#296 | Extended Q&A: RhoGAM; Premature Rupture of Membranes; Meconium; Fevers Cord Traction; Vitamin D; Waterbirth & Cold Plunges [Season 3 Reprise]

Announcement: Between now and year-end, we will be releasing a 50/50 mixture of new episodes interspersed with old-favorites, due to the sudden loss of Cynthia's husband in November. We have a new episode coming next week, and will be back to our usual production schedule by New Year's. If you'd like to donate a gift to the GoFundMe that was set up for Cynthia and her family, you may do so here. Thank you to everyone for your beautiful messages, gifts and prayers.

Please keep an eye out for new content and an expanded Down to Birth platform on Patreon, including a new Community feature where listeners can post questions for us and each other. To join and gain instant access to our entire library of video content, go to our Patreon and sign up.

Onto the show:

For this December Q&A, we kick it off, with a follow-up conversation based on one listener's response to  episode #188 on RhoGAM. Next, we jump into our questions discussing the actual risks of going past 24 hours or ruptured membranes without contractions and how you can mitigate those risks. We break down why meconium becomes more concerning after 42 weeks gestation and what those actual risks are. One mother who has the flu in the third trimester wonders if this is harmful to her baby and what she should do about it; another mom is curious if it is more helpful or hurtful to use assistance to birth her placenta and questions if a hep-lock or IV port is really necessary in labor. Furthermore, is vitamin D supplementation truly necessary for breastfed babies? Also, we discuss how to accurately calculate your due date based on your specific menstrual cycle, not the average cycle. We discuss delayed cord clamping and where to clamp the cord, two-vessel cords and the implications for induction and the safety of home-birth with midwives who have restricted access to emergency medications. 

Additionally, we have a great quickies segment on pregnancy headaches, aging placentas, newborn rashes, breast changes in pregnancy, cold-plunging postpartum, water birth and infections and whether or not sleep training babies is really needed.

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Transcript

There is a real trend right now in routine manual extraction of the placenta. I've done some research on this, and it absolutely is causing more harm than good.

Let's say you had sex on Monday and you ovulate on Thursday, you're not going to conceive on Monday, because you haven't ovulated yet, but the sperm can live for five days, so that can throw your due date off, right? So it's not about the day you had sex, it's about the day you ovulated. I'm just

thinking of the old days when women were like, out in the fields doing their work, or in the kitchen baking their pies, and they were like, Ah, I think it's been a while since I got my period, and then suddenly they're gaining weight, and it's like, oh, when is your baby due? Well, we think in spring, right? They hear this conversation like, ah, but you had sex Monday, but did you ovulate on Monday? Do we overthink it 100% the problem with the due date is the provider. That's really the problem. That's the problem.

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

I want to read this email from a listener named Kelsey. I thought this was really worth, worth sharing, and I really appreciated that she wrote this. So she wrote, Hi, Hi, Cynthia and Trisha. I'm reaching out about your recent episode with the mama who was RH negative and her story. I'm also an Rh negative mom with an Rh Positive husband. My children both are Rh positive. I received RhoGAM with my first during pregnancy and after birth with my second. I questioned it a bit more and did a lot of research, and in the end, I decided not to receive RhoGAM during my pregnancy or after my birth. I will be getting blood work soon to see if I was sensitized during my second pregnancy. One big concerning factor for me with the RhoGAM, especially this time around, was the fact that it is a blood product from multiple people, meaning one dose is composed of plasma from more than one person. I dug and dug and could not find any information that factually stated. If rogram has plasma from donors who have received the COVID shot, the reason I'm reaching out is first to thank you for shining light on this topic, as it is very, very under researched and families have to really dig to find the information. My midwife and I had to really work together to gather the facts. I'm also reaching out, as I would love to see a follow up episode focusing more on the risk benefit analysis of RhoGAM itself. This is a product that is administered across the board to any woman who is Rh negative. There is such little information. So of course, there are even less informed consent conversations happening. I had an ER visit during my pregnancy because of some light spotting, and the first thing the doctor said not asked was all right, so you will be getting RhoGAM. He did not even ask my husband's blood type, if my husband's blood type was RH negative, and I just said, Okay, I would have received the shot for no reason at all. A really great resource on this topic is Dr Sarah Wickham. She talks a lot about it and wrote the book anti D explained as an Rh pregnant mama, it was definitely a very tough decision that caused a lot of stress and worry because of the little and sometimes conflicting information out there. If I were pregnant now and in the decision making process, and listen to your episode, I may have decided to take the rogam out of fear. Of course, you need to hear both sides in order to make an informed decision which. Is why I'd love to hear a discussion where that outcome was different from the one in the episode. Thank you so much for what you do. Kelsey, fair points worth talking about. Interesting. This doctor, they are sometimes routinely recommending program for women who are RH negative, totally, regardless of whether the husband is Rh positive, a non issue if, if he

