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	ask the experts sarah j. buckley

Sarah J. Buckley GP, MD
Pregnancy and Birth, Family Planning, Co-sleeping

• Sleep dependence
• Twins, one breech, one transverse position
• 9 mo old waking to play
• Sleep crawling
• Pregnancy heartburn and reflux
• Weaning to avoid miscarriage
• Gestational diabetes and birthing naturally.

We have a 17 month old son, Max, who wakes three to five times a night and needs help getting back to sleep. Sometimes all he wants is a drink of water but it always has to come from his mom or dad. We all shared our queen-sized bed until Max was about 13 months old. At that point he became too restless to sleep with?neither Dad nor I were sleeping well. We successfully transitioned him to his own bed (a queen-sized futon) and his own room but he still wakes several times a night and needs help getting back to sleep. Max has been teething since he was five months old, continuously it seems, and I know that contributes to some restlessness. But after reading Elizabeth Pantley's book, The No-Cry Sleep Solution for Toddlers and Preschoolers, I'm wondering if he's just used to us being there when he wakes up and is unable to get himself back to sleep without our help. My husband has suggested that perhaps cosleeping has caused Max's inability to sooth himself and honestly, I have a hard time arguing with him. By sharing a bed with Max for so long, have we taught him that he needs help getting back to sleep? We're expecting our second child in September and I plan to share our bed with him/her as well, at least during the period of intense breastfeeding. But I want him/her to know that he/she doesn't need anyone or anything to get back to sleep.

Congratulations on your sensitive parenting for your son. I can also understand your own needs for sleep, and concerns about arrangements with your new baby.

First, I would like to reassure you that you have not caused your son?s need for night-time reassurance.

One way to look at his needs is to consider that, through human history, over 100,000 generations of children have grown up in the wilds, compared to maybe 500 generations living in settled agricultural villages and less than 10 generations in modern multi-bed roomed housing.

Therefore, our children?s brains are still hard-wired for night-times where adult protection and reassurance was crucial for survival. Imagine a 17 month child sleeping alone in the wild: it would certainly risk his life. So it is very normal for a young child to protest at being alone at night: their instincts are telling them that they are in a life-threatening situation.

If we consider this perspective, we can understand that any child who is not old enough to defend them selves against a nocturnal predator (lion, tiger) may feel scared at night.

For example, my six year old daughter (who has been co-sleeping and now wanting to move to her own bed) told me one morning that she awoke in the night and was so terrified that she couldn?t more, or even call out. Her brother (aged 11) said he remembered having the same experience. I realized how lucky I am that my children can share this verbally; the experience for younger children is likely the same (or scarier), and they can?t articulate it, and therefore parents don?t appreciate the depth of these hard-wired fears. (As I say in my book, ?the monsters that our children see under their beds are real, although possibly extinct by now.?)

You might also consider that most parents don?t sleep alone either, and I often find that I don?t sleep as well when my partner is away.

So any method that attempts to get a young child to sleep through the night alone is going to be up against millions of years of human expectations. This is the reason why most sleep training techniques do not produce lasting effects, and why most children will wake regularly for comfort in the pre-school and sometimes school years. This is normal.

There are several solutions, and you will have to see what will work best for your family. Some families cosleep, which is the norm in most non-western cultures throughout childhood, with older siblings often sleeping together as well.

Parents who do not want to cosleep may have a separate close by bed in their room that children sleep in, or can come into in the night.

You may have found yourself that the most difficult time for a child is falling asleep, so lying down with children at this time can be very helpful. Some families (our included) have double beds for young children so that a parent can come in during the night and sleep comfortably with the child for some time. When I had younger babies, my husband had this task with the older children, and it was very sweet to find him, snuggled up in a double bed with several children around him, the next morning.

It is also worth considering what our goals are with our children?s sleep. Generally the goal is for the parents to get adequate sleep so that they can do what they need to do in the daytime. Children?s sleep is usually only problematic if it disturbs the adults. With this in mind, we could also consider if there are other ways that we can care for ourselves so that we are well rested.

Personally, I recommend that all mothers of young children?especially those who are still taking a daytime nap?ensure that they also nap as much as possible. You will find this a great habit with your new baby too.

