by Jordan S. Saalfrank, MSW, CD(DONA), CE
Frequently Asked Questions by pregnant families in Fort Wayne: "Can the placenta adequately support my baby after 40 weeks gestation?" "My doctor is suggesting induction because I'm past 40 weeks.... my baby could get too big and I'll need a c-section....should I induce?" There are many reasons why these seemingly simple questions are actually quite complex and difficult to answer. The short answer to whether a 40 week placenta can continue to fund the baby's uterine party: yes. 40 week placentas are more than capable to sustain a healthy baby in the womb. Should you induce labor when you are told you have a "big baby?" Heck-to-the-no!! Fetal Macrosomia is not reason enough to induce. Let's take a quick look at why our medical society has us so overly concerned about 40 week placentas and big babies before we get into the long answers.
The industrialized, ultra-conservative birth culture in the US has led the community to believe that any pregnancy beyond 40 weeks is considered "late" and requires intervention. Most care providers in Fort Wayne tell their patients up front that they will not be allowed to stay pregnant after 41 weeks. When in actuality "postdate" or "postterm" is defined as "a pregnancy that goes beyond 42 weeks gestation" (Lowdermilk, Perry, 2000). What has happened in our culture to produce such doubt from our doctors in our bodily design? As Valerie El Halta so wisely pointed out in "Normal Birth: Do We Believe? Can We Remember?":
"The obstetrician may say to the pregnant woman, through attitude, words or continual reliance on technology, "You have to prove to me that you can give birth to a baby"' (Midwifery Today, 1998).
This kind of doubt only seaps into the cracks of a new mom's natural uncertainties and propels her into more self-doubt and wondering whether her body can "do" labor and birth without intervention.
How have we gotten to this point of inducing labor before a baby is even truly defined as "overdue"? A short answer could be: lawsuits. A doctor sued for malpractice is labeled "less liable" for a maternal or fetal death if they show "proactive" approaches to managing a pregnancy and labor. This means managing pregnancy and labors and inducing. So inevitably due dates have become a ticking clock for doctors rather than what they truly are: GUESS DATES.
Would you agree with me that every woman is different? From lifestyle to family to physiologic make-up; women are different. A little wheel that predicts a due date isn't going to be right very often. And since every woman's cycle varies it is nearly impossible to predict when the gestation began and how that woman's body will grow that baby (unless the woman tracked her basal temperature and knows the date of conception). The truth is, over 90% of the time a woman's body will grow the baby it can birth! Belief in the birth process that has been happening over thousands of years needs to be reclaimed and nourishing expectant families. Valerie El Halta goes on in her article to say:
"The midwife, on the other hand, with her attitude that birth is, in most instances, a reliable event, says to this same woman, "You have to prove to me that you cannot have a baby!""
We need every woman to be supported in this way and to stop the spreading of doubt in our design to normally birth babies without intervention.
So back to the long answers: Can a 40 week old placenta properly sustain a baby in the womb?" Women's bodies have been designed to sustain a baby well for 42 weeks. While the risk of newborn death or stillbirth is very low, after 42 weeks gestation the risk does increase (BJOG. 2009;116(5):626-636). But this is where a patient care provider, one who BELIEVES in the process and a woman's body to birth, and technology can come together to help calm some of those fears and lower the risk. A patient care provider, a care provider practicing evidence-based care, will track fetal movements and use doppler technology to listen to cord and placental blood flow, periodically monitoring for any signs of a need to intervene. Also biophysical profiles or non-stress tests can be used to evaluate baby and whether there may or may not be any danger in continuing to stay pregnant after 42 weeks. This is a non-invasive office procedure that listens to baby's heart rate, measures the movements of baby and sometimes looks at amniotic fluid volume. This is where the use of technology can ROCK! How amazing to have a "window" of sorts, to check in on baby, see how they are moving, making sure there is good blood flow through the cord and no signs of difficulty. An evidence-based care provider would be more than willing to stand by and allow a mom to go into labor on her own as long as the fetal movement and placental blood flow remain good. The bottom line: 40 week placentas are still very viable and able to nourish a baby.
A short pause for caution here: amniotic fluid levels are constantly changing as baby sucks, swallows and pees. Sometimes low fluid levels can just be a time where baby hadn't peed yet or mama hasn't kept her water intake levels up. It could also be a sign that labor is coming. It is very common to show low fluid and lose a bit of weight before onset of labor. In any case, low fluid levels alone are not an immediate need to intervene (Cochrane Database Syst Rev. 2008). It can be ok to ask to come back to the office the following morning for another analysis and then work in that time to drink appropriate amounts of water and rest. If the second profile shows signs of low fluid again than that can be a good time to discuss intervention and what that would look like for you.
What can be agreed on in many evidence-based articles, "big baby" or "fetal macrosomia" is also not reason enough to induce.
"...many babies delivered early because of concern about their size are born weighing considerably less than the caregivers had suspected. That's because both ultrasound and hands-to-belly estimates of fetal weight are unreliable, and both methods are more likely to overestimate than underestimate the baby's size. It's also difficult to know whether a large baby will pose challenges during labor. Many women do not experience extra difficulty giving birth to larger babies." (BJOG. 2009;116(5):626-636 and Am J Obstet Gynecol. 2009;200(2):156.e1-156.e4)
If a care provider suggests that you induce labor because you have a "big baby" or they are "concerned about the size", the care provider is giving you bad information and poor care. It has been documented over and over in the research that fetal macrosomia is not reason enough to induce labor. The bottom line: your body will grow the baby it can birth.
You can prepare and eduate yourself extremely well, but the mind game of "when will labor start on it's own" and "how long is too long to wait" can sometimes be the hardest battle to fight. What is known:
"is that the most important trigger is a surge of hormones released by the fetus. This hormone surge, which prepares the lungs and digestive system for life outside the womb, signals the fetus's readiness for birth. In response to these signals, hormone receptors in the woman's uterus turn on and the muscles in her uterus change to allow her cervix, at the lower end of her uterus, to open. In short, when a woman goes into labor on her own, this is a powerful signal that her baby is ready to be born and that her body is ready for labor" (Childbirth Connection.org).
The bottom line: those last moments of hormone release and development your baby performs to be born are vitally important. Try not to short change your baby's birth experience and developmental process for reasons of conviennce or bad, fear-based care provider information.
Have confidence in your body's ability to birth. Period. Put yourself in the protective bubble of what the research and information clearly says: when left alone, your body will grow and birth the baby normally. Don't listen to family birth stories or friend's cautionary tales. Their experiences, while they may be valid and at times, difficult, are not evidence-based. Either the family started off with interventive care and therefore continued down the path of increased risks for mom and baby or their birth was an expection to the normal birth process (6 - 8% of pregnancies qualify as high risk) and a situation where technology was used properly and saved lives. These are exceptions and areas where technology helped and could have even saved a life. Your body is your story. As of yet, you may not know the ending. Choose to believe in your body's ability to birth. Walk down the journey of waiting for labor to start on it's own. Use gift of technology as a tool but arm yourself with the knowledge to know what warrants a medical need for induction and distinguish what may be a care provider scare tactic.
I would love to see care providers here in Fort Wayne change their Mode of Operation from asking women to prove that she can have a baby to believing women need to PROVE THEY CAN'T HAVE A BABY. Fort Wayne families would then see the induction rates go down, need for neonatal ressucitation at birth go down, NICU stays go down and unnecesarean rates significantly drop.