it's negative, that shouldn't happen. But the reason that people don't talk so much about the risks of getting rogram is because the risks of a baby getting sensitized in a future pregnancy are so severe, and because the incidence is so high. I

asked her that, and she said, there's conflicting information on that too. You know

what? It's very possible that there isn't good information on that, because everybody gets rogam so there's so few cases of people who don't get it, that how would we really be able to know that? And nobody's studying it, except who she said, Sarah Wickham has written a book on it, and Sarah, if you're happen to be listening to this episode, we are trying to get you on the podcast. I haven't heard back. She's very hard to read. She has to read very hard to reach. We want to talk about vitamin sure she would, and Rogan with you. So

especially because this mom, Kelsey, read Sarah's book and came to a different conclusion. Yes,

I think, I think that's the thing, that nobody studies it and nobody talks about it, because everybody gets it, because that risk is much higher than a lot of other things that we make choices about in pregnancy. And so it just becomes a non issue for most people. And I mean, interestingly, though, in the episode that we did, the rogam didn't work at all. That's true. Nonetheless, mothers should be informed that it is a blood product and what the ingredients are in it, and what the risks of getting the vaccine or vaccine, it's like a vaccine getting what the risks of rogam are. And it goes beyond just risk of infection and pain and bruising at the site of injection. Yeah. All right, they're rare. They're rare, but you still have a right to know, of course.

All right, let's get started. Great.

Hi guys. I have just a quick question. So I know a lot of times when your water breaks, or when you think you're in labor, they kind of put kind of put you on that clock. And it seems like the magical number, from what I've heard, is kind of 24 hours, and then they want to push other options. Just why do they do that? I guess. Is there any rhyme or reason to it, or is it just more out of convenience, or, I don't know, I guess if I first my water broke and I called them, and they told me immediately I had to come in. And they said, if I didn't have her within that 24 hour mark, they were going to start intervention. So I guess, just curious why they do this. Thank you. Well,

we've touched on this a few times before, but it's always worth mentioning again. The 24 hour rule basically comes from the fact that 90% of women who break their water before contractions begin will spontaneously go into labor within 24 hours. So that's sort of become the cutoff that if you go beyond 24 hours, you're outside of that 90% and you're not normal, and so everybody wants you in labor by 24 hours, the risk of infection also goes up at 24 hours. So that's that's the standard of care that you induce or augment or get labor going at 24 at the 24 hour mark to prevent the risk of infection.

What infection? If it's not GBS, all the infections that women can get from all those unnecessary cervical exams. You mean Yes,

exactly? Well, yes, you can without whether you can still develop a choreo or an infection in the uterus without having GBS for sure, right? But it is reduced significantly if you keep everything out of the vagina, so once that bag of water is broken. Now anything, any bacteria that's in your vagina, on your skin, on somebody's hands, on any device that goes inside your vagina, is potentially introducing that into your body, into the amniotic fluid, and now there's potential risk of infection.

And we It's also worth mentioning that this there is there's no evidence to support speeding up labor or getting that baby out within at the 24 hour mark, and Trisha is talking about that statistic related to once membranes released. But what women are facing is arriving at the hospital, and that's when the clock begins. And we have a local hospital right here in Fairfield County, Connecticut, that quote gives women 10 hours, and at 10 hours, they start pushing C section and they want to see, as my doctor said to me, I want to see you dilate a centimeter an hour. Well, the heck with that. There's no research supporting any of that. So this is all rhetoric. Everything we're talking about is rhetoric, except the part Trisha said about infection. That's that's definitely worth knowing, but there's no good explanation, then we can't, we can theorize, but we can't support or explain why these policies are there. They're they're not serving women and their families that we do know.

As long as your baby's doing fine and you are not developing a fever, there is just no good reason to aggressively push labor. Just wait. Keep waiting. It'll come. It will happen. I mean, if you're not in that first 90% you're pretty likely in the next 12 to 24 hours to go into labor.

