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	ask the experts sarah j. buckley

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

• Lying on your back during pregnancy
• Increasing fertility and preparing for pregnancy
• Pets at a Homebirth
• Endocervical polyp - will it affect labor and delivery?
• Herpes and having another child
• Nursing during pregnancy and co-sleeping with a newborn
• Early cord cutting and delivery of the placenta
• Doctor advising induction after 40 weeks

Why should a pregnant woman avoid lying on her back? I have done a couple web searches and come up with nothing, really.

Lying on the back in later pregnancy is said to be harmful because the weight of a mother's uterus and baby can compress the large blood vessels that run alongside the spine- the abdominal aorta (which supplies blood to the lower part of the body) and inferior vena cave (which returns blood from the lower body to the heart).

Some women can actually experience 'supine hypotension' towards the end of pregnancy, where lying on their back (the supine position) causes the blood pressure to drop so low (hypotension) that they feel faint. However, this is unusual, and many women feel comfortable lying on their backs right through pregnancy.

Pregnancy exercise expert Elizabeth Noble advises, based on 30 years of experience, "No one who can freely change position, and does so when she feels light-headed, was ever harmed by supine hypotension."

However, the supine position is not ideal for childbirth. The supine position, which laboring women are often stuck in (with monitors, IV drips etc ) can not only compromise blood supply to the baby during the most powerful contractions, it also fixes the mother's sacrum and coccyx (which need to open widely as the baby comes down) and reduces the diameter of the woman's pelvic outlet.

Upright positions for labor and birth allow the mother the freedom to move as she feels to, in response to the sensations of her baby descending, and also give her the help of gravity to bring her baby down. As Elizabeth Noble comments, "Only pancakes should lie flat."

References

Essential Exercises for the Childbearing Year: A Guide to Health and Comfort Before and after Your Baby is Born 4th Ed Elizabeth Noble (New Life Images, Harwich MA, 2003)

www.elizabethnoble.com.

I am 33 years old, and my husband and I are planning to get pregnant in a year. What are some things I can do in this year of preparation to increase fertility and prepare my body for a healthy pregnancy and birth?

It is wonderful that you are thinking about your health, and your partner's health, well before conceiving. It is a very big topic, beyond my scope here, but I can give you some resources to help you.

Firstly, read my previous answers to 'trying to conceive at 44' and 'conceiving soon after giving birth'. These will give you some good ideas to optimise your nutrition.

Secondly, I highly recommend the UK-based Foresight Pregnancy Preparation Programme website, which has some excellent website resources, including http://www.foresight-preconception.org/programmes/prepprog.html

Thirdly, I recommend that both of you have a hair analysis for minerals and heavy metals. Foresight has resources to do this yourself, but it is preferable to find a local practitioner who has experience in this area and can help you to interpret the results, which can be quite complex. If you do this test soon, you will have the time to remedy any problems (high levels of heavy metals or low levels of essential minerals) so that your bodies can be in good condition for conception.

Lastly, other books and resources that I recommend for this are the Australian 'better babies' books, available from www.fertility.com.au. You can buy the first of these books, released in the US as 'Healthy Parents, Better Babies' from Amazon.

You may also be interested in the nutritional advice on this site www.westonaprice.org and I also recommend the nutritional approach on www.mercola.com.

Blessings for a health-enhancing year and a healthy conception.

My midwife has recommended that I remove my dog and cat from the house during labor and birth because animal hair is a source of bacterial infection. Is this really necessary? How high is the risk of infection? I was hoping to use them as labor partners!

There are several precautions that pregnant women need to take if they have dogs and/or cats as pets.

Cats can transmit the organism toxoplasmosis, which can cause birth defects in early pregnancy, or serious infections around the time of birth. Many women, especially cat-owners, will have immunity to toxoplasmosis before pregnancy, (from previous exposure), and this can be checked with a blood test. All pregnant pet owners need to take care with their pets' wastes, especially handing pet litter, which is best done by non-pregnant household members, otherwise gloves and ideally masks should be worn. Cats can also transmit other harmful bacteria, including salmonella and campylobacter, which cause diahorrea and other gastro upset in humans and cats. For all of these reasons, cats should be kept out of the kitchen and perhaps the bedroom as well during pregnancy.

