Instrumental Delivery: Vacuum Extraction

Vacuum Extraction and Forceps Assisted Delivery are both types of Instrumental Delivery, or methods of assisting the laboring mother in having a vaginal delivery as opposed to a Cesarean Section. The occurrence of both are less than they have been in the past, but they still happen enough for us to discuss here. We will begin with the more used of the two, vacuum extraction.

VACUUM EXTRACTION HISTORY

Attempts to use vacuum devices actually began in the 18th century but because the devices were difficult to create and the techniques difficult to implement, their use was soon abandoned. The first successful vacuum extractor was introduced in 1849 by James Young Simpson of Edinburgh, already famous for his forceps design. Technical problems still existed however and the vacuum extractor continued to be improved over time. Although popular in Europe as the method of choice for Instrumental Delivery, it has only gained popularity in the US more recently.

If the mother is into the second stage of labor, (meaning that her cervix is ten centimeters dilated and completely effaced) her membranes are ruptured and the fetal head is well-engaged into the mother's pelvis, then a vacuum extraction can be attempted. The reasons why a physician may want to utilize vacuum extraction are varied.

INDICATIONS FOR VACUUM EXTRACTION

Suspicion of fetal intolerance of labor
The is perhaps the most classic reason for instrumentation delivery. If the baby is low enough in the pelvis for vacuum extraction (or forceps delivery) to be effective, this can be an alternative that offers fewer risks to the mother and the baby than Cesarean Section.

In deciding to attempt a vacuum extraction, it is important for the couple to realize that it is indeed that, an attempt. Especially when it comes to obstetrics, clinical medicine is not an exact science. This means that a particular outcome of a delivery cannot be 100% predicted. It may be that a physician attempts a vacuum extraction and may still need to perform a Cesarean Section in the end.

Maternal Exhaustion
This would be indicated when they mother's pushing efforts have become ineffectual simply because she is physically exhausted with the efforts. If her second stage of labor has been prolonged, this can contribute to maternal exhaustion. Having a nurse or health care provider at the bedside to give feedback to her pushing efforts can help the mother to refine her pushing efforts to keep the second stage from being longer than it needs to be.

A mother pushing with an extremely dense epidural can also lead to maternal exhaustion.

Shortening of the Second Stage
For some maternal efforts, such as cardiac, neuromuscular and cerebrovascular disorders, pushing efforts are contraindicated or even impossible. For these cases, your health care provider may choose Instrumental Delivery.

Failure to progress in Second Stage
If the baby is low enough in the mother's pelvis, but no further progress has been made with maternal pushing efforts, your health care provider may choose to use a vacuum extractor to facilitate delivery.

CONTRAINDICATIONS OF VACUUM EXTRACTION

There are some reasons when vacuum extraction would not be appropriate for Instrumental Delivery. These include:

• Fetal gestation of less than 34 weeks
• Unengaged fetal head, or station in the pelvis above 0 station
• Incomplete cervical dilation
• Cephalopelvic disproportion - the baby's head is disproportioned to the mother's pelvis
• Malpresentation of the fetal head
• Presentation other than the fetal head
• Large fetal head
• Known or suspected blood clotting defects in the baby

HOW IS VACUUM EXTRACTION PERFORMED

Once the physician applies the cup portion of the vacuum extractor to the fetal head, vacuum is applied. This is performed either by a hand pump which the physician can control, or one which a nurse controls at the bedside. Both have gauges which indicate the appropriate range of suction. Once the vacuum is inside that range, the physician begins to apply traction with the handle portion of the vacuum extractor. The mother's bearing down efforts add to the process. As the contraction wanes, the suction is usually released.

RISKS ASSOCIATED WITH VACUUM EXTRACTION

No intervention, even as simple as having an IV, is without some risks. Just because a procedure is associated with risks does not mean those risks happen in all cases. The incidence of severe fetal injury from vacuum extraction is low, from 0.1 to 3 cases per 1,000 vacuum extraction procedures. The risks associated with vacuum extraction include:

Fetal Risks

Image via Wikipedia

Swelling and bruising at the scalp are the most common risks to the baby. These most often resolve without any addition intervention and are the result of the physics of vacuum against the scalp.

There is one type of hemorrhage which can occur in the baby as a result of vacuum extraction, but the incidence of this is very rare.

