Posts

What To Do When You’re Overdue

So here I am, 12 days overdue with baby #5, and of course I’m feeling a crazy mixture of emotions that range everywhere from excitement to fear.

I’m full of anticipation and wonder as I think about meeting my sweet little boy, but I’m also very thankful for every day that he decides to stay put because I know that he’s active, growing, and doing well while I’m busy taking care of a sick household.

When I was ten days overdue with Elliot (our second), we were living in Colorado, and they had a law about not being able to have a home birth when you were past two weeks overdue. That (in addition to the fact that I was working full time and had limited maternity leave that I was using up with the end of my pregnancy) motivated me to try everything under the sun to get him out (including castor oil…do not do this ever!!!).

Now with this pregnancy, I am a stay at home mom with no agenda or timeline and no laws about timing out of a home birth. The midwives and I continuously monitor things to make sure he is still growing, active, and that I continue to remain healthy, but now as I approach the two week mark of being overdue, I want to be prepared if I DO need to “encourage” him to come out and know with certainty what my risks and options are.

How is a Due Date Calculated?

Before I get into induction methods and such, I wanted to reflect on the accuracy of a “due date” and take a minute to look at where it came from.

A woman’s due date is calculated by Naegele’s rule, which states that the due date should be approximately 280 days (40 weeks) from the start of the last menstrual period. The median found by Naegele’s rule merely shows that half of all births occur before 280 days and half occur after with birth data typically clustering around the “due date”.

A standard deviation diagram of human gestation showing the curve's center is at 280 days (40 weeks) past the last menstrual period.

A standard deviation diagram of human gestation showing the curve’s center is at 280 days (40 weeks) past the last menstrual period. (Photo Credit: Wikimedia Commons, 2009, Nasha)

Naegele’s rule doesn’t take into consideration that women don’t always have menstrual cycles lasting 28 days with ovulation occurring precisely on day 14, so those with a shorter cycle could have a shorter pregnancy and those with a longer cycle could have a longer pregnancy. In addition, studies show that first time mothers are more likely to be overdue and that women of African and Asian descent tend to deliver about a week before Caucasian mothers (Source).

Ultrasounds used to measure the size of the developing embryo before the 12th week of pregnancy are 95% accurate within an error margin of six days and those in the second trimester have an an error margin of 8 days.

When I was in my tenth week of pregnancy, we had an ultrasound (basically because I was wondering if we were having twins…like I do!) and they gave us a due date of Feb. 18th. So if you add six days to that and then two weeks, that would make March 10th as my latest date of arrival. Being that it’s only March 2nd right now, I’ve still got plenty of time!

Risks of Being Overdue

No one really expects to give birth ON their due date (only 5% are in fact), but with most births being clustered around that time, when you reach one week overdue, it becomes common practice for strangers to start telling the mother that she should eat spicy food/go for walks/have sex, and at two weeks overdue, an induction is absolutely expected. Am I right?

So why do we expect induction at two weeks past the due date anyways? Well, in one case, researchers looked at ten studies involving 6,000 women, and they found that when labor was not induced after a certain time, about 9 out of 3,000 babies died and when labor was induced after 41 completed weeks of pregnancy, 1 out of 3,000 babies died. So basically, without knowing any other factors in these individual cases, we could say that inducing labor after 41 weeks of labor reduces the chances of infant death by 8.

When looking at the risks to the baby when the mother is overdue, these are the main concerns (Source):