I am not aware of any specific risks associated with cat fur, and, as with toxo, it is likely that the owner will have developed immunity to bacteria that are carried by a healthy cat. This immunity is likely to be transmitted to the baby through breastfeeding, but it is sensible to keep baby and cat away from direct contact for the early months. Also check and treat your cat for any ringworm or roundworm infections, which could also be transmitted to household members.

There has been some discussion about dogs as possible carriers of Strep A Strep, which is a bacteria carried in the throat and which can sometimes cause infection ("Strep throat"). This is a different strain to Group B strep (GBS), which is a common component of bowel flora, but which can cause problems for some newborn babies when they are exposed as they exit the woman's birth canal. Pregnant pet owners are very unlikely to have problems with this bacteria, but if they are concerned, they can have their dog's throat swabbed for Group A Strep.

According to the information that I can find, the presence of pets during labor poses no additional risk. As I note, bacteria carried by a healthy pet is likely to be part of the pregnant owner's normal microbial milieu, and pose no significant risk. If your midwife has more specific information about this, please ask her to send it to me, (c/o Mothering expert questions).

More information

Cats and Toxoplasmosis
Cats and Babies: Fact vs. Myth
Cats and your pregnancy

Dogs and Strep A
Who Blames the Family Dog?

More considerations about pets at homebirth
Who to Invite

I am 34 weeks pregnant with my first, and my birth center midwife just discovered what seems to be an endocervical polyp. I will see an OB/Gyn soon but in the meanwhile am wondering how this might affect my plans for a natural labor/delivery. I am otherwise in excellent health with no STD or abnormal pap history. Thanks for any general info you can offer or refer me to, I cannot find anything on line about polyps found this late in pregnancy.

Endocervical polyps are reasonably common in women from age 30 to 60. They are an outgrowth of the folds of the cervix. Usually they do not cause symptoms, and are discovered during a routine examination. They may also cause spotting between periods or after sex.

It is likely that your OB/GYN can easily remove the polyp by twisting and pulling, or by tying a loop around its base and cutting. The polyp will usually be sent off to be checked for cancerous changes, but this is rare - around 1 in 200. Once removed, they don’t usually come back.

Unless the polyp is large or causing symptoms, or you are concerned about cancerous changes, you can also choose to leave it alone. It would be very unlikely to cause problems in labour, although there is little research in this area.

More information-
http://www.alife.org.sg/en_cervical_polyp.php
http://www.emedicine.com/med/topic3297.htm
http://www.patient.co.uk/showdoc/40024690/

I have a friend who wants to be pregnant again but has concerns of when she had her first child - a week before he was born, she found out that she had herpes and never even knew she ever had it and had an emergency cesarean a day after her due date. Is it possible that she still can have another child? Her son is now almost 5 and very healthy.

Sometimes we can be grateful for cesareans, and I would put your friend into this category. With a first episode of herpes simplex virus (HSV) at the end of pregnancy, she had a significant risk of passing the infection if she had given birth vaginally. In one study, this risk was around 30%.1 Giving birth by cesarean meant that her baby was 6 to 10 times less likely to be infected.2

HSV (either HSV 1, oral herpes, or HSV 2, genital herpes) is a serious and potentially fatal disease for a newborn baby. HSV can infect the skin/eye/mouth, the brain (encephalitis), or be a widespread (disseminated) infection, which is the most serious. If it is diagnosed early, it can usually be treated with anti-viral drugs, which improve the outcome, but long-term damage (including delay in development) is still possible.

The issue of a recurrence of HSV in late pregnancy is more complex and controversial. Active HSV can be assessed by the presence of lesions, or, more accurately, by swabbing the woman’s genital area (especially her cervix) to test for ‘viral shedding’. Viral shedding can occur even without an obvious recurrence.

According to one study, if the mother has viral shedding, her newborn would have a 3% chance of becoming infected when birthed vaginally,1 although other studies have found lower rates, eg none of 34 babies whose mothers had a recurrence of HSV in labour.3

The chance of transmitting the virus is increased by use of a scalp electrode (needle screwed into the baby’s scalp to record heart rate in labor), by the use of vacuum to assist birth4 (which can cause a cut in the baby’s scalp which allows the virus into the baby’s body) and also if the baby is born prematurely.