Vacuum extraction has not been shown to result in significant neurologic disability to the fetus.

Maternal risks

Vacuum extraction has a very low rate of maternal injury. There are no risks of vacuum extraction, (lacerations, stress incontinence, etc.) that are not also risk factors of vaginal delivery in and of itself.

BEFORE VACUUM EXTRACTION

Unless the indication for vacuum extraction is jeopardy of the fetus, the couple should be given an opportunity to discuss the procedure with their health care provider, to ask questions and have their questions answered fully.

This is also a conversation you can have with your health care provider well before labor ever begins to get a greater understanding of how he/she feels about this particular intervention. Do not be afraid to ask questions, and be sure that you fully understand the answers. This is your labor and your baby!

Emma

Dedicated to my granddaughter. Emma, who recently turned two.
Her smile and curls and beautiful blue eyes bring a joy to our lives we could never have imagined. She is the baby of the "Your Labor Room", and here is the story of her birth-day:


I stood at the side of her bed and watched her little body as she tried to squeeze out each breath. The sound of her breathing reminded me of a weight lifter, or of a woman pushing with the last contractions before delivery – someone giving every ounce of strength to push more than they had strength to push. I had stood at bedsides before and watched preemie babies grunt like this. Many, many times in fact; but this time was so very different. This was my granddaughter. I looked at that little face and saw shadows of myself. Each grunt and groan she uttered ripped at my heart. I wanted so much to pick her up, breathe for her, somehow make it all better, and all the while cry my eyes out. But I wasn’t just Grandma, I was also Mom and I was also Nurse. I felt the need to show strength and calm; to show optimism and hope.

I went back to my son and my daughter-in-law and began to explain the problem with Emma’s breathing. Born almost four weeks early, she didn’t have enough of the surfactant in her lungs to make the air sacs slippery enough for her to close them easily. Along with that, she had a good deal of amniotic fluid in her lungs. She could breathe in well, but she had to use extra muscles to breathe out, which caused the grunting and groaning. As hard as she was working to breathe, she may tire out and then she would need extra oxygen to keep up the oxygen levels in her blood.

Their faces were grim as I explained it all and I felt like the wicked witch who had just come in and stolen their precious dreams and hopes. I tried to prepare them for the next step that I knew, by watching Emma, was almost inevitable. I explained the oxyhood, the IV, the antibiotics – everything that I could think of that would be done. Oh, I had given this speech dozens of times to parents, and I don’t think with any less caring or consideration, but with much less wrenching of my heart at their expressions, their tears, their sadness.

I didn’t tell them all I knew. I knew that if her oxygen was turned up to a certain point, the Neonatologist would be called. I knew that if she had to have high levels of oxygen, she would be entubated and put on a ventilator. I knew that would mean she would be transported across town to the University hospital to a higher level neonatal intensive care unit. I knew there were so many things that could happen. But I wasn’t going to let my mind go down that road. I was going to keep my mind on where Emma was right now and pray, pray, pray. Because I also knew there was one Person who cared and could make Emma better, and I was praying to Him with all my might.

Emma did go under the oxyhood and stayed there for two days. When Aimee and Noah first went to the nursery to see her, it absolutely broke my heart. I had showed them a picture of her under the oxyhood before we went to the nursery, so they would not be surprised at how she looked, and they cried then. But when they saw her for themselves, Aimee broke down in tears. Noah, too, was wiping his eyes. I stood behind and to the side of them and it was all I could do to not collapse into a heap of tears. One of the nursery nurses came to me and put her arms around my shoulders and hugged me. It was so hard, seeing Emma’s suffering and seeing their suffering, for her suffering. Since then I have often thought how much God the Father must have hurt having to watch the Lord Jesus suffer for our sins. The parent suffers doubly when the child suffers.When Aimee started to leave the nursery, to go to her room, I went to hug her and she started to sob. I could contain my tears no longer and I cried with her. I think every nurse in that nursery had tears in their eyes. The L&D nurse with Aimee told me later, it was all she could do to not start crying herself.

Emma’s progression was short compared to that of many preterm babies. By Sunday night she was off oxygen. She started to eat, and like all Davis’, she did that exceptionally well. By the next Saturday, she spent her first night at home.

