>> 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.

>> 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.

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.

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

I might add that both of my babies were born with plenty of vernix and lanugo. My 37+5 baby had substantially more than is typical at “full term” and my daughter had about the same amount as would be typical/normal

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?

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.

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.)

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.

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.

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!

“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.

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?

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?

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.

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.

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?

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.

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

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.

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.

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?

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.

Dr. Fogelson, if all obstetricians were like you, we wouldn’t need this website. I appreciate your respect for your patients.