The chance of transmission is lower if the mother has a good level of antibodies to HSV 2 (genital herpes), in which case she will pass antibodies to her baby, which will give some protection, through the processes of vaginal birth.5 This is most likely if it is a long time since the first (primary) infection , which is true for your friend. ACOG recommends that, if the mother has no active lesions in labour, she can deliver vaginally.

However the risk of viral shedding in labour isn’t predicted by finding viral shedding in pregnancy (even in late pregnancy). This means that having swabs in pregnancy isn’t usually recommended. It is also unfortunately true that the chances of a herpes outbreak are increased in the pregnancy because the mother’s immune system is depressed.

It would be important for your friend to keep herself in good health in pregnancy, to reduce her chances of a recurrence, especially around the time of birth. Ensuring a good intake of vitamin C (supplement up to 200 mg four times daily when an outbreak occurs) and zinc (in meat, fish, seafood, and eggs ) will support the immune system. Higher doses are sometimes recommended, along with supplements of L-lysine, but only for the duration of an outbreak. Aloe vera can be used topically – ideally use the inside of a fresh leaf. Consult a herbalist or homeopath for other specific remedies.

The balance of amino acids in the diet may also influence outbreaks- eating food high in lysine and low in arginine is sometimes recommended- this makes legumes, yoghurt, fish, chicken, eggs, cheese, meat and brewers yeast good choices and chocolate, nuts, seeds and raisins bad choices. Other useful preventatives include fresh air and exercise and of course low stress and lots of time for relaxation and tuning into the growing baby.

Final note for all pregnant mamas: As you can read above, the outcomes for babies who are born to a mother who had her first HSV infection in pregnancy are the worst. You can protect your baby by using condoms during pregnancy, if you have a new partner, and avoiding oral sex, which can transmit either strain of herpes.

PS Thanks to Molly for this response and additional information: "At the end of your answer you mention caution (and avoidance) of oral sex because it can transmit herpes type 1. Actually this is true of both herpes symplex 1 and 2. They are transmitted the same ways and are interchangeable in terms of symptoms and viral behavior. Their diferences are rather minor and inconsequential to an infected person. Additionally, they both appear on the mouth and genitals. A lab test must be done to determine which type is actually present. It is just more common to find one type on the mouth and the other on the genitals."

References
1. Brown ZA, et al. Neonatal herpes simplex virus infection in relation to asymptomatic maternal infection at the time of labor. N Engl J Med 1991;324(18):1247-52.
2. Brown ZA, et al. Effect of serologic status and cesarean delivery on transmission rates of herpes simplex virus from mother to infant. JAMA 2003;289(2):203-9.
3. Prober CG, et al. Low risk of herpes simplex virus infections in neonates exposed to the virus at the time of vaginal delivery to mothers with recurrent genital herpes simplex virus infections. N Engl J Med 1987;316(5):240-4.
4. Kohelet D, et al. Herpes simplex virus infection after vacuum-assisted vaginally delivered infants of asymptomatic mothers. J Perinatol 2004;24(3):147-9.
5. Bujko M, et al. Mode of delivery and level of passive immunity against herpes simplex virus. Clin Exp Obstet Gynecol 1989;16(1):6-8.

Resources:
Electronic

www.herpes.com/pregnancy.shtml
www.midwiferytoday.com/enews/enews0136.asp
www.midwiferytoday.com/enews/enews0433.asp

Written
"Joan Donley’s Compendium for a Health Pregnancy and Normal Birth" (Joan Donley, Auckland 2003) www.birthspirit.co.nz

"Holistic guide to living with herpes before, during and after childbirth" in: The Mother Magazine issue 2. www.themothermagazine.co.uk

"Natural Healing for the Pregnant Woman" Elizabeth Burch and Judith Sachs (Perigee NY, 1997)