As happy as I am that she is home, where she belongs, I am sad too. I have enjoyed stealing away every free minute at work to go to the nursery. The first few days I could only stand there and look at her, or touch her hand and gaze into that perfect, tiny face. And I was perfectly content to do that minute after minute.Then later, as she got better, I could hold her, or feed her. Sitting there, with her in my arms, held a sweetness that can’t be captured in any other way. I will miss that each day, as if a sweet, little friend has moved away.

"Delight thyself also in the LORD;
and He shall give thee the desires of thine heart." Psalms 37:4

Why Am I Bleeding?

There are few things more frightening to a pregnant woman than going to the bathroom, looking down and seeing blood. Whether it is a red streak on the tissue or more significant amounts, bleeding during pregnancy always has an alarming effect. Not all bleeding in pregnancy is from alarming causes, even so, you should call your health care provider or seek medical attention any time bleeding occurs.

There are many different reasons why you may begin bleeding during pregnancy, and slight bleeding may often stop on its own. It is important though to determine the underlying cause of the bleeding. In discussing bleeding during pregnancy, it is best to look at it from the standpoint of when in the pregnancy the bleeding occurs.

EARLY PREGNANCY

Miscarriage. When you have an episode of bleeding early in the pregnancy, the first thing you will probably fear is that you are beginning to have a miscarriage. Bleeding can be a sign of miscarriage, but it does not mean that you are necessarily beginning to miscarry.

.It is not uncommon to have bleeding or spotting in the first trimester, or the first 12 weeks of pregnancy. 20-30% of women will experience some amount of bleeding early in pregnancy. Approximately half of those women do not experience miscarriages. If you are beginning to miscarry, unfortunately, there is little that can be done to stop it or prevent it. Miscarriage most often occurs because there is some type of problem with the pregnancy.

Approximately 15-20% of all pregnancies result in miscarriage and the majority of those occur during the first 12 weeks of pregnancy.

Any bleeding, abdominal cramping or passing of tissue you may experience during the first trimester should be reported to your health care provider. A miscarriage does not mean that you cannot become pregnant again and continue a term, healthy pregnancy. In talking with women, it is often surprising to find just how many women around us have actually had miscarriages, and how many have gone on to have healthy children afterward.

Ectopic pregnancy. An ectopic pregnancy is one in which the fertilized egg implants inside the fallopian tube instead of inside the uterus. As the embryo begins to develop and grow this

Image by euthman via Flickr

can cause pain and bleeding. If the fallopian tube should rupture, this would require emergency treatment. The resulting blood loss may cause weakness, fainting, pain, shock and if untreated, even death.

Ectopic pregnancies are not as common as miscarriages. They occur about 1 in every 60 pregnancies. Women who have had infections in their fallopian tubes or previous tubal surgeries are at higher risk for ectopic pregnancies.

If you have had an ultrasound showing your baby implanted in the uterus, you can relax, you have no chance of having an ectopic pregnancy with this pregnancy.


Implantation. Some believe that bleeding which occurs 6-12 days after possible conception is the result of the implantation of the embryo into the uterine lining. This may be a slight spotting for a few hours, or for some spotting for a couple of days. Regardless of how light, all bleeding should be reported to your health care provider.

Intercourse. During pregnancy, the cervix becomes very tender and sensitive. Some women will experience bleeding after intercourse. Don't be surprised when you call your health care provider to tell them you have been bleeding and one of the first questions they ask is, "When was the last time you had intercourse?" Don't be embarrassed, feel free to tell the truth. Pregnancy is a normal part of life and so is intercourse. Your health care provider assumes you have been having intercourse or you wouldn't be seeing them for a pregnancy! Knowing that you have had recent intercourse will help them to determine the cause of the bleeding. If you are bleeding, you should however, discontinue intercourse until you have seen your health care provider.

Infection. Some types of infection of the cervix or urinary tract can cause bleeding.

LATE PREGNANCY

While intercourse and infection can still be causes of bleeding into the second and third trimesters, miscarriage and ectopic pregnancy are no longer a threat. There are other complications of pregnancy that can cause bleeding though.

