Practical Parenting: Circumcision

There is a lot of false information going around about circumcision — that it’s important for proper hygiene, that it lowers the risk of contracting STDs, that the infant can’t feel it or that it carries no risk of injury or death.  Parents make this decision for their child based on this misinformation, but when things go wrong, their sons are the ones who get hurt.

Circumcision, for those unfamiliar with the term, is the removal of the foreskin, a piece of skin which covers the head of the penis.  The head, or glans of the penis has a similar function to the female clitoris, so the foreskin is similar to the clitoral hood in women — one of it’s functions is to protect the highly sensitive glans.  The foreskin itself also serves a sexual function — the highly sensitive nerves found in the foreskin can enhance sexual pleasure, not only for the man but for his partner as well.  Nearly a third of baby boys are circumcised shortly after birth, and in the Jewish culture it is considered an essential rite of passage.  Most American women have never seen a circumcised penis.

Here are some of the more common reasons parents give for circumcision:

Reason #1: Circumcision is important for hygiene.

This is essentially saying that the vagina would be easier to keep clean if it weren’t for those pesky labia.  That may be true, depending on your definition of clean, I guess.  Lots of things would be “easier to keep clean” if we simply removed a part of our body — ears, bellybuttons, nostrils, between our toes — but instead of removing it, we simply learn how to clean around it.  What a concept.

Reason #2: If he is intact, he will be teased.

This may be very true.  He might also be teased if he has red hair, or freckles, braces, glasses, is fat, is learning disabled, is gifted, has a lisp, has a unique name, is gay, stutters….

Kids can be cruel.  Cutting off a perfectly healthy part of his body doesn’t make him any less tease-able, I’m afraid.

Reason #3: It’s better for his health.

Once upon a time, circumcision was claimed to reduce chances of a boy contracting HIV and other STDs, as well as reducing his chances of getting penile cancer.  These claims have recently been disproved.  The best thing a man can do to prevent HIV, STDs, and penile cancer is to practice safe, non-promiscuous sex — cut or uncut.

Reason #4: He can’t feel it anyway.

Please tell me you don’t believe this.  Can he feel when he gets a shot?  Can he feel you touch him? To think that he can feel everything else but not someone cutting off a piece of his body is just ludicrous.  If someone tells you this, please just laugh in their face.

Here are my thoughts on circumcision:

1. It’s cosmetic, therefore technically unnecessary.  

2. It carries some risk. 

Less than 1% of boys who undergo circumcision will either during or after the procedure.  I mean, that’s still about a 99% chance they won’t, so the risk isn’t HORRENDOUS, but if there’s no health benefit, and arguably no social benefit, is there any reason to take the risk?

And even if they don’t die, what if they botch it?  I once heard the story of a man who realized during puberty that he had a botched circumcision, when the skin of his penis wouldn’t stretch enough during an erection.  Ouch.  What would you rather your child endure — some teasing in the locker room, or learning to associate arousal with pain?  Oh, and one rejected skin graft later, this man is now without a penis entirely.  But hey, at least he didn’t get penile cancer, right?

Or in the 60s, when some doctors took a little bit too much off the top and cut off the penis entirely.  Luckily they convinced the baby’s parents to raise him as a girl, so nobody was any the wiser.  I’m sure that ended well.

My point is, if there was some actually benefit to it, 1% could be an acceptable risk.  But if it carries absolutely NO benefit, why chance it?

3.  Whose choice should it be?

What’s the rush, anyway?  Why do we circumcise as infants?  Couldn’t we just let them make the decision for themselves when they’re old enough to understand it?  Are we afraid they wouldn’t make the choice we want?  This isn’t like getting a little girl’s ears pierced — foreskins don’t grow back.  If he doesn’t like it, he’s pretty much stuck with it.

4. It’s becoming more popular.

If you are considering circumcision because you are afraid of locker room or lover’s lane (Eek! An uncut penis!”) drama, rest assured that circumcision rates are actually plummeting in the last decade.  Over two thirds of all boys born in the US in 2010 were uncircumcised.  So, there might be more intact penises gracing the locker rooms, and any lovers may be more accustomed to the sight as well.

I don’t care if you circumcise or not.  There’s not a HUGE risk, after all.  Just know that you can’t believe everything you read on the internet — an uncircumcised penis can be just as healthy as a circumcised one.  Rather than cut him, teach him how to care for himself, practice safe sex, and let him know that if he ever wants to change it, it’s his body and his choice.  Armed with that knowledge and power, he can have a very happy penis.  And isn’t that what we all want for our little boys?