I am 6 weeks pregnant with our fourth baby. Our first three children were all spaced three years apart, this newest addition is a very close spacing (for me!)I have never been pregnant AND had a night-nursing baby, a co-sleeping baby, or anything like this! We did dabble a bit in tandem nursing, a few sips here and there and we also co-slept with then until they were about 14 months old... but our littlest one is only 18 months old and nursing 'round the clock! He also sleeps with us for the most of the night, and is literally LATCHED onto the breast for hours and hours, never rolls over or takes a breather. So my questions are these: Is it truly safe for my developing baby in the womb for me to be nursing this much? How does it work logistically when you have to pee 3 times a night, what do you do with the co-sleeping tot? Our DS just wakes right up and follows me to the bathroom and thinks it is party-time all over again, I am tempted to not even pee but that isn't healthy! I am getting very nervous about how you can attachemtn parent two little ones. I have these ideas about slowly getting him scaled back off of the nightime stuff, but I feel sorry for him. There is no way I can care for a tiny newborn all night with little mister wild and wiggly in the bed with us, too. I have 8 months to do this! Advice?

Congratulations on your fourth pregnancy! I can understand a little of how you feel: my third baby came along unexpectedly early, when my second was only 14 months and, like you, I was nursing intensely, co-sleeping etc. However, we managed to work it out and everyone enjoyed the new baby!

The most important thing, I have learned, is that you care for yourself as mother, because it is your body that is growing this new baby, as well as breastfeeding your toddler (or weaning, if that is your path). It is essential that you are well nourished, physically and emotionally. I recommend that you pay attention to your diet, and to the wholesome foods that you crave, and follow some of my previous recommendations for whole-food supplements(my preference) or vitamin/mineral supplements. You may need the help of a nutritionist, ND or midwife to ensure your diet is optimal.

I suggest that you also ensure that you are well nourished emotionally through this pregnancy. Whatever it is that ‘feeds’ you, please take the time for it. For me, regular massage has been a must during pregnancy. We can use massage (or whatever form of body therapy we desire) to appreciate our bodies and all that they do for our families when we are intensely parenting, as well as connecting with our growing baby. Massage will also help you to keep your stress levels low and reduce your risk of premature birth.

I have found that taking time just for the new baby is important, whether it be walking, a yoga class, meditation or just a long bath. Regular physical exercise, which can be as simple as taking a 20 minute walk every day or two, will also help your body and growing baby. Yoga and meditation are superb also, and you could ask your family to help make the space for any of these activities.

If you are able to eat well, and to feel well nourished on an emotional level, I believe that your body will be able to continue nursing, if that is what you and your son want. Personally, I have needed to reduce my nurslings’ feeds during my two tandem-feeding pregnancies, with two or three times daily being manageable. Some toddlers will wean spontaneously in pregnancy. Hilary Flower’s excellent book on tandem nursing (nursing more than one baby at a time) will give you more information and reassurance.

I suggest also that you regularly take some quiet time to tune into yourself during the pregnancy and ask your body “What do you need?” If you find that you really do need to wean, it is better to do this than to continue to feed at the expense of your body’s reserves. It is so important that you have some physical and emotional stores of nourishment for the next baby’s birth and early months.

I also suggest that you review your nighttime commitments at regular intervals. Again, you could choose to keep feeding your son as he wishes overnight, but the chances are that sooner or later your body will protest, and you will just not want to do it! It is possible to wean him gently from overnight feeding, preferably with some help from your partner, and you can also decide if cosleeping is allowing you the rest and space that you need.

My suggestion is that, if you take action to wean him from night nursing and/or cosleeping, (perhaps one at a time may be better) you do this when you have some support to allow him to express his feelings, because he is likely to be upset. This is where your partner could become involved, taking him and sitting with him (perhaps even sleeping with him) when he protests.

I highly recommend the work of Aletha Solter, who advocates gentle holding techniques to help children with emotional release. You could spend time holding him and letting him rage- this may be another opportunity for your partner to help. At 18 months, he may not be able to express his feelings with words, but you can help by being present, tuning in to him and acknowledging his feelings. You can also be assured that his rage will pass.

If you stop feeding overnight and cosleeping, he will probably also have periods of daytime rage. Although this can be difficult, if you can allow him to express his anger, and trust that he will finish when he has released his feelings, you will find that he will adjust more easily when your new baby comes.

You also have a great resource in your two older children, who will doubtless be a great help to you in the coming months. I suggest that you take the time to ask they could do to help. Maybe your toddler could sleep in another bed with an older sibling (this worked very well in our family) Your children will gain so much from their youngest sibling, and I think it is very reasonable to ask them to help out as well.