Placental Abruption. This is caused as the placenta detaches from the uterine wall before or during labor. This usually occurs during the third trimester, although abuse of certain drugs can cause it to happen even in the second trimester. The hallmark signs of Placental Abruption are severe abdominal pain and vaginal bleeding. Here is a post focused entirely on this subject:

Call the Doctor, STAT! Placental Abruption

Placenta Previa. This occurs when the placenta implants across all or part of the cervix. The bleeding in condition is without pain. This occurs in about 1 in every 200 pregnancies. Here is a post focused entirely on this subject as well;

Call the Doctor, STAT! Placenta Previa

Labor. Vaginal bleeding can be a sign of labor. As the cervix begins to thin out and open up, the capillaries in it rupture and mix with the mucus inside of the cervix. This bloody discharge is referred to as "bloody show". If this happens before 37 weeks, it is considered pre-term labor.

WHAT TO DO ABOUT BLEEDING?

If you are bleeding, notify your health care provider. Your health care provider will ask you alot of questions about your bleeding. You may be upset and concerned, but it is important to take a moment to pay attention to the details of your bleeding so you can help your health care provider to make the best decision for you and your baby. Here are some practical tips to help you:

• Put on a pad or panty liner so you can easily describe the amount of bleeding. Describe the amount in easily communicated values: a spot the size of a quarter or the size of a dime. Remember, if you are trying to describe blood in the toilet, once the blood hit the water, it was mixed with the water and there would be no way to tell how much bleeding there actually was.
• DO NOT INSERT A TAMPON!
  
• Do not douche or try to clean up the blood in any way. Evidence of how much blood was there is very helpful to your health care provider when trying to determine the extent of the bleeding. If you meticously clean all the blood away, the condition may seem much less severe than perhaps it was.
• DO NOT HAVE INTERCOURSE UNTIL TOLD YOU CAN DO SO.
• Note when the bleeding began. Were you having any contractions at the time?
  

WHAT WILL HAPPEN TO ME?

Once you see your health care provider, they will most likely want to perform a pelvic exam and pehaps a speculum exam. An ultrasound will probably be done as well as some blood work. Depending upon where you are in your pregnancy and the severity of the bleeding, you may be hospitalized for monitoring of the baby and observation for awhile. Severe bleeding may require delivery.

Remember, bleeding in pregnancy is fairly common and is not always a sign of serious complications. Please though, report any episodes of bleeding to your health care provider.

September 11th -- Labors to Remember

Love and Joy from Terror and Fear

I would never have imagined that someone could transform the horror and fear of September 11, 2001 with such love and joy a year later, but because of the grace of God and the faith of two young parents, that is exactly what happened.

That first 9/11 morning started much like any other morning. My patient, Maegan, was in labor, all the admission procedures were completed and she had settled back to watch TV as I had settled back watching the fetal monitor. We had notified the pediatrician and the nursery because our baby was five weeks premature, but we were not expecting any serious complications. A baby is considered term at thirty-seven weeks. Most babies delivering “near-term” will do well, but some will need additional support, usually in the form of supplemental oxygen and an IV for a period.

In the quietness of the labor room we listened to the "whoosh, whoosh, whoosh" of the baby's

Image via Wikipedia

heartbeat and the steady drone of the morning television program when breaking news reports flashed on the screen. We watched in horror as planes crashed first into the Twin Towers in New York and then the Pentagon in Washington. We continued to watch until later the Towers collapsed to the ground. It was a struggle to keep my thoughts on the fetal tracing in front of me. More than anything I wanted to hear my husband’s voice, which never failed to calm and reassure me. Maegan’s labor was progressing far too rapidly to afford the luxury of a phone call, however. My thoughts were also flying to Camp LeJeune, North Carolina. My son, stationed there for the School of Infantry with the United States Marine Corps, was beginning the second phase of his training, having completed Boot Camp a few weeks earlier. Would they pull them out of training for deployment? Could he already be on a ship to who knows where? I thought too, of my niece who worked in Manhattan and her brother who worked at a law firm near the White House. Were they safe? How would one possibly contact them in all this chaos to know? I considered calling my sister, but I knew she would have no information and my concern would only amplify her own. These thoughts were not those of the idle daydreamer, but intruded upon preparations for delivery: turning on a radiant warming baby bed, mixing perineal prep, and arranging warm baby blankets. While my hands and feet set the final stage for delivery, my mind and heart ached for all those unknown to me whose lives had just been shattered by terror.