Hi, Trisha and Cynthia. My name is Regan. I am 37 weeks pregnant. I'm actually from Manitoba, Canada, I have a question for you regarding meconium. So my question about meconium came up quite early on when it came to appointments with my midwife, because I was born at 42 and four at seven pounds and six ounces. So obviously I wasn't a big baby to be born over 42 weeks. So I was talking to my midwife about it, and she didn't bring up all the usual things that I've heard, like the big baby thing or the fluid thing or the pelvis. She brought up that the baby would start inhaling meconium the longer it goes over 42 weeks. The other thing is, is, after 42 weeks, I don't have the option of bursting out of the hospital anymore, so the free birth or in a hospital, and she would not be happy at all if I went over 42 weeks. Yeah, I just wanted to ask you guys if going over 42 weeks, if meconium is as big a deal as she was making it sound to be, or Yeah, if there's not, if it's not as big a deal. Thank you.

So the risk with meconium later in pregnancy, after 42 weeks, is that the baby, one is more likely to pass meconium, and two, that your fluid is likely to be less and that combination increases the risk of meconium aspiration syndrome, which is very severe. It doesn't mean it's going to happen, but you put those two things together and the risk goes up. So that's the concern in babies born at 42 weeks and beyond have a higher incidence of Macquarie and aspiration.

So in your opinion, does normally when women are being pressured into induction at 42 weeks, it's a lot of talk around stillbirth. Are you saying you think it's reasonable justification to to routinely induce a woman at 42 weeks just because of the concern of meconium.

No, I'm just saying that the risk goes up. But no, I'm not saying routine induction at all. I don't know the percentage right off the top of my head of meconium aspiration syndrome at 42 weeks, but I think we'd be hearing a lot more pressure about that if it was greater than the risk of stillbirth, which is, you know, mostly what we hear, but if you have, usually when you go that late in pregnancy, you are doing some sort of surveillance of the baby, like a biophysical profile. And if on a biophysical profile, it was determined that you had very low fluid, then maybe you would consider those risks differently.

According to medical news, it says that meconium aspiration syndrome is a rare complication that, according to the International Journal of Pediatrics, affects .18% of full term newborns. Okay, that's a very small number. That's like less than a fifth of 1% that's a very small number. That's 18 per 10,000, so we're talking about a risk that's still half of what the stillbirth risk is at 42 weeks. So yes, the risk goes up, but again, we have to always look at what the actual numbers are and not just the relative risk. I mean this, if you, if you just flip it for a second, we're talking 99 point 99 point 22% 99 over 99.2% of women are not going to experience this, and we're talking about a woman who's who has a family history of having babies later. So 18 per 10,000 is 1.8 per 1000. So we're talking about one per 500 babies.

Hi, ladies. I've been battling the flu for the last couple of weeks, and I am just curious. Thankfully, in that time, I've only had a fever, a low gray fever once and then again today. But I'm just curious how it's hard to find information on fevers and third trimester and how concerned I should be and what I should be doing, if anything. I tend to just let my body do what it does naturally, and I don't usually take anything to lower my fevers, but I also want to make sure baby is safe.

My perspective on this is, you're not seeing much about this, because it really isn't as big a deal as as it's led, as we're all led to believe. There's a lot of rhetoric around this, but your body heats up to kill the virus. It's not affecting your baby. You get the flu, it feels miserable, it feels crummy. Your baby is just fine in there. We're led to be afraid of getting the flu. Some people say the flu is worse than getting the vaccine. But in fact, there's a lot of controversy around the vaccine. When you get the flu, you've got to take care of yourself. I believe in letting the fever do the work, as long as you're able to sleep and rest and if you're staying very well hydrated and hopefully taking really good supplements, but the baby is sitting there collecting antibodies, which is a beautiful thing, and when the baby's born, your baby's going to have all those antibodies. So that's what's happening for your baby while you're while you're laid up in bed, suffering, your baby is strengthening.

I would only just add the one thing is that if you develop a really high fever, that can cause increased heart rate or tachycardia, and it might be worth taking a fever reducer at that point. I mean, I'm all for letting the body burn it up and ride it out. But in pregnancy, sometimes we want to just have a little lower threshold. And you can take time. You can take Tylenol. What would be the threshold in your mind? Like 102 and a half? 103. Yeah, probably. But you know, it depends on how long it's prolonged to if it's just a short interval of time that it's high, then fine. But if you're really enduring a high fever for a long period of time, it a little dose of fever reducer is probably better than not.

