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A Campaign to Carry Pregnancies to Term

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The March of Dimes opened a new campaign this summer to curb the large and growing number of otherwise healthy pregnancies that are deliberately ended early by induced labor or Caesarean delivery.

Research has clearly shown that a change in approach that emphasizes allowing babies to develop fully when both mother and baby are doing well could result in healthier babies and lower medical costs. The campaign is called “Healthy babies are worth the wait.”

What prompted the campaign is what many experts view as an alarming trend in American obstetrics — the steady rise in elective deliveries of singleton babies before 39 weeks of gestation, when fetal development is complete. Gestation is calculated from the first day of a woman’s last menstrual period. Studies have shown that as many as 36 percent of elective deliveries now occur before 39 weeks, and many of these early deliveries are contributing to an unacceptable number of premature births and avoidable, costly complications.

Although guidelines issued 12 years ago by the American College of Obstetricians and Gynecologists cautioned against elective delivery by induction or Caesarean before 39 weeks, an overwhelming majority of new mothers and many doctors who deliver babies believe it is just as safe for birth to occur weeks earlier.

Complications

But the medical facts say otherwise. With each decreasing week of gestation below 39 to 40 weeks, there is an increased risk of complications like respiratory distress, jaundice, infection, low blood sugar, extra days in the hospital (including time in the neonatal intensive care unit), and even deaths of newborn babies and older infants.

Although tests may show that the baby’s lungs are well developed at, say, 37 weeks, research has demonstrated that the risk of newborn complications is still significantly higher than if delivery occurs two to three weeks later. In a study published last December of babies demonstrated to have mature lungs before birth, those delivered at 36 to 38 weeks had two and a half times the number of complications compared with those delivered at 39 to 40 weeks. Problems more common among babies delivered earlier in gestation included respiratory distress, jaundice and low blood sugar.

Yet in 2008 among a national sample of 650 women who had recently given birth, 51.7 percent chose 34 to 36 weeks of gestation as “the earliest point in pregnancy that it is safe to deliver the baby” and 40.7 percent chose 37 to 38 weeks. Only 7.6 percent selected 39 to 40 weeks, the true length of a full-term pregnancy, and the time when complications, including stillbirth, are least likely to occur.

Although many women think that weight gain is all that happens to babies during the last few weeks of pregnancy, Dr. Eve Lackritz, chief of the maternal and infant health branch of the national Centers for Disease Control and Prevention in Atlanta, said vital organs like the brain, lungs and liver are still developing. There are also fewer vision and hearing problems among babies born at full term.

“Babies aren’t fully developed until at least 39 weeks,” Dr. Lackritz told a news briefing in New York convened by the March of Dimes. For example, a baby’s brain at 35 weeks gestation weighs only two-thirds of what it will weigh at 39 to 40 weeks.

“If there are no medical complications, the healthiest outcome for both mother and infant is delivery at 40 weeks,” Dr. Lackritz said.

This is not to suggest that women should panic if labor begins earlier on its own. “It’s a whole different story when a woman goes into labor early than when labor is induced,” Dr. Uma M. Reddy of the National Institute of Child Health and Human Development said in an interview. She explained that the labor process helps to prevent lung problems. At the same gestational age, there are fewer respiratory problems when labor occurs naturally than when it is medically induced, Dr. Reddy said.

Dr. Reddy and colleagues analyzed more than 46 million singleton live births that occurred from 1995 to 2006 and found that newborn death rates at 37 weeks of gestation were two and a half to nearly three times the number at 40 weeks and were also elevated at 38 weeks of gestation. For example, in 2006 the infant mortality rate at 37 weeks gestation was 3.9 per 1,000 live births; at 38 weeks, 2.5 per 1,000 births; and at 40 weeks, 1.9 per 1,000 births. They reported their findings in the journal Obstetrics & Gynecology in June. The researchers also found that these so-called early-term births were associated with higher rates of death after birth and during infancy than were full-term births occurring at 39 to 41 weeks.

Dr. Reddy said that the textbook definition of “term pregnancy” as one that lasts from 37 to 41 weeks “is arbitrary — it has no biological basis. If a woman’s water hasn’t broken, if labor hasn’t begun on its own, if there are no medical or obstetrical problems, there’s no reason for a woman to be delivered before 39 weeks.”

The recommendation applies not just to women whose labor is induced, but also to those having a scheduled Caesarean delivery. Too often, women are mistaken about when they got pregnant, which can throw off the calculation of their due date. Even when a “dating”ultrasound is done during the first trimester of pregnancy, there can be as much as a two-week margin of error. Thus, a woman may think her pregnancy has lasted 39 weeks when it is only 37 weeks along. Or she may think she is 37 weeks pregnant when she is only 35 weeks; a delivery at that point would result in a premature birth.

