Friday, January 8, 2010

At a Bible Study

I tell you, people.... Being a birth junkie is hard. You can't get away from your hobby - because wherever one goes, there are women who are either pregnant or who are discussing someone they know who is pregnant.... and generally some of the decisions being made are upsetting to the average natural-birth junkie. Can I get an amen?

Yesterday at Bible Study was no exception. I attend a large, monthly Bible study at a local church, and at this past month they were holding a diaper drive for a mama who is currently pregnant with twins (and who, when the twins are born, will have four kidlets age two and under - yikes!!). Good so far.

So they get this sweet girl up on the stage to present her with the diapers, and she has to go through the usual good-natured teasing and jokes, and then they ask her the big question - "So, when's your due date?" And (though I'll pass over all the underlying issues with "due dates"), she replies, "I'm due on [date X]......." (pause for delighted applause and cheering) "...... but they'll be inducing me a month early, so the babies will be here by [date X - 4 weeks]."

You can guess my original reaction. It was something along the lines of:


That semi-coherent thought continued as such: "Oh, my goodness! Why are they doing this? Are they TRYING to create premies who will be spending their first weeks in the NICU after a failed induction leading to cesarean and increased respiratory morbidity (plus other problems), or even just vaginally-born twins who were NOT READY to come out yet? Don't they know that even ACOG has recently recommended against elective induction before 39 weeks?"

Then I thought: "Hmm. Induction. That means vaginal birth. That means that her doc is not sending her for an automatic cesarean, which is unfortunately what many doctors are currently doing with multiples. That's cool. Very cool. So why is he trying to sabotage a vaginal twin birth by intentionally complicating it? Is this a compromise, i.e. Mom says "I want a vaginal birth" and doc says "Okay, but only if you agree to a 36 week induction"?

I don't know. There are a hundred possible scenarios. I'm really just thinking out loud here.

Of course, I should add that I do not KNOW that there are no complications calling for an early induction. But I suspect that there are no serious complications, simply because (a) this girl was the talk of the morning's Bible study, and no complications were mentioned - it was just excitement for her pregnancy, (b) when the item was discussed from the podium, it was the same - just lots of excitement and congratulations, no "Let's keep so-and-so's babies in prayer, as they are suffering from complication X, etc., (c) the girl herself mentioned nothing when given the microphone. So, while I will freely admit that I do not know all the details, I think that this is most likely an elective or doctor-led induction.

Then I went and posted on my local birth network group to find out what people had to say. Here's what one lady had to say about twin induction at 36 weeks:

"It's because they say twins mature faster than singletons, so a 36 wk twin baby will have the lung maturity and placental maturity of a 40 weeker."

So assuming that it's safe (which is questionable), the question becomes, regardless - WHY? She added:

"There are a lot of docs that routinely induce at 40 weeks so I assume they would give the same reasons - concerns about placental insufficiency, stillbirth, and the thought that "if we're going to have to induce anyway why not do it before the baby gets bigger and makes it harder." ACOG doesn't recommend routine induction at 40 weeks or routine induction for a suspected big baby but of course many OBs still do it anyway.

"I wanted to add though that for what it's worth, I had a friend who had a vaginal birth with twins, an induction at 36 weeks, and she thought her babies seemed premature despite what the official textbooks say. And I have heard some doctors (and not necessarily very natural-minded ones) inducing at 38 or even 40 weeks with twins. So the 36 week recommendation thing isn't a
hard and fast rule even among seems to be a little bit of a personal preference."

Another lady replied to the thread:

"My only question would be, if they are "full term" and fully " mature" at 36 weeks, why do they naturally stay in for 40? And of course when born early, they are obviously smaller than average and often must stay in the NICU, are those not indicators that they were meant to be in longer? I have never had twins. But I've had babies and they seem to come out when they are supposed to...."

One final lady added this:

"When I was pg with my girls and talking to my ob about the twins he had delivered before, he told me about two moms that went to 42wks before they did their c/s (they were breech). The moms didn't want to schedule a 39 wk c/s like most moms do, and so he honored their choice. They were born healthy and were really great sizes from what I remember. He never said anything about inducing early and I have to agree that 36wks is NOT a good rule of thumb to go off of. A lot of times they are off when it comes to due dates and I would think it wise to leave the babies in as long as they and mom are fine. I could see that if there is some IUGR going on or some other complication, but inducing early without medical reasoning doesn't make any sense. I had NSTs done starting at 35wks and as long as everything was looking good, they weren't going to do anything. Hopefully there is a good reason, like you say."