Advertisements

Evidence-Based Medicine: VBAC vs Repeat Cesarean

“Once a c-section, always a c-section.”

Every day, across American, millions of women face this “reality.”  For the last decade, the American College of Obstetrics and Gynecology (ACOG) has supported this sentiment through its policies discouraging VBAC (vaginal birth after cesarean).  But what many women and their doctors view as an unfortunate (and unavoidable) side effect of the growing c-section rate is in fact something that 60-80% of women can avoid.

VBAC became very popular during the late 1980s and early 90s, as an attempt by women to regain their birth experience from the then all-time high cesarean rate of about 24%.  Many women were able to experience vaginal birth during this time, but obstetricians noticed a disturbing rise in the rate of uterine rupture, a phenomenon that is a life-threatening emergency to mother and baby.  It was especially prevalent among VBAC mothers, whose cesarean scars caused weak spots in the uterine wall.

Source: Childbirth Connection

Because of this troubling observation, in 1999, ACOG issued a recommendation to its members that VBAC only be attempted in a hospital where an obstetrician and anesthesiologist were consistently present.  Since women insisted on VBACs, and VBAC seemed to cause uterine rupture, the idea was to be prepared for the emergency.  But what ACOG failed to address was the relationship between the routine use of induction drugs on VBAC patients, which caused hyperstimulation (harder and more frequent than natural labor contractions), thus leading to uterine rupture along the cesarean scar.  So rather than dealing with one of the causes of the problem and discouraging unnecessary inductions (especially with off-label drugs like Cytotec), ACOG decided to instead deal with the fallout of such imprudent practices.

Source: Born in the USA (Wagner, 2008)

BUt while ACOG and its members crusaded against VBAC, striking the fear of uterine rupture into the hearts of pregnant women, they failed to educate women on the risks of the only other alternative – repeat cesarean.  By doing this, they made it impossible for the women in their care to make an informed decision as to what was best for their baby.  If you were given the choice of vaginal birth, with an “increased risk of uterine rupture,” and could lead to hysterectomy, fetal brain damage, or death, or a repeat c-section, which would you choose?  This imbalanced attitude toward educating patients persists with many obstetricians today.

The truth is, repeat cesarean has its own risks, which are frequently downplayed by ACOG and its members.

For the mother, risks of repeat cesarean include:

  • Physical problems for the mother, including hemorrhage, blood clots, and bowel obstruction (caused by scarring), infection, long-lasting pelvic pain, and twisted bowel.*
  • Longer hospital stay, with an increased risk of being re-hospitalized.*
  • Negative impact on bonding and breastfeeding due to separation during the critical first few hours after birth.*
  • Placenta Previa** – the placenta attaches near or over the opening to her cervix; this increases her risk for serious bleeding, shock, blood transfusion, blood clots, planned or emergency delivery, emergency removal of her uterus (hysterectomy), and other complications.
  • Placenta Accreta** – the placenta grows through the uterine lining and into or through the muscle of the uterus; this increases her risk for uterine rupture, serious bleeding, shock, blood transfusion, emergency surgery, emergency removal of her uterus (hysterectomy), and other complications.
  • Fertility problems**
  • Ectopic Pregnancies** – the egg implants somewhere other than the uterus.
  • Placental Abruption** – placenta detaches before birth

For the baby:

  • Breathing problems at birth*
  • Increased risk of asthma during childhood*
  • Prematurity**
  • Low birth weight**
  • Physical abnormalities or injuries to brain or spinal cord**
  • Death before or shortly after birth**

* These risks are associated with cesarean section in general, not just repeat procedures, but the overall likelihood of experiencing such complications increases with each subsequent surgery.

** These risks are more common in repeat cesareans than with vaginal births, and have been shown to increase in frequency for each subsequent surgery.

[Source: Childbirth Connection]

Last year, ACOG changed its tune, lifting the restrictive recommendation.  But a decade of anti-VBAC sentiment has left its mark.  Because of the “increased risk of uterine rupture” that ACOG has repeatedly emphasized, insurance companies have become reluctant or even unwilling to cover the procedure.  An obstetrician who would like to offer VBAC may be hesitant when faced with increased malpractice insurance costs.  In some states, home-birth midwives and alternative birth centers are forbidden to offer the option.  Some women have turned to home VBACs because they were unable to find a provider willing to offer it, and decided they’d rather take the risk of an unassisted home birth over a mandatory c-section.  It remains to be seen how the new ACOG recommendation will affect the choices of women as to how (and where) they give birth.

Let’s hope it’s for the better.

