Posted by My OB said WHAT?!?.
Sep
12
Posted by My OB said WHAT?!?.
“Twins Are Ready Sooner Because They Grow Faster Than A Singleton.”
“Twins are ready sooner because they grow faster than a singleton.” – OB
There are 206 comments to this post.
I wonder if this is considered medical malpractice…out right lying to a patient? I mean, did he seriously think this mother was going to buy this line of BS? on what planet is it ethical to assume the person you’re caring for is an idiot, and then lie to them because of this assumption? I mean this is like telling someone who brings their car to the shop with a flat tired and gets told that their car drives better and faster on three wheels instead of four…
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“The reason twins are born sooner is because I grow impatient faster than with a singleton.”
The thing that grows faster is the mom’s belly.
Twins are almost always slightly smaller than singletons. Explain that one, doctor genius.
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Cmat Reply:
September 12th, 2010 at 6:52 am (Quote)
Hmm yeah, I always thought it was the mom’s belly factor + how much strain they put on the body. Having one is demanding, I can’t imagine the demands of two.
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Cassie Howe Reply:
June 4th, 2011 at 12:37 pm (Quote)
I have twin boys. They came when there was no more room and my oldest broke my water! It’s a matter of space and fluids that decide on when twins are born!
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Wow Doc, I’d LOVE to see the medical, scientific evidence of this! Do twins continue to grow faster once they’re outside the womb too? Or is the magical growth substance in twin amniotic fluid? OOhh! I know! Maybe we should save twin amniotic fluid and bathe babies with failure to thrive, since twins grow so much faster… >.<
Now, I have heard that if twins come early on their own, they can have a tendency to recover faster than singletons. Based on what I read this was especially remarkable in male twins of a male-female fraternal twin pregnancy, as male preemies tend to have more risk of complication.
However, I think this line was just put out there to justify the doctor's wish to schedule a c-section at 36 weeks rather than waiting for the babies to be ready. I have been told by twin moms I have spoken with that most of the doctors in my area consider twins an automatic c-section at 36 weeks *even if the presenting twin or both are vertex* at the end of pregnancy, and both mother and babies are healthy.
One mom I know went through every OB practice in the area before she found one even willing to "wait and see" how her twins did. They were both vertex and were born naturally at 37-38 weeks.
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I can’t tell you how many times I have heard this. Even one twin mom to another, saying “I can’t believe your doctor isn’t inducing you, my doctor said my twins were ready at 36 weeks. Your doctor is putting your babies’ lives at risk.” Etc, etc. Just like some singletons aren’t ready until 43 weeks, some twins aren’t ready until later!!
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Jane Reply:
September 12th, 2010 at 7:35 am (Quote)
Wait, you mean some women actually believe this? Now this comment isn’t funny anymore. 
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Lindsey Reply:
September 12th, 2010 at 8:38 am (Quote)
She believed it and told the other mom she should be demanding a c-section at 37 weeks.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 10:50 am (Quote)
Any singleton ‘not ready’ at 43 weeks was misdated.
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Lindsey Reply:
September 12th, 2010 at 10:59 am (Quote)
Definitely possible! I’m not arguing that at all. But if the baby that takes “too long” was just misdated, that would mean they aren’t really that far along, and what if labor had been induced at the doc’s 40-week mark, and the baby was really not ready? There’s no good answer, except that all babies are not ready at the same time–it’s impossible to know a baby is ready until s/he is here, or an amnio is performed, and a lot of moms aren’t willing to have an amnio (myself included), especially just because they hit that magical 40-week mark.
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Dreamy Reply:
September 12th, 2010 at 11:03 am (Quote)
Citation please.
Again with the absolutes.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 11:06 am (Quote)
Now you are asking about the nondisprovable. Are you saying that there are accurately dated infants 43 weeks along in pregnancy who are not mature enough to be delivered? Honestly?
BTW I am not in support of routine induction at 40 weeks, nor is ACOG.
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Robyn Reply:
September 12th, 2010 at 11:35 am (Quote)
Actually, I know a woman who went to 43+ weeks with her first and 45 weeks with her second. She charts her cycles and was absolutely sure of her dates. Both babies were perfectly healthy when they were born and neither one of them showed any signs of post-maturity.
And whether you or ACOG support routine induction at 40 weeks or not, there are still many practices that will induce anywhere from 37 to 41 weeks routinely. Many will acquiesce to some mothers requests to be induced before they would normally consider induction. In fact, this practice is so common that there are women who become angry at their doctor because they got someone who absolutely refuses to induce before they’ve gone to at least 40-41 weeks unless it is medically indicated. God forbid they got a doctor who cares more about the health of the infant than the comfort of the mother.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 5:53 pm (Quote)
>> Actually, I know a woman who went to 43+ weeks with her first and 45 weeks with her second. She charts her cycles and was absolutely sure of her dates. Both babies were perfectly healthy when they were born and neither one of them showed any signs of post-maturity.
It is my belief (well justified I think) that a “45 weeker” that does not show signs of postmaturity is not a 45 weeker, but a younger fetus that is misdated. You are basing your ideas on a belief that it is possible to know for certain when a pregnancy started based on charting, which we know from early ultrasounds is untrue. Some people can make a perfect chart and still it is off.
The physical characteristics of a fetus of a given gestational age are quite consistent, enough so that there are detailed charts for dating babies (born fetuses) based on them.
**
Its funny to me that this all started with folks arguing that twins could not possibly grow faster than singletons (which they don’t), and now you are arguing that one particular fetus develops signs of maturity substantially slower than another. Sort of an opposite idea.
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Louisa Reply:
September 12th, 2010 at 9:26 pm (Quote)
Now you have really, really pissed me off. don’t start this $h!t about “a woman can have her dates wrong but the 6 week, 10 week, whatever scan is most accurate”.
Let me tell you something buster & you listen good. My husband were geographically removed from each other except for a 4 day period when I conceived DS so you would think I would know to within 4 days of his conception date wouldn’t you?!?!?!?!?!??!?!?!?!?!?!?
Do you know that the “most accurate & reliable” 6 week scan showed me at 6 wks, not 10 wks like I said I was. Did you know that then opened up alot of problems because I was going to have a “huge” baby because it was messuring 4 weeks further along then “it should be”, well, no, not if they believed my dates, he was right on target.
So, I dare you to tell me that I was cheating on my husband so the scan could be “correct” & I could be wrong.
Sorry, buster, pull your head in. No, I take that back, not sorry at all. That argument just doesn’t wash with me.
So guess what is happening next time I conceive???
No way in the world am I giving a LMP, or telling anyone when I cycled or even going for a scan until after 20 wks because the amount of stress it caused me last time just isn’t worth the effort.
BTW – DS was born 41wks + 3, my dates, 38 wks +1 day their dates
Now you sir, can go jump >:(
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Robyn Reply:
September 13th, 2010 at 9:39 am (Quote)
You know, those scans are not always accurate. In fact, they are notoriously inaccurate. But I’m not going to argue with you, though. The woman I was referring to also had a family history of women who gestate longer. She has admitted that if she ever went into labor earlier than 40 weeks, she would be scared because her babies just cook longer.
Different women have different outcomes. There’s another woman I know who has consistently had her children between 34 and 36 weeks gestation and not a single one of them has had a single sign of prematurity. Granted, everything I’ve stated here is pure anecdotal evidence and should only be taken with a grain of salt. My point is simply that these things happen
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Krista Reply:
September 13th, 2010 at 8:20 pm (Quote)
Dr. Fogelson,
I’d like to say thank you for sticking around here. You really tick me off sometimes as I’m sure I’ve also done to you. 
Even so, I appreciate your insight. I consider myself the best expert on my own birth, but I’m not the leading expert on everyone else’s birth or the complications they might have so there are times when it helps to have someone who can fill in the blanks. As Dreamy stated, from what I’ve seen you seem to usually be pretty reasonable and honestly would be someone I’d consider as an OB if I thought I needed one. After all, I know you can take abuse. lol!
Anyway, just a tidbit on the ultrasounds…
I was post-40 weeks with all three of mine, but with my youngest I had some cramping early in pregnancy. I was unsure of my LMP and didn’t chart so I could only guess how far along I was. I went to the doctor to get an ultrasound which stated I was 4 weeks earlier than I thought. Ultimately, my son was born at 43w1d and showed no signs of pre- or post-maturity. He was right on time – maybe that means he was actually 40 weeks. Maybe he needed longer to mature. Either way, inductions are concerning because if I’d been induced at 39 or 40 weeks (according to the US)he wouldn’t have been ready. I think it’s a perfect example of the problem with using US dates or most LMP dates conclusively. IMO it’s also a good reason why the “big baby card” should never be pulled. They’re great tools, but they aren’t very good measuring devices. Any measurement taken via US should be taken as a rough estimate.
Here’s a great article about SP-A triggering labor. I haven’t looked deep into it and I don’t know what, if anything, has been found since this was written (2004), but I find it very intriguing. Maybe it’s something you’re familiar with.
http://www.scienceblog.com/community/older/2004/10/20049334.shtml
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Brittney Reply:
September 26th, 2010 at 11:52 am (Quote)
Just wanted to say a few things…. My mother knows exactly when I was conceived because she and my dad were apart before and after for a few months, and I was born 24 days past my due date. I weighed 8lbs, 1oz, and had no signs of pre or post maturity.
Another thing to keep in mind, the “average length of pregnancy being 40 weeks or 280 days” was literally pulled out of some physicians a$$ in the 1850′s (I believe), without any proof, and has since become “obstetric law”.
Here’s the info on that
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Susan Reply:
September 27th, 2010 at 3:30 am (Quote)
Quick note, but sperm can live for up to 5 days in the presence of fertile cervical mucus, so it’s possible conception occurred 5 days after intercourse. That being said, you still would’ve been at least 19 days past the due date, if that were the case. Just wanted to add that, though.
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Suzanne Reply:
January 3rd, 2012 at 11:14 pm (Quote)
my sister-in-law just recently shared that her OB had told her it can last a couple weeks, if it’s really hardy sperm (and this seemed to be true for the pregnancy she was confused about). I’d never heard that before…but it was interesting.
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Dreamy Reply:
September 12th, 2010 at 12:14 pm (Quote)
Are you saying that there are accurately dated infants 43 weeks along in pregnancy who are not mature enough to be delivered? Honestly?
Are you saying there aren’t and have never been? Honestly? Oh yeah, you did.
I know you are, but what am I? This is just silly, now.
You made an absolute statement that cannot be proved. Why are you asking me to prove the opposite? I never stated the opposite– I was merely implying what you also understand to be true: that your original statement is not provable at this point. So why make the first statement when you know for a fact you have no proof it is true?
BTW I am not in support of routine induction at 40 weeks, nor is ACOG.
As I’ve said elsewhere, you seem reasonable– I am not surprised that you aren’t. The problem is that routine induction at 40 weeks IS pretty standard (even at 38-39 weeks, and let’s not forget, like you said, that dating is a very inexact science).
Of course, I’m sure a reason, besides “we do this to every woman, just because,” is given for insurance and other purposes, but at this point there are relatively few American women who are not induced before 41 weeks if they haven’t gone into spontaneous labor before that time. If that’s not routine, I don’t know what is.
Now, I don’t want to project a whole mess onto you (it would hardly be fair, though it’s tempting, since we don’t get a lot of MDs around NCB spaces). But I do feel that when I have the occasion to speak with MDs about this issue, they assume that I just don’t understand and will be therefore be calmed by official policy.
I mean, I haven’t looked at the ACOG guidelines in a while, but I assume they don’t read as follows:
-C/S is indicated for women whose pelvises are too small to birth vaginally, as determined not by any actual measurements, but when, for example, pitocin and lithotomy at 39 weeks fails to end in vaginal birth within 12 hours.
-Even though it rarely improves outcomes and studies on the subject are pretty conclusive, episiotomy is a good idea if you, as an OB, have always performed them.
-C/S is indicated when 36-week ultrasounds show that a baby might be 8 pounds or more.
-The less English a woman speaks, the more interventions she needs.
-Nuchal cord is overwhelmingly likely to end in fetal demise unless a C/S is performed.
-If your patient expresses a desire to homebirth, you should tell her it’s a bad idea and her baby is likely to die.
Yet, somehow, even though they’re not “official policy,” these things are all pretty “routine” in obstetric practice.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 5:31 pm (Quote)
>> Are you saying there aren’t and have never been? Honestly? Oh yeah, you did.
No doubt, because that’s what I meant. 43 weekers are mature. Can I prove this by some paper? No. But everything we know about fetal physiology and lung development would show that. RDS at 40 weeks is < 1%, and is decreasing asymptotically at that point. At 43 weeks there are really no fetuses that are not mature. On the flip side, as time goes on around this gestational age, there is an exponentially growing number of fetuses that are developing post-dates related placental insufficiency, which is why no OB would recommend going this far.
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Louisa Reply:
September 12th, 2010 at 9:33 pm (Quote)
You know there is a post on this site where a woman was told that for every day over 40 wks she was pregant her baby died a little bit more. Told that by an OB wanting to induce at 39+6.
Mate, there are too many educated women here who have been screwed over to take anything you say lying down.
Walk away now or dig yourself a deeper hole.
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Claire Reply:
September 19th, 2010 at 3:45 pm (Quote)
Everything we know???
You mean like when a baby’s lungs are mature enough for birth it releases a signal to start labour? So a baby that hasn’t started itself off hasn’t got mature lungs.
I’ve seen many babies who were born supposedly at term but needed to go to NNU because they weren’t mature enough. Dates again? They were big babies for premature.