Then, almost in a daze, we began delivering this baby. The joy and happiness which normally surrounds this event seemed so inappropriate with the images of horror so fresh in our minds, which were still visible on the television in the room. We couldn’t bring ourselves to turn off the television, it seemed almost as if we were deserting the dead. We were fearful, too, for what might happen next. I found I couldn’t sing "Happy Birthday" to this little one, as I usually did, because I felt anything but happy. It would have been a pitiful rendition if I had tried.

There was a strange silence in the room and as I placed this newborn baby on the warm blankets, I realized immediately, the mood of the room would not soon improve. His little body showed all the signs that he had to work too hard to fill his lungs with air. His nostrils flared, his chest sunk deeply with each breath and the space between his ribs deepened with each dramatic breath. A preterm baby can usually open their air sacs at first, but they are lacking the lipid substance, a surfactant, which reduces the surface tension between the wet lung tissue and the air the baby breathes in. This surfactant helps to keep the tiny sacs, called alveoli, from collapsing between breaths. To squeeze the non-pliable sacs closed, the baby must use other muscles, such as the abdominal muscles, to help the diaphragm to breathe. As the diaphragm tries to inhale more air, the thin skin over the baby’s ribs pulls in as well. Since the preterm baby has yet to put on its layer of baby fat, the ribs, and the spaces between them, can be seen when the skin is pulled tightly over them. The worst sign, though, was the grunting.

Preterm babies tend to make a rhythmic, grunting sound when they are struggling to close their tiny air sacs. While parents often unknowingly think this sound is cute, Labor and Delivery nurses know this grunting is due to a struggle for oxygen. A premature baby will use these accessory muscles to keep their oxygen levels up as long as they can, but before long they will tire out and their blood level of oxygen will begin to drop. That is why premature babies may often look good immediately after delivery, but need more assistance and help within a few hours. As I listened to this little boy grunt and watched his retractions get worse with each breath, I quickly foot-printed him, applied his identification bracelets, wrapped him up and after a quick kiss from Mom, took him to the Special Care Nursery, where he would stay for several days.

I returned to Maegan and started her recovery period, and she turned to me and said, "I should feel so happy today, but I just feel so sad." She drew out the last word and said it almost as a sigh, until it alone expressed all of our attitudes. I tried to reassure her that her feelings were valid. Not only had she just witnessed the brutal murder of thousands of people, but also I had whisked her newborn son out of her presence with hardly a "hello.” It had been such a sad experience, and apart from those deliveries where there had been loss of life or severe newborn anomalies, it was by far the saddest delivery I had ever witnessed. Never will I forget the events of that morning, the cheerless, quiet delivery, or the mother with the grief stricken face.

A year later, I was amazed that we even had any cases scheduled for 9/11. Who would knowingly choose that date for the birth of their baby? What memories would always be associated with this child's birthday? Yet, here they were, pillows and suitcases in hand, ready and anxious to have their baby. They were not strangers to me either; they had been in my six week childbirth classes.

Image by liz.schrenk via Flickr

I had been teaching childbirth classes since shortly after the birth of my first child. It was during my own childbirth classes that I fell in love with the process of labor. Our instructor had been knowledgeable, kind, encouraging, and enthusiastic. She sparked in me a desire for new experiences both personal and professional, which have influenced to me to this day.

This particular class had been my favorite in twenty-one years of childbirth education. It had been a big class and the only one of that size that still had all couples attending by the sixth class. These couples had so bonded with each other, and with me, that I if I had let them, they would have continued to meet each Monday night long after the classes had finished. In that series, we all laughed together, we cried together and then laughed together again. It was by far the best series I had ever taught and the best group of couples I had ever had the pleasure to teach.

When I saw Jill and Ben with their pillows and suitcases, I was thrilled to be a part of their special occasion. It was probably my first real smile of the day. As I got Jill admitted and settled into bed, she told me that many of her family and friends had suggested she change the date of her induction from 9/11. Her response to them changed my outlook for the whole day.

"I thought the best way to thwart the terrorists," she said, "is to bring love and joy and laughter to this date." What a glorious thought…and what a glorious day!

Image by Jon Ovington via Flickr

A beautiful, healthy, baby girl was born and this time I sang "Happy Birthday" to their gorgeous, little daughter with a heart full of joy.

