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Entries in PCOS in pregnancy (1)

Thursday
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.