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Jess Reply:
August 24th, 2011 at 5:10 pm (Quote)
I think part of the issue here is that the “natural” mamas and the doc are talking two different things when they reference a baby’s ‘readiness” to be born. A TRUE 43-weeker is not going to suffer respiratory distress or other complications related to prematurity. (They may suffer complications due to method of delivery, but I think it’s too far of a stretch to think that a 43-week gestated baby is going to be “premature”.) HOWEVER, most natural-birthers refer to “readiness” in terms of the body being ready to release the baby, if you will. At 43 weeks, not all babies are ready to be “released”, and attempts to force delivery may result in complications. In that sense, no, not all 43-weekers are “ready”. So before tearing each other down, let’s clarify what kind of readiness we’re talking about.
Mature enough to survive outside of the womb without medical assistance? Yes, a 43 week old fetus will be. Ready to be born spontaneously without being forced? No, not all will be. Hence why many of you know women who gestated naturally for 44 weeks, or whatever, before naturally birthing a healthy baby. Had she been induced 2 weeks sooner would her body have willingly released the baby because it was “ready to”? Quite possibly it would not have. Would the baby, being accurately dated at 42+ weeks, been too immature to thrive outside of the womb? Highly doubtful. Nearly impossible.
I guess my point is that all of you are right in one way or another. What needs to be noted is that “mature enough to survive” is not always the same as “ready to be born.”
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Rachel Reply:
September 12th, 2010 at 4:10 pm (Quote)
Clearly English was not your strong point. “Just like some singletons aren’t ready until 43 weeks” I believe the magical conjunction that was used was “until”.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 5:27 pm (Quote)
huh?
I think I was interpreting that line correctly. It implied that some infants are not mature enough delivery by 43 weeks gestation, a factually incorrect statement.
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Claire Reply:
September 19th, 2010 at 3:33 pm (Quote)
My mum was threatening to miscarry and previa all the way through. Because of this she had a scan at 5 weeks pregnant. She then carried to 44 weeks, apart from the fact she wouldn’t have been pregnant on her 5 week scan as the egg and sperm wouldn’t have even had a date yet, my sister was born with long finger nails and a cone head as she’d been head down ready to go for a month.
Historically pregnancy was considered to be around 15 days longer than it is now, when you add in some babies take longer to cook than others it is not unreasonable to imagine that some babies really do go past 43 weeks all on their very lonesome.
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Lucia Reply:
September 12th, 2010 at 5:54 pm (Quote)
I view the issue of postmaturity as a game of statistics. I see 40 weeks as an average of the gestational dates where the baby breaths well on it’s own and is thus deemed term. With this in mind, some babies are born at 36 or 37 weeks with breathing problems and some are just fine. On the other end of the scale some babies go to 43 weeks and are just fine and some have postmaturity issues or death. I think that what Lindsey meant by not ready is spontaneous labor had not occured and those of us who advocate NCB believe that unless mom and baby (or babies) is(are) sick the best time for the baby to be born is when spontaneous labor occurs. If the baby who would have been born at 43 weeks is instead induced or sectioned out at 40 weeks it’s going to breath fine most likely and may or may not have feeding issues. Spontaneous labor at 43 weeks gestation is just x standard deviations from the norm just as 36 or 37 weeks gestation would be at the other end of the bell curve (although more rare with most pregnancies being induced at or before 42 weeks but this is an iatrogenic change in the statistic). If you consider baby to be ready when spontaneous labor occurs and not when it’s statistically most likely to be ready then the statement makes perfect sense. If you see the baby being ready at the age of lung maturity then what Lindsey stated is entirely false. I’m seeing this whole argument as a NCA to MD transtlation error .
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 6:17 pm (Quote)
I appreciate these comments.
I really can’t much merit in the idea that spontaneous labor is somehow a marker that the baby is ‘ready’ to be delivered. Clearly, many women go into spontaneous labor long before the baby is ready. We call this preterm labor. Similarly, many women have not gone into labor long after the baby is fully ready to be outside. We call this post-dates.
We don’t really know what causes labor, and it very well may be a biochemicalsignal from the fetus that it is ‘ready’, but clearly this isn’t the only way, as frequently labor is too early, and sometimes it is too late.
Fortunately, post dates testing ought to be able to pick up most or not all post dates IUFDs. Hopefully the folks that want to deliver 42 weeks + avail themselves of this technology.
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Kit Reply:
September 13th, 2010 at 4:16 pm (Quote)
A girl I know went to almost 43 weeks before her labor started. Her doctor was comfortable with it (or he claimed he was… at her 42 week appt I swear he was climbing walls worried, but he didn’t push her to induce or try to convince her to get cut.) and when she finally went into labor she got pretty far, then stalled. Her poor doctor was about to drop. (When her ontractions stopped he went white… like paper white.) He gently told her that it might be time to try something to “help it start up again” and when she agreed, three hours later she had her baby. her five pound, two ounce baby.
Her doctor actually was holding the little wiggler, looked up at her and said “Oh I’m glad we waited on her.” She measured like a very slightly early baby, but both my friend and her doctor felt that she HAD gone to 43 weeks. Explain that. (No seriously! I’m not being nasty or sarcastic If you can, its bugged me for the last two years how that kid was so teensy. She even had the breathing troubles the doctors expected from a slightly early kiddo.)
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Nicholas Fogelson, MD Reply:
September 13th, 2010 at 5:22 pm (Quote)
Three explanations I can think of
1) she was misdated somehow and was actually much earlier in her pregnancy
2) she was 43 weeks and the infant was constitutionally small (small from genetic influence rather than pathologic process)
3) she was 43 weeks and the infant had growth restriction of some etiology
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Karen Reply:
September 14th, 2010 at 8:17 pm (Quote)
OK, so we really don’t understand all the intricate mechanisms that cause labor. It’s true. But what I’ve never understood is the mindset that even without this understanding, we somehow need to be in control of it. In my opinion, the evidence does not show that we do such a great job of deciding when labor should start, either. I mean, yeah, we can often get it going, but induction is a crude science at best, and it often doesn’t work. The best outcomes for both mom and baby occur when labor begins spontaneously.
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Jade Reply:
November 5th, 2010 at 12:05 am (Quote)
I have had 2 pregnancies. Both times I was sure of my conception dates, both times I required very early scans due to the fact that I knew I was pregnant but could not for the life of me turn a pregnancy test positive (either urine or blood) (as a side note I was able to turn a test positive at about 5 weeks with my daughter but not until 20 weeks with my son, by which time of course i ahd a huge belly, could feel movement and indeed see that movement fromt he outside)
The scans in my case did in fact line up with my known conception dates, so my pregnancy was dated “correctly” by the method Drs like (U/S)
My son was born at 37+5 he was a NSVD. He weighed 6lb 9 oz, had nearly no sucking reflex, became very jaundiced, was unable to maintain his temperature as well as a host of other minor issues. The hospital agreed that either they had stuffed up (meaning on the early scan) or that I tend to “cook” them slower. I didn’t much consider this, until….
my daughter was born at 43+5, she was also a NSVD, she weighed 9lb 3, her placenta was in perfect condition with no deterioration or calcification, her skin was not flaking, her nails were not long and the amniotic fluid was not meconium stained at all.
Unfortuantely I don’t much trust EDD’s anymore, and next time I get pregnant I will be telling my care provider the above story and therefore requesting that my due date is extended 2 weeks to account for the fact that my “37+5″ baby was fairly clearly a little early and my “43+5″ baby was quite clearly not almost 4 weeks overdue.
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Heather Reply:
September 13th, 2010 at 12:04 pm (Quote)
That may be your belief, but you are mistaken. While twins do not grow faster than their singleton counterparts just because they are twins, that does not mean that individual babies do not develop at different rates.
I’m not sure if it’s a study or anecdotal, but it was shown that Asian and African women tend to “cook” babies faster, averaging spontaneous labor about two weeks earlier than white women, who average a first labor at 41-43 weeks, NOT 38-40 (which the Asian and African groups fell into).
I, also know two post-43 week babies (one was 44 weeks, no signs of post maturity, her mother was a nurse who was 100% on the conception date, and she only weighed 5lbs; the other was 44 1/2 weeks, 10lbs and some change and still didn’t have fully formed tear ducts–her mother was also certain on the dates… she was also a very easy vaginal birth, unlike her 12lb brother who tore their mother as he was vaginally born–the only difficulty in his birth, btw, and who was NOT ‘late’).
It may drive you nuts, but history is full of women who went 44 weeks (and in rare cases, beyond) and know when they had sex and thus, when the baby was conceived wit about 3-5 days margin of error.
42 weeks is still in the range of expected normal, btw. The average of 40 is derived from the botanist’s 40 week rule based on an average of 38-42 weeks.
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Cassie Howe Reply:
June 4th, 2011 at 12:40 pm (Quote)
True story: My sister was due on July 22, her birth date is August 23. She was born with a head full of hair and a tooth coming in.
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Erica Reply:
August 17th, 2011 at 7:11 am (Quote)
I’m sorry sir, but you are mistaken. My own first baby came (after medical encouragement) at 42 weeks plus one day. Stunned at her tiny 6lb 4oz self, they examined her and declared she was actually only 38 weeks gestational age and that my dates had been wrong. My dates were not wrong. My husband and I were actually in the process of separation when she was conceived. We had sex ONE confused and half-drunk (him) time. Then I missed my period (for the first time in my life.) I took a urine test five days later and it was positive. We did not have sex again for several months (at which time we reconciled and I was quite pregnant.) All my prenatal ultrasounds confirmed the original date. So, either her conception was achieved without sexual contact (a miracle?) two weeks after my positive urine test–or she was actually 42+ weeks and yet not fully mature.
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Cassie Howe Reply:
June 4th, 2011 at 12:52 pm (Quote)
My Dr said that some say it’s perfectly safe to let twins go full term. Others say 36 weeks is long enough. He told me that at 38 weeks he was going to induce me because: after that time period it can be dangerous to continue because of the limited space could put strain on my boys. Plus there was many chances of all kinds of things: my blood pressure going up, not enough fluid around each baby, cords getting wrapped around their necks, one getting more nutrients than the other, ect. My sister-in-law went 41 weeks with her twin boys(no, neither of us were trying and neither of us were on drugs to try and we were both pretty young{I’d like to blame the fact that both of us had a set of twins with in 9 mths of each other on my husband and his brother, but unfortunally, it is all on the female when it comes to having twins} it was just a fluke we both have amazing twin boys, hers are ferternal and mine identcal) and yes one of them was really sick for awhile afterwards(not blaming it on his time in mommy, but the other is now fighting ALL and would appricate those of you who pray to pray for him, his name is Tyler and he’s 3). My boys came at 35.5 wks and were in good shape(5 lbs 3 oz and 4 lbs 14.2 oz)my oldest decided he was done and broke my water. They spent 2.5 wks in NICU learning to eat and then came home on the day I was supposed to be induced!
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Nicholas Fogelson, MD had this to say,
Sep 12, 2010 @ 9:09 am (Quote)
Twins achieve pulmonary maturity earlier than singletons,typically about 2 weeks ahead on average.
Twins at 36 weeks also have the same rate of intrauterine fetal demise as a 41 week singleton, when we recommend elective delivery of singletons.
No baby needs 43 weeks to mature. Waiting until 43 weeks to deliver a singleton accepts a 1-3/1000 risk of intrauterine fetal demise, without a decrease in cesarean rates. Maybe its natural for some pregnancies to last that long, but it is also natural for some fetuses to die in utero.
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Sheva Reply:
September 12th, 2010 at 9:14 am (Quote)
What about someone like my client, whose cycles are about 43 days long? Her official due date was at 40 weeks from her LMP, but since she ovulated (and she was checking) 2 weeks later than the wheel allows for, her actual due date was at 42 weeks from her LMP.
To push her for an ‘elective’ delivery on her ‘due date’ would be pushing her to take her baby out 2 weeks before it was ready.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 9:27 am (Quote)
Your comment illustrates why menstrual dating of pregnancies is so problematic. It is often off by many days and sometimes weeks. An early ultrasound can date a pregnancy to an accuracy of 4-5 days.
I would also be surprised if any woman had a consistent cycle that was 43 days long. That would be very unusual. It is more likely that she has oligoovulation and is not ovulating on a regular basis at all.
There is no data to suggest that we should electively deliver on the ‘due date’, no matter how that date was determined. Large randomized trials have shown that elective induction at 41 weeks does not increase the rate of cesarean delivery. Large sets also show a rate of fetal death of 0.5/1000 in singletons between 41 and 42 weeks, and 1.6/1000 from 42-43 weeks. These are small risks, but when they hit they are completely avoidable tragedies.
Your comment underlies a believe that labor necessarily happens ‘when the baby is ready’, which is clearly not true. Many women fail to go into labor until long after fetal maturity is established, and many women labor long before the baby is mature. If it is accepted that pre-term labor is a pathologic process that puts the infant at risk, why is it hard to accept that failure to enter labor is similar?
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Dreamy Reply:
September 12th, 2010 at 11:18 am (Quote)
Your comment underlies a believe that labor necessarily happens ‘when the baby is ready’, which is clearly not true.
It bothers me that so many people who eschew (or are “skeptical” of) NCB, homebirth, etc., project such naive, absolutist attitudes upon those who support it.
With all due respect– because I think many of your points are well-reasoned– it seems to me that you are the one who is making statements of absolutes, not Sheva. To believe that a process usually works a certain way does not mean that one believes it ALWAYS works that way.
Of course there are pathological issues with pregnancy and birth, as there are with any bodily process. What I hear from most NCB advocates is that the process is not inherently or even frequently pathological, when not subjected to non-evidence-based (or litigation-avoiding) interventions.
I’ve just been feeling frustrated by this topsy-turvy picture that’s being painted of NCB advocates… It’s not to say that there exist NO NCBers that are “True Believers” and irrationally reject anything that does not align with their world view. Sure, there are a small number, as with any group.
But the way they/we are painted, one would think we believe birth is completely predictable and works out beautifully 99.99% of the time as long as EVIL DOCTORS and SCIENTIFIC EVIDENCE are kept out of the picture.
