Thoughts to Ponder:
The Lie of the EDD: Why Your Due Date Isn't when You Think September 24, 2008 by Misha Safranski
Due Date | Pregnancy Myths We have it ingrained in our heads throughout our entire adult lives-pregnancy is 40 weeks. The "due date" we are given at that first prenatal visit is based upon that 40 weeks, and we look forward to it with great anticipation. When we are still pregnant after that magical date, we call ourselves "overdue" and the days seem to drag on like years. The problem with this belief about the 40 week EDD is that it is not based in fact. It is one of many pregnancy and childbirth myths which has wormed its way into the standard of practice over the years-something that is still believed because "that's the way it's always been done". The folly of Naegele's Rule The 40 week due date is based upon Naegele's Rule. This theory was originated by Harmanni Boerhaave, a botanist who in 1744 came up with a method of calculating the EDD based upon evidence in the Bible that human gestation lasts approximately 10 lunar months. The formula was publicized around 1812 by German obstetrician Franz Naegele and since has become the accepted norm for calculating the due date. There is one glaring flaw in Naegele's rule. Strictly speaking, a lunar (or synodic - from new moon to new moon) month is actually 29.53 days, which makes 10 lunar months roughly 295 days, a full 15 days longer than the 280 days gestation we've been lead to believe is average. In fact, if left alone, 50-80% of mothers will gestate beyond 40 weeks. Variants in cycle length Aside from the gross miscalculation of the lunar due date, there is another common problem associated with formulating a woman's EDD: most methods of calculating gestational length are based upon a 28 day cycle. Not all women have a 28 day cycle; some are longer, some are shorter, and even those with a 28 day cycle do not always ovulate right on day 14. If a woman has a cycle which is significantly longer than 28 days and the baby is forced out too soon because her due date is calculated according to her LMP (last menstrual period), this can result in a premature baby with potential health problems at birth. The inaccuracy of ultrasound First trimester: 7 days 14 - 20 weeks: 10 days 21 - 30 weeks: 14 days 31 - 42 weeks: 21 days Calculating an accurate EDD Recent research offers a more accurate method of approximating gestational length. In 1990 Mittendorf et Al. undertook a study to calculate the average length of uncomplicated human pregnancy. They found that for first time mothers (nulliparas) pregnancy lasted an average of 288 days (41 weeks 1 day). For multiparas, mothers who had previously given birth, the average gestational length was 283 days or 40 weeks 3 days. To easily calculate this EDD formula, a nullipara would take the LMP, subtract 3 months, then add 15 days. Multiparas start with LMP, subtract 3 months and add 10 days. The best way to determine an accurate due date, no matter which method you use, is to chart your cycles so that you know what day you ovulate. There are online programs available for this purpose (refer to links in resources section). Complete classes on tracking your cycle are also available through the Couple to Couple League. ACOG and postdates One of the most vital pieces of information to know when you are expecting is that ACOG itself (American College of Obstetricians and Gynecologists) does not recommend interfering with a normal pregnancy before 42 completed weeks. This is why knowing your true conception date and EDD is very important; if you come under pressure from a care provider to deliver at a certain point, you can be armed with ACOG's official recommendations as well as your own exact due date. This can help you and your baby avoid much unnecessary trauma throughout the labor and delivery. Remember, babies can't read calendars; they come on their own time and almost always without complication when left alone to be born when they are truly ready. Sources: Mittendorf, R. et al., "The length of uncomplicated human gestation," OB/GYN, Vol. 75, No., 6 June, 1990, pp. 907-932. ACOG Practice Bulletin #55: Clinical Management of Post-term Pregnancy
Pain Medications Used in Childbirth and the effects on Mother, baby, breastfeeding and bonding
The purpose of this paper is to examine the more commonly used pain medications, including epidurals, during labor and delivery. We will examine how it affects both mother and baby, as well as risks, benefits, and adverse reactions. We will also examine how the initiation and continuation of breastfeeding is affected, and whether or not the medications are passed to the newborn during the first feeding.
The medications most commonly used in hospital labor and delivery wards in the US are: Demerol (meperidine), Morphine, Stadol (butorphanol), Fentanyl, Nubain (nalbuphine). It should be noted that Demerol and Morphine are not commonly used as much as Stadol, Fentanyl, and Nubain. The anesthetics that are more common in epidurals are Lidocaine (xylocaine), and Bupivicaine (marcaine, marcain).
The benefits are obvious to the relief of pain in childbirth… relief of pain. If a mother has been in labor for a very long time and is exhausted, an epidural can make the difference between a vaginal birth and a cesarean section, by allowing her some relief so she can sleep and gain new strength. Pain relief can relax a laboring mother enough that her contractions become more effective and allow her labor to progress more efficiently. In the rare case of soft tissue dystocia that is purely physiological, pain medications may resolve it, as long as there are no emotional factors to consider.