As September 11 rolls around each year, I remember those who were lost in that horrible tragedy and those brave firefighters and police officers who died trying to save them, but I also remember something else. I remember two smiling, joyous faces and the daughter they love, destined to bring love and joy out of terror and fear.

Fact or Myth

As soon as the word is out that you are pregnant, advice starts to flow, whether you have asked for it or not. Everyone from your Grandmother to the cashier at the grocery store will begin to tell you what you can and can't do, what you should and shouldn't do. Some of the things they tell you will be "secret" information, such as the sex of your child, or when your baby will be born. Some of that advice and information is wonderful and helpful. Some of it is not. Let's take a moment and try to sort out the fact from the myth.

SEX OF THE BABY

The most common variety of "Old Wives' Tales" revolves around the sex of the baby. While this is losing some popularity with the advent of the routine ultrasound, still older women may want to tell you what sex your baby is dependent upon a variety of thing, mostly the shape of your abdomen.

MYTH:

• If you are carrying hig, it's a boy and low, it's a girl
• If you are carrying in front, it's a boy and wide, it's a girl
• If your belly is low, the baby will be here soon
• A big belly means a big baby
• If you can tell you are pregnant from behind, it's a girl; if not, it's a boy
  

FACT: None of these things mean anything. The position of the baby has nothing to do with the sex of the baby. The baby positions itself in the uterus in accordance with the shape of your uterus, pelvis and body. If you are short, then there is less area for the baby to go than if you are taller. If you have relaxed abdominal muscles, you will naturally carry the baby lower than someone who had very tight abdominal muscles prior to pregnancy. A bigger belly before pregnancy means a bigger belly during pregnancy, regardless of the size of the baby.

The only certain way to tell the sex of the baby is to look between it's legs after it is born. Yes, even an ultrasound has been wrong once or twice.

Some people will have you to "do" something to determine the sex of the baby. Perhaps dangle your wedding ring, or a needle, over your hand or your belly to tell the sex of the baby. Or urinate in Drano (I can't figure out who thought up that one). These, while perhaps entertaining if the electricity is out, do not predict the sex of the baby. The fact that they have a 50-50 chance of being correct, however, tends to give credence to the person on the times they are "right".

The one Old Wives' Tale that we still hear from time to time in Labor & Delivery is the one about the baby's heart rate. Supposedly if the baby's heart rate is fast, it is supposed to be a girl, if it is slow, a boy. Like most Old Wives' Tales, it is based on a little fact. FACT: The smaller something is, usually the faster it's heartbeat. MYTH: All baby boys weigh more than all baby girls.

Years ago, one of our doctors told me once that he would tell all the mothers in odd numbered exam rooms that they were going to have boys according to the heartbeat, and all the mothers in even numbered rooms they were going to have girls. He said he had a 50/50 chance of being right either way!


HEALTH OF THE BABY

Some Old Wives' Tales center around the health of the baby. The most common of these is about the umbilical cord.

MYTH: If the pregnant woman reaches her hands over her head, it will wrap the umbilical cord around the baby's neck.
FACT: There is nothing the pregnant woman can do to prevent a nuchal cord, or the umbilical cord wrapping around the baby's neck. This occurs earlier in pregnancy when the baby has plenty of room to move about. In fact, according to the March of Dimes, about 25% of babies are born with a loop of cord around their necks and rarely does it cause any problems. I was in a delivery the other day and the baby had three loops of cord around her neck and she was just fine.

The pregnant mother raising her arms does not contribute in any way to the movement of the baby or the position of the cord.

MYTH: A pregnant woman shouldn't take baths because it can cause germs to be passed to the baby.
FACT: The cervix, or the opening of the uterus into the vagina is sealed during pregnancy with mucous. Also, the baby is protected in the amniotic sac which prevents any bacteria from entering. The vagina itself is a potential space, meaning it isn't open all the time, it stays collapsed until it needs to be open for a particular reason, so water doesn't enter the vagina during a bath anyway.

Bathing is a wonderful way for the pregnant woman not only to achieve cleanliness, but also to achieve relaxation. The warmth can relieve that lower backache that occurs in the third trimester. Caution should be taken during the first trimester that the temperature should not exceed 100 degrees.