I have found that over the years I have come to enjoy cosleeping more and more, appreciating the sweetness (and cuddliness) of my children at night and realizing that this time is really very brief. I have also relinquished any expectation of nighttime independence (which is very much a cultural expectation), which has helped me to become more sensitive to their needs.

On a practical note, I also find that my children sleep most peacefully when their nutritional and emotional needs are met, including the need to ?let off stream? with rough play and/or sometimes a tantrum before sleep. See Aletha Solter?s book for more about this.

Many blessings to you and your expanding family.

Resources
Gentle Birth, Gentle Mothering: The wisdom and science of gentle choices in pregnancy, birth and parenting by Sarah J Buckley MD. www.sarahjbuckley.com
Chapter 22, The cosiness of co-sleeping
Chapter 23 Getting a good night?s sleep: gentle approaches to nightwaking (previous version online at http://www.sarahjbuckley.com/articles/good-nights-sleep.htm

Our Babies Ourselves by Meredyth Small

Night-time Parenting by William Sears

Sleeping with your Baby by James McKenna

Tears and Tantrums by Aletha Solter www.awareparenting.com

I am 34 weeks pregnant with twins. One is breech and the other is in the transverse position. Is there anything I can do to avoid a c-section?

Congratulations on your twin pregnancy; having twins is very special. I need to firstly tell you that I am trained in GP(family MD) obstetrics, but not as a specialist ob/gyn, and I am not trained or experienced in caring for women having twins. However, I can give you some general principles that apply to everyone, as well as some research that I have done to help you in your situation.

I fully support your preference for a normal birth with your babies. Although there is a trend towards cesareans for twins, the medical evidence does not show that this is beneficial and, as you probably know, having a cesarean has its own risks foryour self and your babies. (See resources for more information). Natural birth also gives you and your babies many advantages in terms of health, well-being and empowerment - as well as the natural ecstasy that Mother Nature prescribes for all new mothers and their babies (See resources for my article on this subject.)

Perhaps the most important factor in getting what you want for the birth of your babies is your choice of carer. If you have chosen an ob/gyn, you need to know that he/she is sympathetic to your wishes and (even more important) will act on your wishes during birth. Ask your carer how many twins they have cared for and their cesarean rate for these twins. Also ask lots of questions to see if he/she will support you in having a vaginal birth, including if he/she is happy for you to choose your own positions for labour and birth, and to eat and drink if you desire.

Making a birth plan and showing it to your carer will help to further clarify your wishes and your carer’s attitudes (see resources for an excellent birth plan for multiples). You may also consider asking other women in your community, and especially nurses or midwives who have worked with your carer, to geta range of opinions about his/her attitudes and care.

If you are not happy with what you discover, I recommend that you seek another carer, using the same questions and investigations to find someone whose philosophy and practice is in line with yours. You may even be able to find a midwife who can care for you in the setting ofyour choice, with obstetric back-up, or as part of a ob/gyn-midwifeteam. I also recommend that you organise your own support for the birth- a private midwife or doula (see resources for more about doulas and how to find one), especially if you are going to have your babies in a high-tech setting. You can get to know this person and they can help to advocate for your wishes during labour. This person will be invaluable support for your partner, as well, if he is going to be present at the birth.

However, I need to add that, with your twins in non-vertex (ie not head down) positions at present, your carers may be nervous about offering you a vaginal birth. I am presuming that your first baby (ie the twin lowest in your belly) is breech and the second transverse, which is much more likely than vice versa. In this case, there is a reasonable chance that your transverse baby will change position as he/she gets less space in your belly, but this is a bit less likely for your breech twin, who would need to turn 180 degrees to get into the best position. This is even harder for this first baby if his/her bottom is already‘engaged’- ie positioned deeply in your pelvis. I suggest that you talk to your carer about ECV- external cephalic version. This is a gentle way to help your babies to turn into better positions, done with ultrasound guidance. Again, you may need to seek out a carer (usually a ob/gyn) who is skilled in ECV.

It is also possible that your transverse twin will correct his/her position after the first twin’s birth, and there is also the option, if you have a skilled carer, of an ICV- internal cephalic version- where the carer reaches inside your womb and gently guides your second twin into a head-down (or possibly breech) position. Again, please ask your carer before the birth whether he/she has this skill.

