Research: Hold on those last few weeks if you can (eat your fish oil)

In the twin forums I've been involved with, there has always been discussion about the issues of 'term' - about half of all twins are born before 36 weeks. Many doctors think that twins should be delivered by 36 1/2 weeks, regardless of any other indication - it is just 'too hard' or 'too risky' to stay inside at that point. Research continues to not support that thinking - babies are really meant to stay in for 38 to 42 weeks, and while there are real and important reasons to take action sooner, the trend is toward increasing preterm births (many of them by c-section). Late preterm seems like it is safer - 34 - 36 weeks is 'close enough' ... but 'close enough' may not be as close as the doctors think.

Researchers seeing the trend (70% of preterm births are in the late pre-term period) have tried to determine what the impact of that gestational age of birth is - and it is definitely still a high-risk situation. Neurological impacts are particularly notable as major issues. Yes, their lungs are mature 'enough' and they usually have a suck reflex. But.

It is hard for the mom (dad, partner, family) to balance the risk profile effectively. And it is also hard for the OB to take a long-term look - the baby comes out 'looking healthy', and they are not the pediatrician or family doctor, so they do not have to deal with the long-term picture of developmental delays or neurological deficits. So it's important to make sure the care provider you have is aware of the issue, especially if you have a risk condition that might indicate pre-term birth as a potential offset to risks of a longer gestation (gestational diabetes being one issue that is tricky to balance - how big IS the baby, really? We don't have an accurate way to find out for sure, late term, so it becomes a guessing game).

In the twins research world, even 'near-term' (now effectively 37w - that last week between the end of late preterm and the start of term at 38 w - the terminology is changing, near-term used to have a different range, and was used interchangably, and is probably not settled even now) has been noted to have a laundry list of risks associated. 38 weeks really is the lower limit. It's really hard to reach that, though there's some indication that omega-3 fatty acids (especially DHA) can extend twin gestation (six days just by changing to DHA-enhanced eggs and eating a dozen a week).

Interestingly, the tie-in with DHA may be a contributing factor to both the preterm risk and the neurological factors. A diet low in Omega-3 fatty acids both increases your preterm labor risk and increases the risk of neurological issues for the baby. While this presentation is long and includes multiple factors, the discussion of DHA and other fatty acids is really important. (Someone ping me if you can't read it, I have a Medscape membership on the professional side, and I can't always tell if something is locked down to casual readership.)

It is reassuring that more doctors are being given access to the information about nutrition as an important factor. It is also reassuring that (as noted in that presentation) women are going to their doctors asking about nutrition, bringing it to the doctor instead of just waiting for the doctor to bring it to them. Keep doing that. They've noticed!

Comments

[Parisienne Mais Presque]

Okay, this only tangentially relates to your post, but...

At the hospital where I gave birth in France (singleton birth), I was a little shocked (and even more shocked in retrospect) that term is considered TERM. Like, you come in for a monitoring session and ultrasound the morning of your due date, and if they aren't happy with what they hear and see, you're induced. If they judge everything OK, you come back two days later and they monitor again, then potentially two days again after that, at which point you're induced no matter what.

In my (extremely uninformed) understanding, the due date is more of a statistical mid-point of a bell curve, so logically you should have as many babies falling a bit behind as before. Granted, at some point the bell curve analogy fails because while you have very premature babies, you aren't going to have babies going beyond a couple weeks late, but anyway. What's with this obsession with the date?

FWIW, in France we have three routine ultrasounds including one very early in pregnancy to date the embryo. Which is quite useful when dealing with health care professionals who won't believe you when you tell them have a long cycle. I can only imagine how early le Petit would have been forced to come out if they'd relied on the date they first calculated from a 28-day cycle. As it was, labor started naturally and he arrived nine minutes before his due date!

I did make sure to take my Omega 3s.

[hedra]

There was a really good study out of Brigham Women's in Boston that said that your best bet is monitoring at 37 weeks on a bi-weekly basis, and inducing if there is a sign of cause, but going to the full 42 waiting for sign of cause. If they do that, they catch twice the unexplained fetal demise numbers that they'd catch with a strict 41-week cutoff, without excess premature inductions. But the cause was also quite clearly stated, so there had to be placental degradation (and you'd be able to tell better because there were baselines stacked up one after the other). BUT, lots of MFM visits with biophysical profiles that way. Maybe more costly, but it a) caught more potential losses even before 40 weeks, and b) allowed babies to go to their full term without interference if they seemed to be doing fine.

I thought it was a grand idea - the best combination of expectant management and technology I'd seen. And, er, nobody seems to be using that protocol, DESPITE the reduction in risk it produces, and the increase in satisfaction (and reduced accidental pre-terms). ARGH. Sigh.

And France is home of what I think is called Free Birth, too (like, birthing in the woods by yourself, unattended) - methinks it is maybe a backlash movement?

[Parisienne Mais Presque]

Actually, in France they ALSO do routine weekly (not bi-weekly, if I remember correctly) monitoring starting at 36 or 37 weeks. I thought it was a pretty cool experience, actually: you go in, meet with a team of midwifes, they hook you up to the monitor, and for a half an hour you listen to the noisy world of your uterus, which sounded to me like an underwater commuter train. That was how I finally figured out that all those rhythmic bumps against my ribcage that I felt at the end of pregnancy were the baby's hiccups, because le Petit got a case of the hiccups during a monitoring session and the midwife explained it to me.