For more information on the safety of repeat cesareans and VBACs:

The Unnecesarean (blog)

Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First by Marsden Wagner (2008)

Ina May’s Guide to Childbirth by Ina May Gaskin (2003)


Evidence-Based Medicine: Are Inductions Safe?

A couple weeks back, I researched the necessity of labor induction.  I learned that, according to the Listening to Mothers Survey from 2005, about 40% of all labors are medically induced.  I also learned that, according to birth experts Ina May Gaskin and Marsden Wagner, induction is only medically indicated in about 10% of births.  This means that about three-quarters of all women who are induced are doing so without medical indication.  If induction is perfectly safe, there would be no concern — so what does the research say?

The stats…

80% of medical inductions were done using a drug called Pitocin, a synthetic oxytocin, which causes the uterus to contract.  Other methods of induction include prostaglandin medications applied to ripen the cervix, stripping/sweeping the membranes, and “breaking the water”  (artificial rupture of membranes (AROM)).  Most mothers included in the survey were subject to 2 or more methods of induction, the most common combination being Pitocin and AROM.

Not only are many labors medically induced, but many are also augmented using the same methods listed above.  When these numbers are included, about 50% of women are given artificial oxytocin to either induce or augment labor, and 65% have their water broken.

The risks…

  • More painful labor — Common induction methods such as artificial oxytocin can lead to longer and stronger contractions that are closer together.  This means more pain for the mother during contractions, as well as a shorter period of time between contractions to recuperate.  This can quickly exhaust a laboring woman, not to mention tarnish her birth experience.  Many women whose labors are induced or augmented find an epidural to be a necessity.

“I went into labor on my own with my daughter, but was induced with my son.  With my daughter, I found that sitting in a warm bath made the pain very manageable, and I didn’t get the epidural until very late — 7 cm, I think.  With my son, I got an epidural at 3 cm — I just couldn’t stand the pain.”  — Annie, 31

  • Prematurity — Miscalculation of due dates can lead to a woman being induced before her baby is mature.  Iatrogenic (doctor-caused) prematurity is on the rise, and with it comes all the risks commonly associated with prematurity, such as breathing problems.  New research shows that the production of fetal lung proteins trigger labor — meaning that the baby triggers spontaneous labor when its lungs are ready to breathe.  Inducing without medical indication means your baby may not be totally ready to breath independently.  Labor should NEVER be induced before 39 weeks for this reason, and should ideally be around 42 weeks as long as the baby shows no signs of distress.
  • Fetal Brain Damage or Death —  The only time a fetus can get oxygen is during the rest period between contractions, so when those periods are shorter, the fetus gets less oxygen.  Lack of oxygen is associated with an increased risk of brain damage.
  • Maternal death —  According to Marsden Wagner’s book Creating Your Birth Plan, induction of labor is linked to higher rates of uterine rupture and amniotic fluid embolism (AFE), both of which are rare but usually fatal (80% of AFEs are fatal — 50% within the first hour after symptoms appear).  C-Section dramatically increases the incidence of both.  Many women who survive uterine rupture undergo hysterectomies and are unable to have any more children, and most that survive AFEs are severely brain damaged.  Fetal death is also common with both of these complications.
  • “Cascade of Interventions”A woman who is either induced or has her labor augmented artificially is at an increased risk of instrumental (forceps and vacuum-assisted) and surgical (c-section) interventions.  So even if the induction drug itself is considered safe (which Pitocin is), the risks associated with all other forms of intervention must be calculated as well.  While the more severe risks (uterine rupture, AFE, fetal brain damage) are relatively rare, the so-called “cascade of interventions” is fairly common.  A woman who is induced more than doubles her riskof having a C-Section.  A woman who goes in to be induced may find her plans for a low-intervention birth go awry very quickly.

 “I got induced at 41 weeks because they thought she was going to be too big too birth otherwise.  First came the Pitocin, then the epidural for the increased pain, which meant I was tethered to the bed with IVs, so I couldn’t move around.  Then my labor slowed down, and they broke my water to speed things up.  I went into labor thinking that I could manage an induction naturally, but instead I ended up with a C-Section because of failure to progress.”— Silvia, 26 

  • Interferes with Bonding/BreastfeedingArtificial oxytocin alters the mother’s natural hormones during and after birth, potentially affecting her ability to bond with or breastfeed her baby.  Any other interventions she experiences (such as cesarean) can also interfere.  

“When my son was born, I felt like he belonged to someone else.  I kept waiting for that overwhelming feeling of attachment I knew I was supposed to feel, but it just didn’t come — I felt like I was just going through the motions for weeks.” — Patty, 29

What is the alternative?