You can also use positions and visualization to help your baby to change position. See Resources for more about turning techniques. Communicating with your baby is an important part of any pregnancy, and I recommend that you take the time to tune in to your babies so that you can work together in birth, as well as in preparing for birth. You may be able to hear if your babies have anything to ‘say’ to you about their positions.

If first twin remains breech, please note that there has also been a lot of bad press about vaginal breech birth because of a study that was published in 2000, which may also influence your carers. You may like to read a summary and some critiques of this-see resources- and there is an excellent article in Mothering no 125June-August 2004 on vaginal breech birth. My own opinion is that vaginal breech birth is a safe option- my 4th baby was a breech baby born easily at home - but you need attendants who will be supportive,calm and confident at the birth.

Finally, if you want to avoid a cesarean, you would be wise to avoid, as much as you can, the‘cascade of intervention’. This means, the increased chances of one medical procedure leading to another, eg induction leading to epidural leading to cesarean or forceps. I especially would suggest that you work with your body (and your mind) before and during labour so that you can avoid the need for pain relieving drugs, especially epidurals (See my article Epidurals- real risks for mothers and babies in resources). If you do need a cesarean though, I highly recommend an epidural, so that you can see and hold your babies as soon as possible.

You can use yoga, meditation and tapes beforehand and, as above, choose a doula or midwife to support you who can offer you suggestions and non-drug tools to help you through labour. Stay upright and mobile, eg standing, walking, to help your labour to progress and your babies to stay in a goodposition. Your resolve to have the best birth possible for you and your babies will help you enormously.

If it becomes medically necessary to have your babies by cesarean, I recommend www.birthrites.org and especially their booklet'Caesarean birth... making informed choices'. Look at the chapter'Planning Future Births' - for information that will help any cesarean mother to have the best experience. Again, an experienced doula can be an important resource for cesarean birth.

Wishing you a beautiful twin birth!

Resources

Having Twins- Third Edition by Elizabeth Noble. See www.elizabethnoble. com
(Thanks to Elizabeth for her input with my answer, and for her excellent book)

The undervalued art of vaginal breech birth by Ina May Gaskin. Mothering, issue 125, June-Aug 2004 p 52-58,

Review of cesarean vsvaginal birth for twins

Risks of cesareans
http://www.motherfriendly.org/Downloads/csec-fact-sheet. pdf

Ecstatic Birth- Mother Nature's hormonal blueprint forlabour

Birth plan for multiples (see also Having Twins, as above).

Doula resources
www.dona.com

Term Breech Trial critiques
http ://www.radmid.demon.co.uk/breechbanks.htm

Turning a breech baby
Mothering issue 125, June-Aug 2004, p59-63 p 59-63
www.breechbabies.com

Epidurals- real risksfor mothers and babies
www. birthlove.com/free/sarah.html

My 9 mo old son is learning so many new skills – crawling, sitting, waving clapping. He loves to show us his new talents – and we love to see them. The problem is he likes to show us at 3 AM. We co-sleep, and he has been waking up to play for 1 – 3 hours in the middle of the night. We try to lay him back down and tell him we would love to see his talents in the morning when the sun is up, but it is hard because he is so happy and proud. Should we ignore his attempts to play in the middle of the night? Will this pass?

I agree that this is probably to do with your son's new skills, but you can encourage him to choose a better time to display his excitement. My suggestion is that you don't react at all to his night-time activities - that you lie as still as possible with your eyes seemingly closed, and don't let him 'wake you up'. If you do need to get up, keep your voice low, lights dim and don't engage in any play. If this has been going on for a while, it may take a few hours and a few nights for your son to get the message, but it is worth persisting- he will eventually learn that night is for sleeping!

Other things I have found useful at night-time include a dab of lavendar oil on a child's chest (and/or pillow) and playing quiet, relaxing music. My children have become used to the association between these things and sleep times, and this may help your son also to know when it is sleep time.

For more information and problem-solving around co-sleeping, I recommend the book Night-time Parenting by William Sears.

My 7 1/2 month old son has been having bouts of sleep crawling since he learned to crawl several weeks ago. He will crawl a few paces then sit down and become discombobulated and upset. He sleeps with me so I am right there when this happens and am quickly able to try to help him resettle. I have read that sleep crawling is sometimes part of an infant's developmental process- they are practicing their new skill in their sleep. Is this just a phase that I need to ride out with him or is there something I can do to help him help himself?