Countering Early Elective Births

Dr. Reddy pointed out that “late preterm births” — between 34 and 37 weeks of gestation — in pregnancies with no complications are more common among older white women with higher levels of education who “are more likely to ask their obstetricians to deliver them before term.”

Well-educated women may be more inclined to want to schedule birth at a convenient time for themselves and other family members. Doctors, too, may suggest an elective delivery so that birth occurs at a time that best suits their schedules, including office hours and vacation times. Sometimes doctors, fearing a malpractice suit if something should go wrong if a pregnancy proceeds to term, choose to deliver babies early when they are alive and well.

To counter the avoidable complications and higher costs associated with preterm elective deliveries, beginning in January 2001 a network of nine urban hospitals in the Intermountain Healthcare system in Utah instituted a program to greatly limit elective deliveries before 39 weeks of gestation. The program included educational programs for doctors, nurses and pregnant women. However, not until strict monitoring of births was instituted by the hospitals did the rate of early deliveries drop to less than 3 percent from 28 percent, with a host of benefits but “no adverse effects” seen on the health of the mothers or babies.

www.healingpowerhour.com

My VBAC Success Story: I ignored my doctor to have the birth I wanted.

- By Jana Llewellyn

When I was pregnant with my son in 2007, I read articles, listened to radio broadcasts, and watched TV shows that all reported the alarming rate of C-sections. Since my pregnancy had been without complications up to that point, I assumed this wasn’t something I had to worry about. I was more interested in the increasing popularity of natural birth.

“Should I forego an epidural?” I asked my doctor.

He said, polite as always, that some women thought they’d decline an epidural, but once they hit active labor, “they realized why epidurals were invented.”

He tapped into one of my biggest fears: pain.

So after the obstetrician broke my water and told me I’d be in “excruciating pain,” I agreed to the epidural. She assured me that epidurals didn’t slow down labor as I had thought. Ten hours later, I was in the operating room. I had been given enough Pitocin to dilate, but the doctor suspected that my baby was positioned sideways and mandated a C-section.

When I got pregnant with my daughter almost two years later, I did not want another C-section. In fact, I was planning my VBAC (Vaginal Birth After Cesarean) only hours after my son was born. After all, my body was well-equipped to carry other human beings — both of my children wanted to stay well past 40 weeks — and I knew that I could labor successfully if given the chance. But, my doctor warned me, due to my first C-section, I was now considered a high-risk delivery case.

The biggest fear doctors and patients have with VBAC is a uterine rupture, where the scar tissue of the uterus opens, necessitating an immediate C-section to save the mother’s and/or baby’s life. This, of course, is to be taken quite seriously. But since the risk of uterine rupture is less than 1 percent, which means only 7 or 8 women in 1,000 will experience it, I thought I’d take my chances. After all, there are plenty of fatal complications that can occur in labor, like placental abruption, which affects women who have not had C-sections. Even women who have never had previous abdominal surgery are vulnerable to uterine ruptures. Furthermore, there are risks with C-sections, too — hemorrhaging, blood cots, bowel issues, and breathing problems for the baby — and I knew that having a second one could make those more likely should I get pregnant again. I also knew that a vaginal birth would come with a shorter recovery time and therefore allow me to be more attentive to my son during a transitional time.

For weeks I carried the weight of my decision in my chest, fretting about whether I was succumbing to unnecessary risks, whether I was being selfish in wanting to avoid surgery and somehow putting my life before my baby’s. The only way to face this labor, I decided, was to hire a doula, someone who would personally assist me before, during, and after delivery. I emailed one who was recommended by a friend and meanwhile continued to read more about the benefits of vaginal delivery as opposed to C-sections.

When I posed more questions to my doctors though, I became confused and overwhelmed. The male doctor who performed my C-section the first time around seemed eager to use this opportunity to convince me that a C-section was a better option, even though for my first two trimesters, I had told him I wanted a VBAC. He explained that many female obstetricians prefer to schedule Cesareans for their own births rather than endure the pain of vaginal labor. He also went into a story about women in third-world countries who labor for so many hours, their bladders collapse and urine shoots out of their vaginas. On my next visit, the female OB (the one who convinced me to have an early epidural) recounted how the doctors and nurses on call gulp down bottles of Pepto-Bismol when they have a VBAC patient in labor because they’re so afraid that something will go wrong. And when I told her I was considering avoiding the epidural, she told me that was not an option. It would be mandatory once I was three or four centimeters dilated.

Feeling discouraged, I wrote to my doula, Ellen, to tell her I didn’t think it would be worth it for her to be part of my labor. If I had to get an epidural that early, there wouldn’t be much pain management she could help me with. She called me before I even closed my laptop, angry for what she thought was my doctor’s dishonesty. I did not need an epidural, she said, and I had as much chance of succeeding at a VBAC as I did at a regular birth. In the more than 500 births she had attended, she had only seen a uterine rupture once, and it was for a first-time delivery. To my surprise, she told me I needed to leave my practice, or I’d end up in the same situation I did the first time around, with a stalled labor and a baby who hadn’t moved into position because of a premature epidural.