Let us go over some of the general adverse effects of using pain relief and epidurals during labor and birth. Keep in mind that these are the adverse effects that are general among all of the more commonly used medications. Both mother and baby can experience these.
- Sleep problems/insomnia
- Nausea/ vomiting
- stomach pain/ diarrhea
- loss of appetite
- Memory problems
- Sweaty, clammy skin
- Breastfeeding difficulties
- Bonding difficulties
- Withdrawal symptoms
These are the less serious side effects of the pain medications commonly used.
Some of the more serious adverse effects include:
- Increased need to resuscitate newborns at birth.
- Breathing difficulties in mother and newborn
- Very rapid heartbeat
- Very slow heartbeat.
- Severe allergic reactions
- Numbing of face and extremities
It is known that these pain medications cross the placenta and affect the baby before birth.
Most women who birth in the hospital will be offered these medications sometime during their labor, unless you have specifically requested that these not be offered. Some studies show that 90% of healthy, low-risk women who birth in hospitals will have narcotic pain medications and/or an epidural during labor. This means that 90% of healthy infants born in hospitals are born drugged! Clearly information has not been shared with these mothers of the side effects of these medications.
Babies who are exposed to narcotics have stress put on their kidneys and livers as they try to metabolize the drugs. This can cause problems as well, considering that their livers and kidneys are still immature.
Physiological effects of Epidurals in labor
Epidurals are used to numb the nerves from the waist down during childbirth. An anesthetic/narcotic combination is injected into the dural space of the spinal column via catheter, which is in place throughout labor and delivery. Granted it can be an extreme relief during the pain of labor, but it is known to increase the length of labor and the second (pushing) stage, the need for forceps or vacuum assisted birth, episiotomy, and c-section. Those have an entire range of risks in and of themselves. It is also known to cause maternal fever and low blood pressure.
Because a woman is numbed by the epidural, she is not able to get up and move around during labor. This can cause labor to last longer and she may not be able to push as effectively because she cannot feel where to push.
Pain Medications and Breastfeeding
It is known that all of the narcotic medications used in labor and birth are exuded in Breastmilk. This means not only is the newborn baby getting an adult dose during labor, but also with the first feeding. Hence the sleepy baby that is more commonly seen in hospitals. Babies born without narcotics have a better latch during breastfeeding, are more alert and responsive during the first hours after birth, have less feeding problems and crying spells in the first 8 weeks of life, and are in general healthier, happier, and more content. American Academy of Pediatrics has taken the position that it is safe to breastfeed after receiving narcotics during labor, although they have stated that if a mother is prescribed these medications after birth, while still breastfeeding, it is recommended that the risks to the baby and the benefits to the mother should be weighed before taking these medications.
Some medications are known to actually hinder successful breastfeeding; in fact the drug Fentanyl is one of these.
Pain Medications and Bonding
To put it simply, it is hard to bond with someone who is so drugged that they can’t respond in a normal fashion to us. This is not to say that women who use pain medications in labor love their babies less, it is just harder to get to know them.
Babies who are exposed to pain medications during labor and birth actually spend more time away from their mothers in the first hours of life than their non-drugged counterparts. This is due to the aforementioned adverse effects caused by narcotics.
This article is not meant to be a scare tactic. It is simply meant to educate, and hopefully encourage research by pregnant women as to the medications used to relieve pain during labor and birth.
Maternity Care Analysis Finds Danger Of Routine Birth Interventions
Findings from a two-year review of the science behind maternity care indicate that the common and costly use of many routine birth interventions, such as continuous electronic fetal monitoring, labor induction for low-risk women and cesarean surgery, fail to improve health outcomes for mothers and their babies and may cause harm.
The review entitled, the Evidence Basis for the Ten Steps to Mother-Friendly Care, will be published in The Journal of Perinatal Education and the results will be premiered at the Coalition for Improving Maternity Services (CIMS) Forum.
Need to RE-lactate?
Studies on safety of homebirth
we have another study to
add to the short list (de Jonge 2009); Janssen 2009) of studies of planned home birth,
with a qualified home birth attendant,
in women eligible for home birth at labor onset,
that had a comparison group of similar women planning hospital birth,
where outcomes were obtainable for hospital transfers.