I have also found that, when older children have been gently parented and had their own needs met, they are very willing, capable, and loving with younger siblings. (In my own family, we actually had a meeting and talked about having a fourth baby. The children were so keen, and gave us promises that they would help out, which they certainly have done)

I also suggest that you ensure you have more hands-on help when your new one comes along, especially in the early months. For me, the babymoon became more and more essential with each baby, giving me a store of nourishment from which to draw for the first year.(With my fourth, I didn’t even leave the house for six weeks!)

Lastly I observe that a new baby will add their own energy, and a new and magical dimension, to the situation. What seemed impossible or concerning can actually be possible, even easy and delightful, once the baby comes along. Of course you need to set things up well, but then you can trust that you and your family will find a new, expanded, and joyful path as a family of six!

Resources

Aletha Solter www.awareparenting.com

Books by Aletha Solter The Aware Baby (2001)
Tears and Tantrums (1998)
Helping Young Children Flourish (1989)
(All published by Shining Star Press, Goleta, CA)
Hilary Flower Adventures in Tandem Nursing (La Leche League Intl., 2000)

My first son was born at home. 3 mins after his delivery we cut the cord. Immediately I lost a lot of blood and my midwives had to do a manual removal of my placenta because of the sudden blood loss and because it was partially attached. I am now about to have another homebirth and the midwives are recommending I have syntometrin (pitocin) immediately afterthe baby is out to aid delivery of the placenta. What is the safest option, and could the early cutting of the cord been a negative factor?

Your question concerns what is called the 'third stage of labour' ie the time between birth of the baby and birth of the placenta. This is also when mother and baby meet for the first time. I see it as a time when the mother is very open and extremely sensitive to her surroundings and to her baby.1

One of the most important factors for a healthy third stage is having good levels of oxytocin, the hormone of love. Oxytocin has a powerful effecton a birthing mother's uterus, initiating the contractions of labour and causing ongoing contractions after birth. These contractions are necessary to stop bleeding and to encourage the baby's placenta to separate easily.

Oxytocin levels will naturally be very high after an undisturbed birth, but levels will be affected if the labouring woman has felt disturbed, unsafe or lacking in privacy.2

Oxytoinis also a hormone of bonding- levels are increased after birth when mother and baby are skin-to-skin and eye-to-eye. Oxytocin also causes dilation of blood vessels on the new mother's chest which makes a natural warming mechanism for the baby3 that is more efficient that wrapping (or an incubator)3 4 and that gives perfect skin-to-skin conditions for mother and baby to fall in love, as Mother Nature intends.

For oxytocin to work perfectly during third stage, the new mother needs to feel private, safe and undisturbed at this time. As Michel Odent suggests, she should have nothing to do but touch and gaze at her new baby.5 A warm atmosphere is also crucial to enhance oxytocin release. If the new mother is fearful, cold or disturbed, her oxytocin levels can be affected which can increase her risk of bleeding. We should consider this time, after the birth, in the same light as love-making (when we also make peak levels of oxytocin, the hormone of love) and offer the new mother and baby the same privacy and respect.

With this in mind, I do not recommend clamping or cutting the cord, at least until the baby's placenta is delivered and possibly for an hour after birth. Not only does this activity disturb the sacredness of this time, but it can also seriously affect the well-being of mother and baby.

For example, early clamping (within 30 seconds ofbirth) can deprive the baby of around 100 ml of blood, and may compromise the function of newborn organs and brain.6 This blood, known as the placental transfusion, is passed through the cord from the placenta to the baby with each uterine contraction in third stage, and is designed to fill all the organs that the baby has not used in the womb- the lungs, kidney, gut, liver and skin. Early-clamped babies also lose the iron contained in the placental transfusion -- which is equivalent to the iron in 100 litres of breastmilk -- and are more likely to be anemic at 3 months.7 Early clamping is necessary for cord blood collection, which is one reason I do not recommend this.

Clamping the cord may also be harmful for the mother, because if the blood (placental transfusion) hasn't been passed to the baby, it will remain in the placenta, making it bulkier. This makes the placenta harder to deliver and can also compromise the mother's uterus, which cannot contract as efficiently with a bulky placenta inside. Clamping the cord was obviously never practiced by our ancestors, nor by our mammalian cousins and is, I believe, a significant birth intervention.