Time and again, I have literally made statements like “For low-risk women, blah blah usually happens without need for XYZ intervention.” And received responses like, “Oh, so you think that ALL women will ALWAYS have PERFECT outcomes without XYZ?!?! You’re a crazy fanatic!!!! By the way, that’s why EVERY woman should ALWAYS birth in the hospital with XYZ lest she almost certainly DIE!!!!”
Projection, much?
Just because someone believes that a certain course is best for most, does not mean she thinks that course is best for all, or never goes haywire.
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Lucia Reply:
September 12th, 2010 at 6:22 pm (Quote)
There is no data to suggest that we should electively deliver on the ‘due date’, no matter how that date was determined. Large randomized trials have shown that elective induction at 41 weeks does not increase the rate of cesarean delivery. Large sets also show a rate of fetal death of 0.5/1000 in singletons between 41 and 42 weeks, and 1.6/1000 from 42-43 weeks. These are small risks, but when they hit they are completely avoidable tragedies.
Ah but how many of those deaths were babies born via induction or c-section? If you’re looking at date of babies born spontaneously is it the same or are the increased deaths due to induction or c-section. I used to have a link to some statistics from before induction and c-section were the norm and it showed more stillbirths at 38 weeks then at 41 weeks, of course now I can’t find the info *doh*. We do know that the rate of intervention rises greatly after 40 weeks so you have to be careful when looking at that data when determining risk to the baby because you may be compating apples with oranges.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 6:27 pm (Quote)
You misunderstand my point. I am not referring to deaths that occur in labor. These are the rates of intrauterine fetal demise, prior to the onset of labor or induction. They have nothing to do with interventions. If anything, they are for lack of intervention.
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Lucia Reply:
September 12th, 2010 at 6:57 pm (Quote)
Ah Gotcha. I’m curious to know the rates of IUFD at other gestations and what the deaths were attributed to (is it congenital or due to placenta or cord issues?). I’m also curious about the risks of monitoring for these risks and what the false positive rate is, and what the risk of intervening is. Balencing the risks is important. If you section every mother who’s baby looks like they might be in distress, you increase the maternal mortality rates. Do we as mothers value the life of the baby? Absolutely and more so then any other person on the planet, but is the risk of death improved with intervention and also is the risk of death to the mother and baby combined any better? These are very small numbers of deaths we’re talking about. Preventable, maybe but is it worth the cost?
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 9:30 am (Quote)
>>> What about someone like my client, whose cycles are about 43 days long? Her official due date was at 40 weeks from her LMP, but since she ovulated (and she was checking) 2 weeks later than the wheel allows for, her actual due date was at 42 weeks from her LMP.
To elaborate this point – if one is going to not use ultrasound to date a pregnancy, one has a hard time using and hard cutoffs for any actions related to gestational age. This is one of the differences between midwifery practices that do not routinely scan patients and obsetrics / CNM practices. In my opinion, it is advantageous to establish an accurate due date early in a pregnancy, as it may impact what we do later. Without that information, we are flying blind.
When one does have a routine practice of doing first trimester scans, one finds that menstrual dating is often way off.
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Sheva Reply:
September 12th, 2010 at 9:37 am (Quote)
I did not recommend menstrual dating, which, as you say, is often way off. I am recommending dating from conception and/or ovulation, when it is known.
That is a big difference.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 10:00 am (Quote)
How are you measuring exactly when ovulation occurred? Do your clients space out their intercourse to once a month so they always know when conception occurred?
Admittedly snarky
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Robyn Reply:
September 12th, 2010 at 10:11 am (Quote)
Women who chart their cycles by paying attention cervical fluid, cervical position, and basal temperatures are very accurate at determining when they ovulated. There are other tools they can use to corrolate their obvious fertility signs such as ovulation predictor kits, saliva ferning microscope, fertility monitor, and the OvuWatch.
I have very erratic cycles, but since I’ve started using Fertility Awareness as a means of contraceptive I have always been able to pinpoint when I was going to get my period to within a day.
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adrienne Reply:
September 12th, 2010 at 10:45 am (Quote)
This is exactly why I learned fertility awareness, well before I was even sexually active. To pinpoint when my next period would come because without it, I would never know.
I currently menstruate on my 14th high temperature every cycle. this past cycle, the first high temp was day 30! most people would be freaking out and getting a pregnancy test by day 28 but since I knew I was only ovulating at that point, I didn’t bother. Period came right on time, day 43. (Note: for me as of late this is very long. since my last baby I’ve been in the 28-31 day range.)
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Sheva Reply:
September 12th, 2010 at 10:55 am (Quote)
Actually, yes, my client was charting her cycles with these methods and did know her exact date of ovulation. There are also women who experience severe mittleshmertz on the day of ovulation.
And, as to your question about the once a month intercourse, no, they do not limit it to once a month, but most religious Jews do not have sex for at least the first 12 (and sometimes many more) days of their cycle, so they know for sure when they didn’t conceive.
And what about the women whose husbands work out of town, or are on tour, and know for certain when they conceived?
It’s not as uncommon as you think, and the smiley face after a snarky comment doesn’t make it OK.
(PS The snarkiness before wasn’t aimed at one person directly, and in my opinion is therefore not as offensive as your comments that are directly attacking someone personally.)
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 11:00 am (Quote)
You have got to be kidding me. My initial comment was a statement of my opinions in this matter. There was no ‘snark’ whatsoever. Somehow you give a pass to the 15 or so comments that preceded it that sarcastically criticized someone the commenter didn’t even know, as if anything a physician says must be wrong. Unbelievable.
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Melissa Reply:
September 12th, 2010 at 2:28 pm (Quote)
Now I’m just confused. You WROTE: “admittedly snarky.” In other words, you offered your own assessment of your comment, and Sheva agreed with you. She also offered her assessment, that labeling your comment in such a way does not make it less “snarky.” Sheva also offered a very specific example of a woman’s cycle, and that particular set of data was what you were responding to with such a dismissive attitude. Sheva then shared her evaluation as to the relative values of “snark” in her responses and yours, explaining that she felt her responses were less offensive because she was aiming her frustration at a status quo rather than at any one particular person, while you on the other hand dismissed and ridiculed a woman in particular (the woman whose cycle Sheva reported on).
Perhaps you misread/misinterpreted? I’d like to think so, as it’s really helpful and interesting to have doctors chime in on MYBSW.
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Nicholas Fogelson Reply:
September 12th, 2010 at 3:23 pm (Quote)
It is my impression that I was accused of being snarky just because I expressed an opinion contrary to the ongoing dialogue going on at that time. And in reviewing the history of the comments… I WAS.
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Jessers Reply:
September 12th, 2010 at 5:42 pm (Quote)
It is your BELIEF. Too bad the FACTS are different, doc.
-Fertility web-community administrator of 3 years and 360 users-
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 5:58 pm (Quote)
feel free to check the timestamps
Melissa Reply:
May 22nd, 2011 at 10:04 am (Quote)
I did check the time stamps…
your “Admittedly snarky ” comment came at 10am. Then Sheva’s “the smiley face after a snarky comment doesn’t make it OK” came at 10:55. It was your 10am comment as listed above to which she was replying. You wrote a lot of replies to many different posters in a relatively short period of time; certainly understandable that you might be confused about Sheva’s response to your comment.
My summation is accurate.
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Nicholas Fogelson Reply:
September 12th, 2010 at 3:30 pm (Quote)
As for all these methods for dating the pregnancy, its my belief that none of these are going to be as accurate as an early scan. Furthermore, given that people often don’t deliver on their due date, anybody thinks that X method for dating a pregnancy is always accurate, without early ultrasound confirmation, is really just assuming they are correct without any real feedback to confirm that this it is so.
I have seen many many patients who believed that they had their date of conception nailed down based on any number of systems be surprised when the early ultrasound showed them that there were significantly off.
As so many folks here like to say “show me the paper!” I challenge somebody to show me the paper that shows that any particular system of dating a pregnancy achieves a similar reliability to an early ultrasound.
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Susan Reply:
September 12th, 2010 at 11:10 pm (Quote)
First off, I appreciate your input. I have no data on the accuracy of the Billings Ovulation Method in dating pregnancy, per se, but there have been many hormone studies conducted showing the accuracy of that Method in identifying ovulation, and if the woman knows when that is, then she can more accurately pinpoint conception (within a window, of course). Here is one such study: http://www.ncbi.nlm.nih.gov/pubmed/12201328
I believe you that you have patients coming in sure of their dates who turn out to be incorrect. Sometimes women aren’t as confident in the system of charting they are using, or aren’t charting in a consistent manner, and thus misread the chart. That happened to me when I first started charting. I was sure I’d ovulated, then second-guessed myself and decided I hadn’t, and so was a month off on my dates with that pregnancy. However, an experienced BOM user or instructor wouldn’t have made that mistake. While it is easy to use, it does take some time to develop confidence.
All the best,
Susan
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Susan Reply:
September 12th, 2010 at 11:42 pm (Quote)
Oh, to clarify, the reason I second-guessed myself was because I was thrown off by the heavier breakthrough bleeding just prior to ovulation, and wasn’t sure I’d actually be fertile that soon after coming off the pill, having been on the pill for something like 7 years prior to that. Now if I had a client show me a chart like that, I’d be immediately tipped off. (I’m now a Billings instructor).
Serene Reply:
September 13th, 2010 at 4:51 am (Quote)
OK doc,
When I was pregnant with my son, I was consistently told I was 2-3 weeks ahead of where I was, because my menstrual cycle is 35 days with late ovulation. I told them repeatedly when conception was, and the midwife even tried to have my due date adjusted accordingly. My own calculations put my EDD as Feb 11-14, but theirs, from the scan and my LMP (april 20) gave them January 26th. According to their scans, conception occurred Conception Occurred : Wednesday, May 5. But I was not in contact with my BF at the time, he was not even in the same state.
This is according to http://www.medcalc.com/pregnancy.html and I KNOW it is wrong. Would you like to know HOW I know its wrong? I know its wrong because the first and ONLY time I sad intercourse up until I slept with the man I am married to, is the time I fell pregnant. It was not until May 19th. I remember this because it was my brothers birthday. Would you like to tell us AGAIN that a dating scan is more accurate?
Tell me doc, how is it “more accurate”?
I had a fall on Jan 23, and on jan 24 had a baby boy with breathing difficulties because (their words, not mine) “he was still premature”. But my THEIR dates, he was just on time, so they refused to stop my labour.
I defy you to explain that one to me, and I challenge you to take that back to your practice.
Oh and FYI, I ovulate every month. only have to LOOK at my husband naked and I get preggers.
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Nicholas Fogelson Reply:
September 13th, 2010 at 6:43 am (Quote)
The accuracy of a dating scan depends on when it was done in pregnancy. A scan done in the mid first trimester is quite accurate, to 4-5 days at worst. If one waits until 18-20 weeks to do a scan the accuracy is no better than 10 days.
Ya’ll have to remember that due dates are estimates. An early scan is a very accurate way to establish that date, but its still an estimate, since human pregnancies can deliver +- several weeks of the accurate “due date”.
Every 6 week fetus is the same length (to a few mm or so), so when we measure the fetus at that GA we are dating the pregnancy quite accurately.
Rachel Reply:
November 19th, 2010 at 3:43 am (Quote)
I’m pretty sure I conceived because of sex I had the early morning of March 24, 2010. 38 Weeks from fertilization would put me at December 15th. I wasn’t sure what the first day of my last period was (I’m thinking about 10 days before that). So based on my guess I had EDD’s of 12/18 and 12/20 (thank goodness Kaiser is using the latter). However, an ultrasound at about 9 weeks (or 7 weeks after the “event”) gave me a due date of 12/15 (again, this is EXACTLY 38 weeks from the event that I believe led to conception, either that day or shortly after, since sperm can live a while). Turns out I’m having a boy, so I likely conceived sooner, rather than later, from said event, since Y sperm swim fast and die young. Soooooo, I know when I conceived and the first trimester ultrasound confirmed it.
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Elizabeth Reply:
May 21st, 2011 at 7:52 am (Quote)
There is a problem with that though. Ultrasounds have had no real safety tests when it comes to using them on pregnant women. In fact as of right now ultrasound is being tested as a possible male birth control. A 15 minute shot of ultrasound strait to the testical’s will render a man infertile for 6 months. So what on earth is it going to do to a newly gestating baby after a 30 minute ultrasound? Most likely its causing cellular damage that will last a lifetime. So to help prevent this alot of women are turning down ultrasound or only getting one scan done after 20 weeks gestation. So the only way you can really determine how many weeks the baby is is in fact by studying the patient’s menstrual cycle. Besides that fact America has extremely poor maternal/infant outcomes for a 1st world country. The countries that have the best outcomes ie. Argentina and the Netherlands do not have anywhere near the amount of routine intervention that America does and only a small percent of their babies are born in a hospital and the c-section rate is almost nothing and most of the babies there are delivered by midwives or their own fathers. So your going to tell me that “WE’RE” as in American OBGYN’s and doctors are improving the birthrate here when according to the FBI website we clearly have worse rates then even some 3rd world countries and the countries that have the best rates have almost no intervention and the majority of the babies born are delivered at home with no intervention and no doctors. That simple fact tells me that as a woman I know more about my body and what its capable of then you ever will be and that almost everything that is considered standard here and thought to be improving outcomes really isn’t and its all so doctors such as yourself can apply a fast food routine to delivering babies so you can get a bigger paycheck and not have to work as much. Which if you let womens bodies do what they were built to do all you would really have to do is keep an eye on the mother and make sure she had enough to eat and drink so she would be strong enough to push. Which is another topic that grates me and I am not going to get into right now.
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Nicholas Fogelson, MD Reply:
May 21st, 2011 at 8:07 am (Quote)
This is just utter nonsense.