  • Aging Placenta – The main risk with being overdue is that the placenta might stop providing the baby with the nutrients or oxygen that he or she needs.
  • Infections – The risk of infections in the womb and unexpected complications during childbirth increases too.
  • Meconium Aspiration – The risk of breathing in meconium is decreased with induction (from 11 out of 1,000 to 7 out of 1,000). When the baby’s bowl contents are released into the amniotic fluid during labor and the baby becomes distressed, he or she may breathe in the meconium and it can cause breathing problems.
  • Stillbirth – The risk of stillbirth between 37 and 42 weeks is 2 to 3 per 1,000 deliveries and increases slightly to 4 to 7 per 1,000 past 42 weeks (Source).
  • Health Problems with the Mother – If the mother is overdue and at risk for preeclempsia, high blood pressure, gestational diabetes, or any other health complications, it could lead to an emergency Cesarean section.
  • Baby is Too Big – Macrosomia is the medical term for a big baby and some researchers consider babies over 8 lbs. 13 oz. to be big while others say anything over 9 lbs. 15 oz. is big. Trying to predict whether or not a baby will be “big” can be difficult and researchers have found that ultrasounds are only accurate at predicting “big babies” 50% of the time and that women suspected of having “big babies” have higher inductions, Cesarean sections, and maternal complications. If you don’t have type 1, 2, or gestational diabetes, then the risks of vaginally delivering a “big baby” (such as perineal tears and shoulder dystocia) are not statistically significant to warrant any intervention (Source…this is a good one!).

I have heard many stories of women who have had “ten month pregnancies” and they feel like their babies just needed to “cook” longer. Many practitioners feel that we should actually be advocating for 43 weeks to be considered the definition of late. Basically, reaching your due date (or getting close to it) is not reason enough to force an induction.

Making Sure Everything is Safe

Although some sources say that medical examinations are not typically able to detect problems when women go past their due date (and use this as justification for inducing ALL women who go past their due date), there are several things that my midwives check for to ensure the safety of both myself and my overdue baby.

  • Fetal Kick Count – This is the most effective assurance that the baby is doing fine. Every baby will have his or her own patterns of movement, and if a mother is in tune with the times, duration, and frequency that her baby moves, that is the best way to ensure that everything is fine. Basically, when your baby is active, you should feel at least ten movements in two hours (Source).
  • Fundal Height – The measurement from the top of the pubic bone to the top of the uterus is the fundal height. After 16 weeks of pregnancy, your fundal height measurement (in centimeters) should match the number of weeks you’ve been pregnant. So if you’re 40 weeks, you should measure 40 cm. Just keep in mind that you will lose some ground when the baby drops!
  • Low Amniotic Fluid Levels – This is known as oligohydramnios and affects about 12% of pregnancies that go past 41 weeks. Low levels of amniotic fluid could be an indication of declining placental function and lead to intrauterine growth restriction (IUGR) where the baby doesn’t grow as it should (Source). Trained midwives are able to use abdominal palpation (feeling with their hands) in order to detect the amount of amniotic fluid. Basically, the baby would be very easy to feel and in some cases you could see limbs, the uterus would be smaller than expected, and there may be fewer movements (Source).
  • Fetal Non-Stress Test (NST) – The goal of this test is to measure the heart rate of the fetus in response to its own movements. Healthy babies will respond with an increased heart rate during times of movement and the heart rate will decrease when the baby is at rest. This test is an indicator that the baby is receiving enough oxygen and uses electronic fetal monitoring (Source).
  • Auscultated Acceleration Test (AAT)– This is an alternative to the fetal non-stress test that doesn’t involve any electronic fetal monitoring. Basically, you’re listening to the baby’s heart rate for 6 minutes and looking for at least one acceleration (Source).
  • Swelling – Some swelling is to be expected during pregnancy, but excessive swelling could be a sign of preeclempsia, and if a woman were to show signs of preeclempsia (high blood pressure, protein in the urine, retaining water) after she reached her due date, she would definitely want to deliver very soon. If left untreated, it can lead to serious complications for the mother including liver or renal failure and future cardiovascular issues. It can also prevent the placenta from getting enough blood which will deprive the baby of oxygen and food (Source).

Baby’s Growth Towards the End of Pregnancy

I am thankful for every day that my baby is growing inside of me. During the final days and weeks of pregnancy, some amazing growth and development is taking place (Source). If you were to rush into an early induction, your baby could be missing out on some of the following.