This is a fairly common event for newly-crawling babies, and I would not be concerned at all about it. I expect that it will pass within a couple of months.

Your son is very fortunate to have your presence at night, so that you can help him as soon as it happens. This saves you sleep, and the effort of getting up to help him as well. I trust you are not leaving your son alone to sleep on your bed at any time, as this could be hazardous, espacially with his unpredictable movements- see my article 10 tips for safe sleeping at http://www.naturalparenting.com.au/articles/issue4/ safesleeping.htm.

I'm 37 weeks pregnant and have begun experiencing terrible heartburn and reflux acid burn at the back of the throat. It's worse at night when I lay down and is keeping me up most of the night. Can you recommend any natural treatments that are safe during pregnancy?

Heartburn is fairly common towards the end of pregnancy, because your growing baby is pressing on your stomach, putting pressure on the sphincter that keeps your very acid stomach contents in their place. In pregnancy this sphincter, like the rest of your gut, is more relaxed, and both the pressure of the stomach and the relaxation of the sphincter cause your acid stomach contents to ‘reflux' through the sphincter into your lower oesophagus. This can cause burning because, unlike your stomach lining, your oesophageal lining is not resistant to acid. It may ease when your baby engages and drops lower into your pelvis.

Here are my suggestions:

• Eat small meals often to lessen the pressure on your sphincter
• Drink fluid between meals, rather than with meals for the same reason
• Keep your diet fairly low in fat. Fat delays the emptying of your stomach, but healthy fats (eg fish oil, flaxseed oil,hemp oil, good-quality dairy ) are important for your baby's braingrowth, so don't cut them out altogether
• Avoid highly processed foods, especially white bread and processed cereals
• Also avoid spicy foods, alcohol and smoking, which can further irritate the oesophageal lining
• Keep yourself well rested and happy- stress can make heartburn worse, as well as affecting the well being of your baby

• Chew 6 to 8 almonds, preferably blanched
• Slippery elm powder, 1tsp in cold water, add 1 pint hot water, flavour with honey or cinnamon, sip as required
• Fennel seed tea
• Chamomile tea, especially if your heartburn is worse with stress
• Chew papaya tablets to help with digestion
• a tablespoon of milk or cream before eating to coat the stomach

Avoid antacids if possible, as they can contain aluminium, not good for your baby, as well as causing rebound when you stop them. Alternatives are drinking milk before and after meals, and taking a calcium-magnesium supplement, eg NF formulaliquid Ca-mg , 1 tsp to 1 tbs when needed.

If your heartburn is still severe, I recommend consulting a homeopath or a practitioner of traditional Chinese medicine (TCM). Some TCM practitioners will give dietary advice based on the specific balance in your body, which can be very helpful for many pregnancy complaints.

For more information about heartburn and other pregnancy problems, I recommend the following books:

My 3 year old son still nurses 3-4 times per day. I recently had a miscarriage and my OB says I have to wean my son because nursing makes the lining of my uterus inhospitable for another pregnancy. Is this true?

Congratulations on maintaining your breastfeeding relationship with your son to three years old. He will be enjoying many health benefits, including less risk of ear infections, gastroenteritis, meningitis; he will have less risk of childhood diabetes and lymphoma; and as an adult, he will have some protection against multiple sclerosis, high blood pressure and heart disease. You are also reducing your own risk of ovarian, uterine and premenopausal breast cancer and of osteoporosis. (See promom below for references and more benefits!)

Although extended breastfeeding is not common in our society, many other cultures nurse for two to four years, and it has been estimated by Katherine Dettwyler, Professor of Anthropology and Human Nutrition, that the natural age for weaning is between four and six years.

With regard to the impact of breastfeeding on your fertility and pregnancy, this is a poorly researched area. The best resource is Hilary Flower’s excellent book Adventures in Tandem Nursing - Breastfeeding during pregnancy& beyond, and some of this information comes from her book and website as below.

It seems that, for most women, the return of their menstrual cycle coincides with the return of their fertility. A small minority of breastfeeding women may experience a deficiency in the second half (luteal phase) of their cycles, when their bodies are preparing the uterus for pregnancy, and so will be less fertile for several cycles.