With these understandings, I would be interested to know if you felt disturbed or hurried in the third stage? Were you cold or afraid? Were you skin-to-skin with your baby? Clamping and cutting the cord soon after birth could also have contributed to your haemorrhage (and to partial separation of the placenta), for reasons outlined above.

I would also be very interested in your feelings at the time, your feelings about birth and any memories or associations from previous experiences or from your own birth. Early clamping, for the baby, is equivalent to losing 1.5 to 2 litres of blood, and I believe that this can be carried as a deep imprint, even into adulthood.8

Obviously you do not want a repeat of your experience, and you are very likely to avoid this with attention to all of the above, especially to an undisturbed labour and a warm and private atmosphere in third stage and to delayed clamping. The feelings of your carers are also important, and I can understand that attending a woman with a postpartum haemorrhage, especially at home, is an experience that they will also not want to repeat, and they will be very aware of the responsibilities for your well-being.

Ultimately, you will need to weigh up the pros and cons with your carers. By optimizing your oxytocin after birth, as above, your chances of bleeding will be substantially reduced, but I cannot say that there is no risk of a repeat. You could consider no pitocin, accepting pitocin as preventative, or perhaps a compromise where you accept it at the firstsign of problems.

You also mention the drug syntometrine, which is a combination of pitocin (also known as syntocinon) and ergometrine (also called ergonovine). This drug is more powerful than pitocin, but with more chance of side-effects such as nausea and headache- check with your carers and especially ensure your blood pressure is not high if you decide to accept it.

Wishing you a blissful birth and smooth and easy third stage

References:
1. Buckley SJ. Leaving Well Alone- A natural approach to third stage. In: "Gentle Birth, GentleMothering". (In print), 2005 Previous version posted at http:// www.cordclamping.com/Buckley.htm
2.Buckley SJ. Ecstatic Birth-Nature's hormonal blueprint for labour. Mothering March-April2002;111.
3. Uvnas-Moberg K. "The Oxytocin Factor".Cambridge MA: Da Capo Press, 2003.
4. Christensson K, Bhat GJ, AmadiBC, Eriksson B, Hojer B. Randomised study of skin-to-skin versusincubator care for rewarming low-risk hypothermic neonates. Lancet1998;352(9134):1115.
5. Odent M. Don't manage the third stage oflabour! Pract Midwife 1998;1(9):31-3.
6. Morley GM. CordClosure: Can Hasty Clamping Injure the Newborn? OBG Management July1998;29-36, p 33.
7. van Rheenen P, Brabin BJ. Late umbilicalcord-clamping as an intervention for reducing iron deficiency anaemia interm infants in developing and industrialised countries: a systematicreview. Ann Trop Paediatr 2004;24(1):3-16.
8. Rachana S. "LotusBirth". Yarra Glen, Australia: Greenwood Press, 2000.

I am a few days past 40 weeks pregnant, according to an ultrasound I had that said I was 13 weeks pregnant at the time. My doctor wants to schedule me for an induction. Ifeel very healthy and I believe that the baby will initiate labor when the time is ripe. I am not uncomfortable and I am much smaller than I was when I was this pregnant with my son. Other than this ultrasound, we have no way of knowing exactly when I became pregnant. I have been continuously nursing my now 22 month old son since his birth, and I have not had a period. What are the chances that the ultrasound was inaccurate as to my real "due date"? I was shocked when the ultrasound said I was 13 weeks pregnant - I had guessed at the time that I was only about 8 weeks along. How long can I safely wait before giving in to my doctor's desire to artificially induce labor?

Your question has two parts, which I will answer separately:firstly, the accuracy of ultrasound dating and secondly the pros and cons of induction.

Ultrasound is more accurate earlier in pregnancy, when babies vary the least in size. For example, at 18 to 20 weeks, dates will be accurate to around a week either side- ie the baby may be a week older or younger than the date given. There are also a few babies at any gestation that will be outside these figures, more so as pregnancy advances and babies vary more in size.