My name is Shelby, and I am six months pregnant with my first but I got the kind of two questions, and feel free to only answer one. I know that's a lot, but my first question is around the delivering of placenta, and kind of this idea of assisting it by my OB, she misses it with routine, and I know routine is not necessarily good word, and she's been really open to all of the other things that I've proposed and the difference that I wanted to do. And so I guess my question is, is, like, is there really any benefit to the light assistance of the delivering of the placenta? Are there downsides? And then my other question is, around the I guess it's called a hemlock, where they insert the IV. She seems to really want to use one of those, not pushing IV, but I feel like it's one step from IV, and I'm really concerned that that means that other types of interventions might be pushed with that kind of being a gateway intervention. I really appreciate your thoughts on those. Thanks.

Yeah, this is really important stuff here. They're both great questions, so I think we have to answer both of them absolutely. So as far as the delivery of the placenta, it's sort of funny, because back when I was in school, which is now 18 years ago, 18, yeah, 18, active management of third stage of labor, or active management of the placenta, was then that was what we were being taught, that's clamping the cord, giving the Pitocin cord traction to birth the placenta. Now it's sort of like, okay, well, everybody knows that delayed court camping clamping is better. So we'll let that part of active management go, but we still have to do something. It's like they can't quite let go of just letting the placenta be physiologically born. So what she's asking is, is, is a little bit of traction or a little bit of active management of the placenta necessary?

It's not, no, it's just not. And what concerns me is, and I've been talking about this more and more in my HypnoBirthing classes, there is a real trend right now in routine manual extraction of the placenta. And I find this to be absolutely appalling, like the to to insert the whole hand, slash arm, lower arm, into a woman, and to pull out the placenta. I can't believe this is happening at the rate it's happening. And I've done some research on this, and it absolutely is causing more harm than good. There is a much higher risk of infection, a much higher rate of postpartum hemorrhage, possible genital tract trauma. So when we're having these, if you're very flexible with a Doctor Who, quote, likes to do this stuff, I'd be careful. I would really err on the side of saying I don't want assistance birthing my placenta, my body is going to expel. Doula, the placenta. Now, obviously, if something comes up, you would change your mind, as is your right, and you could get assistance, but I think you're in a better position to draw kind of a hard line around that, so they don't start messing with you. It's not supported by evidence. Cochrane did Cochrane had research on this. Did I say that? Right? That word Cochrane. Cochrane did research on this and some other Yeah, because it also increases postpartum endometriosis, it's really problematic. It's really problematic. So we keep looking for ways to try to reduce postpartum hemorrhage. Postpartum hemorrhage is the leading cause of maternal death worldwide, right? It's the it's the riskiest part of birth. So it's really hard for providers to not feel like they have to do something to ensure that that placenta is born as swiftly and safely as possible, when really the right thing to do is not intervene during the labor and oversaturate all the oxytocin receptors so that the body can do its job postpartum and effectively contract and stop the bleeding. So we try all these different things to see if we can do better at at birthing the placenta faster, because the longer the placenta sits there, the feeling is that the risk of postpartum hemorrhage is higher every minute we wait, so there's this sense of urgency to get it done.

The research is currently saying that there's a higher risk, if the placenta doesn't count, come out within an hour, and it normally comes out quite quickly. But I just want everyone to understand the common sense behind it, so that it makes a little bit of sense to you, if you're listening, when a placenta comes out naturally on its own, it's attached, think about it, and attached to the inside of your body through open capillaries. This is how blood is getting transmitted, right? It's blood. This is how everything is getting transmitted from the mother to the baby. It comes out on its own, only because those capillaries pinch and seal off, which is how that placenta detaches itself. It doesn't rip itself out with these open capillaries where all the bleeding is happening. That is what happens when they reach in there. Never mind what a miserable experience that is for any human being when they reach in there and take it out, all those capillaries are exposed and open, and that's why that procedure is linked to higher rates of postpartum hemorrhage,

because your body has to produce a massive amount of oxytocin when that placenta detaches in order to contract the uterus down effectively enough to seal off all of those capillaries. So this is a major reason why it's so critically important that after your baby is born, you do not lose your focus. Your birth is not over. You have to stay in your birth zone so that your body can stay in that safe, quiet, calm space that we were just in while we give birth to the baby. We have to remain there through the birth of the placenta. And so often after the baby is born, it's kind of like we snap out of it. The lights go on, the people come in, the baby's taken away. How do you expect your body to stay in that zone when all that excitement and action is happening around you? So then the placenta takes longer to be born because you're not staying in that safe nest to allow the oxytocin to do its job.