Anecdotally, I have heard some women say that they did not conceive until they weaned, or cut down their child’s breastfeeding. It makes sense that the mother’s body will be less likely to conceive when she is receiving the feedback, with each nursing episode, that she still has a dependant child to nurture. Reduced fertility while nursing, world wide, makes an important contribution to child spacing.

Breastfeeding in early pregnancy does not, as far as we know, increase the risk of miscarriage. According to UK miscarriage expert Professor Lesley Regan, (Miscarriage Clinic at StMary's Hospital, London and author of Miscarriage: What every woman needs to know) " If luteal functioning is sufficient for implantation to be successful, there is no indication that breastfeeding can have any negative impact." (Quoted in Adventures in Tandem Nursing, as below)

There have been concerns expressed by some about the effects of the release of oxytocin in a pregnant nursing mother. Oxytocin is a hormone that is released with each nursing episode and, later in pregnancy, acts to contract the expectant mother’s uterus. However, oxytocin does not have these effects until very late in pregnancy and in labour, and your baby is well protected from this effect in early pregnancy by the hormone progesterone. Breastfeeding during pregnancy does not seem to increase the risk of premature birth, but solid medical evidence is lacking.

Another way to look atthis issue is in terms of the nourishment that a woman needs to give to a growing baby. If she is not adequately nourished because she hasn’t kept up with her breastfeeding requirements (or for any other reason), it is likely that her fertility will be reduced.

This underlines the importance of being in excellent nutritional form when you begin trying to conceive; a woman’s nutritional state at conception is actually more important for her baby’s health than her nutritional state later in pregnancy. While you are waiting to conceive again, I suggest you use my suggestions and resources in the question above to maximize your health and nutrition.

Personally, I have also breastfed through two healthy pregnancies and then ‘tandem fed’. I found nursing through pregnancy to be challenging at times, especially in early pregnancy, but also immensely satisfying. My children have also been breastfed to around 4 and Maia, aged 4 ½, is still enjoying the occasional‘boobies’.

Wishing you a satisfying nursing career, for however long (and however many) you choose to nurse!

Reference and resources

A Natural Age of Weaning, Katherine Dettwyler

Adventures in Tandem Nursing - Breastfeeding during pregnancy & beyond by Hilary Flower and published by La Leche League International. A New Look at the Safety of Breastfeeding During Pregnancy by Hilary Flower.

Parental Concerns About Extended Breastfeeding in a Toddler
Martin T Stein et al
Pediatrics; Nov 2004, 114(5),1506-8

101 reasons to breastfeed your child

I have been diagnosed with gestational diabetes. I am so heartbroken as I truly want a natural birth. Is there any chance I can still birth naturally?

Firstly,I can understand your concern at being diagnosed with what sounds like a serious condition. However, as I will explain, this is not something to be overly concerned about, except for the influence it will have on your carers.

Gestational Diabetes Mellitis (GDM) refers to an elevation of glucose (a simple sugar) in the blood of a pregnant woman, whose blood glucose level is normal outside of pregnancy.

GDM is mostly caused by the woman’s normal pregnancy hormones (made by the baby’s placenta), which make her body somewhat resistant to the effects of insulin. Insulin is the hormone (the body’ schemical messenger) that lowers the levels of glucose in the blood by transporting it into the cells. You could imagine insulin as opening the door of the cell and allowing in glucose, which used as the primary energy source for most of the body tissues.

Insulin resistance means that the body is responding less to insulin (the door is not open as wide), and so less glucose enters the cell and more stays in the bloodstream, giving higher levels than usual. In pregnancy this is beneficial, as it leaves more glucose in the mother’s bloodstream,which makes more glucose available to the baby, who gets all the glucose needed for growth and development from the mother’s bloodstream, via the placenta. This transfer of glucose is dependent on the mother’s levels being higher than the baby’s.

The level of insulin resistance that an individual pregnant woman has depends on her own biochemistry and genetics, as well as her diet and activity levels. Some women, and some families, seem to get more insulin resistance than others in pregnancy, and this may reflect a slightly increased susceptibility to diabetes in later life. The baby also plays a part, because he/she can signal the mother’s body to increase glucose levels by producing more pregnancy hormones, giving more insulin resistance. As above, this is more likely to happen when the baby is big.