Ultrasound is quite accurate at determining gestational age, and poses no risk to the baby. It can be produced at a wide variety of power levels, and at the level used for diagnosis has no impact on the baby. A laser can be used to make a fun little red spot on the wall, just as one can be used to burn a hole in the same wall. Its all a matter of focus and power (scientific concepts)
Paris Reply:
May 21st, 2011 at 10:03 am (Quote)
Dr. F, here’s a study for you though I’m sure you’ll discount it as it doesn’t agree with your religion. For those interested in some research though, here you go! http://www.telegraph.co.uk/news/uknews/1364783/Ultrasound-scans-linked-to-brain-damage-in-babies.html
Jade Reply:
August 17th, 2011 at 7:54 am (Quote)
Ok, So as I explained above, I had an early scan with both of my children (the due dates produced from those scans coincided with the dates I had already worked out) both were NSVD. My son was born at 37+5 and after he was born had a number of issues associated with prematurity. The hospital thought that perhaps my dates were wrong (remembering that those dates were based on an early (5 or 6 weeks) scan) I didn’t think much of this, until….
my daughter was born at 43+5. She showed no signs of post maturity, her placenta was not deteriorating and she was till covered in lanugo and vernix. How can this be explained, i am genuinely curious.
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Jane Reply:
September 12th, 2010 at 10:59 am (Quote)
My cycles used to average 36 days, and I pinpointed ovulation based on daily cervical mucus observations, cervical position observations, and daily temperatures. When I experienced a temperature rise, a egg-white type cervical mucus that dried up, and a change in cervix position, I knew I had ovulated. Based on that, I would come up with a due-date which was always later than my OB practice wanted to use, and yet which was accurate with the ultrasound *and* exactly the day on which my baby came.
When I changed over to midwives, they calculated my due-date based on when my charts said I ovulated, not based on the little wheel of LMP.
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sara Reply:
September 12th, 2010 at 6:27 pm (Quote)
Does anyone actually remember when their last missed period was, anyway? I was charting and still didn’t know! I mean, it was “missed”, right? I know my memory stinks, but surely others have noticed the same thing?
With my pregnancy I never told them LMP because I just didn’t know. I was charting though and knew within 3 days conception, so I just used that every time. I knew that since I had 35 day cycles I’d be off anyway. As it was, using my date, my daughter was also born within 5 hours of her ‘due date’
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Jane Reply:
September 12th, 2010 at 6:35 pm (Quote)
One nurse at the OB practice could NOT get it through her head that I ovulate late, so I didn’t bother noting the LMP and just gave her the ovulation date. Finally I took the wheel from her, dialed it to the correct due-date, and then told her the LMP it was pointing to when I did it that way. Yes, I lied through my teeth. But she accepted it.
When I changed to a midwifery practice, the midwife’s hair stood on end. “Wait! If your cycles are ordinarily that long–” and I had to explain what I’d done. The midwife LAUGHED and then corrected the records.
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Kate, Ren's Mom Reply:
September 12th, 2010 at 7:03 pm (Quote)
Dr. Fogelson, I am disappointed in you. Until this point, I felt this was a interesting and civil discussion between opposing sides of an issue; but your statement about how could one measure when a women ovulated belies your ignorance and condescension. I know many women, including myself, who know EXACTLY when we ovulate because we are in tune with our bodies. The signals may differ from one woman to the next, and admittedly some women have more difficulty telling than others, but for many women the signs of ovulation are crystal clear. The supposition that a woman can’t possibly be trusted to tell when she has ovulated and the ONLY way to tell accurately is via ultrasound is just the sort of skewed thinking that equates pregnant women with the irrational, emotional, wrong and dirty, while technology is clean, correct and rational. And that’s the kind of thinking that makes me want to birth at home, where I am respected.
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Erica Reply:
August 17th, 2011 at 8:06 am (Quote)
Even if you limited intercourse to once a month you would still not know the date of conception. Fertilization can happen up to five days after intercourse.
The only way to know such a thing is to daily chart basal body temperature (also charting cervical changes can add to accuracy.) Doing so allows you to monitor the key hormonal changes that signal ovulation has/will take place sometime within 24 hrs. No one can conceive until they ovulate! Once released, the egg is then viable for 24 hours. Therefore, by charting, you can know when you conceived (even if you had sex every day of your cycle) +/- 24 hours–based on the date of ovulation itself. This is MORE accurate than an early scan!
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 10:04 am (Quote)
But to address your earlier question, I suppose if you feel like you have the true date nailed down more accurately than the menstrual dating, then I would use the due date you think is more correct. I can’t say I have great expertise in how we should date people in the absence of ultrasonography.
I tend to think that the belief that we can date pregnancies with great accuracy without scans is a self-fulfilling idea. Pregnancies don’t all deliver on their due date, even when it is established very accurately.
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Susan Reply:
September 12th, 2010 at 11:46 am (Quote)
“Pregnancies don’t all deliver on their due date, even when it is established very accurately.”
Very true. I know with my second pregnancy the person doing the scan told me it could be off by 5-6 days (the scan was between 11 and 12 weeks), and it was off of my dates by 6 days. I chart with the Billings Ovulation Method, so I knew when my Peak was, and thus could narrow down conception to a 3-day window (ovulation usually occurs on Peak day as identified on the chart, but sometimes up to 2 days later, then allow 24 hours for life of the ovum). Of course, Billings itself says to calculate the due date as 266 days +/- 6 days past Peak, so their date was still within that time frame. I personally prefer using my dates, just so that I don’t get the induction talk if their dates are earlier than mine (as they were with my second pregnancy). Of course, had it come to that, where maybe they thought I was 41 weeks, and I was actually 40, I’m sure I would’ve talked to them about my dates more. *shrug* (Oh, and using LMP was right out, since I’d been having quite long cycles as I was still breastfeeding). I’ll also admit to being biased since I’m an instructor for Billings. 
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Liv Reply:
September 13th, 2010 at 1:47 pm (Quote)
Hi Dr. Fogelson, appreciate your comments.
In an earlier post, you said “every six week fetus is the same length.”
Can you explain how the standards were derived? How was it established that the fetuses being measured were all six weeks?
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Crystal Reply:
June 27th, 2012 at 7:11 pm (Quote)
How can all six week fetuses be the same length? When all newborns are not the same length, all six month old babies are not the same length, all 35 year old males are not the same length? Does human variation only begin at 6 weeks and how ever did someone discover this? I’d like a citation on that one please.
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Jamie Reply:
October 12th, 2010 at 3:17 pm (Quote)
Here’s a scenario for ya, Dr. Fogelson.
My second baby was born, according to at least one of my dates (a range of 3-5 days) at 40w4d.
I have long cycles, but they are reliably 35 days. My husband and I don’t have lots of opportunity for intimacy, and we were trying, so I was quite sure of our possible conception date.
I tested positive just under two weeks *after* that date, when I wasn’t quite ‘late’ yet.
Through dates (adjusted for my long cycle) and a single scan (I thought I had an early one, but in retrospect, just at 20wks), I went past 40wks.
My baby was born, spontaneously, *covered* in vernix and lanugo. He had no difficulties breathing, but weighed only 6.5lbs (at 20in long). His brother had been a week later (from a precious early scan) and exactly one pound heavier (same length).
If my dates were off, I only could have been farther along, right? Is it possible that his lungs might not have been ready a week earlier?
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Louisa Reply:
September 12th, 2010 at 9:41 pm (Quote)
Yow, can you hear an echo, the hole you are digging is getting deeper……. Now …
<<<<>>
That, buster, is the whole point. Not having a hard & fast cut off time, letting mum GIP. Especially when new articles out in the last fortnight show that 50% of first time mums who are induced end up with a c/s (someone pls provide the link, I can’t find it just now) And another study came out and said that more patience was needed by both patients & care providers to decrease the rate of interventions & eventually c/s.
Your turn, no doubt you still haven’t figured out when to quit.
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Krista Reply:
September 13th, 2010 at 9:26 pm (Quote)
I think these are the links you are looking for.
http://www.nlm.nih.gov/medlineplus/news/fullstory_100234.html
http://www.latimes.com/health/boostershots/la-heb-cesarean-20100830,0,7690846.story?track=rss
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Sheva Reply:
September 12th, 2010 at 9:29 am (Quote)
Also, according to AJOG, Volume 176 Issue 6, twins do not have an accelerated maturation compared with singleton infants at the same gestational age. On what research do you base your statement?
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Nicholas Fogelson, mD Reply:
September 12th, 2010 at 9:34 am (Quote)
I’m not sure what data you are referring to, as you have cited an entire magazine, not an article.
One question is how we are defining pulmonary maturity. Are we using lab values like TDX and PG or just looking at rates of RDS upon delivery? If the latter, which makes the most sense as we do not amnio the majority of twins pregnancies for maturity, twins do show a decreased rate of RDS at matched gestational ages.
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Sheva Reply:
September 12th, 2010 at 9:37 am (Quote)
American Journal of Obstetrics & Gynecology
Volume 176, Issue 6 , Pages 1193-1199, June 1997
http://www.ajog.org/article/S0002-9378%2897%2970334-X/abstract
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 9:56 am (Quote)
Thanks for the reference. Previous work has shown an advancement in pulmonary maturity for twins vs singletons based on LS and TDX levels (Winn et al).
The mean gestational age in this study was 31 weeks, with over 95% of patients being less than 33 weeks. One could interpret these data as saying that twins do not have better outcomes. Alternatively, one could say that the effects of prematurity, a clear risk factor for pulmonary difficulties, outweighs the twins benefit documented in previous work.
A 30 weeker is going to have lung issues, twins or not, and likely a 32 weeker as well.
We recommend delivering twins two weeks before their due date because of a lack of noted pulmonary issues at that gestational age, and the increasing rate of IUFD as the pregnancy continues.
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JeanB Reply:
September 12th, 2010 at 12:39 pm (Quote)
Just wanted to say thanks for your interesting and insightful comments! I see that you are getting piled on a lot here, so I wanted to note that some of us do appreciate your notes.
I think that this community is so used to really antagonistic trolls and doctors like Dr. Amy showing up to denounce every single thing that the natural childbirth community thinks, so we can be very defensive when an MD shows up. I appreciate you showing up with an understanding perspective and interesting data.
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Dreamy Reply:
September 12th, 2010 at 1:38 pm (Quote)
Speaking for myself, it’s not just defensiveness, it’s finally having the (online) ear of someone with an MD after his name.
I appreciate his notes, but I also don’t completely agree with all of them, or where they’re coming from, if that makes sense.
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mamamor Reply:
September 12th, 2010 at 9:32 am (Quote)
Maybe when you’ve passed your snarkiness urges, you can explain: how pulmonary maturity 2 weeks earlier than singletons explains why twins “grow” faster; or why the unstated “rate of intrauterine fetal demise” outweighs the negative effects of “elective delivery.” While you’re at it, try some citations. An MD doesn’t automatically instill faith in your assertions any more than a PhD would, and I still require citations and argumentation from assertions made by professionals with PhDs – and they are required to keep up on current research to keep their jobs.
If you can deliver it all without the snarky dead baby card, I will even add it to my knowledge-stash.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 9:43 am (Quote)
Its fascinating how you deprecate the value of a live baby, and how you think my comment was snarky in comparison to all the comments that preceded it, which were for the most part pure sarcasm.
I’m looking for references to all the comments made by previous writers. Not there either..
If you don’t think that having spent years in medical school, residency, and academic practice gives one some license to quote the literature without referencing everything I write, that’s a problem for you not me. If people don’t want to trust, that’s fine. When I’m in my office I don’t cite papers every time I counsel a patient either, unless they specifically ask.
I don’t have the rate of fetal death for gestational age reference off the top of my head, but its in both Gabbe and Williams.
As for the negative effects of elective delivery, what are those exactly? Awaiting labor after a well dated 41 week pregnancy takes on risk to the fetus, and does not improve cesarean rates. Clearly folks can do what they like, and should make their decisions based on the best data they can get. I have had many patients go past 41 weeks, and they generally do fine. The risk is very small, so if a woman sees a personal benefit in continuing the pregnancy, that’s fine. Fetal testing likely decreases the rate of IUFD in those situations.
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Robyn Reply:
September 12th, 2010 at 10:38 am (Quote)
I do believe her “snarkiness” comment was in regard to your admitted snarkiness in the previous comment about women actually knowing when they conceived without having an early ultrasound for dating.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 10:48 am (Quote)
Nope – her claim of snarkiness preceded that.
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mamamor Reply:
September 13th, 2010 at 9:27 am (Quote)
When I read your statement, I interpreted it as being glib. I substituted the term snarky for glib because I thought the more casual term would be less confrontational – and I see how I was mistaken in that. For what it’s worth, my partner reads your statement as being completely reasonable and in line with how he would expect a doctor to present information. He works in a hospital, and did not experience my hospital birth, so we understand and approach birthing issues very differently. I would like to explain how I interpreted your comment, not to “jump your shit,” as my partner put it, but so that maybe you can see some of a woman’s sensitivities after having gone through the hospital birthing system.
“Twins achieve pulmonary maturity earlier than singletons, typically about 2 weeks ahead on average. Twins at 36 weeks also have the same rate of intrauterine fetal demise as a 41 week singleton, when we recommend elective delivery of singletons.” My internal translator returns: twins can breathe and thus be viable earlier than a single baby, while they begin to be likely to experience IUFD at an earlier date (36 weeks), so they require and are fit for an earlier delivery. The suggested date for induction is thus earlier (36 weeks?) for twins than for single babies (41 weeks); effectively twins experience the problems associated with post-dates babies (which are you give in another comment) at this earlier time.