If you had as can done by an experienced operator with good quality equipment, and he/she took the time to accurately measure the various parts of your baby's body (especially abdomen, head and femur) then the date that you were given should be accurate to within 5 days either side at 13 weeks. This means that it is very unlikely that your pregnancy was 8 weeks at the time of the scan but could have been close to 12 or 14.

You can help to assess the accuracy by thinking about your own experience sof this pregnancy. For example, when did you notice nausea and breast tenderness- usually this happens around 5 to 6 weeks, and is often very noticeable when feeding another child!

When did your belly begin to 'pop out'? Usually at around 12 to 13 weeks, your uterus grows above your pubic bone and you can feel it, or notice a small bulge there. You can also consider when you felt your baby start to move, which is usually around 16 to 18 weeks for a second or subsequent pregnancy. However, I can understand that you might have been distracted by caring for your older child, so not noticed these things; I had the same experience in my third pregnancy!

The second part of your question, is it wise to consider induction when you go past your 'due date'? This is a very controversial area of obstetrics, with some carers adamant that going post-dates is dangerous, and others not at all concerned. You also need to consider the effects of being induced for you and your baby, so that you can make an informed choice about your doctor's recommendation.

The idea that going a week or two overdue is risky is actually fairly new. In older times, babies were not even considered overdue until past 42 weeks from the start of the mother's last menstrual period (LMP). In my training, we cared for a pregnant woman in hospital who was around 47 weeks (she had not had a scan) and she was being monitored but not induced.

This idea of post-dates being risky for the baby has come from some large studies(randomised controlled trials) that showed a very small increase in risk of stillbirth for normal babies born after 41 weeks, compared to babies induced before this time.¹ These studies have been rightly criticised² and it is possible that their conclusions are wrong, and there is no advantage to induction over 'expectant management' for babies up to at least 42 weeks. If there is an increasedrisk, it may be an extra 2 per 1000 risk of death around the time of birth (perinatal mortality) for babies induced at or after at 41weeks.³

Observational studies show a risk of death around the time of birth of 7 to 8 per 1000 at 42 to 43 weeks⁴ - note that this includes some babies with abnormalities. Overall, around 1 in 100 babies die around the time of birth in developed countries.

Babies who go overdue are usually healthy. The baby's placenta can continue to provide nourishment as long as the placenta was well implanted in the early weeks and health, nutrition and the baby's growth has been good in the pregnancy. (See my upcoming article in Mothering 131, July-August 2005 for more about placentation) There is a higher risk of passing meconium in labour for a 'post-dates' baby, which reflects their maturity, and sometimes a baby may inhale this during birth, which can cause problems.

There are also a small number of babies who go overdue who have 'post maturity syndrome' because their placenta has not been able to keep up with the baby's needs. This is also called 'dysmaturity' and can actually happen at any time. It can almost always be diagnosed by poor growth and other tests, eg scans, heart rate monitoring, which are usually offered when babies are 'overdue'. Note that reduced fluid levels (oligohydramnios), which may be found 'post dates', may sometimes be normalised simply by the mother drinking more water.

You also need to consider that a baby who is induced is not, by definition, ready to be born. We do not know for sure what triggers labour, but recent research suggests that it is a signal that the baby's lungs are mature. When babies are born before they are due, they have a higher risk of breathing problems because their lungs are not mature, and even with ultrasound, babies can still be induced prematurely.

Induction also means, by definition, that the mother's body is not fully ready for labour. If her cervix is not 'ripe', she is at high risk of a failed induction, and so needing a caesarean. Her body will also not be as soft and open. This is the reason why there is no advantage to inducing because of concerns about the baby being too big: if nature takes its course, the women's body will be more soft and open when she goes into labour and, even though her baby may be bigger, the chance of getting stuck is no greater.⁵

Lastly, you need to consider the risks of induction for you and your baby. Induction will bring strong labour on more quickly than normal, and your own hormones won't have a chance to build up and to help you. This means that you will be more likely to need pain relief because your own pain-relieving beta-endorphin levels are still low. Any drugs that you receive will pass through to your baby, making them groggy at birth and interfering with early breastfeeding behaviour.⁶