The problem in France is that they are very, very interventionist and any risk is considered too much. I can understand that, and it certainly has its positive side: three standard ultrasounds, routine screening for toxoplasmosis (and monthly blood tests if the initial screening shows you have no immunity), truly exceptional pre- and post-natal care, all fully paid for by the state health care system.

But pretty much all births are in a hospital setting, and hospitals seem to want to push births to be controlled, standardized, medicalized. Which isn't to say that the hospital where I gave birth wasn't good or that my experience was bad. And I think that most hospital births are attended exclusively by midwives, unless there is a problem that requires an OB.

I'm a bit surprised by your mention of a back-to-nature birthing movement in France. It would definitely be a teeny, tiny backlash movement, since most people I've met seem quite happy with the status quo. I think that even home birth midwives are virtually impossible to find. Personally, I wouldn't want to give birth outside of a hospital setting, but I would love to see hospitals be a bit more natural in their approach.

Is there in the US a broadly applied cutoff date, like there is in France? How late really is considered too long to wait?

[hedra]

Maybe an underground backlash, but one of the best OBs supporting the idea of freebirth or at least couple-only birth is French.

The usual standard in the US 'medically speaking' (not as-practiced but as specified) is 42 weeks max. That's when the risk of unexplained fetal demise (stillbirth without an understood cause) spikes up sharply. Most hospitals have a 41-week limit, which you may be able to argue with depending on your provider(s). Most licensed midwives practicing separately from a hospital have expectant management standards and limits for their insurance that go to 42 weeks, but may be stretched for individual cases (for example, since my due date for Mr G landed on a Saturday, we were able to move the 'deadline for induction' to Monday provided I came in for a biophysical profile on the 42-week date, and again on 42w 1d - they would then use that to determine if they induced on Saturday, Sunday, or waited to Monday. And then I went into labor the Thursday before, and delivered on Sunday anyway.)

There are some hospitals/providers that use 40w 3d (not even 41w), and there are all sorts of odd rules for multiples - like, many won't 'allow' a triplet pregnancy to go past 36 weeks, EVEN if the pregnancy is going well, and many push to induce or c-section by 36 weeks or 36w 3d for twins. My own OB had a 40-week comfort limit for twins, because he'd seen a few sudden turns for the worse after 40w, and was personally uncomfortable with waiting after that. But 40w was fine, and he refused to try to induce before 38w, including for major discomfort (though he has shifted toward more c-section default births for twins, possibly because of the double-breech twins I had. Dangit.).

Also, there are hospitals that are very medical-model, 'all births shall look like this, last this long, have these interventions, and occur on our schedule' - big hospitals especially. Others are midwifery model - our state used to publish the c-section rate by hospital, and the range was 14% (the expected normal range) to 36% (at the high-risk center, so skewed slightly upward because of people being transferred for their ultra-NICU and emergency staff - probably around 32% without the risk, though, as they're the major normal birth location as well), to 40% (NOT at a high-risk center, eek!). The lowest center used a midwifery model of care, but included both midwives and OBs; the highest rate also used midwives, but insisted on a lock-step medical model. The place I birthed most of my kids had a 19% rate, and had a kind of mid-range midwifery-acceptant model (even when they shifted to all OBs attending) plus a faith-based underpinning (Catholic hospital with very positive Catholic culture regarding birth - much faith, not so much human pride or arrogance allowed on the part of the doctors, though definitely still some there - and the faith meant they trusted how our bodies are made, and had low-intervention procedures sequenced before high-intervention. For example, they had posted on the wall 'if mom has a fever, first check if she's been in the jacuzzi - might be heat from that. Then do X to see if her temp will drop. Then check whether epidural is in place. Then consider antibiotics/further action.' or something to that effect; they also had something listing interventions for fetal distress that included fetal scalp massage as a first step, and staged up from there including position changes for mom and other low-risk actions, rather than 'distress, ignore to see if it goes away, then panic if it doesn't' which seems to be the default in the medical model.

Anyway, uh, probably more answer than you needed! Heh.

[Parisienne Mais Presque]

On the contrary, I find all that information fascinating! What's the name of the French OB you mention? I'm curious.

[Kellie - Mother Of Twins]

I went into labor naturally with my twins at 36 weeks. My OB would not consider inducing until after 38 weeks and would definitely not feel comfortable with a twin pregnancy progressing further than the standard 40 weeks.
Thanks for all of the interesting info!

[hedra]

@Kellie, I'm glad you found someone who took that line. It's been four years since mine were born, maybe more are getting the message. I still hear quite a bit about doctors scheduling c-sections for 36w, period, no matter what you want. My mothers of multiples club sees it all the time. One mom had her c-section scheduled for 36 weeks when she was only 24 weeks along! Pretty much everyone told her to find a new OB, but I don't know if she did. A lot of twins are born spontaneously in that late preterm period, but there's a question about whether that's maybe due to the twins taking up more of the nutrients, and making it harder for the mom's body to hold off on labor - there's initial evidence that things like DHA suppress progression of cervical ripening, for example (see the linked presentation). So if the twins are consuming all the free DHA in your body, it may make a difference for preterm or later - not that 36 weeks isn't a great success, because I know exactly how hard it is to handle. Just trying to keep the message out there that more DHA (presumably up to a point, but obviously talk to a professional on what point that is) is a good thing for reducing the odds of preterm issues.

@PMPresque, I'll see if I can find it. He's written at least one book. I think he's pretty old, now. I'll link here if I can find the info.

[hedra]

On a quick search, this is the only resource I could find, but it is a good one. Their movement surged right around when Mr G was born, which may be why I noticed it.

http://www.childbirthsolutions.com/articles/worldbirth/france/naissance/index.php