Midwifery is catching

April’s Joyous Birth meeting 

EDD or EDB - expected due date, date of delivery, date of birth
VBAC - vaginal birth after c-section

It’s a common question - when is the baby due? And what happens if my pregnancy goes longer than the expected period?

Well, firstly let’s consider how a "due date" is calculated and what it means. Most are calculated using Naegele’s Rule which adds a year to the woman’s last period, subtracting three months and adding seven days to that date. It assumes that the cycle is 28 days, that 9 months = 281 days (ie about 30 days in the calendar months between those dates) and also that the gestation period is average at 40 weeks. Given that full term is anywhere between 37 and 42 weeks though, this is just the centre of the period where the baby may decide to make an entrance.

Or alternately:

Wood’s method:
nullips: LMP + 1 year - 2 months - 14 days, +/- days cycle varies from 28 days
multips: LMP + 1 year - 2 months - 18 days , +/- days cycle varies from 28 days
Nichols, Carol Wood, "Postdate Pregnancy, Part II: Clinical Implications," J. of Nurse-Midwifery, Vol. 30, No. 5, Sept/Oct., 1985, pp. 259-268.

Mittendorf’s Study
31 nullips, 83 multips found first pregnancies lasted on average 288 days and multips 283.
Nullips: LMP -3 months + 15 days (adjust for variation in cycle length)
Multips: LMP -3 months +10 days etc . . .
Mittendorf, R. et al., "The length of uncomplicated human gestation," OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932.

So if you had someone with a last period starting on 08/07 and a 28 day cycle, my obs wheel would tell me 14/04, Wood’s rule gives a date of 24/04 and Naegele’s rule gives a date of 15/04! So if you’re promised a VBAC if you go into labour before your due date, when you may never have had a vaginal birth before so you can be 10 days behind the mark before you can even think about being ready for labour. So yes, your ob or midwife is just humouring you.

Me bitter much about a recent experience? Yes, yes I am.
 

I get asked by women I am following through a pregnancy - should I make a birth plan? What kind of birth plan? Long or short? How? What to put in it? So some dot points from experience:

• If you want a birth plan, then consider a homebirth because otherwise you are having to negotiate on someone else’s playing field. You don’t know where the towels are = you aren’t in control
• Make it short and sweet. One page. Dot points. No ifs, buts or maybes. If it is important enough to write down, it’s important enough to state plainly.
• Don’t put "unless medically indicated" because this is a great out for anyone. If you don’t give them that out, you will have to be negotiated with.  

Areas that you will want to consider:

• Support people
• Vaginal examinations
• IV canula - say no to these routinely, and if it needs to be inserted, tell them where they can stick it
• Wearing your own clothes (singlet and sarong, undies, pink wig, scarf and thongs, whatever…)
• Catheterisation
• Monitoring
• Pain relief (do not offer me pain relief, or offer me massage, heat packs, pressure points, reiki, reflexology, aromatherapy, shower, water etc only)
• Food and drink (because you are after all an adult and can work these things out for yourself!)
• First stage - say plainly that the bed needs to be moved, or room made for ball, beanbag or whatever. Do not ask for permission but make a statement.
• Second stage - declare that you will not need guided pushing, that either you or your partner will catch the baby, that you want a lotus birth, that the first words your child will here will be a prayer to the goddess or the Sun, or whatever you want.
• Third stage - how do you want your placenta dealt with? Do you want to keep it, or make prints,
• Fourth stage - BONDING!! So important! You will have to be clear about bathing, weighing, immunisation, and vitamin K (these last two will be asked of you a couple of times during labour which is really irritating!), feeding, rooming in. 
• Afterwards - if you plan on being in hospital for a few days, think about heel prick tests, bathing, circumcision, immunisation etc.

You will have to do research into these things, and I encourage you to do so before giving birth. It is going to be hard to get your hands on information about these things with a newborn and away from your usual resources (read: the internet and your own phone).

And people ask me - do I need a c-section plan? I’m of two minds about this, because if you plan for it are you headed for it, and yet on the other hand our c-section rate here in Australia is more than 1 in 3, so chances are relatively high if you birth in a hospital and higher in some than others. Investigate this before birthing somewhere. And in the end yes, I do suggest you write a plan because it’s in a c-section situation that you will want to have what aspects of the birth you are wanting especially respected. Again, look at skin to skin contact, immediate baby care, partners staying with your baby if they need to be taken somewhere.