My concern here is ultimately that, while you present the reasons FOR an elective induction, you do not include, and thus seemingly dismiss, the potential risks of induction. You responded: “As for the negative effects of elective delivery, what are those exactly?” Perhaps I should have referred to what I consider the “negative effects” of induction as these “potential risks” instead; it seems they are so common as to be routine, and thus lose their potentiality and become given. Your statement that waiting beyond 41 weeks “does not improve cesarean rates” tells me that there is something to be improved, although not what. So while most people acknowledge that cesarean rates are too high, and need improvement, your focus on the risk to the fetus seems to downplay the risk of cesarean. I appreciate your follow up that generally patients do fine after 41 weeks. There just seems to be a pattern that doctors often follow: mention fetal risks in detail; in passing, mention risks of intervention, but not in detail; and follow up with reassurance that it will probably be okay. While on its face such a statement seems not to be problematic, when so many doctors use this tactic to achieve a particular, desired result and pair this tactic with a general lack of information about potential outcomes and alternatives, then I take issue with the statement as it seems manipulative. It is probably NOT intentional, but seems part of the medical rhetoric that so regularly has the outcome of routine induction, cesarean, etc.
What really got to me, and what I interpreted as snarky, or glib, was your last paragraph, most specifically that: “Maybe its [sic] natural for some pregnancies to last that long, but it is also natural for some fetuses to die in utero.” This is what I was referring to as the “dead baby card,” which if you would peruse this site you would see refers to doctors’ tendency to try to persuade a mother to do procedure x by threatening her with a dead baby if she does not comply. Roughly, ‘Do this or your baby will die.’ In this case, ‘If you go beyond 41 weeks, your baby will die.’ Generally, the “dead baby card” is NOT accompanied by all relevant information, is misleading, or an outright lie. The single quotation mark above suggests that I am paraphrasing. I realize that is not, verbatim, what you wrote (and it’s not so much misleading as it is glib). I inferred that because of your promotion of elective delivery and the way that the statement was used to reinforce that assertion.
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mamamor Reply:
September 13th, 2010 at 9:52 am (Quote)
Okay, no more typing for awhile after this. Just wanted to say, in the spirit of what I hope you can tell is diplomacy, I did catch the attempt at lighthearted response with the “admittedly snarky” smiley. Sorry the ordering makes it hard to follow, but I appreciated the humor. And I will repeat the assertion that it would be awesome to have MDs on here, *so long as the dialog is all in good faith.
So… good natured high five?
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Sheva Reply:
September 12th, 2010 at 10:59 am (Quote)
Where in her comment was she devaluing the life of a baby?
She was just requesting that you back up your comment with proof.
Which I think is taking her life and the life of her baby very seriously, considering the vast amounts of false information that pregnant mothers often get (and as a result have to be extra careful to weed out the junk).
Having ABCs after your name doesn’t automatically entitle you to respect. You have to earn it, same as everyone else.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 11:12 am (Quote)
Where in her comment was she devaluing the life of a baby?
Where she claims that quoting real statistics on fetal demise is “playing the dead baby card”
>> Having ABCs after your name doesn’t automatically entitle you to respect. You have to earn it, same as everyone else.
Right. Around here it entitles one to disrespect, given that this is the general point of the website.
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Sheva Reply:
September 12th, 2010 at 11:21 am (Quote)
No, it does not entitle on to anything.
There are many awesome doctors out there, and I can list many. (My midwive’s backup, my children’s pediatrician, my own GP, to name a few.) But all of them earned my respect with common decency, respect for me as a person, not just an anonymous organism, and competent, evidence based care that never endangered my life or that of my children, or made me feel as if they might.
Things the docs quoted on this site don’t do, at least not for the patient who quoted them.
So in my personal opinion, that entitles them to a bit of fairly earned disrespect.
And if you treat your patients with respect due to them simply for being human (which it sounds like you do), I’m sure you get the same from them, and you deserve it, too.
In every profession there will be some people who are an embarrassment to the rest. And it’s not fair for the good ones to team up and support the bad ones, just because they share the same profession. It should be every man for himself.
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Louisa Reply:
September 13th, 2010 at 2:32 am (Quote)
Firstly Dr, here is your olive branch, I am sorry if I offended you in any way shape or form with my earlier comments.
However, the purpose of this site (I can not speak for the creators as I am not one of them but I think I get the gist of it) is not to disrespect your profession, it is to show how your professional peers have disrespected women. I am sure if you just did a few random scrolls through any of the categories listed, you would even raise your eyebrows at some of the lies & untruths told to women by your peers who have gone through med school, residency etc etc of your quote, I can’t find it now. People who (what was it) can “tell absolutes” is that how you put it? Some are absolute garbage.
I think this site allows women to see that they are not alone, not stupid to have believed lies, to share information & stories, share research and give shoulders to cry on. But above all, it is to educate women to educate themselves
We do hope you stick around for future posts but might I make a suggestion, just reword your comments, the OPs on her have been smacked around enough just to get here without it happening here as well.
Cheers
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Kit Reply:
September 13th, 2010 at 4:33 pm (Quote)
Adding to the list of awesome doctors I know: My own OB/GYN (who has only doen the GYN part for me so far) but delivered both of my god-children, and claims he recently delivered his “third generation” (The grand-daughter of a woman he delivered.) He is strangely amused by this, but claims that his first “fourth gen” might make him feel a bit old. He’s also the only GYN I know who believes me when I tell him I am 22 and still a virgin. I am tired of doctors who snear at me when I tell them that.
The OB who my aunt went to, who kicks out anyone who is stressing out the laboring moms he cares for because (an exact quote) “Birth is scary, and is she’s freaking out, i might have to DO SOMETHING. Doing something is the LAST thing I want to do.”
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Paris Reply:
May 21st, 2011 at 10:09 am (Quote)
Repeating asinine things that medical professionals say to women = disrespect? Wow, somebody’s thin skinned. If there was a site called My Car Mechanic Said What!?! and it was stupid things that mechanics say I bet you wouldn’t be jumping all over the posters there. Play your boo hoo card elsewhere. If Doctors didn’t set themselves up as God and get drunk with power, there wouldn’t be a need for places like this.
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Lindsey Reply:
September 12th, 2010 at 9:38 am (Quote)
“Twins achieve pulmonary maturity earlier than singletons,typically about 2 weeks ahead on average.”
That’s a very different statement than “…because they grow faster.”
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 9:45 am (Quote)
This it true, but we don’t know the context of the statement, like most comments on this site. They don’t physically grow faster.
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Dreamy Reply:
September 12th, 2010 at 10:58 am (Quote)
No baby needs 43 weeks to mature. Waiting until 43 weeks to deliver a singleton accepts a 1-3/1000 risk of intrauterine fetal demise, without a decrease in cesarean rates. Maybe its natural for some pregnancies to last that long, but it is also natural for some fetuses to die in utero.
This is such a weird statement to make. If you mean “No 43-week baby (IF accurately dated– as many are not) would have died BECAUSE he/she came at 42 weeks instead”… Well, yes, I guess– if you change “No baby” to “Almost no baby.” And I do understand that C/S rates don’t necessarily increase ON AVERAGE when you induce after 42 weeks. But that doesn’t mean:
-No baby induced at 42 weeks will come out with any pre-dates issues.
-No baby induced at 42 weeks will end up with a C/S for a failed induction.
-As stated earlier, that the slightly increased risk of demise (which is still only correlated, not demonstrably causative), would DEFINITELY outweigh the inherent morbidity (and slightly– though less– increased risk of mortality) of the interventions used to get the baby out at 42 weeks (or whatever).
This is such a tiny, tiny sample size anyway– how many women go to 43 weeks nowadays? Even in the past, pre-modern-induction-methods-etc., it was statistically uncommon. Again, we’re still really unclear on the correlation vs. causation issue for this tiny group. Not to mention that the lack of a difference in C/S rates when C/S rates are so artificially inflated now… It’s really difficult to make a statement like “No baby ever…” and I’m surprised to hear it coming from a scientist, especially about an area of medicine naturally severely lacking in double-blind studies, etc.
Well, I’m not surprised, really… But it’s something my own mother, who has an MD herself, would be highly unlikely to assert. So I guess I’ve been sheltered.
I’m also a bit put off by your semantic comparison– “Some babies might take that long, but some babies die.” As if “some” and “some” were equivalent, or as if there were even reliable stats on the first “some.”
All this from a woman who would absolutely consider various induction methods at 42 weeks, but who doesn’t appreciate the absolutism and slippery-slope implications of your statements.
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Nicholas Fogelson Reply:
September 12th, 2010 at 12:13 pm (Quote)
You are right that my statements are based on averages of large groups of women. We cannot predict what will happen with any individual, or assign blame to any particular intervention or non-intervention for that outcome. Only through large groups and statistical analysis can we prove such relationships.
But the original statement is still correct. Human fetuses achieve pulmonary maturity by 40 weeks on a consistent basis. No baby needs 43 weeks to be ready to come out. That’s as close to an absolute as you can get.
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Jane Reply:
September 12th, 2010 at 11:04 am (Quote)
What’s the mechanism that causes twins to have lung maturity sooner?
It honestly wouldn’t surprise me if a woman’s body “knew” it had to prepare the babies for delivery sooner. I’ve come to respect that my body seems to know a lot more than I do. So if there’s some mechanism at work such as “Twins secrete more of XYZ hormone, and the doubling of that hormone reaches a threshold that signals their lungs to begin maturing approximately two weeks earlier than a singleton would…” then that’s cool. It shows that our bodies are working right.
But the idea that two babies grow faster than one is a little simplistic.
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Nicholas Fogelson, MD Reply:
September 12th, 2010 at 11:14 am (Quote)
Kind of a deus ex machina explanation for a physiologic process. As for exactly why, I don’t know. The idea that anybody’s body knows anything is outside of my view of human physiology. We are very complex machines, full of tiny little molecules that physically interact with each other based on shape and charge.
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Jane Reply:
September 12th, 2010 at 11:19 am (Quote)
I’ve had five full-term pregnancies. The only pregnancy in which I could not gain any weight at all for the first 24 weeks was the pregnancy in which the baby had anencephaly. I believe my body “knew” I didn’t need that layer of fat for producing milk afterward. Surely there was a molecular/hormonal trigger, but the result is my body “knew” before I did. (I put on weight in the next 18 weeks.)
But in the absence of an explanation why twins would mature faster, it sounds more like wishful thinking on the part of the mother, or pressure on the part of the doctor to induce or section her early.
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Nicholas Fogelson Reply:
September 12th, 2010 at 12:05 pm (Quote)
There are a zillion things that we don’t know about how the body (and the universe) works. Some choose to fill those areas of ignorance with some idea that our body “knows” something. In my universal view, everything that happens in the universe does follow physical rules, but we don’t know all those rules. Our lack of knowledge of some areas of the universe does not require that one fill that space with a supernatural idea.
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Jane Reply:
September 12th, 2010 at 12:09 pm (Quote)
And instead of calling it bodily wisdom, some of us fill those areas of ignorance by saying we don’t yet know the rules.
My point was: WHAT IS THE MECHANISM? I asked about hormonal triggers and such. Since your point is that the body doesn’t know anything–which is fine, it probably doesn’t even though it’s clearly responding to some mechanism–then what is the mechanism that “tells” fetal twins to begin the process of lung maturation sooner than singletons?
Because unless you know that, really you’re only telling me the obstetric version of “The body knows what it’s doing.” You’re using bigger words but it’s the same empty concoction.
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Medical Student Reply:
September 12th, 2010 at 2:24 pm (Quote)
I think you’re moving the goalposts here a bit – a mechanism is useful information but not necessary in the face of reasonable clinical data to make a decision about care.
Why do ACE-inhibitors seem to reduce the harmful remodeling of the heart muscle that occurs after a heart attack? We don’t know, but by your argument a doctor must have ulterior motives (such as “wants to induce her early” in your example) in ordering it for a patient despite plenty of published evidence that it does reduce remodeling.
Secondly, his “the body works according to physiological rules” is vastly different from your “the body knows what it is doing” – the implication in your phrase being that the physiological response of the body is always beneficial when it is obviously not always the case.
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Jane Reply:
September 12th, 2010 at 5:15 pm (Quote)
I think whether the body knows what it’s doing and reacts to the presence of twice as much of a certain fetal hormone (or whatever) by triggering lung maturation faster, or whether it “just happens” is a semantic difference. What I’m asserting is that if there’s really a reason twins begin to mature faster, it’s happened by evolution or by outside design to help the twins survive a potential earlier birth. You can say evolution and I can say design, and there’s no big difference.
But if there’s no reason for this, no data to support it, then a mom has the right to be suspicious of ulterior motives. Many of the women who visit this site do so because we’ve been lied to by doctors. I was told by one doctor that just because I felt the baby kicking didn’t mean the baby was actually alive. No, really–she said this with a straight face. Please pardon me for asking all doctors since then to back up what they’re saying.
I’m not asserting that the human body is a flawless machine that always works perfectly. But many times, healthy systems DO work in order to meet normal needs within a certain tolerance. Pregnant women sometimes crave a food that contains a nutrient their body needed, even though they didn’t know they needed it. That’s a “bodily wisdom” it pays to listen to, and it’s a no-cost, no-side-effect listening. And if a woman’s body does something to trigger lung maturation in twins to prepare them for an early delivery, then I have to say that’s wise. Whether it happened by accident or by design, that’s a good thing.
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Nicholas Fogelson Reply:
September 12th, 2010 at 2:43 pm (Quote)
OK
So
“the body knows” is approximately equal to “we don’t understand the mechanism yet”
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laura Reply:
September 12th, 2010 at 11:33 am (Quote)
Dr. F, I really do appreciate your thoughtful and knowledgeable comments, and I hope you give some of the shoutier folks a little slack and keep coming back here. It’s great to know that there are still good docs out there.
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crunchymommy Reply:
September 12th, 2010 at 9:41 pm (Quote)
I want to chime in and also thank you, Dr. Fogelson. I found the information you shared helpful.
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Monika Reply:
September 16th, 2010 at 7:32 pm (Quote)
I don’t know if it affects twin pregnancies, but when I was preparing myself for a potential preterm previa baby I read a study talking about how some things which were known to cause preterm babies, like preeclampsia, also caused the babies lungs to be statistically more mature than the average preterm baby at that gestational age…their theory was, IIRC, that the cortisol of the stressed pregnancy caused the earlier lung maturity and the normalcy of the pregnancy until the bleeding from the previa did not cause a matching early lung maturity.