  • Passage of Antibodies: During the last weeks of pregnancy, maternal antibodies that will help fight infections in the first days and weeks of pregnancy are passed on to the baby.
  • Putting on Weight: Starting at about 35 weeks, your baby will start to gain weight rapidly at the rate of about half a pound per week.
  • Growing Brown Fat: Brown fat is found in hibernating animals and newborn babies and develops in the final weeks of gestation to help regulate the newborn baby’s body temperature.
  • Building Iron Stores: In the final weeks in the womb, babies build up a reserve of iron stores.
  • Developing Sucking and Swallowing Abilities: Oral feeding that requires coordination of sucking, swallowing and breathing is the most complex sensorimotor process for newborns sensorimotor process for newborns and develops in the later part of pregnancy.
  • Lung Development: The final phase of lung development occurs during the final weeks of pregnancy. If a baby is suspected to be premature at the time of delivery, the mother can be given a steroid injection to speed along the lung development process (Source).
  • Brain Development: The last three months of pregnancy provide your child with the basic brain structure that he or she will have for the rest of his or her life. The brain grows rapidly during this phase and roughly triples during the last 13 months of gestation (Source). Every day in the womb allows the brain to grow and develop even more.

Risks of Inducing Too Early

Many women breathe a sigh of relief at 37 weeks because that has typically been considered “full term”, but now the true definition of full term is considered 39 weeks for the best chance of optimal development. Not only that, but you may think that you’re 37 weeks based on inaccurate measurements and really only be 33 or 34 weeks along. Yes, the later part of pregnancy is uncomfortable, but inducing a baby to be born before she is ready can bring about way more problems. If a baby is born premature, there are several risks involved (Source):

  • More Interventions: Interventions tend to lead to more interventions. If you are induced before your body is ready and labor doesn’t begin, it can lead to a Cesarean section and other interventions that might not have been necessary.
  • Stay in the NICU: Babies born too early can have problems breathing, staying warm, dealing with jaundice, sucking and swallowing, and may require a stay in the NICU.
  • Long Term Health Problems: Attention Deficit Hyperactivity Disorder (ADHD); and as adults, they are more likely to get diabetes, high blood pressure or heart disease.

Medical Methods of Induction

According to birth certificate data in the US, 23% of labors (in 2012) were medically induced, but this is not something that is always reported on a birth certificate. Survey data shows that number to be more like 41%. Here are the possible medical methods of induction (Source).

  • Prostaglandins: You can be given a medication containing synthetic prostoglandins inserted into the vagina to thin and dilate the cervix or an oral dose of misoprostol that will do the same thing. *Note: there are MANY natural ways to do this, see next section.
  • Foley Catheter or Cervical Ripening Balloon: By inserting a thin tube into the cervix with one or two tiny uninflated balloons on the end and then filling these balloons with water, the pressure on the cervix stimulates the body to release prostoglandins which can ripen the cervix. Then when the cervix opens, the balloons fall out and the tube is removed.
  • Strip or Sweep the Membranes: If the cervix is already somewhat dilated, a finger can be inserted and manually separate the amniotic sac from the lower part of the uterus. This will cause the release of prostoglandins as well. This can be a bit painful and uncomfortable, but can stimulate contractions. *This is something a midwife can do or you can do if you are familiar with your body.
  • Rupture Membranes: This is otherwise known as “breaking the water” and involves inserting a small hooked instrument through the cervix to break the amniotic sac. There’s a small chance that this will stimulate contractions, but if it doesn’t, then pitocin will be given.
  • Pitocin: The synthetic version of oxytocin (the hormone released that naturally stimulates labor) is called pitocin and can be given through and IV pump to stimulate contractions.
    • Oxytocin versus Pitocin: During natural labor, oxytocin is released into the mother’s body in a pulsing action that provides for breaks during labor, but pitocin is given in a steady stream through an IV so it causes contractions that are longer and stronger than your baby or placenta can handle which can deprive him/her of oxygen. It also prevents the mother’s body from releasing endorphins (that will prevent and counteract pain), is not as effective at dilating the cervix as oxytocin so more is required, lacks the peak that oxytocin provides allowing for a faster easier birth, and interferes with the release of oxytocin…otherwise known as the love hormone that helps promote bonding after birth.