MYTH: If you don't drink enough water, the baby will be dirty.
FACT: You do need to drink plenty of water during pregnancy, because it is very easy to become dehydrated, which can lead to preterm contractions. You should drink enough water each day to keep your urine a pale yellow. However, even becoming dehydrated will cause your baby to be dirty. This myth most likely came about from a baby which was born with meconium stained fluid. Meconium is the first bowel movement the baby passes. It is thick, dark-green and tarry-like. When mixed with amniotic fluid, it can create a thick green-pea like liquid which would cover the baby.

The body is an amazing thing. Most people don't realize it, but amniotic fluid actually replaces itself every three to four hours, even after the membranes are ruptured. That's why the water continues to leak and leak and leak! Baby drinks this fluid and also urinates into the fluid. So you affect the level of fluid and so does the baby.

MYTH: If a mother drinks too much coffee during pregnancy, baby will be born with light-brown birthmarks.
FACT: The exact cause of birthmarks is unknown. Birthmarks can't be prevented and they are not caused by anything the mother did or didn't do during pregnancy. They are not caused by something the mother ate. They are unrelated to trauma to the skin during childbirth. They are mostly harmless and many even go away on their own or shrink over time. Some birthmarks, however, can be associated with other health problems, so be sure to talk to your baby's doctor about your child's birthmarks.

This is always a particularly interesting topic for me, because I have a port-wine stain birthmark from the bottom of my foot to the top of my hip. I also have two cafe-au-lait stains which are smaller. I have had many opportunities in Labor and Delivery to reassure mothers who have just delivered babies with birthmarks, that their children will adapt well to their own personal "tatooes".


LABOR

These Old Wives' Tales still abound, in fact I heard a Grandmother telling a patient one just the other day. The truth to all of these attempts to start labor is, if the cervix isn't ready, nothing will jump start labor. Yes, you may start some contractions, but remember, the definition of labor is not just having contractions.

As one old obstetrician said to me once, "You can't shake a good apple off the tree." If the cervix isn't ready to begin to dilate, all the things we try to do to make ourselves go into labor will not be affective to do so. If the cervix is ready, then some of these things may help push the cervix over the edge and the resulting contractions may actually stimulate labor. Sometimes however, intervention can cause more problems than it solves.

MYTH: Drinking castor oil will put you into labor.
FACT: Castor oil will make you deliver something, but not necessarily a baby! Many women experience painful cramps, diarrhea and even vomiting using Castor oil and most don't go into labor.

MYTH: Eating _____ (fill in the blank here, Balsamic vinegar, spicy food, Mexican food, whatever the most recent myth food that is circulating around) will put you into labor.
FACT: There is no food out there that will absolutely put you into labor. Some foods may cause gastric distress which will result in diarrhea. This can cause some sympathetic uterine contractions, but not necessarily.

MYTH: You will go into labor during a full moon.
FACT: There are not more babies born during a full moon. We do see more patients during the period of a full moon, but we do not see more babies. We do however, see more patients with ruptured membranes during a time of sudden drop in barometric pressure!


MYTH: Having lots of sex will put you into labor.
FACT: Semen contains a prostaglandin which helps to soften the cervix and prepare it for labor. Orgasm in the mother can cause rhythmic contractions. Remember though, that labor is more than just having contractions.

If your health care provider has advised you to avoid intercourse, you would need to follow their advice.

MYTH: Nipple stimulation can put you into labor.
FACT: Nipple stimulation causes the brain to secret the hormone Oxytocin, which can indeed stimulate labor. However, the stimulation required is for several hours of more intense stimulation. It is also possible to cause over-stimulation, which could result in a contraction pattern which would promote a lack of oxygen to the baby.

MYTH: Walking will put you into labor.
FACT: Walking is perhaps the perfect exercise for the pregnant woman, but it will not put you into labor. If you are already in labor, it will make your labor more efficient, but it will not stimulate the beginning of labor.


MYTH: Accupressure/Acupuncture will induce labor.
FACT: There are two points on the body that can cause uterine contractions. If your cervix is not ready for labor however, these contractions will not dilate or efface the cervix.

The best advice for you is if you are told something from someone that is not a medical professional, or even that is, please discuss it with your health care provider. This is the person who knows all about your medical history and your particular obstetrical and medical situation. Your health care provider is the best person to give you advice concerning your pregnancy.