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Janice Reply:
November 4th, 2010 at 3:14 pm (Quote)
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1160585/
Several studies have focused on the “prospective risk of fetal death” to help determine by which gestational age a multiple pregnancy should be delivered [7,8]. For twins, the prospective risk of fetal death appears to be equivalent to that of post-term singletons at approximately 37 to 38 weeks’ gestation [7,8]. The prospective risk of fetal death for twins intersects with neonatal death at approximately 39 weeks’ gestation, indicating that it may be reasonable to consider delivery of uncomplicated twins prior to 40 weeks’ gestation [8]
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30 weeks pregnant with twin boys right now, I have heard this exact same thing from my doc AND from the crunchy home birth midwife I work for. I have no reason to disbelieve it.
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melanie Reply:
September 12th, 2010 at 9:27 am (Quote)
Ugh. Sorry, it told me this comment didn’t post and ate it. Obviously thats not true, and I can’t seem to delete it.
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Janice Reply:
November 4th, 2010 at 3:27 pm (Quote)
@Melanie
Hope your birth goes well. Your midwife & Ob are not very well read.
Prospective risk of fetal death in singleton, twin, and triplet gestations: implications for practice*1
Bronwen Kahn MDd, L. H. Lumey MDb, Patricia A. Zybert PhDb, John M. Lorenz MDc, Jane Cleary-Goldman MDa, Mary E. D’Alton MDa and Julian N. Robinson MD
Methods
We analyzed 11,061,599 singleton, 297,622 twin, and 15,375 triplet gestations drawn from the 1995–1998 National Center for Health Statistics linked birth and death files. Prospective risk of fetal death was expressed as a proportion of all fetuses still at risk at a given gestational age and compared with fetal death rate. Fetal death risk and neonatal death rates were represented graphically for singletons, twins, and triplets.
Results
The prospective risk of fetal death at 24 weeks was 0.28 per 1000, 0.92 per 1000, and 1.30 per 1000 for singletons, twins, and triplets, respectively. At 40 weeks, the corresponding risk was 0.57 per 1000 and 3.09 per 1000 for singletons and twins, respectively and, at 38 or more weeks, 13.18 per 1000 for triplets. Plots of gestation-specific prospective risk of fetal death and neonatal mortality converged for singletons and twins at term but crossed for triplets at approximately 36 weeks’ gestation.
Conclusion
Prospective risk of fetal death is greater for triplets and twins than for singletons and greater for triplets than for twins during the third trimester. The pattern corroborates with uteroplacental insufficiency as a suspected underlying mechanism. When prospective risk of fetal death exceeds neonatal mortality risk, delivery might be indicated.
When this model is used, this data set suggests that it might be reasonable to consider delivery of twins by 39 weeks
and triplets by 36 weeks to improve perinatal outcome.
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Both my doctor (who backs up midwifes that transfer to the hospital) and the midwife I work for (who does home birth) have told me the same thing. I am 30 weeks pregnant with twin boys, who are measuring in the 50th and 70th percentile. I worry sometimes that just because something does ‘sound’ correct, people fail to research it and just jump on the anti bandwagon. I love home birth because its the safest thing for low risk women (among which I am currently not) and the research proves it. You can be sure I’ve researched the choices we are making for my two baby boys as well. I agree with Dr. Fogelson.
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Lucia Reply:
September 12th, 2010 at 5:28 pm (Quote)
I hope that doesn’t mean you’re planning to have the babies at 36 weeks? The maturity of the babies is a comfort if you happen to go into labor at 36 weeks but It’s absolutely not a reason to plan to have them that early. Twins tend to be born with term maturity at 38 weeks give or take 2 weeks, but that doesn’t actually mean they should be born at that time. There’s nothing unsafe about having twins at 39 or 40 weeks if mom and babies are healthy. There are plenty of variables with multiples that make early birth safer for mom and babies but if it ain’t broke, don’t fix it. My twins were 39w4d when they were born, they had NO feeding issues and were screaming as soon as they hit air. I know plenty of folks who had their sets at 37 weeks and had a tougher time breastfeeding. 40 weeks is 40 weeks no matter how many babies are in there.
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Sarah Dorrance-Minch had this to say,
Sep 12, 2010 @ 1:06 pm (Quote)
Oh, so that’s why they are frequently tiny and wind up in the NICU with respiratory distress after emerging (or being sliced out) too early. Thanks for clearing that up.
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Alyson Miers had this to say,
Sep 12, 2010 @ 1:17 pm (Quote)
I was under the impression that twins more often come out earlier (and I mean obvious prematurity, not just a gray area like 37 weeks) because growing two babies puts a lot more strain on the mother’s body than just one, and sometimes she can’t keep them inside for as long as they need. I didn’t realize that maintaining a twin pregnancy up to 40 weeks might be considered a bad thing.
What happened, OP? Did your OB want you to schedule an induction/C-section at an earlier date than you wanted?
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Hm, the twins I photographed last week were born via elective c-section at 36 weeks and were 4 lbs 3 oz and 5 lbs 5 oz. The little one spent 9 days in the NICU. I, on the other hand was born just shy of 40 weeks and was 7 lbs, while my twin sister was 7 lbs 11 oz. Oh, and we were a VBAC.
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I just had identical twins (monochorionic) and both my perinatologist and very NCB friendly OB recommended a c-section at 37 weeks. I don’t think they would have given the same recommendation for fraternal or dichorionic twins though. With monochorionic twins, the rates of complications from acute TTTS during labor go up, hence the recommendation for a section at 37 weeks.
As it was, my twins were 7 lbs on average and my placenta was definitely showing signs of aging. And though I hoped for a VBAC (my doc said she would support me if I went into labor on my own before 37 wks), I did go with the c-section at 37 wks.
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Lucia Reply:
September 12th, 2010 at 6:46 pm (Quote)
Unless your babies had TTTS it doesn’t sound like you had a NCB friendly Dr. It sounds like you got sectioned on bad info. The risk of TTTS is only 10-15% So while you may have developed it it’s really unlikely to have happened at all. You got pushed into an elective c-section for no reason other then the Dr’s fear. My NCB friendly Midwives and Drs including my perinatologist didn’t reccommend intervening until I was having medical issues or until I was 40 weeks. When I protested the 40 week limit they gave on that too. In the end my health failed and I got pre-e and their position was very unfavorable (breech/vertex) so we did the c-section. My mono/di’s were 39w4d, normal weights, and no sign of ttts (only 3oz difference between the two)
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Holly Reply:
September 12th, 2010 at 11:15 pm (Quote)
You’re right, the risk of TTTS overall is 10-15%, but we were considering the risk of acute TTTS (which can be brought on for the first time in labor with no previous symptoms) rather than chronic (unfortunately not many statistics are available on acute TTTS). And 1-in-10 is a rather high statistic. Pregnant women heat deli meats to steaming because of a bacteria that they have an only 3-in-1,000,000 chance of contracting.
The rate of perinatal death (not just complications) in monochorionic twins after 37 weeks is between 2-6.8% (a more conservative study even said the rate was more like .7%) But the rate of perinatal death for an elective repeat c-section is .13% and I realize that there are other risks and this is just one of the factors, but it is a means of comparison. (I can provide references).
My OB & perinatologist were hoping for a VBAC for me and my OB is known for her high VBAC rate. In fact, she even felt comfortable delivering my vertex/breech babies vaginally (for both!) In the end, I feel very comfortable with my decision because I did my research and was not pushed. Knowing the actual numbers, I just wasn’t willing to take the risk.
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CallumSheaMom Reply:
January 5th, 2011 at 12:21 pm (Quote)
you shouldn’t feel you have to defend your decision in any way! 10-15% is an incredibly high risk when you are talking about your babies’ lives. i am glad everything turned out well for you, and congrats on the birth of your babies!
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I have heard it is SAFE for me to go at 36 weeks, vs. 37 weeks with a singleton, however, I am under no pressure to induce or have a c-section with my identical twins (mono-di)at any point and I am actually expected to go pretty far since I typically have big babies that go 2 weeks over. Then again, it might have something to do with a NCB/HB friendly primary doc, and my HB midwife… (Mind you, I am seeing a perinatologist as well…)
Everyone will be glad the longer I bake these boys…
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Lucia Reply:
September 12th, 2010 at 6:38 pm (Quote)
Sounds like you found a great place to birth. I hope they remain supportive after 38 weeks. Unfortunately not all are. The pressure to c-section started at about 38 weeks at my NCB friendly hospital from the midwifes and backup obs in my midwife practice. Most places consider anything afte 38 weeks to be overdue and with my girls (also Mono-Di) 40 weeks was my cut off according to them (not according to me… the fighting was fierce). Keeping my fingers crossed for a safe and easy pregnancy and birth with your little guys! Twins are so much fun, and watching Identicals grow up together is just miraculous. Congratz.
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Tracy Reply:
September 12th, 2010 at 10:44 pm (Quote)
I have had the same provider for the last 2 pregnancies, both homebirths at 40+ weeks. )I have had 1 hospital and 3 homebirths to this point)
She actually does twin homebirths a few times a year, which midwives in Texas can do as long as a perinatologist checks the pregnancy out and says all looks good. Thus far things are going well. So well that I did not even know I was having twins until the ultrasound at 22 weeks LOL. (I have a son with Down Syndrome so we do an US to check on the heart)
Thanks for the well wishes!!! Glad to know someone else fights for the birth they want with twins instead of giving in to an elective csection.
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Twins have a 60% prematurity rate, but not because they grow faster but because the uterus becomes so dystended that the majority of moms can’t carry to 37 weeks. No matter the gestational age babies born earlier then 37 weeks are still neurologically immature and while they’re statistically more likely to not have breathing problems near term they do still have feeding problems and other issues as any singleton born at the same gestation. I think while some twins are born normal sized, I think statistically they’re smaller not only because of gestation but also because of IUGR, TTTS, placental insufficiency and other risk factors that tend to occur in a twin pregnancy. My twins were born at almost 40 weeks, they were rail thin and with very little fat on them probably due to their shared placenta or placental insufficiency due to pre-e (the drs said they looked preterm but they were neurologically right on for their GE). They were my smallest babies at 6lbs 7oz and 6lbs 10oz.
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Every 6 week fetus is the same length (to a few mm or so), so when we measure the fetus at that GA we are dating the pregnancy quite accurately.
*FAIL*
Apparently you did not read my question.
Again. How is a dating scan more accurate than a woman who KNOWS when she conceived? Especially when her dates are NOT based on the normal 28 day cycle, which the radiographer uses ANYWAY to assess the accuracy of his scan?
Answer me that, Doc.
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trimester
Absolutely agree that due dates are estimates, even when sure of the date of conception or with an early scan. I’d be fine if due dates were given in ranges, like “late March”.
I’ve never had a scan earlier than 11.5 weeks, so I guess it being within 6 days for that pregnancy was pretty good (was within 7 days for the pregnancy where I only had a scan at 21 weeks).
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Nicholas Fogelson Reply:
September 13th, 2010 at 7:39 am (Quote)
Perhaps we should not use the word “due date” at all.
The medical term is “Estimated Date of Delivery” (EDD), which is a better description of what the date actually is.
Historically, it was actually “EDC” or “Estimated Date of Confinement”, based on some misogynistic idea of where women needed to go when they were about to have a baby.
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Nicholas Fogelson, MD had this to say,
Sep 13, 2010 @ 7:19 am (Quote)
Ok – so here’s the basic theory of dating in the OB world.
ultrasounds in the first trimester are accurate to about 5 days
in the second trimester about 10 days
in the third trimester to about 15 days
I say “about” because it depends on the exact gestational age. the programs in the ultrasound machines have nomograms that specify the accuracy of a given scan.
If a patient has a sure LMP or sure ovulatory date or sure date of conception, and it fits within the window of the ultrasound, that date establishes the due date.
If the patient’s date does not fit within the window established by the ultrasound, the ultrasound is more accurate and the ultrasound date will be used.
Many women do provide accurate dates by many different methods. My previous comments are not to say that women do not ever accurately know their dates. However, there are many women who believe they accurately know their dates, who are shown by early ultrasound to be incorrect. If this wasn’t true, we would just date every woman by what they tell us and not even use ultrasound for dating.
And at that, I sign off. this is far afield of the original topic. Nice chatting with you all.
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Jane Reply:
September 13th, 2010 at 8:08 am (Quote)
{If a patient has a sure LMP or sure ovulatory date or sure date of conception, and it fits within the window of the ultrasound, that date establishes the due date.}
In other words, when I walk into your office with a chart that shows definitively (by STM signs) that I ovulated on the 10th, but your machine says I must have conceived on the 3rd, you’re going to believe the machine? And then when I reach your due date for me but I’m nowhere near going into labor, you’re going to recommend induction because you trust the machine more than me?
Please make sure you tell this to all your patients at their first prenatal appointment, just so they know how much you trust technology (and the ultrasound techs).
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Heather Reply:
September 13th, 2010 at 12:17 pm (Quote)
A comment in favor of ultrasound dating–My LMP indicated that I would be due on 9-23-06. However, since I only had sex once that month (and none following because my first symptoms of pregnancy, that I didn’t recognize, were burning skin and exhaustion–I couldn’t stand to be touched until my second trimester, even just casual hugging–so, the sex stopped and there’s no chance of having conceived later), in a final hope of conceiving after a year and a half of infertility, I knew my EDD was appropriately 10-1-06.
The ultrasound, however, showed an EDD of 10-14-06.
My daughter was born 10-15-06, zero signs of post maturity, a beautiful and perfect baby 8lbs, 7oz (exact same weight as her sister born at 39weeks, 6 days).
By my LMP, I was 43 weeks. By my EDD based on conception (that my OB moved when the u/s showed the later date, but refused to move to the u/s date) I was 42 weeks to the dot.