Natural Ways to Induce Labor

If your body is ready to go into labor and just needs a helping hand, then there are many natural methods that can help to spur things along. Some are very gentle and safe while others carry a certain risk and must only be used with extreme caution (Source).

  • Get the Baby into Optimal Position: Ideally, a baby will be LOA (left occiput anterior) when engaged for labor, meaning that if the mother looks down at her belly, the baby’s head will be down and the back can be felt on the mother’s left. If the baby is in an OP (occiput posterior) position with its back lined up with the mother’s spine, it can prevent a mother from going into labor or make labor start and stop. Spinning Babies is a wonderful website and goes into great detail about baby positions, when it’s recommended to turn them, and how to go about doing this.
    1. Bouncing on a Birthing Ball – This can help tremendously to get the baby into an optimal position. I must have a uterus perfectly designed for posterior babies because they have all started out this way and then turned during labor. But I have always relied heavily on my birthing ball to help me bounce and swivel my hips at the same time. My husband has also been a great help by pushing on my hips or on my lower back…it really helps to be very vocal about what feels good and you want your partner to do!
    2. Kneeling on all Fours  – I love getting on my hands and knees to release the pressure of the baby. It also helps to stick my butt up in the air to let the baby move more freely into an optimal position.
    3. The Miles Circuit – This is a series of positions and movements involving lunges, walking on an uneven curb, and side stepping up stairs to open your pelvis and get the baby into an optimal position. (Read more here.)
    4. Chiropractor Visiting a chiropractor trained in working with pregnant women can help to align the spine and joints to help the baby be able to get into optimal position for birth.
    5. What About Deep Squats? The idea that squatting with your knees higher than your hips may seem like a good idea to get the baby further into the pelvis, but really should be avoided in later pregnancy because it can cause the baby to get settled into an unfavorable position. (Read more here.)
  • Walking – With every baby, we always talk about “walking it out”. The bumping up and down can help to move the baby into the birth canal. Walking up and down stairs, especially two at a time while lifting your legs up really high can also help to move the baby downward. Swimming can also be a nice low impact way to help move things along.
  • Sex – What you did to make the baby can help the baby come out too! As long as your waters haven’t broken, it is still generally safe. Also, have fun talking to all of your coworkers and friends about all of the raunchy details of your sex life when they suggest this method of induction. 🙂
    1. Sperm – Sperm contains prostoglandins that can soften the cervix. May be taken orally or vaginally. 🙂
    2. Female Orgasm – The uterus contracts during orgasm and this can help to stimulate labor.
  • Nipple Stimulation – You can gently rub or roll the nipple in order to release oxytocin to help stimulate contractions. But it can make contractions very strong, so use with caution! (Read more here.)
  • Stretch or Sweep the Membranes – By inserting a finger into the cervix and doing a gentle sweep between the uterus wall and amniotic sac, it can help to stimulate labor within hours or days. (I’m not sure how many women would feel comfortable doing this to themselves, but I did this to get Elliot’s birth going. Here’s some more info on how to do it.)
  • Oils to Ripen the Cervix – Instead of synthetic methods or sperm, there are other ways to soften the cervix. Borage seed oil, evening primrose oil, and black current oil are natural sources of prostoglandins which are fatty acids that can soften the cervix and increase the flexibility of the pelvic ligaments that will help with effacement and dilation. You can take them orally starting at about 35 weeks and with the evening primrose oil, you can insert it vaginally (just do it at night and use a panty liner).
  • Meditation, Visualization, and Yoga – I recently wrote another blog about this because I think that having a peaceful mindset is very crucial before giving birth. Recently, everyone in my family has been sick and needing me, and I have certainly felt the signs of labor stop when I am needed or stressed out.
  • Acupressure – There are accupressure points in the ankles and webbing between the thumb and forefinger that can cause muscle contractions in the uterus and help to stimulate labor. (Read more here.)
  • Herbs to Take Towards the End of Pregnancy
    1. Motherwort – This herb makes contractions more effective, regulates Braxton Hicks contractions, and stops false labor. If taken before birth, it can calm nerves and potentially help to prevent postpartum depression. (Read more here.) *Get the herb here and the tincture here.
    2. Red Raspberrry Leaf – Starting at about 34 weeks, this herb can be taken as a tea or a pill to strengthen the uterus and potentially lead to a shorter labor, especially the pushing stage (Additional source). *Get some in bulk here or in tea bags here.
  • Foods to Help Stimulate Labor
    1. Bananas – Bananas have a lot of potassium which is crucial for muscle contractions, so being low in potassium could potentially delay labor. *Don’t overdue the potassium or take supplements as they can be poisonous when taken incorrectly.
    2. Basil and Oregano – These herbs are emmenagogue that can help to bring on a late period and in higher doses can cause uterine contractions. You can make food with these herbs or steep them in a tea to get things going. (Read more here.)
    3. Dates – Six dates a day leading up to your delivery date can make labor start sooner, make it shorter, and help with dilation (Additional source).
    4. Pineapple – Fresh raw pineapple contains a small amount of an enzyme called bromelian which can soften the cervix and get labor going.