And a quick word about hep locks, they are not linked to safer birth outcomes. I do believe it's the first step in unnecessary interventions. They can get one in in an emergency situation, if they had to, even when women need emergency C sections. It's so often a part of their story that they're sitting around waiting for the surgeon to show up, or they're sitting around waiting for the paperwork to sign. And there's a lot of pressure around this, but hep locks, never mind IVs, we're just talking hep locks, which is attached to nothing. It's just a catheter in your vein. These aren't linked to safer outcomes at all. You do not need one if you want to give birth with a catheter in your vein, go for it. But this is not linked to better outcomes. It's just, in my opinion, a really unnecessary way to tether you, and you're going to be much more likely to receive intervention if you have it. It's your personal decision, but there is no evidence to support this. Trisha, I have to tell you, someone in my class the other day said that she was told she would need to have a hep lock, and she was pushing back a little bit, and the provider said to her, if we don't give you a hat lock in labor, your veins will collapse because we're not going to feed you or hydrate you. So have you ever heard that? Well, that's what happens when you get dehydrated.

So collapse. But what does collapse mean? What are they means? They they go. They go. You know how when you are looking for a vein, you want it to be protruding and bulging, so you can get a cat an IV in there. And when you're dehydrated, they get really flat. And they're hard to access, so that's what they're saying. But that's silly.

Well, the rhetoric terrified her. She thought, oh my gosh, this sounds like something I have to do, right? Like my veins are going to collapse and I'm not going to be able to breathe anymore, or it's going to cause something horrible to happen within my body. That's just all not true, right?

Next!

Hey there. I've been listening to your guys' podcast for the past several weeks of my pregnancy, several months actually, and have been so grateful for it. I do have a question, ever some women avoid dairy or other foods while breastfeeding, this includes alcohol due to the way their baby reacts. Can you explain why someone would avoid certain possible allergens and or how you would know how to avoid them. Thanks, guys.

Basically the way I see it, and I'm sure I'm going to learn a lot in our upcoming episode, in our upcoming interview. But my my training and understanding about allergens and breast milk is that whatever the mother is highly sensitive to food wise. So she has an allergy to dairy, wheat, corn, soy, whatever it is that she's more likely to produce antigens when she consumes those foods. In the antigen itself that her body produces can sometimes leak through into the milk ducts and be transferred to the baby. It's more likely to happen in moms who have abundant milk supply or oversupply or lots of engorgement. It's like the ducks get a little bit more leaky under pressure. So it's very common with oversupply to see babies have allergy type reactions and breastfeeding, which can be colic, reflux, rashes, eczema, excessive fussiness, that kind of thing. The most common culprits are dairy, soy, corn, wheat. So it's really common for moms who have any complaint about their babies, for their pediatrician to say you should cut dairy out of your diet. That's like the go to get rid of dairy, and dairy is the number one culprit. But I like to take a step back and you know, there could be some underlying breastfeeding issue that the pediatricians not picking up and picking up on. It's not always a food allergy. It might be a hyper lactation issue, and if you're not sensitive particularly to dairy, you've never noticed you have an issue at all with it. It's not likely that your baby is.

Hi, Cynthia and Trisha. Long story short, I had a beautiful VBAC birth in June, and it was only detected two weeks ago that I actually had a cervical laceration. I had a slight postpartum hemorrhage that was quickly controlled with the use of Pitocin. And my provider is a an osteopathic doctor, and she said that she would have to look into the implications and whether to repair or not. I currently don't know if we want another child. That is up for debate, but I'm wondering, like, what are the implications? What are the risks of having a cervical laceration? I know it has been linked to incompetent cervix, which I know we don't love that term, but I you know there's some information out there about whether you should have a cesarean before you go into labor. So it's just curious what your thoughts are. Of course, going to see what my provider says. But in the meantime, I would love to know your thoughts.