If the mother has a diet that includes a lot of carbohydrates with a high glycemic-index (ie foods that cause a rapid rise in blood glucose) and/or low levels of activity, her blood glucose may be higher and she may be more likely to be given this diagnosis.

So you can see that it is normal and healthy to have higher levels of glucose in pregnancy. However, when levels reach a certain point, a woman is at risk of being labeled with ‘impaired glucose tolerance’ (IGT, also called ‘pre diabetes’)and at even higher levels, with GDM.

GDM is a very controversial diagnosis. Some experts in the area have called it ‘a diagnosis still looking for a disease’, a ‘non-entity’ and a ‘useless diagnosis’, while others think it is so important that every pregnant woman should be tested for it. Michel Odent believes that the diagnosis of GDM causes more harm than good by labeling the pregnant woman ‘high risk’ which increases her anxiety but has no benefits for her or her baby, as below.

The US Preventative Services has not recommended routine screening and a Canadian committee of experts also concluded, ‘Until evidence is available from large randomised controlled trials that show a clear benefit from screening for glucose intolerance in pregnancy, the option of not screening for GDM is considered acceptable.’ The UK-based Cochrane database, which has analyzed the best medical evidence, also concludes that there are no benefits to treating GDM, in terms of outcome for mother and baby, which makes the diagnosis also very questionable.

Some doctors are concerned that women with GDM are more likely to have a very large (‘macrosomic’) baby, and it is true that there is an association between GDM and large babies. However, these large babies can be explained by other factors,such as the mother being overweight. Medical treatment does not seem to change this significantly, and it seems more likely that the size of the baby is causing the GDM, (because a big baby needs more glucose and so makes more hormones to increase insulin resistance) rather than GDM causing a big baby.  

International studies show that the only major outcome from making this diagnosis is to increase the risk of a caesarean. This is unfortunate, but makes your concerns very valid.

My advice to you is the same as I would give to any pregnant woman- ensure that your diet is balanced, with adequate levels of protein, high-quality fats and low-GI carbohydrates.(See website below for more about GI index of foods) Keep a good balance between rest and exercise- walking and/or swimming regularly (at least 3 to 4 times per week) are beneficial. Unless your blood glucose is very high and/or causing symptoms such a thirst and passing lots of urine (this is uncommon for GDM), I would not recommend that you take any medication. If you need to control your blood sugars, consider exercising more and/or changing your diet.

You may also want to ask around and ensure that you have a carer who has a reasonably relaxed attitude to GDM. Your chances of a normal birth are much more related to your carers attitudes to GDM than to your condition. In particular, you need to consider that the extra tests and scans that are often used to check the baby’s condition and weight are more likely to cause more interventions (especially caesareans) and unlikely to improve the outcome for you or your baby. Henci Goer’s paper, as below, is an excellent resource.

After the birth, there are sometimes concerns about the baby having a low blood sugar. This is less likely if your blood sugars have been stable and you have not received iv glucose in labour. It is wise to ensure that your baby has free access to your breasts after birth, and is kept warm and dry.
La Leche League advise
“The best way to stabilize blood sugar and prevent hypoglycemia (low blood sugar) in all infants is prompt and frequent feedings of colostrum and human milk.”

Blessings for a gentle and straightforward birth.

Resources:
Guide to low GI foods
http://www. glycemicindex.com

Comments by Michel Odent
http://www.birthpsychology.com/primalhealth/#anchor336050< /p>

Comments by Henci Goer
http://parenting.ivillage.com/pregnancy/ pcomplications/0,,9cgc,00.html

Low Blood sugar in newborn babies
http://www.lalecheleague.org/NB/NBJulAug97p107.html

Tuffnell DJ, West J, Walkinshaw SA. Treatments forgestational diabetes and impaired glucose tolerance in pregnancy.The Cochrane Database of Systematic Reviews 2003, Issue 1. Art.No.: CD003395. DOI: 10.1002/14651858.CD003395.

Canadian TaskForce on the Periodic Health Examination. Periodic health examination,1992 update: 1. Screening for gestational diabetes mellitus.Can Med Assoc J 1992;147(4):435-43.

ACOG. Diabetes and pregnancy. Technical Bulletin No. 200, 1994.