So if induction carries with it the risks listed above, it could be argued that elective induction is not in the best interest of the mother or baby.  So what’s the alternative?  Well, waiting.  Just remember, every day your baby “cooks,” s/he will be a little bit stronger, a little bit healthier.  As we talked about last week, babies can and have been (vaginally) born past their due dates perfectly healthy.   Trust your baby, and trust your body to go into labor on your own — it’s better for both of you!


Empower Yourself: Know Your Rights!!

Nothing can be more empowering than standing up for your wishes and needs.  But much too often, women in labor are unaware of their rights as patients, and their birth experience could be sabotaged because of it.  When I read Marsden Wagner’s Born in the USA, I became particularly interested in the political aspects of fixing the maternity care system in our country.  One of the most powerful things a woman can do is arm herself with information, and knowing her rights as a patient is the first step.

Informed Consent

The right to informed consent and the right to refuse treatment are protected in the Constitution by the First and Fourteenth Amendments, the right to privacy and self-determination.  They are also protected by federal law through the Emergency Medical Treatment and Active Labor Act (EMTALA) and the Patient Self-Determination Act.  The American Medical Association (AMA) an the American College of Obstetricians and Gynecologists (ACOG) also cover both these rights in their ethical guidelines.

So what does “informed consent” and “self-determination” really mean?  And how does it apply to labor and birth?

  1. The right to exercise self determination and autonomy in all medical decisions, including the decision to refuse treatment.  This is especially important for situations where hospital policy requires you to birth a particular way, or prevents you from having the type of birth you want.  Mandatory c-sections for breech and twin births, as well as bans on Vaginal Birth after Cesarean (VBAC), are just two examples of how hospital policy limits the patient’s choice regarding her health and the health of her baby.  Such policies are not protected by law, and you have every right as a patient to refuse treatment, no matter the consequences of that choice.
  2. The right to bodily integrity.  Any non-consensual touch or procedure in a medical setting constitutes battery and should not be tolerated.  This includes non-consensual Artificial Rupture of Membranes (AROM) and episiotomies, both of which should only be done with the woman’s knowledge and consent.  A woman’s who experiences birth trauma is more likely to suffer from Postpartum Depression (PPD) or even Post-Traumatic Stress Disorder (PTSD), and is more likely to have difficulty breastfeeding.  These experiences can be so traumatic that a growing number of women are classifying it as “birth rape.”  If you feel you were violated in any way during your birth, please report it — that’s what the legal system is intended for.
  3. The right to be provided with the necessary information on which to base medical decisions.  This includes getting a diagnosis, recommended treatments and alternatives, the risks, benefits, and side effects of proposed treatments, realistic expectations of outcomes, a second opinion, and any financial or research interests a physician has in proposing certain treatments (I find that last one particularly interesting).  Clearly, it may be difficult to get all of the above information while in labor.  I know I certainly couldn’t have sat through it!  It is important to discuss these issues with your doctor before you go into labor, not during.  Make like a boy scout and be prepared.
  4. The right to be informed of any potentially life-threatening consequences of a proposed treatment, even if experiencing such such an outcome is unlikely.  C-section is a major procedure for which the consequences and risks are often downplayed or left out, especially if it is a repeat surgery.  Other interventions, such as induction/augmentation and epidurals also have risks which are rarely discussed in depth.
  5. The right to make medical decisions free from coercion or undue influence from physicians. Many women are talked out of VBACs because of the risks only to undergo an (at least) equally risky repeat C-section.  Women are also “talked into” more minor procedures like epidurals, augmentation, and induction when doctors talk about the “risks” (like hypersomia and shoulder dystocia).  This right is especially poignant during labor, when a woman is experiencing the effects of lots of hormones, stress, and exhaustion, as she could be more suggestible at that time.
  6. The right to revoke consent to treatment at any time, either verbally or in writing.  I have read many stories where a woman stated to her care provider, “I don’t want an episiotomy,” or “I don’t want a C-section,” only to have her wishes dismissed.  While these procedures are sometimes necessary, a women does have the right to take the risk and not have one.  Even if you’ve already consented, you have the right to “backsies,” and legally a care provider must respect your choice, even if they disagree with it.  A care provider’s purpose is to advise and serve, not make decisions regarding your health.

Another helpful bit of information — a doctor can only terminate care after reasonable notice, and after providing necessary care.  Many people, including physicians, believe that if a doctor disagrees with a patient’s choice, they can simply discharge you on the spot, but that’s not true.  When you are in labor, discharging you against your wishes is considered patient abandonment.