Congratulations, It's TWINS!

For many people, the thought of having two babies at once would at first be overwhelming. In fact, I work with a young womanl who was pregnant with twins and this was her initial reaction.

"How am I going to take care of TWO of them?" was what she asked me. The truth of the matter is that she takes care of the two of them exceptionally well and is a wonderful multiples mother. Not the job is easy, but she has learned what she needed to learn and she had time to adapt to the thought of two babies instead of one.

In the days when I first was having babies, people didn't always find out about their twins until the delivery was upon them. In fact, we have a good friend who didn't know he was the father of two until his wife was in labor. The story is told that he went out to the waiting room to tell their families and he was in such shock, all he could do was to hold up two fingers.

Some people actually desire to have twins from the beginning. This may be for different reasons. Some may enjoy the mystery and challenge that twins bring with them. Others may want to complete their family with only one pregnancy. Some may have difficulty actually getting pregnant and are thrilled with a multiple pregnancy.

One of the most common questions about twins, is "How likely am I to have twins?". In general, the chances of having twins in this century are about three in 100, or about 3%. This question, however, was precisely what prompted this entry. A cousin of mine, whose mother was a twin and father had twin sisters, asked this question. Let's look at her case specifically.

Her mother is a fraternal twin. This means that two separate eggs were fertilized at the same time. Her mother was in a state of hyper-ovulation allowing more than one ovum to be released during that particular month. This is a key factor in the hereditary tendency of twins. Fraternal twins are not identical and may be of the opposite sex, as was the case with my cousin's mother. This increases my cousin's likelihood of having twins herself, because the gene for hyper-ovulation may have been passed onto her. If you are a fraternal twin your chances of having a twin could be as high as 1 in 17.

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Her father had twin sisters. If they were identical, that would mean that one egg was fertilized and then completely split in two creating two separate embryos. The rate of occurrence for identical twins is random, it doesn't change from race or population. It has remained constant over the years and there is no familial tendency. The chances of having identical twins is about 1 in 285. My cousin would have no added likelihood of having twins if her father's sister were identical.

We know that there are some factors which increase the likelihood of fraternal twins in the general population. There are areas where twins are more prevalent and different factors which predispose women to conceive twins.

FACTORS WHICH INCREASE THE ODDS

• Age - The increased risk begins with 35 and increases with each year. 17% of mothers over the age of 45 give birth to twins. Older women are more likely to release more than one egg in a cycle, thereby increasing the risk of fraternal twins.
• Already have a set of fraternal twins -- If you have already had one set of fraternal twins, your chances of conceiving another are four times greater than the average woman
• Be overweight - A 2005 study published by the American College of Obstetrics and Gynecology reported and increase the rate of fraternal twins born to mothers who had a BMI of 30 or greater

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• Be tall -- the same ACOG study reported a higher incidence of twins in mothers who were in the top 25th percentile for height
• Be Nigerian. This country supposedly has the highest rate of twins in the world, at 1 in 22 births. Some attribute this to their consumption of large quantities of yams.

HOW TO INCREASE YOUR ODDS OF HAVING TWINS:

• Take fertility drus or undergo fertility treatments- Fertility treatments have had a major impact on the increased multiple birth rate.
• Eat yams - it is thought a certain chemical in the yams helps to stimulate ovulation
• Be breastfeeding when you get pregnant - recent studies show that breastfeeding mothers who conceive are more likely to conceive twins.

HOW TO DECREASE YOUR ODDS OF HAVING TWINS:

• If you are Hispanic or Asian. A study done by the National Center for Health Statistics showed that Japanese and Chinese women have the lowest twin rates (1 in 150 and 1 in 300 respectively). This study also showed that women of Hispanic origin were much less likely to have twins than Caucasion or Black mothers.
• Live in Hawaii. This state has the lowest twin rate in the United States, about 30% below the national average.
• Give birth before the age of 25. The chance of having twins before your 25th birthday is half of what it is after your 35th birthday.

Whether you are hoping for two, or hoping not to conceive two, having twins is a double blessin

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g for those who conceive them. It is a stressful time of adjustment as new parents adapt to the needs of two newborns, but the rewards are doubled as well.

Not double trouble, but twice blessed. ~Author Unknown