Look on the interwebs to find some examples and think about it before talking to your care provider or a friendly midwife. 

Yep, now in part 3, I’ll tell you which of these do / are going to come up for me 

Practices which are Demonstrably Useful and Should be Encouraged

1.A personal plan determining where and by whom birth will be attended, made with the woman during pregnancy and made known to her husband/partner and, if applicable, to the family.
2.Risk assessment of pregnancy during prenatal care, reevaluated at each contact with the health system and at the time of the first contact with the caregiver during labour, and throughout labour.
3.Monitoring the woman’s physical and emotional well-being throughout labour and delivery, and at the conclusion of the birth process.
4.Offering oral fluids (my addition: and food - whatever the woman wants, with encouragement) during labour and delivery.
5.Respecting women’s informed choice of place of birth.
6.Providing care in labour and delivery at the most peripheral level where birth is feasible and safe
and where the woman feels safe and confident.
7.Respecting the right of women to privacy in the birthing place.
8. Empathic support by caregivers during labour and birth.
9.Respecting women’s choice of companions during labour and birth.
10.Giving women as much information and explanation as they desire.
11.Non-invasive, non-pharmacological methods of pain relief during labour, such as massage and relaxation techniques.
12.Fetal monitoring with intermittent auscultation.
13.Single use of disposable materials and appropriate decontamination of reusable materials throughout labour and delivery.
14.Use of gloves in vaginal examination, during delivery of the baby and in handling the placenta.
15.Freedom in position and movement throughout labour.
16. Encouragement of non-supine position in labour.
17.Careful monitoring of the progress of labour, for instance by the use of the WHO partograph.
18.Prophylactic oxytocin in the third stage of labour in women with a risk of postpartum haemorrhage, or endangered by even a small amount of blood loss.
19.Sterility in the cutting of the cord.
20.Prevention of hypothermia of the baby.
21.Early skin-to-skin contact between mother and child and support of the initiation of breast-feeding within 1 hour postpartum in accordance with the WHO guidelines on breast-feeding.
22.Routine examination of the placenta and the membranes.

Practices which are Clearly Harmful or Ineffective and Should be Eliminated
1.Routine use of enema.
2.Routine use of pubic shaving.
3.Routine intravenous infusion in labour.
4.Routine prophylactic insertion of intravenous cannula.
5.Routine use of the supine position during labour.
6.Rectal examination.
7.Use of X-ray pelvimetry.
8.Administration of oxytocics at any time before delivery in such a way that their effect cannot be controlled.
9.Routine use of lithotomy position with or without stirrups during labour.
10.Sustained, directed bearing down efforts (Valsalva manoeuvre) during the second stage of labour.
11.Massaging and stretching the perineum during the second stage of labour.
12.Use of oral tablets of ergometrine in the third stage of labour to prevent or control haemorrhage.
13.Routine use of parenteral ergometrine in the third stage of labour.
14.Routine lavage of the uterus after delivery.
15. Routine revision (manual exploration) of the uterus after delivery.

Practices for which Insufficient Evidence Exists to Support a Clear Recommendation and which Should be Used with Caution while Further Research Clarifies the Issue
1.Non-pharmacological methods of pain relief during labour, such as herbs, immersion in water and nerve stimulation.
2.Routine early amniotomy in the first stage of labour.
3.Fundal pressure during labour.
4.Manoeuvres related to protecting the perineum and the management of the fetal head at the moment of birth.
5. Active manipulation of the fetus at the moment of birth.
6.Routine oxytocin, controlled cord traction, or combination of the two during the third stage of labour.
7.Early clamping of the umbilical cord.
8.Nipple stimulation to increase uterine contractions during the third stage of labour. - it’s called breastfeeding

Practices which are Frequently Used Inappropriately
1.Restriction of food and fluids during labour.
2.Pain control by systemic agents.
3.Pain control by epidural analgesia.
4.Electronic fetal monitoring.
5.Wearing masks and sterile gowns during labour attendance.
6.Repeated or frequent vaginal examinations especially by more than one caregiver.
7.Oxytocin augmentation.
8.Routinely moving the labouring woman to a different room at the onset of the second stage.
9.Bladder catheterization.
10.Encouraging the woman to push when full dilatation or nearly full dilatation of the cervix has been diagnosed, before the woman feels the urge to bear down herself.
11.Rigid adherence to a stipulated duration of the second stage of labour, such as 1 hour, if maternal and fetal conditions are good and if there is progress of labour.
12.Operative delivery.
13.Liberal or routine use of episiotomy.
14.Manual exploration of the uterus after delivery.