Also, you are NOT required by law to sign a hospital’s consent form, and you also have the right to make any changes regarding specific treatments (get a copy of whatever you sign upfront, especially if you made changes).  If your wish to refuse a specific treatment is documented, and you receive that treatment anyway, the hospital and doctor can be held liable, just like they can if they violate a Do Not Resuscitate (DNR) order.  If a patient refuses a C-section upfront, and she receives one anyway, the doctor and hospital can be subject to battery charges, regardless of whether or not she or the baby were harmed.

Know your rights BEFORE you go into labor. Make your care provider(s) know that you are aware of your rights — by empowering yourself in this way, you are setting yourself up for a more respectful birth experience.

If you feel like your care provider was negligent or abusive of your rights, speak up!  In recent years, the courts have repeatedly upheld the rights of pregnant women to refuse procedures, even C-sections.  It is dangerous for this vigilante medicine to be practiced, where the doctor thinks he cares more about the baby than the mother, which is exactly what coercion and blatant disregard for a patient’s wishes imply.

What you can do if your rights are violated:

  • File a complaint with the chief compliance officer of the hospital.
  • File a complaint with the state medical board.
  • Don’t be afraid to press charges if you feel it is justified.

This is a heavy subject, and it is very unfortunate that our maternity care system is in a condition where laboring women must concern themselves with such matters.  Take this information and use it to your advantage.  Flex your legal muscles, and see how powerful you become.


Practical Parenting: The Family Bed

I don’t remember the first time I realized that the practice of the family bed existed, but I certainly remember my attitude toward it.  It was the same I’ve heard time and time again — that it was dangerous, that co-sleeping fosters dependence — if you bring the child into the bed, they’ll never leave, that overall, it was just…weird.  Oh, and you’ll never have sex again.  I heard that one a lot.

I knew that I would want my baby in my room, and I knew that was better for her than across the hall.  I’d read about all the benefits, like a reduced risk of SIDS, less time getting up and down in the night, etc.  I even went to all the trouble of getting a heirloom bassinet, which had been handcrafted by my late grandfather.  My biggest fear in late pregnancy was that I wouldn’t get the bassinet mattress on time, and would have no place for her to sleep.  I was that dedicated to her sleeping in a cradle.  But she most certainly wasn’t sleeping in our bed.  It was too dangerous.

Then, she was born — and she didn’t want to sleep in the cradle, and even next to my bed felt too far away that first night.  I felt so…empty…without her close.  And I just loved her so much, it was unbearable, and I wanted her in my arms.  So into bed with us she came.  And she’s still there today, five months later.

At first, I did it with a conflicted heart.  I had been told about the dangers of bed-sharing — she seemed so tiny, and us so big, wouldn’t we roll over on her? — I was even told that if anyone found out about it, I might get her taken away.  My mother, who stayed with us the first week after Sweet Pea was born, kind of shook her head at it, but otherwise seemed to write it of as a sweet new mother thing (but she still asked the midwife about it to make sure it was safe).  At first, I told most people, even my pediatrician, that she slept in the bed with me.  It felt so natural to have her there, I kind of thought everyone would accept it as an instinctual maternal thing.  And at first, they did — but as she got older, I started to feel a lot of pressure to get her into her own bed.

So I started to hide it.  When we traveled, I took along the Rock N Play sleeper to make it look like she was sleeping in her own bed.  When people started to ask about where she slept (which happened a lot for some reason), I started to say, “we have a little cradle in our room.”  (Notice that I didn’t specifically say she slept in it.)  Every few weeks, I would commit to myself that I was going to get her in her own bed, that it was truly better for her that way.  I didn’t want her to become too dependent on it to sleep.  But in reality, bed-sharing was just so much easierEspecially when I learned how to nurse laying down.


It wasn’t until recently that I finally admitted to myself that I’d like to continue to bed-share.  Even at five months, I still feel like having her close, and she sleeps best snuggled up to me.  And I sleep better, too.  And as it turns out, there’s even evidence to suggest she’ll be even more independent because of it.

If you want your baby to sleep in a crib, I won’t tell you not to.  I think the best arrangement is what works for everyone — father, mother, and baby.  Everyone’s wishes should be considered.

But I also think that there’s a lot of negative feedback about bed-sharing out there, and the truth is, it’s a very natural thing to fall into.  I didn’t think I would bed-share, but, like so many other things, my feelings changed when I actually had my baby.  I felt so connected to her, like she was still part of me.  I couldn’t (and still can’t) imagine putting her to sleep in another room.  I was really surprised by that, and you might be too.  And if you do find yourself desiring to pull your baby into bed, I would encourage you to try it (but do it safely).  You might be surprised at how much you actually enjoy it.  And you’re definitely not alone.