So, the u/s was the most accurate at telling us when she was supposed to be born.
With my second, my conception-based EDD (I showed my new OB my chart) was supported to the day by u/s. And she was born the day before her EDD, so again, u/s was correct.
BTW, the only time I had a first trimester u/s, my baby died the next day, so I will NEVER do that again. My second trimester ultrasounds have been super-accurate thus far.
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However, there are many women who believe they accurately know their dates, who are shown by early ultrasound to be incorrect.
I am one of those women, according to you. Yet please tell me how conception occurred May 5th if I was not sexually active AT ALL until may 19th? That is 14 days and not a single person would listen. When I had my son, I was told he was premature. Funny, I had been saying their dates were 3 weeks early all along. I just want to know why you all put so much stock in your little machine, but a woman who DOES know, as soon as the machine says something different, nope not gonna listen to the woman, gonna listen to the bloody MACHINE! And you wonder why people here are OB-haters. Heres the thing. Im not an OB-hater. I am a moron-hater. My Ob is a lovely man. I wish all pregnant women could have him as their doc. But you are like all the others. You have just proven that you do not see a pregnant woman as a person. You see them as something to lie to you, to make your job difficult, and to cause you hassle. Well we are NOT, you would have no job if not for us, so how about show us some respect, and if we SAY we concieved on x-date and have reason to think it is ONLY x-date, YOU BELIEVE IT!
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Nicholas Fogelson Reply:
September 13th, 2010 at 10:41 am (Quote)
You can probably know when you ovulated, and you can certainly know when you had sex, but you can’t know when the sperm and egg joined and the embryo began.
I have had strange situations like you mention where the woman’s history seems to clearly indicate one day and an early ultrasound is several weeks off. I have no explanation for this, but I still would use the ultrasound dates. Its not that I think that the woman is lying, its that I have actual physical evidence of when the pregnancy began.
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Susan Reply:
September 13th, 2010 at 10:51 am (Quote)
Yes, though if a woman know when she ovulated, and knows that the ovum has a very limited life-span unless fertilised, then she can estimate conception fairly accurately. I’d say it’s more accurate if there’s only one act of intercourse occurring after Peak, as then there are fewer possibilities, but she can still narrow it down to a 3-day window if intercourse occurs prior to Peak or at various times during the fertile window.
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CCindy Reply:
September 13th, 2010 at 11:29 am (Quote)
And which one was right, Dr. F? When you got to the end of the pregnancies with the weird circumstances, whose numbers where closer? If you have never looked go look now. If you have never looked or if you interfered in the natural end of the pregnancy you are showing bias and afraid to look. Afraid you might have been wrong. So go look up those dates a report back. We are an evidence based community. Our evidence shows that you ultrasound is an unreliable. You can’t claim to be the expert if you haven’t looked at the results.
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Nicholas Fogelson, MD Reply:
September 13th, 2010 at 12:28 pm (Quote)
Your questions doesn’t make sense to me. The idea that a six week fetus is somehow actually a four week fetus is a misunderstanding of human (or any animal) embryogenesis. This early fetuses follow the path of humankind genetics, not the genetics of their family members. A six week 0/7 day size fetus was created four weeks previously (+-5 days or so) (two weeks off because of how we refer to pregnancies, with LMP being 2 weeks prior to actual conception).
As for evidence saying that early ultrasound is unreliable, I don’t think you have that at all. What you have is some anecdotes, which are self referentially confirming based on preconceived notions that they are right.
The whole thing is ridiculous. All of these dates are estimates. An early ultrasound that is more than 5-6 days off from the reported dates is a better estimate, than the reported dates, but its still just an estimate.
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CCindy Reply:
September 13th, 2010 at 1:18 pm (Quote)
You said you have no explaination but would use the ultasound dates. I want to know if after using those ultrasound dates rather than believing the mother your ultrasound was right and a 6-9 lbs baby delivered spontanously at ultrasound 39-41 weeks or the mother was right and 6-9 lbs baby delivered spontanously at mother’s 39-41 weeks. And yes I know to adjust for the 2 weeks between LMP and ovulation/conception when you are not really pregnant. I thought it was a pretty simple question. If you have in fact had such an occurance, what was the result?
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CCindy Reply:
September 13th, 2010 at 1:23 pm (Quote)
I also want to know when your panic date is (induction required date) is it 40 weeks? 41 weeks? 42 weeks? 43 weeks? Does it matter if there have been multiple dates? Which one counts most?
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Nicholas Fogelson Reply:
September 13th, 2010 at 2:34 pm (Quote)
The earliest date confirmed by U/S is the most accurate (either by the U/S or by the clinical dates c/w early ultrasound). Any later scans are measures of fetal growth relative to that earlier standard, and do not supersede the earlier dates. Many OBs screw this up all the time, reestablishing a new date after an accurate EDD has already been established.
There is no ‘panic date’. Its all about what a patient wants to do. 41 weeks is a reasonable time for an elective induction, but if a patient wants to wait it out that’s fine. I would recommend antenatal testing 1-2 times a week in those cases, as this will likely pick up the few cases of intrauterine demise before they happen.
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Nicholas Fogelson Reply:
September 13th, 2010 at 2:40 pm (Quote)
I don’t really know the answer to your question. Its a theoretical case that I have seen many many times, so I wasn’t really talking about a specific patient. Pregnancies dated by early ultrasounds tend to deliver based on those dates, but since its just an estimate its tough to be definitive.
The “due date” is ultimately an artificial number we have created to help us to predict when a pregnancy will come to an end. I hate to anthropomorphize a phsiologic process, but the pregnancy doesn’t know what due date we write down. We do our best to figure out what the most accurate estimate is. If a patient really disagrees and wants to modify her care based on that thought, that’s fine. If she labors spontaneously its not going to matter. Its only going to matter in a few cases:
1) whether or not to stop preterm labor around viability (24 weeks or so)
2) whether to give steroids in preterm labor (we stop at 34 weeks)
and
3) whether or not to induce post dates.
Any one of these decisions have some general guidelines around them, but there is nothing with individualizing care for various patients.
If a first trimester scan shows somebody 7 days off from what they thought was their day of conception, I’m going to go by the scan, but if that becomes important in some critical decision, sure I’d take that into account, particularly if it were concerning to the patient.
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Nicholas fogelson, MD Reply:
September 13th, 2010 at 2:41 pm (Quote)
>> Any one of these decisions have some general guidelines around them, but there is nothing with individualizing care for various patients.
nothing _wrong_ with, I meant
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Birth Unplugged Reply:
September 14th, 2010 at 4:30 pm (Quote)
This conversation comes at an interesting time for me because I’m currently reading a book about fertility charting (Taking Charge of Your Fertility by Toni Weschler) as part of my doula training. Based on what I have read, if a woman experiences an obvious basal body temperature shift (not everyone’s are obvious) that corresponds with fertile-quality cervical fluid, and a high, open cervical position, she can pinpoint ovulation within about a 24 hour window. Eggs don’t usually live more than 48 hours after ovulation (usually less) and it is not possible for conception to occur without an egg. The timing of implantation can vary, though not by much.
I used basal body temperature charting the cycle I conceived my first, and the date I calculated using my thermal shift was only 2 days different from the one given by ultrasound dating at 6 weeks.
I believe that fertility charting is something that OBs should become familiar with, as it can not only determine approximate timing of conception without ultrasounds (which some women prefer to avoid), but it can also be a diagnostic tool for gynecologic and fertility problems.
Dr. F. do you think it’s possible that ultrasound dating is subject to mechanical or human error (even if such errors happen very rarely), and that there are possibly cases where the ultrasound date is off by more than the margin of error you cited?
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Nicholas Fogelson, MD Reply:
September 14th, 2010 at 4:52 pm (Quote)
>> do you think it’s possible that ultrasound dating is subject to mechanical or human error (even if such errors happen very rarely), and that there are possibly cases where the ultrasound date is off by more than the margin of error you cited?
No question that doing a first trimester ultrasound requires training and the right equipment. A crown rump length isn’t that hard to measure, but if one doesn’t know what one is doing one is going to be off by at least a few days. With the right training, 5-6 day accuracy should be reliable attainable.
Like all statistical distributions, the accuracy range is based on 2 standard deviations from the mean, so theoretically one could be further off.
But at an underlying level, one shouldn’t be too far off.
The reason that an early ultrasound is so accurate is that it is done so early in embryogenesis. Imagine day 1 of embryogenesis – a single cell. If you can see that cell, you know for certain that you are on day 1. Now imagine day 3 – there will be 8 cells. If there are 8 cells you know that you are on day 3. This progresses on through blastocyst and blastula and morula and finally a trilaminar embryo. By six weeks, you have a head and a tail and a spine and beating heart, and the beginnings of a few other organs.
The point of this is that the timing of these progressions are pretty much set in stone. If you can measure them, then you know how old the fetus is.
When you are doing a very early ultrasound, you are really measuring embryogenesis, and so you can date the pregnancy pretty accurately. when you do scans much later in pregnancy, you are measuring a combination of embryogenesis and the baby’s genetic growth potential, so your accuracy starts decreasing. At full term, our ability to date a pregnancy is miserable, as is our ability to estimate its weight. By that time, there are too many variables to fit into a tidy mathematical formula. But early on, its pretty straightforward.
>> I believe that fertility charting is something that OBs should become familiar with, as it can not only determine approximate timing of conception without ultrasounds (which some women prefer to avoid)
One can certainly get a lot of information from basal temperature charting, but given that the same information can be gotten more accurately from a LH surge kit you can get at the dollar store, a lot of people would rather do that.
As for doing something to cater to folks that want to avoid ultrasound, that’s not something I am interested in. Ultrasound is not dangerous for a fetus, and it is an extremely useful tool in what we do. Fertility charting can be useful, but as you noted in many people it can be hard to intepret these charts. Serum estradiol and LH levels, on the other hand, are very easy to interpret.
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Birth Unplugged Reply:
September 14th, 2010 at 6:35 pm (Quote)
I am not against ultrasounds and although it can not actually be proven that they do not have some adverse affect nobody has thought to test for, I, personally, am not worried about them. However, concerns about whether or not ultrasounds are safe are not the only reason some women prefer to avoid a lot of prenatal ultrasounds. Ultrasounds (and serum level tests as well) cost money, whether it is out of pocket or coming out of insurance premiums. If we are really serious about decreasing the cost of healthcare, we have to recognize the value of trying options that are free or almost free before moving on to more expensive procedures, both in dating pregnancy and in things like diagnosing infertility or recurring very early miscarriage. If a woman’s chart is clear, and her doctor can look at the chart and see that the signs indicate ovulation at a certain time, then it is not necessary to do an early ultrasound to date that pregnancy.
One advantage of charting fertility signs is that it is very inexpensive–all you really need is a thermometer and the knowledge of how to chart. An LH surge kit costs money every month and there are conditions which can influence the results (such as Luteinized Unruptured Follicle Syndrome or Polycystic Ovarian Syndrome)–there is a section that goes onto detail about limits of these kits in Weschler’s book.
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Susan Reply:
September 15th, 2010 at 1:44 am (Quote)
Doesn’t cost anything if you do a mucus-only method. And you beat me to mentioning a LUF. One reason I love Billings, though, is that I don’t need any equipment, and I know exactly what’s going on. I can identify a LUF or a true Peak (and thus true ovulation). A study (believe I posted the link earlier) showed that an LH kit matched a Billings chart, so buying the kit isn’t necessary. Oh, and charting was also nice when I started ovulating again postpartum and could see that I had a deficient luteal phase at first.
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Nicholas Fogelson, MD Reply:
September 15th, 2010 at 3:26 pm (Quote)
Good comments. Basal body temperature charting works great if one is committed to being consistent about when they log the temperature. No doubt there is lots you all could teach me about it, as I go to LH kits and progesterone levels when I want to confirm ovulation.
Susan Reply:
September 16th, 2010 at 12:04 am (Quote)
It won’t let me reply to your last post here, Dr Fogelson. Anyway, I really don’t know as much about basal body temp, since I do a mucus-only method, but I believe you. I know an experienced Billings instructor can graph oestrogen, progesterone, LH, and FSH fairly accurately from looking at a chart. That was part of my training, but I think I need more experience before I’m as confident in that aspect of charting. But the geek in me thought it was pretty amazing.
My friend gave birth to twins at almost 40 weeks… her doc was trying to get her to do a c/s much sooner then that starting at 36 weeks and she refused…
one of her babies was over 7 1/2 lbs and the other was 8.8lbs… (on a vegan diet btw)
She is not the only one… I have met/heard of many women that have not consented to an early c/s or induction even though it was recommended and went to 40w+ with twins…
I really wonder how many women are not able to compares to how many women are not “allowed” to…
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JulietsButterfly had this to say,
Sep 13, 2010 @ 10:08 am (Quote)
I think babies, singleton or twin, come when they’re ready. Sure there’s a “safe” gestational age where twins are likely in the clear. I would be worried to have twins at 34 weeks, but much more relaxed if I made it to 36 or 38 weeks. There are some who, like a PP mentioned, come just at 40 weeks.
My dates for DD were way off. So when she came the last weekend of March instead of mid-April, I wasn’t too worried. The drs weren’t either since she was 8lbs 12 oz at birth.
I wish more doctors would listen to women though. My BFF and I tried for #1 and #2 respectively at the same time. We didn’t really plan it that way. I told her happy birthday near the end of July and BTW, we’re trying to have a baby. She said her AF was due that week and they’d start a week behind us. I got my BFP about two weeks later. She tested a week after me and got a BFN. And again the following week. She went to her OB and had extra tests and some u/s that showed no pg yet. Five weeks after my BFP, when she should have been a week behind me, she finally got her BFP. So our babies were due 6 weeks apart, but our LMP had been a week apart. Hers started the day that mine ended. And she had extra testing etc to ensure that she wasn’t pg after I’d conceived.