Induction also interferes with other hormones and processes of labour. Induction with synthetic oxytocin (pitocin) makes your uterus less sensitive to your ownoxytocin, which you need to stop bleeding after your baby'sbirth.⁷ This puts you at extra risk of haemorrhage and of needing more pitocin to stop bleeding. Induction also interferes with your ecstatic birth hormones, making labour more complicated and difficult and less ecstatic from a hormonal perspective.⁸

Induction with misoprostol (Cytotec), which is increasingly used inthe US, also has risks. Its effects are unpredictable, especially for women who have previously given birth. Misoprostol can cause excessively strong contractions, risking distress for the baby and even rupture ofthe mother's uterus.^9,10 Women who have had a previous caesarean have about three times increased risk of rupture using this drug compared to induction with pitocin.¹¹

Personally,I had an experience going 'overdue' with my third baby who was conceived when I was intensely breastfeeding my unwell toddler, giving me very unsure dates a little like yours - I didn't have a scan. I went 3 weeks past the date calculated from my last period and, although as a doctor I realised there were theoretical medical concerns, as a mother I had a strong feeling that my baby was healthy. I was lucky to have carers who were happy to revise my 'dates' and to accept my decision to avoid tests. When Jacob was born, he had so much vernix (the white cream onnewborn skin) that we wondered if he was actually early!

I think it is good to remember that there are no guarantees in birth- 'birth is as safe as life gets' We also need to look closely at the advantages and disadvantages of interventions (such as induction) that promise us small theoretical improvements in outcome but very big differences in the experience of birth for ourselves and our babies. Interventions such as inductions involve using drugs and procedures that may significantly affect the unborn baby, who is at a very vulnerable stage of brain development.⁸

Ultimately, as our Australian 'HunterHome and Natural Birth Support' summarize,
"Women have the right to be fully informed of the statistical likelihood of an efficacious or adverse outcome. It is then the right of the woman to interpret this as a risk or benefit when taken in the context of herlife and philosophies."

References:

1. Hannah ME, Hannah WJ, Hellmann J, Hewson S, Milner R, WillanA. Induction of labor as compared with serial antenatal monitoring inpost-term pregnancy. A randomized controlled trial. The Canadian Multicenter Post-term Pregnancy Trial Group. N Engl J Med1992;326(24):1587-92.
2. Menticoglou SM, Hall PF. Routine induction of labour at 41 weeks gestation: nonsensus consensus. Bjog2002;109(5):485-91.
3. Crowley P. Interventions for preventing orimproving the outcome of delivery at or beyond term. Cochrane DatabaseSyst Rev 2000(2):CD000170.
4. Hilder L, Costeloe K, Thilaganathan B.Prolonged pregnancy: evaluating gestation-specific risks of fetal and infant mortality. Br J Obstet Gynaecol 1998;105(2):169-73.
5. IrionO, Boulvain M. Induction of labour for suspected fetal macrosomia.Cochrane Database Syst Rev 2000(2):CD000938.
6. Ransjo-Arvidson AB,Matthiesen AS, Lilja G, Nissen E, Widstrom AM, Uvnas-Moberg K. Maternalanalgesia during labor disturbs newborn behavior: effects onbreastfeeding, temperature, and crying. Birth 2001;28(1):5-12.
7.Phaneuf S, Rodriguez Linares B, TambyRaja RL, MacKenzie IZ, Lopez BernalA. Loss of myometrial oxytocin receptors during oxytocin-induced andoxytocin-augmented labour. J Reprod Fertil 2000;120(1):91-7.
8.Buckley SJ. Ecstatic Birth- Nature's hormonal blueprint for labour.Mothering March-April 2002http://www.mothering.com/articles/pregnancy_birth/birth_preparation/ ecstatic.html;111.
9. Wagner M. Misoprostol (Cytotec) for LaborInduction: A Cautionary Tale. Midwifery Today Spring 1999http://www.midwiferytoday.com/articles/cytotecwagner.asp;49.
10.Gaskin IM. Induced and Seduced- the dangers of cytotec. MotheringJuly-August 2001http://www.mothering.com/articles/pregnancy_birth/birth_preparation/ cytotech.html;107:51-5.
11. Lydon-Rochelle M, Holt VL, EasterlingTR, Martin DP. Risk of uterine rupture during labor among women with aprior cesarean delivery. N Engl J Med 2001;345(1):3-8.