Natural Methods That Might Do More Harm Than Good

  • Castor Oil – Because castor oil causes severe diarrhea, the theory is that these bowel movements will stimulate contractions. I actually got desperate enough with Elliot and tried this method, and let me tell you IT WAS NOT WORTH IT! Yes, my body was ready to go into labor and it probably did help to kick things off, but my butt hurt worse than my vagina after labor, plus I ran the risk of dehydration. No thanks.
  • Licorice rootLicorice root and licorice extract contain an ingredient called glycyrrhizin, which can cause uterine contractions but also have some negative side effects, so beware.
  • Spicy food – Even though there is no scientific evidence that spicy food can bring on labor, many women swear by it. The theory is kind of the same as castor oil in that it can upset your digestive system enough to cause cramps that may lead to contractions. Personally, I’d like to avoid the discomfort, but if you’re really desperate, it can’t hurt too bad!
  • Black/Blue Cohosh – If you’re past 40 weeks and already experiencing contractions, these herbs can help to strengthen and regulate uterine contractions. While generally regarded as safe, there was an isolated incident of it causing heart trouble in a new baby, so use with caution. (Read more here.)
  • Clary Sage Oil – By mixing with a carrier oil and rubbing on your belly, it can help to promote labor and relieve pain, but it should only be used under the guidance of a trained professional as there can be other complications if not used correctly.
  • Golden Seal – Golden seal can be taken orally in tablet form and has hydrastatine and berberine that have been known to induce labor. Because of complications, however, it is recommended that you only take it with professional guidance.

What Causes Labor to Start

Labor will typically begin when the maturing baby and aging placenta trigger an increase in prostoglandins that will soften the cervix and get it ready for effacement and dilation. Estrogen will rise and progesterone will increase which will make the uterus more sensitive to oxytocin. The baby will move down into the pelvis and contractions in the last weeks of pregnancy may start the effacement and dilation of the cervix. Women will typically feel a burst of energy to help them make the final preparations before labor begins (Source).

In addition, the uterus has an increased number of immune cells (macrophages) there to help to fight lung infection that begin to migrate to the wall of the uterus during late pregnancy (called surfactant protein, aka SP-A). Once there, a chemical reaction takes place stimulating an inflammatory response in the uterus that starts the process of labor. So basically, when the baby’s lungs are developed, labor will begin (Source).

In Conclusion

Even though I am anxiously awaiting the arrival of our precious little guy, I am in no hurry to “make him” come before he is ready. I have viewed each additional day as a gift where I get to accomplish one more task or cuddle with one more child before my little guy enters this world and demands my full attention. I have also enjoyed eating special meals, treating myself to organizational tools for my home, doing yoga daily, nesting in every possible way, getting caught up on things I would have never dreamed I would get caught up on, reading, journaling, spending time with my husband, and taking lots of time to reflect and enjoy every aspect of life.

Now that I am knowledgeable in all of the risks of being overdue and aware of a variety of methods of induction, I am ready to turn this part of my brain off as I listen to my body, become aware of my baby, and prepare for this miraculous journey that will bring a new life into the world.