And if you’re worried about your sex life, remember — bed-sharers have subsequent children, too.


Evidence-Based Medicine: Is Induction Necessary?

During my last month of pregnancy, I had a few “false alarms,” where I was convinced I was in labor, but it turned out I wasn’t.  I was so anxious to meet Sweet Pea, a little nervous about what labor would actually feel like, and it started to do weird things to my brain.  After our third false alarm, my husband and I finally sat down and accepted the reality that we had no control, and that Sweet Pea would come when she was ready.  We knew that every day she “cooked,” the healthier she would be.  I went to bed that night at peace, knowing that the best thing I could do for her was to be patient.  The next morning, I woke up in labor – at 39 weeks on the nose.

Many first time mothers experience the same kind of anxiety and anticipation that I did, but the weeks stretch on an on, even surpassing their due date.  And those women and their doctors are talking more and more about artificial induction, using labor-stimulating drugs like Pitocin.  A study from 2006, featured in the New England Journal of Medicine, found that 40% of low-risk, first time mothers were induced into labor.

Induction is definitely a growing trend in America.  But is this trend necessary to improve the outcomes for mothers and babies?  Are there situations where induction is medically indicated?  And how much of this trend is based on convenience — either for the mother or doctor?

When is induction medically necessary, improving the outcomes for mothers and babies?

According to Ina May Gaskin’s Birth Matters, up to 10% of all labors may call for labor induction.  She lists specific circumstances that may call for induction, such as:

  • cancer
  • hypertension
  • diabetes
  • kidney disease
  • IUGR (intrauterine growth restriction)
  • significant decrease in amniotic fluid
  • intrauterine fetal death (followed by a long (weeks, not days) wait for labor to begin)

Marsden Wagner (perinatologist, and author of Born in the USA) adds two other conditions:

  • documented placental malfunction (placenta losing its ability to nourish the fetus)
  • deteriorating preeclampsia (high blood pressure during pregnancy)

According to Gaskin and Wagner (both specialists in their fields), under these conditions, induction actually improves the outcome (as opposed to spontaneous labor).  But they both state that only about 10% of all pregnancies need to be medically induced.  And when you add up the statistics for each of the above circumstances, it comes very close to 10% of pregnancies.  But, according to Childbirth Connection‘s 2005 Listening to Mothers Survey, half of all pregnant women experience induction.  So why the major discrepancy?

You may notice that two of the most commonly-given reasons for induction — postdate (overdue) pregnancy and big babies (macrosomia) — are not listed.  This may explain the difference in recommendation versus reality.  Let’s see what the evidence says about those two reasons.

Induction Due to Post-Dates (Overdue)

This is the normal distribution for gestational age.  Notice when the largest majority of babies are born — 40-41 weeks.  And approximately the same percentage give birth between 41-42 weeks as do 39-40.   And this is all with spontaneous labor!

I think this about says it all.

Normal, low-risk pregnancies go to 40 weeks and beyond quite often.  First time mothers are especially likely,.

What about the risks of going past 42 weeks?  Isn’t there a risk to the baby?

According to Wagner, a study from 1963 found that a slight increase in the number of stillbirths after 42 weeks, with a significant increase after 43 weeks.  This study has been frequently cited as evidence to support induction before 42 weeks.  But Wagner puts the risk to the individual woman into perspective —  as it turns out, only 3 percent of pregnancies even extend beyond 42 weeks, and even after 43 weeks, only 10 percent (of that 3%) have any problems.  So as you can probably deduce, the chances of going so far past your due date that you put your baby at risk is pretty insignificant (about 0.3%).  You have a much greater chance of going into labor spontaneously before you reach 43 weeks, and an even if you don’t, there’s a good chance your baby will still be born healthy.

Another risk in induction due to postdates is the inaccuracy of EDDs (Estimated Due Dates).  Because of normal variations in the menstrual cycle length amongst average women, and the tendency to base due date on the last menstrual period (LMP), a woman’s due date could be off by 2 weeks or more.  So if a woman gets induced at 40 weeks, her baby could actually only be 38 weeks (or less), which is associated with more health problems for the baby.  This is a phenomenon called iatrogenic prematurity (essentially, doctor-caused prematurity), and is a growing portion of the increasing prematurity rates.

So, post-dates is generally NOT a medically indicated reason to be induced.

“Big Babies” or Fetal Macrosomia

First, macrosomia is defined as a baby weighing over 8 lbs 13 oz.  It legitimately effects about 10% of all pregnancies in America.