This study even had the bonus of being prospective, that is, the study
was organized ahead of time, as opposed to retrospective, that is,
data were collected after the fact from records or surveys. The
studys abstract concludes:
The results support a policy of offering healthy women with low risk
pregnancies a choice of birth setting. Women planning birth in a
midwifery unit* and multiparous [prior births] women** planning birth
at home experience fewer interventions than those planning birth in an
obstetric unit with no impact on perinatal outcomes. For nulliparous
[no prior births] women, planned home births also have fewer
interventions but have poorer perinatal outcomes (p. 1 of 13).
*The study also looked at freestanding and hospital-associated birth
**Women with prior cesareans were excluded.
Let us dig deeper into this conclusion and consider the risk trade-
offs between planned home versus planned hospital birth in low-risk
Investigators created a composite perinatal outcome in order to
increase the studys power to detect a statistical difference in rare
outcomes and to evaluate outcomes relevant to intrapartum quality of
care. Some of the latter have no permanent or long-term consequences,
so I will focus on the ones that do because these would matter most to
women deciding where to plan to birth.
Their foremost concern would be, of course, the risk of perinatal
death. Investigators report an intrapartum demise plus early neonatal
(up to 7 days) death rate of 1.3 per 1000 in nulliparous women
starting labor at home (6/4568) versus 0.5 per 1000 in similar women
beginning labor in hospital (5/10,626), or a difference of 0.8 per
1000. Confidence intervals overlapped, which means that differences
were not statistically significant, i.e. unlikely to be due to chance,
but this could be because even populations this large are too small to
detect a significant difference in an event that occurs so rarely. Let
us assume, though, that the difference is real and that 8 more babies
per 10,000 low-risk nulliparous women starting labor at home would die
as a result of that decision. To be sure, no excess death rate,
however small, is trivial, but to put this into perspective, the
excess risk of losing the pregnancy as a result of having an
amniocentesis is 60 per 10,000. No one is advising women against
amniocentesis on grounds of its danger, so we may conclude that an
excess risk considerably more than 8 per 10,000 is deemed tolerable by
the obstetric community. Moreover, we have no details about the
deaths, so we do not know whether some may have been unavoidable. For
example, the study did not include congenital anomalies among its
exclusion factors, which means it is possible that a couple who knew
their baby would not survive might have chosen to give birth in the
privacy and comfort of their home, or a woman might have refused
The second concern would be outcomes that could result in permanent
deficit, which in this dataset were encephalopathy (neurologic
symptoms) with no perceptible cause other than hypoxia during labor,
and brachial plexus injury (injury to a nerve complex in the
shoulder). Here, too, rates in nulliparous women planning home birth
(5.5 per 1000) exceeded those with planned hospital birth (3.3 per
1000). Again, differences failed to achieve statistical significance,
but, again, this may be because the population was too small to detect
one. Assuming the difference is real, 2.2 more babies per 1000 of
women beginning labor at home will experience encephalopathy or
brachial plexus injury compared with women beginning labor in
hospital; however, almost all babies will recover fully, making any
difference in permanent injury rates miniscule.
Against perinatal risks must be set the excess maternal risks of
planned hospital birth. No woman died, but investigators reported
cesarean surgery and anal sphincter injury rates, both of which can
result in future or permanent adverse effects.
Rates of anal sphincter injury in nulliparous women were nearly
identical (43 per 1000 planned home birth vs. 45 per 1000 planned
hospital birth), but differences are likely to be much greater in the
United States and Canada, where median episiotomy (cut straight toward
the anus) is usual, because, unlike mediolateral (cut angled to one
side) episiotomy, the norm in the U.K., median episiotomy strongly
predisposes to anal sphincter laceration. Women planning home birth
were less likely to have episiotomies (160 per 1000) compared with
women planning hospital birth (293 per 1000), which amounts to 133
fewer episiotomies per 1000 women beginning labor at home.
As for cesarean surgery, planning home birth cut the likelihood of
cesarean nearly in half. The rate in nulliparous women starting labor
at home was 85 per 1000 compared with 160 per 1000 in women planning
hospital birth, which calculates to 75 fewer women per 1000 beginning
labor at home ending up in the operating room. The consequences of
cesarean surgery can be serious for both the current delivery and
future pregnancies and deliveries, and the risks includeincreased
likelihood of future maternal and perinatal death. Furthermore, the
excess risk of cesarean can be much greater. A large, multicenter
Canadian studyin women who would have qualified for home birth
according to the U.K. studys criteria reported a cesarean rate of 299
per 1000 in nulliparous women.
So there you have it. For multiparous women with no prior cesareans,
planned home birth confers no excess risk. For nulliparous women, it
isnt a matter of risky versus safe but of which risks the woman
prefers to run. As the other two high-quality studies conclude, home
birth is a reasonable option with the provisos of low-risk status and
a qualified attendant.
Posted by: Henci Goer
Helpful explanation of what to expect of your baby and BF: