I think the discussion about omega fatty acids and prostaglandins here is a good start, but quite oversimplified. Some prostaglandins are pro-inflammatory, while others are anti-inflammatory. Not all prostaglandins play a role in cervical ripening.

Omega-3 and Omega-6 fatty acids are prostaglandin precursors (and so is arachadonic acid from animal fats). Via a series of enzymatic reactions, these are converted into prostaglandins and eicosanoids.

The same enzymes govern the omega-6 and the omega-3 biochemical pathways. That is one reason why we need a balance of fats in our diet--too much omega-6 substrate can "clog the gears", effectively monopolizing the enzymes needed for conversion down the pathway. Thus what little omega-3 is present cannot compete.

Flax seed oil provides an omega 3 fat that's further up the pathway than the EPA and DHA found in fish oil. Basically our bodies convert the ALA in flax into EPA and DHA. It is thought that, optimally, only about 10-15% of the ALA from flax ever gets converted down the pathway. Still, for vegetarians, Flax oil or hemp oil or the latest craze Chia seeds, will provide omega-3s.

The enzymes on the biochemical pathway need some vitamin and mineral co-factors in order to work. In particular, Magnesium, Zinc, Selenium, Vitamin C, and some of the B-complex vitamins play a role in the enzymatic reactions. A deficiency in any of these makes for suboptimal prostaglandin conversion.

Also--people with certain conditions such as hypothyroidism or diabetes mellitus cannot effectively convert ALA into EPA and DHA. They should take fish oil, rather than a vegetarian source of omega 3 fats.

The website www.westonaprice.org has a nice article called "Tripping Lightly Down the Prostaglandin Pathways" which explains this much better than I.

Also the book "Women, Hormones and the Menstrual Cycle" by Ruth Trickey does a nice job explaining prostaglandin roles and pathways. AND Trickey has a great chapter all about phytoestrogens (plant-based estrogen-like molecules) and phytoestrogen biochemistry.

Finally, and back on topic, the Weston Price website has a fab article on Vitamin D.

Happy browsing!

July 9, 2008 | Unregistered CommenterAbundant B'earth

Interesting that caucasian nulliparous women average 41 3/7 weeks of pregnancy, and the cutoff for postdates is only 2 days past the MEAN.

July 9, 2008 | Unregistered CommenterAbundant B'earth

I'm slightly sensitive about this topic.

I had two lovely natural births of two obviously "cooked" post-dates babies. Easy deliveries, both of them.

Both of them needed a push to get out of the womb.

With the first, I went to 42 weeks, with the second to 41, and in both cases I woke up one morning "done." As in, I Am Having This Baby Today. I had some sex, had some cohosh, got contractions started, got my attendant to do a little membrane stripping when things were well underway, and off to the races. I don't regret it.

I get TONS of grief about this from people. You'd think I'd gone in with a scalpel myself. The natural-types say I didn't "trust the process" and the mainstream-types just can't believe I didn't wait for my doctor to make it all happen for me.

So I don't know.

Like I said, a touchy subject for me.

July 9, 2008 | Unregistered Commenterretiredwaif.com

I'm curious where is the reliable info that discusses that pregnant women shouldn't eat liver or flax. I haven't heard that before and can't see the correlation but would like to know.

July 9, 2008 | Unregistered CommenterAnonymous

Great information and certainly something for me (all of us!) to continue reading about.

Of course all of this is in the simplified manner. It's getting more in-depth, but most of us aren't scientists and the simplified information is what we (I!) can understand.

I'm continuing on my Vitamin D article and it might not interest anyone but me (HA!), but I am learning so much about this one Vitamin.

I do have to say it is rather weighted towards that one vitamin and all the things we are discussing here in this thread are just as important. For those reading here, please take this information into account, too!

July 10, 2008 | Unregistered CommenterNavelgazing Midwife

As far as nudging things along, I believe if you have the informed consent about it all, it's your body and your labor... go for it!

When women ask me to *do* something, I ask, "How will you feel if nothing happens/you are 3 cm/ you have diarrhea but nothing else/ you have a buttload of painful cramps, but no labor/ etc. If they say they will be fine with whatever the outcome is, then I feel they have the information they need to move forward.

You sound like you did the same thing! You know your body and you did what you wanted to do. Nothing wrong with that!

July 10, 2008 | Unregistered CommenterNavelgazing Midwife

From BabyCenter:

Liver contains very high levels of the retinol form of vitamin A, which can be harmful to your developing baby, particularly in the first trimester.

Searching "flax seed pregnancy" will turn up a slew of sites that explain a variety of reasons why not to take flax in pregnancy... from the phytoestrogens to causing periods to begin (labor prematurely?) early.

July 10, 2008 | Unregistered CommenterNavelgazing Midwife

I just reviewed the handful of Vitamin A abstracts I have here, and it seems it's the [i]synthetic[/i] form of Vitamin A that is teratogenic.

Traditional societies feed pregnant women high-fat, vitamin A-rich foods such as eggs, fish eggs, and organ meats. (again see Weston A Price foundation website.)

July 10, 2008 | Unregistered CommenterAbundant B'earth

Going post-dates is an emotional roller coaster because the threat is always there that you will have to transfer care to an OB.

I typically go overdue and my last babies were born 42+5 and 42+3 wks.
It was very scary knowing that my care was likely to be transferred to an OB if I didn't go into labor on my own. I wanted labor to start spontaneously, but it didn't. With both of those births, we tried everything: membrane stripping, herbs, help from husband, etc. Finally, castor oil got things rolling for both births.

The castor oil births were fast and furious - the 42+5 days was born 19 minutes after midwife arrived and placenta was delivered seconds after baby was born. It was pretty scary.

The last baby (42+3 days) was born 2 hours after castor oil was taken - pushed a big 13 lb 3 oz posterior out in 3 contractions.

But it does make me question myself - why won't my body go into labor on its own? In my case, I'm thankful for the castor oil because waiting any longer - that baby only would have gotten bigger. But why? I wish I had the answers.

Slightly off subject- I don't know why so many midwives recommend castor oil & orange juice. A much better alternative is mixing it in a peanut butter smoothy (I used frozen banana pieces instead of ice). The castor oil combines with the peanut butter and there is virtually no castor oil taste.

July 10, 2008 | Unregistered CommenterHomeJewel

Curious why it is called 40+12 and not 41.5?

+++++++

My guess is that 40 is the magic day. As is T for Term (T+12). Irritates me though. Term is, usually defined as 38-42 (or 37-42) not the EDD.

41+5 is more accurate.

What does it mean to be "risked out" of midwifery-led care in the UK though? Women who go beyond 41+5 can certainly have home births if they demand it (even if the midwives don't like it much, and even if there is a high likelihood they will recommend transfer when the waters go, because there is almost bound to be some meconium staining at late gestation). If you are in a obstetric unit you would still be cared for by midwives.

Does it mean that you would be outside the criteria for a midwife-led birth unit? That does make sense in some ways - if you are likely to transfer for mec (even if it is just a tinge) then it doesn't make sense for them to admit you only to transfer.

July 11, 2008 | Unregistered CommenterYehudit

Dear NGM,

I've been reading a few months now, and first let me thank you so much for putting your thoughts and experiences into words and making them available to all. I so appreciate your insights.

I have a question I've been meaning to ask you for a while, one that I also plan on asking a local midwife when I'm ready to have my second child/start trying.

I'll try to give you the important info without drowning you in details, I know you're a busy woman!

I was due last year July 26th. We practiced NFP (or more like pull and pray) for over two years, and the first month we decided to really try to conceive ended up pregnant. Pretty sure of my LMP dates.

Early May of that year I started having consistent contractions.They weren't painful, but my L&D team never said they were BH contractions. They simply called them preterm contractions. Every time I would go in with 30-45sec contractions, 2-3 mins apart, and no change to my cervix. They'd watch me a while, hydrate me, check for UTI, the whole shebang, sometimes those helped but usually after an hour or two they would get worse, and I would end up with a terbutaline shot.

I was scarcely 30 weeks, we were scared, didn't know what else to do. The contractions never gave up till the very end. I got no sleep the remainder of the pregnancy because they got painful as I slept. We kept thinking "Man, we may have this little dude early!". For weeks on end I had every pre-labor symptom in the book. I seemed to be right on the brink of full on labor (which was exciting and frustrating once we hit full term). Then the due date. Then 41 weeks. NST's were perfect, he was always active and did great.

Finally, after all the homeopathic methods failed, (primrose oil, castor oil, sex, nipple stim, frequent walks) we went in for an induction 2 days short of 42 weeks.

Cytotec (yeah I know, I know, it was that or straight to the pit in our tiny navy hospital), did little. Foley bulb, a little more. Two days of pit, until they broke my water. After that things went pretty quick, but ended in c-section after hours of pushing. (He was asynclitic, head was to the side) He ended up being a big, healthy, ten lb boy. Of course, I'm fairly petite, so everyone just said "Well he's huge, he would never have come out! Life SAVED!!" and we both know that may not have been the case in better circumstances.

So finally to the question! Lol. What do you do (if anything) aside from changing positions, lots of water/UTI check for a woman with preterm contractions that has no cervical change? In your experience, does the use of terbutaline in situations like these affect a womans ability to go into labor on her own? I stopped going in/using the terb as soon as I hit 35/36 weeks because it just didn't seem to matter, and terb sucks.

Sorry for the novel! I totally understand if you don't have the time to answer something like this, but in all my reading it's one area I've seen very little information on and I'm deadly curious. Thank you so much for putting up with my ramble, whether you have time to respond or not. Hugs!

July 11, 2008 | Unregistered CommenterStassja

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