Perhaps the one of the most prominent concerns about big babies is a complication called “shoulder dystocia,” where the baby’s shoulders get stuck on the mother’s pelvic bone.  The risks of this complication include paralysis, Erb’s palsy, and fetal hypoxia (baby doesn’t get enough oxygen). Sounds scary, doesn’t it?  And if you are of the unfortunate 1% of women who experience it, it will definitely be treated as scary in the typical US hospital.

So what happens when a woman experiences shoulder dystocia?  Just think ALARMER.

  • Ask for help. This involves requesting the help of an obstetrician, anesthesia and pediatrics for subsequent resuscitation of the infant.
  • Leg hyperflexion (McRoberts’ maneuver)
  • Anterior shoulder disimpaction (suprapubic pressure)
  • Rubin maneuver
  • Manual delivery of posterior arm
  • Episiotomy (Does anybody else wonder how cutting open the perineum has any impact on a baby who is stuck on the pelvic bone?  Okay good, me either.)
  • Roll over on all fours

According to Wikipedia, the advantage to this mnemonic is that it goes from least invasive to most invasive.  That sounded all fine and good, until I got to the last method — roll over on all fours.  Wait, what??  How is rolling over on all fours less invasive than say, an episiotomy (you know, where they cut your perineum)?

Turns out “Roll over on all fours” has a name — Gaskin’s maneuver, and was discovered by midwife Ina May Gaskin (yes, the same one mentioned earlier).  This maneuver opens the pelvis (wider than lying on her back) , allowing the shoulders to slide through. Sounds pretty non-invasive.  In one study, the Gaskin maneuver had the following results:

“Half of the eighty-two babies weighed more than 4000 grams (about 8.5 pounds); 17 or 21 percent weighed more than 4500 grams (about 8 pounds, 10 ounces); thirty of the 1-minute Apgar scores were less than or equal to 6, and two were less than or equal to 3; only one of the 5-minute Apgar scores was less than or equal to 6, which is 1.2 percent; forty-nine of the women or 60 percent delivered over an intact perineum, and there were no third- or fourth-degree lacerations; one woman had postpartum hemorrhage not requiring transfusion; and one infant had a fractured humerus.

That sounds a heck of a lot better than an episiotomy to me.  So why aren’t more hospitals using this technique?  Probably the biggest reason is that movement during labor is limited by current birth practices, such as epidurals and electronic fetal monitoring, which generally require the mother to lay on her back.

Another issue with justifying induction because of macrosomia is the accuracy of the diagnosis.  Macrosomia is generally diagnosed using an ultrasound, which has been found to be inaccurate in nearly two-thirds of cases.

And according to Wagner, while macrosomia has been used to justify induction, evidence does not support this practice.  In fact, C-Section rates increase with induction due to macrosomia, with NO improvement in outcomes.  As he puts it in Born in the USA, “trying to hammer out too large a baby can harm the baby.”

Conclusion:

  • Evidence suggests that induction rates of less around 10% are essential to optimal outcomes for mothers and babies.
  • About 50% of pregnant women experience induction in the US.
  • Gestational ages range, and 42+ weeks pregnancies can still be healthy and deliver spontaneously.
  • Due dates can be up to 2 weeks off.
  • Big babies have a higher risk (1%) of developing “shoulder dystocia,” which has serious complications.
  • Diagnoses of macrosomia can be inaccurate up to two-thirds of the time.
  • If you induce due to macrosomia, you have a greater risk of undergoing a C-section

Oh, and:

  • Episiotomies widen your vagina (skin/muscle), not your pelvis (bone).  Just say “no” to episiotomy.
  • Patience is key.

With all that I’ve read, I have to say I come down on the side of “very wary” of induction.  Unless you are in the 10% whose medical condition requires it (see above), it’s probably better for you to wait until your baby is good and ready to come out.

Here are some more natural ideas for inducing labor:

  • Walk.  A lot.  — I walked more in the last month of my pregnancy than I did in the previous 8 months combined.  Which was nice, since I couldn’t walk farther than 4 feet without pain for about a week after she was born.
  • Have sex.  A lot. — As awkward as it sounds, the prostaglandins in semen help soften the cervix.  And it might sound a little dirty, but let’s admit it, that’s how we all got into this predicament to start with.
  • Start a lengthy project.  — Not only does this fill your time, but you are almost guaranteed that your baby will come before you can finish it.
  • Buy expensive concert tickets for right around your due date.  — Along the same vein, it’s likely that you won’t get a chance to use them.

HAPPY WAITING!


Practical Parenting: Spanking

Were you spanked as a kid? 

Most people our age or older can recall being spanked as a child.  You bet your buns that I was.