Remind me to dig up research that "supports"  the need for and success of incubators, in terms of helping babies who will have a good outcome to survive - because I’m genuinely curious as to whether the investment of money and hours and equipment is worth it for the families, or the babies.

From a Peak Oil point of view, I do wonder what will happen to premature babies when the oil runs out. Will we continue to invest so heavily in premature infants, and at whose expense? And yes, my asking this question does point to me being a hospital-trained midwife. I’d welcome some views on this as well .

Incubators seen to change babies’ heartbeats
Could the electromagnetic fields of incubator motors affect babies’ health? Katharine Sanderson

The incubators used to nurture premature babies give off electromagnetic fields that change the babies’ heart rhythms, researchers in Italy have found. Carlo Bellieni at the General Hospital of the University of Study in Siena and colleagues monitored the heart rates of 43 newborn babies being cared for in incubators.

They measured the babies’ heart rate variability (HRV) — a measure of the time lapse between heart beats — when the incubators were switched on and when they were switched off. Human hearts don’t beat at the same rate all the time, but rather quicken and slow when breathing in and out and with changes in hormones. This variation is healthy, and it can be used as a marker of how well the nervous system works. In adults, a low HRV is thought to point to a risk of heart disease. Bellieni and his colleagues found that when the incubators were switched on, the babies were exposed to 8.9 milligauss of electromagnetic frequency (normal background levels are around 1 milligauss) and their heart rate became less variable: the HRV dropped to half that of baseline levels. “This is not good at all,” says Bellieni. The results are reported in the Fetal and Neonatal Edition of Archives of Disease in Childhood 1. Bellieni doesn’t want to alarm parents: “We cannot save [most premature] newborns without incubators,” he says.

“Incubators are necessary to these babies, and no actual correlation with health problems has been shown.” But he hopes to prompt improvements in incubators to make them as safe as possible. Bad vibrations To check that it was the electromagnetic frequency rather than the noise or vibration of the motor to blame, Bellieni did separate experiments with 16 of these newborns in which he replicated the noise and vibrations without the EMF-producing electric motor. There was no change in the HRV of the babies in these experiments. The researchers are not sure why this is happening.

The World Health Organization notes that EMFs of higher than 1 gauss can stimulate nerves and muscles, as well as changes in the central nervous system. But for less intense exposure things are much less clear. Several epidemiological studies have suggested that childhood leukaemia is more frequent in households exposed to magnetic fields higher than 3 milligauss than in those with lower levels of exposure, says Sander Greenland, an epidemiologist at the University of California, Los Angeles. But the reason for this is unknown, and it might not have anything to do with EMF. Despite the controversy though, Greenland says that sustained exposure of newborns to levels of about 10 milligauss could be cause for concern.

Room for improvement
The abrupt changes in HRV as the incubators are turned on or off is worrisome, says Cynthia Bearer, a paediatrician at Case Western Reserve University in Cleveland, Ohio. About 10% of babies are born premature, she says, and most need to spend at least some time in an incubator. Changes in the nervous system such as those implied from HRV variations have been suggested, but not proven, to be involved in sudden infant deaths, for instance. "We know that premature infants are at risk for Sudden Infant Death Syndrome. Could this exposure be why?" says Bearer. Incubators can be improved, Bellieni says.

His previous work has shown that babies’ exposure to EMF in incubators can be significantly reduced if a ferromagnetic material is used to shield babies from the motor. These improvements would be trivial to make, and are well worth following up says Alan Preece, a medical physicist from Bristol University, UK. The study highlights a problem that needs more probing, he says. “We do not understand any of the mechanisms of low-frequency, low-power magnetic fields that seem in different studies to throw up effects," he says, on anything from gene expression to the development of leukaemia.

a.. References 1.. Bellieni, C. V. et al. Arch. Dis. Child. Fetal. Neonatal Edn doi:10.1136/adc.2007.132738 (2008).