So odd stuff like that CAN and does happen! I’m just glad that her drs knew something was up with her cycle and didn’t try to help her meet her LO a month early.
EDDs are just that…estimates! I have some friends due in October, and anything within two weeks of their EDD is fair game in my book. I’d be concerned if someone due in early October hadn’t had their baby by Halloween and I’d be worried for a baby with a Halloween EDD to be induced before mid-October.
Sometimes you have to wonder how women got along having babies before ultrasounds, charting cycles and other gadgetry came along. A woman had relations with her man, confided in a midwife or female elder and they guessed the month and probably settled on first half, middle or end of the month.
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I want to respectfully chime in that I have had a friend with a similar situation. When she went into labor, her doctor considered by the EDD in her chart that she was just shy of 37 weeks. She was certain that the due date in her chart was two weeks late. When the pediatrician examined her 9 lb + baby, he declared something to the effect of, “There’s no way this is 37-weeker. This is a full-term baby.”
I honestly don’t remember how early an ultrasound scan she had. I’m actually going to e-mail her right now, because knowing her, I doubt she turned down an early scan offered by her OB.
I completely understand that there are definite markers that indicate development in human fetuses and that these can pinpoint gestational age to within a few days in the first 10 weeks of pregnancy. However, could it be human error on the part of ultrasonographers that explains the apparent cases of “mom was right and the ultrasound was wrong?”
I mean, nobody’s perfect, right?
And as far as “her body just knew,” I don’t ascribe anything magical or supernatural to that phrase. Of course, there’s an entire chemical and electrical symphony going on that we don’t fully understand, and “my body knew” is a simple way of saying, “Hey, look, the process works on a very consistent basis.” Of COURSE there are those times when the process doesn’t work, but that doesn’t mean that the process itself is inherently faulty.
And my one issue with comparing how the body reacts following a heart attack to how it conducts itself during pregnancy and birth is that a heart attack is not a normal function of the human body, whereas pregnancy and birth are.
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tara Reply:
September 13th, 2010 at 1:48 pm (Quote)
One more little thing. I feel that the level of disrespect to fellow human beings, MD or not, I’m seeing from a few posters at this site, is sad. Here we are commiserating with women and comforting them about the fact that their doctor/midwife/labor nurse/next door neighbor/whoever used no tact when dealing with them, and then we turn around and treat another human being tactlessly? Let’s think about that.
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Liz Chalmers Reply:
September 14th, 2010 at 11:55 am (Quote)
I totally agree. I don’t know if I want to read this site any more if the comments consist of name calling.
We shouldn’t worship a visiting MD or agree with everything he has to say. But Dr Fogelson is an OB who speaks at midwifery conferences! He has passionately advocated for things that the normal birth community has long believed (eg. the value of delayed cord clamping). If we’re going to yell at, demonize, and insult a doctor who’s willing to engage in real conversation, how are we EVER going to serve the women and babies of this country best (ie. with a vibrant midwifery and OB community that works together instead of against each other)
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Lucia Reply:
September 14th, 2010 at 6:37 pm (Quote)
Hear hear! I think it’s wonderful that Dr.F takes the time to read this stuff and respond to it. He and I may not see eye to eye but he really seems to be a good Dr and trying to balance modern medicine with his patients wishes and uses evidence based medicine. I commend that. If we can’t be respectful to all posters here, even MDs we’re just as bad and the Drs and Nurses and Midwives we quote here… we alienate each other and the rift is part of what is killing women in this country. Drs need to take NCB seriously and they’re not going to do that if we attack them. Course if certain other Drs were to post here and attack I would view it the same way. Dr F, I hope you keep watching and posting I think you add a valuable POV to this site.
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Krista Reply:
September 14th, 2010 at 9:08 pm (Quote)
I have to agree. I know that my temper and emotions flare sometimes, but that’s why I love the internet. I can take a breather before responding so I can be considerate even when someone has inflamed my senses.
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Susan Reply:
September 15th, 2010 at 1:45 am (Quote)
Agreed. Dr Fogelson, I truly appreciate your input here, and I’ve learnt some things about ultrasound from your posts.
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Dreamy Reply:
September 15th, 2010 at 10:13 am (Quote)
I am all for the honey vs. vinegar thing, but it’s not surprising that every woman here– many of whom have been treated with not just a lack of “tact,” but physically violated by OBs– might not be sweetness and light. I’m not interested in spending much time chastising them.
People (not necessarily Dr. Fogelson) who are unwilling to listen to challenging truths from people with relatively little power are generally unwilling to listen regardless of how “tactful” those people are. That doesn’t make “tact” irrelevant, but it does make the focus on “tact” a bit of a red herring.
Not to mention, we’re not saying these things while standing over the good doctor’s genitals and holding a scalpel.
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Tara Reply:
September 15th, 2010 at 1:43 pm (Quote)
I’m not talking about honey vs. vinegar. I’m talking about basic human kindness and the tenet we all learned in about first grade: two wrongs don’t make a right.
I see your point, and I understand that many of the women posting here have experienced trauma at the hand of an OB. It’s understandable that this is their reaction, in such cases. I don’t mean to prevent women from expressing their outrage. And when some certain OBs post at this site (again, not Dr. Fogelson), I can see how they really have it coming, even if again, I would like to see NCB advocates taking the high road.
I’m just saying that in general, we should try to remember that behind those avatars are real people with feelings. Always a good idea in any online forum.
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Nicholas Fogelson, MD Reply:
September 15th, 2010 at 3:23 pm (Quote)
Thanks for all that. Dialogue is important.
Its also important to note that the internet is a bit of a relaxer of inhibitions. Many things that people will write in the safety of a blog comments would never leave their mouth in a face to face communication. I suspect that many people who destroy docs online wouldn’t be as aggressive face to face, and docs who are really against homebirth don’t lay into every transfer they get. When it comes to actually taking care of patients, professionalism is usually the rule.
Occasionally I have a patient that has a completely misunderstood view of why they are having gynecologic problems, sometimes coming from a very non-scientific point of view. I could certainly try to talk them out of that view, but ultimately that would just be disrespecting her right to have her own beliefs. Even if I can’t understand her point of view, or think that it is just wrong, being a good doctor is giving her what she needs to the best of my ability.
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Tara Reply:
September 15th, 2010 at 6:52 pm (Quote)
Dr. Fogelson, if all obstetricians were like you, we wouldn’t need this website. I appreciate your respect for your patients.
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Nicholas Fogelson, MD Reply:
September 15th, 2010 at 7:52 pm (Quote)
So here’s something for folks to think about.
Look back at this thread and see how often intentions were mistaken based on differences in language. Doctors speak one language, patients another. They try to communicate in between, but sometimes what one means isn’t what is heard on the other side.
Now look through all the comments on this site. While some of theme are stupid and insensitive, a lot are just signs that we all speak different languages sometimes. The people that are saying these things don’t necessarily share the NCB world view, and don’t cater every word they say to match that view. That doesn’t make them bad, or even insensitive – they are just coming from another perspective.
“I know you believe you understand what you think I said, but I am not sure you realize that what you heard is not what I meant.” – Richard M. Nixon
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Dreamy Reply:
September 16th, 2010 at 1:58 pm (Quote)
I agree. I do. I am just wary of any comparison* that semantically equates the possible rudeness of a very few women here toward Dr. Fogelson with the often horrifying comments from OBs toward women that are detailed on the site. Comments that are emblematic of a truly backwards and injurious system, which are often accompanied by equally horrifying behaviors, and which are actually made to these women’s faces. It’s very important to treat others with respect, and it’s easy to forget that when they are “words on a screen.” Which is what makes some of the incredibly disrespectful, callous comments of OBs, L&D nurses, midwives, etc., even more upsetting– because virtually all of them are made face to face with vulnerable, often naked women who are frequently (in these stories) in pain/crisis and/or just doing the very difficult work of bringing a baby into the world. Just saying.
*Per your original comment, though it may not have been your intent.
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Lori Flanagan had this to say,
Sep 14, 2010 @ 12:11 pm (Quote)
I submitted this.
It was told to me by a woman in her FIRST trimester. It was the explanation of why she wouldn’t be pregnant more than 37 weeks this time (40 with her prior singelton) and her twins WOULDN’T be premature at that gestation so not to worry.
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CCindy Reply:
September 15th, 2010 at 2:03 pm (Quote)
I’m a bit confused. Was this said to you by a female OB in her first trimester? Are you the OP?
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Lori Reply:
September 16th, 2010 at 10:33 am (Quote)
I am neither the doctor or the patient. This was part of a conversation with a friend.
The physical impossibility of doing anything twice being quicker than doing anything once apparently was beyond both OB and patient.
Can you sign your name twice quicker than once? Bake 1 or 2 cakes? Run 2 miles? No. Certainly with appropriate equipment you can sign your name or bake the cakes in EXACTLY THE SAME AMOUNT of time as only doing it once. But you can not make it faster by adding more tasks.
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Melissa Reply:
September 16th, 2010 at 1:24 pm (Quote)
I can appreciate the eye-roll moment over hearing this bit of “information,” but your analogy doesn’t work. The mom isn’t “making two people at the same time instead of one” as if those were serial tasks or tasks that she has to split her time between. In fact, it would be more appropriate to say that it isn’t her task at all. Her body does, certainly, provide the nourishment, the safe haven, and half of the “dialogue” between her hormones and chemicals and those of her baby. And as a mom of twins, it is harder on her body to meet the doubled demands. I’m not underselling that. It’s pure miracle what a mom does. But each of the twins is directing their own growth. Not in a vacuum, certainly, but the mom pregnant with twins is not, in her gestating, anything like someone trying to bake two cakes at once.
As Dr. Fogelson has been pointing out, if we measure readiness for delivery by lung maturity (and many of us would like that to be only one of many criteria), twins seem to reach that point faster than singletons. No, that’s not what your friend’s doctor told her (“they grow faster! It’s magic!), but your illustration is beside the point.
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Lori Flanagan had this to say,
Sep 14, 2010 @ 12:13 pm (Quote)
And just because twins are often born earlier does not mean they are healthy or fully developed. It means Mom’s body is spontaneously terminating the pregnancy to save her own life same as any singelton pregnancy where Mom is malnourished.
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Lucia Reply:
September 14th, 2010 at 6:11 pm (Quote)
I disagree with the malnourished thing. We just don’t know what causes labor. With twins we see cervical thinning and dilation early on so I think it had alot to do with all the extra stretching and pressure. The more stretch, the more the mother’s uterus responds to whatever chemical signals the baby puts out there, so double the baby, double the hormones, extra responsiveness due to stretch, you get the idea. I’ve also not heard of any mother of multiples going much past 40-41 weeks even when the babies are 8 or 9 lbs each. I suspect and have read elsewhere that the Baby or Babies are starving they will signal earlier. We wouldn’t be successful as a species if we couldn’t carry a pregnancy while malnourished and we def have strong evidence that starving women will keep lactating under extreme conditions. The woman’s body just takes care of the baby to it’s own detriments sometimes.
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Nicholas Fogelson, MD Reply:
September 15th, 2010 at 7:54 pm (Quote)
There was a nice study that unfortunately I cannot directly source right now that looked at birth records during the Russian Potato Famine, a time of widespread malnourishment. Despite the incredible lack of calories, the average birth weight was hardly different than in times of plenty.
The baby is an excellent parasite.
(gotta razz you all with that one!)
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Lucia Reply:
September 15th, 2010 at 9:22 pm (Quote)
The baby is an excellent parasite.
My first Ob used the same line with me when I was concerned about not gaining weight (I didn’t gain with my singletons and only gained 7 lbs with my twins). Of course we don’t want women starving themselves during pregnancy, as the mother’s health is sure to suffer but we’ve been malnourished our entire history with the exception of the past 50 or so years so If we couldn’t make it on fat stores we would have died out long ago.
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Lori Flanagan had this to say,
Sep 16, 2010 @ 10:19 am (Quote)
Lack of adequate protein or other crucial nutrient/vitamin/fat is not the same as lack of adequate calories.
Plenty of new research shows that most severly obeese people are still malnourished.
I believe Twins and More is where you will find the story of a HBAC with 42 week tripletts. The mom talks about how eating/nourishing (per Brewer diet) became a full time job for her.
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Huh, must be our twins didn’t get that memo. They were born at home at 41+1 weeks. None of my babies *ever* would have been ready at 37 weeks. Our twins weighed 6lbs 14oz and 7lbs 15oz BTW, my MW stressed protein and rest as my body directed, common sense advice that really worked!
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How are you measuring exactly when ovulation occurred? Do your clients space out their intercourse to once a month so they always know when conception occurred?Admittedly snarky
My turn to be snarky: Wow.
Do you not know as an MD that even if you limited intercourse to once a month you would still not know the date of conception? Fertilization can happen up to five days after intercourse.
The only way to know such a thing is to daily chart basal body temperature. Doing so allows you to monitor the key hormonal changes that signal ovulation has/will take place sometime within 24 hrs. No one can conceive until they ovulate! once released, the egg is then viable for 24 hours. Therefore, by charting, you can know when you conceived (even if you had sex every day of your cycle) +/- 24 hours–based on the date of ovulation itself.
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Levi Waters had this to say,
Jan 11, 2012 @ 9:16 am (Quote)
Hey folks, May be the U.S. much better off staying with Syria’s Assad?
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**boggle** And if you have triplets, they grow REEEEAAAAALLLY fast!
Yes, twins are usually born sooner than singletons. It has nothing to do with growing them faster. So the question is, was the doctor lying because s/he didn’t feel like explaining and didn’t want the mom to worry (ie, lazy and patronizing) or was the doctor stupid?
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Serene Reply:
September 13th, 2010 at 4:18 am Serene(Quote)
im gonna go with stupid. Chances are this doc actually *believes* it, or he would not have said it.
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Kristin Reply:
February 17th, 2011 at 8:47 am Kristin(Quote)
Really? I guess by that logic quadruplets would be done with gestation in 10 weeks then?
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