My mother tells (fond?) stories of picking her own switch off a bush, as well as a particular “paddling” where she whipped out the wooden spoon on my brother because he started laughing at her, and “he couldn’t feel it through his diaper” (my emphasis).

I don’t remember exactly what kinds of behaviors deserved spanking, but I’ll say it was generally disrespect — lying, “backtalk”, etc.  I got spanked a lot.  To contrast, I seem to remember my older brother getting spanked much less frequently.  That speaks loads about our different personalities. 

I remember getting my last spanking sometime around 12 or 13.  I don’t remember what it was for, but I do remember thinking, “I’m way too old for this.”

My husband claims he got spanked maybe once or twice.

But today?  A few years ago when I was teaching preschool, I remember being surprised to see a mother of a toddler spank her child, and I’m pretty sure she was in the minority in that community.  But she did it in front of the teacher, as if it was perfectly acceptable.  It got me to thinking…is spanking perfectly acceptable?

Is spanking an effective form of discipline?

A lot of research is being done, not just on spanking, but on rewards and punishments in general, and is coming to some interesting conclusions — namely, rewards and punishments are not as effective in changing behavior as many people think. Oh, you might see a change on the outside, but the inside, the conscience — the thing that controls future behavior, remains unchanged, or even resentful and likely act to out.

The ineffectiveness of punishment is displayed frequently in the driving behaviors of adults.  Maybe you’re driving down the highway, when all of a sudden you spot a patrol car.  What do you do?  If you’re like most adults I know, you slow down.  You certainly don’t pass it.  But what if that patrol car wasn’t there?  Would you behave differently?  Again, if you’re like most adults I know, you probably would.  You might drive over the speed limit, or squeak under that red light, or pass on the highway without flinching.  The fact is, that while the police have succeeded in altering our behavior when they’re around, we behave as we please when they’re not around.

Children are the same way.  While punishment is effective in controlling your child’s behavior when you’re present, as soon as you take the “punisher” away, the child is likely to behave differently.  I saw it first-hand in the preschool — I could always tell the kids who were spanked at home, because they kind of went nuts once their parents left.  Alternatives to spanking were less effective on them, because they knew that we couldn’t and wouldn’t spank them.  To them, if they weren’t getting spanked, it wasn’t worth behaving.

So is it effective?  Kind of.  In the short term.  For the child reaching for a tempting item, a spanking will alter his trajectory.  This short-term effectiveness is what keeps parents spanking.  But long-term is a different story.  And isn’t a long-term change in behavior the ultimate goal of discipline?

Is spanking harmful?

I suppose it depends on your definition of “harmful.”  Many people my age and older have proudly given credit to spanking for the way they turned out.  Some people would claim that without spanking, children would be “soft” or disrespectful.  But corporal punishment has left the schools, and fewer and fewer parents will (openly) admit to disciplining their children in this manner.  So clearly, it’s fallen out of public favor.  It has also fallen out of favor among child development experts and psychologists. Study after study have found spanking to effect aggression in children, self-esteem, success in school, etc.

In fact, the majority of sources I found to extol the benefits of spanking were primarily religious, using the famous line “spare the rod, spoil the child.”  What I found most interesting about this study was that the negative effects of spanking seemed to be strongly influenced by the age of the children when they were spanked.  Children spanked after age 6 were more likely to have behavioral problems than kids spanked before 6.   And teens who were spanked had the worst problems. (Teens?? Do people really spank teens??)

Another uncommon view to consider is not only the effect spanking has on the child, but on the parent.  Our brains respond in surprising ways when we spank our child, and not in ways I think many parents would find to be beneficial.

Being spanked myself, I have difficulty accepting that spanking has a universally negative effect on a child.  I did well in school and generally stayed out of trouble.  I haven’t had a particularly close relationship with my parents, but I hesitate to blame spanking.  But I’m sure there are people who were spanked more frequently (or more harshly) than I, and perhaps they do blame spanking for the way they turned out.  And when spanking turns into abuse, it is definitely harmful — and sometimes that line is easy to cross when you’re angry with your child.

Conclusions:

Personally, I wouldn’t classify spanking as abuse.  Not by itself, anyway.  It definitely has the potential to be harmful, though, and at it’s best it’s mostly ineffective.  As a nanny and preschool teacher, I would’ve lost my job if I had relied on corporal punishment to correct behavior, and I quickly learned many peaceful strategies that were quite effective.  So if a discipline strategy is at best ineffective, and has the potential to be harmful at its worst, and there are more effective, arguably less harmful strategies available, wouldn’t it make sense to try something else?