Who could I trust? And why did it seem that natural birthing advocates were on such opposing sides from the obstetricians I had entrusted to deliver my baby? This time I listened to my gut and took down the names of three practices that my doula felt would support my VBAC. But when I called, no one would schedule an initial consultation. Instead, they would only see me if I officially switched from my current practice. Not wanting my maternal health to be in limbo 10 weeks before my due date, I looked at the bottom of Ellen’s list, at the only name I hadn’t yet considered: the midwife who worked out of a hospital a half hour away.

I never thought I’d choose a midwife. I didn’t know they existed beyond history books and the birth center a few miles from my home. But from the first minute I talked to Ronni, I knew I was in good hands. She was willing to meet with me for a consultation so she could answer all of my questions. She explained the slight differences of treating a VBAC patient and a regular patient. She was honest with me, and she fully supported my decision without ever skirting around the reality of the risks involved. (It also helped that in all her years as a midwife, she had never seen a uterine rupture.)

When I expressed concern over my obstetricians’ feelings about the switch, Ronni told me that they probably wouldn’t know I was gone. She was right. The office charged me an arm and a leg for select photocopies of my record, but I never received a phone call from a doctor asking me why I left. At my new prenatal appointments, in a cozy apartment with warm, green walls and a counter lined with tea, my two-year-old was welcomed with a box of toys and the title of “midwife’s helper” as he squeezed my blood pressure pump. In our half-hour appointments, Ronni did all the things my doctors did, but we also compared iPhones and talked about our lives and her recent deliveries.

Though my prenatal care was great, my labor was not as fun. Seven days past my due date, my daughter still hadn’t arrived, and it was the hospital’s procedure to induce before she got too big. I could receive only a small amount of Pitocin (large doses increase the chances of uterine rupture) through an IV to help things along, and as I sat on a hospital bed that morning, I lamented that the labor was already not going as I had hoped. Would I ever have this baby?

After seven hours, contractions were intense enough that I knew my baby was on her way. Surrounded by my midwife, doula, a hospital nurse, and my husband, I breathed, moaned, and visualized the clouds of Paris to get through particularly painful contractions. My husband stood by my side, rubbing my back as I rocked, sat, and walked, trying to get the baby to move into position. When I finally started pushing, I tried as much movement as possible. I squatted, I stood, I rocked. When the pain got so bad, I did what most women do: I asked for drugs. Ronni told me I was 9 centimeters dilated, and it was too late for drugs. Knowing I had come that far along gave me the boost I needed to get through the rest of my labor. A little after 9 p.m., I started feeling the urge to push, but after an hour and a half, the baby had barely moved. I got a thigh cramp that was worse than the contractions, and that’s when I started to curse at my midwife. I wanted her to DO something.

But within minutes I realized that no one could do anything. It was up to me, and solely me, to push this baby out. I closed my eyes and reached into the darkness, into reserves I never knew I had, in order to bring my daughter into the world. At 12:34 a.m., three hours after I started, I felt her body leave mine, and Madeleine, my nine-pound, one-ounce baby girl, was laid on my stomach. She and I locked eyes, and I can still remember the new warmth of her, those chubby hands.

That night, despite my exhaustion, I couldn’t sleep. I relived the whole surreal experience over and over in my head, still in disbelief that a baby with a head that big could come out a five-foot two-inch body. All the adrenaline convinced me I was the most amazing person alive, practically a superhero. The memory of my painful labor didn’t go away for a long time, but neither did my amazement at what I was actually capable of.

Related: The case for VBAC — what you should know before having a repeat C-section

If I had stayed with my obstetrics practice, there were a few things they would have done differently. First, I would have had an ultrasound in the last trimester to see whether my second baby was bigger than the first, and therefore not suitable for a vaginal delivery. Considering my first baby was 7.5 oz. and the second was 9.1, they would have probably forced me to have a C-section. Second, the practice would most likely not have induced me seven days after my due date. Instead, they would have wanted to perform a scheduled Cesarean if I didn’t go into labor soon enough. Lastly, most doctors are not willing to let a woman push for three hours. Even though the average pushing time for a first-time delivery is two hours, most doctors start mentioning the dreaded “C” word after much less time, which is not helpful for a woman’s mental and emotional state. Believe me, I wish I didn’t have to push for three hours, but I am glad I had a caregiver who let me finish what I started. In essence, I am convinced that my doctors would have looked for ways to encourage surgery, rather than allowing my body to perform its natural functions.

I look back on the birth of my daughter as the most difficult physical exercise I may ever undergo, as something that taught me the utmost limits of what a body — my body — can do. I was exhausted in the days and months after her birth, as all mothers are, but I was also triumphant, with a new inner confidence.

What better way to enter the next stage of motherhood?

www.healingpowerhour.com

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