Anyone have any thoughts? It just seemed a less-than-optimal situation, and my heart hurts for the very real possibilities that this mama is going to be facing, albeit unknowingly - a failed induction, an unnecessary cesarean, babies in the NICU because they were forced to come too soon, etc. etc. etc. ad infinitum.

I remember when my pastor's daughter had twins, they were working like mad to KEEP her pregnant past 36 weeks, because she had problems with preterm labor. When she hit the 36 week mark they conceded defeat and let her body go into labor, and her babies were still in the NICU for quite a while because they were born too soon. We need more doctors (and hospital midwives) who recognize the value of a natural gestational term. In other words, when the baby is ready to come, the mother will go into labor. Seriously. We really don't need to be inducing an ungodly percentage of pregnant mamas into premature labor. Really.

Comments, corrections, things to throw? Please let me know (politely, of course!).


  1. According to the research I've done (which it's been a while, so my memory may be fuzzy), at least one study and perhaps more point to an increased risk of stillbirth at or after 36 weeks with twins. *However* I've seen other studies and/or critiques of the first type of study which showed that the risk of fetal demise did not suddenly spike at 36 weeks, but rather that babies who had died prior to that point were finally born and were (obviously) stillborn. In other words, a woman may have known that one of her babies had died at 30 or 33 weeks, but they waited until 36 or 37 weeks to induce/section so that the surviving twin would be more fully developed. Presto - another "stillbirth at 36 weeks." I don't know if there is a study that looks at twin pregnancies and fetal demises and plots the actual gestational death week, or if it only looks at stillbirths.

    I also don't know that twins actually "develop faster," or if the mom's uterus just gets to the point where it says, "I can't grow any bigger -- these kids are outta here!!" so labor commences naturally earlier with twins. Of course, there are also plenty of twin stories of women having twins at 37+ weeks, so this is not an absolute, either.



  2. I don't know, but I hear you. A gal who's younger than me told me the other day she was pregnant and her doc had transferred her to a high-risk specialist. Why? AMA.
    (For the record, my midwives put "advanced maternal age" in air quotes every time they use it, ha!)
    Anyway, what're ya gonna do? It drives me bonkers.

    And as far as twins developing faster, anyone with a basic knowledge of human development (or common sense) knows that following that logic, Kate Gosselin's babies should have been "developed" at oh, about 4 months. Having a twin beside you in utero does not alter the fundamental truths of nature
    Babies gestate for 40 weeks, give or take a week or so. Some come earlier, some come later, but it's NOT because their development is different.


  3. What bothers me is the automatic assumption that our bodies don't know when our babies should be born. If twins are really supposed to be born earlier, then (most of the time) the body should take care of it. God didn't mess up the birth process.

  4. You bring up a lot of questions in your post and then speculate what the answers are, sometimes correctly and sometimes not. A lot of these questions do have answers demonstrated in quality research (which is what obsetricians learn in years of training!) - not to say that we don't do anything stupid from time to time :)

    The rate of neonatal death in monozygotic (one placenta) twins starts to increase to a level we consider unacceptable after 36 weeks, which is why most OBs induce at that time. Dizygotic (two placenta twins) are lower risk for intrauterine demise, and usually are delivered at 38 weeks. Pulmonary maturity for twins is accelerated relative to term babies, and these babies tend to not need any special care after delivery. Stillbirth/fetal demise is a heartbreaking outcome that we will do a great deal to prevent.

    The last commenter (Buscando La Luz) is espousing a view that is not shared by Obstetricians. The natural course of life, whether by God or evolution or whatever, if for some babies and mothers to die or be injured in pregnancy in childbirth. Our training and practice exists to prevent as many of these problems as we can, and we do prevent a lot of them. Some babies don't know when to come and die in utero for one reason or another. Some are sick from bad placentas and need to be delivered before they expire. Some are just in there too long and also should be delivered. The placenta starts to lose oxygen carrying capacity after term, and sometimes labor does not come on before it has lost too much. Induction of a term fetus at 41 weeks decreases intrauterine death without increasing cesarean section rates in randomized trials.

    Nicholas Fogelson, MD


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