Okay, so the risk here with having a cervical laceration is in a subsequent pregnancy, there is, would be the consideration of the, you know, pre term labor, preterm birth, because the cervix would not be staying closed and tight. However, this does not pan out in the evidence. There was a study done back in 2016 which showed that there was no difference in preterm birth rates for women who have cervical lacerations in a prior pregnancy, and that the management of care of her pregnancy should not be altered in any way. So she doesn't necessarily, she certainly doesn't need a C section. She doesn't necessarily need progesterone or a circle, which are the two things that would be most likely offered to prevent, to keep the cervix closed and prevent it from early dilation.

Yep. And I reached out, um to Tara Gibson, and she said sometimes a pelvic floor physical therapist can help with lacerations. So it just depends on the laceration, on the laceration, but they, but they absolutely do work on these.

The cervix heals, just like any other part of the body, just like the uterus, it heals, and there's no such thing as an incompetent cervix. That's just terrible language.

Hi, ladies, I'm wondering if you have any thoughts on the use of a Doppler, particularly to check the heartbeat in the first trimester, around 10 to 12 weeks, I'd put. Prefer to use a pedoscope, but I know it won't pick up the heartbeat that early, and I'm a first time mom, so I just want to hear the heartbeat and have some confirmation that everything's going okay, but I am concerned about radiation, and want to limit that. So just wondering if you can share your thoughts and anything about the safety of using a Doppler. Thanks.

Oh, if only every provider knew how to use a feed a scope.

I know. What is the big deal? This, this aversion to it. It's such a lovely means of getting the heart rate.

And you hear the heart rate actually in a natural way. It sounds like a real heartbeat, and not this amplified sound that comes through the Doppler. However, yes, it is harder to get it earlier on. We can certainly get confirmation of heartbeat much earlier on with a Doppler, or even earlier with ultrasound. But yeah, there's some risk of exposure. What that is exactly, you know, nobody's talking about it as being a real major problem, but it's not benign.

Yeah, more and more research is coming out on that now the point is, I mean, Doppler is less than ultrasound. Intrauterine ultrasound is the most. These higher tech ultrasounds now have more the duration that you're exposing the baby has more. And we're not saying this to distress anyone, because virtually everyone is getting ultrasounds, but there is good reason to not get any ultrasounds unless you really need to or want to. I mean, the anatomy scan makes sense for a lot of people, but after that, just to keep checking on the baby with ultrasound, you really can turn those down. And if you don't, there's research to show if you're getting unnecessary third trimester ultrasounds that is linked to dramatically different birth outcomes, and we'll cover that in one of our upcoming live streams on Patreon Trisha, because there's really good meta analysis to show the bad information that comes from that. So Doppler is, you know, you can view it as a it is less exposure than an ultrasound. You can view it as a necessary evil. You can choose to get it and not let it bother you at all because the risks are still debatable, or you just decline. You can decline those as well, right?

You don't have you definitely don't have to have that. I think your point about duration is really important. Many people are just going to want confirmation of the heartbeat. It only takes a second. You hear it beat a couple times, and you can turn that thing off. You don't need to sit and listen to it for a minute. And that's a Doppler. Doppler, yeah, yeah. Or even with ultrasound, yeah, the moment they see it, you can be like, That's it. I'm good, done.

And the provider is happy because they get to bill for that one right?

10 seconds. Everybody's happy. All right. Next,

Hello, ladies. I had a question about vitamin D supplements for breast fed babies. I feel like I'm getting conflicting information where my breast milk is everything my baby needs, but I also need to be supplementing with vitamin D, so I was just wondering your thoughts about it. All right? Thank you. So yes, your breast milk should have everything your baby needs. But the issue is that human adults are not always as nutritionally replete as we should be. Many of us are deficient because we eat highly processed foods, and our soil is deficient in many vitamins and minerals, and we certainly don't get enough outdoor exposure. So most of us have low vitamin D, therefore we can't expect, expect the breast milk to be sufficient in vitamin D. So the recommendation is that babies receive 400 I use daily of vitamin D via dropper. If they're exclusively breastfed, formula fed, babies are supplemented in formula with vitamin D. Or if a mother takes, I believe it's 5000 5000 I use daily of vitamin D, then her body should have enough vitamin D to sufficiently provide vitamin D for the baby via the breast milk.

Hi, I have a question about the calculation of due dates. Given that so many women are not tracking their own cycles in pre conception, I imagine that the due dates calculated by medical providers when a pregnancy is confirmed, can potentially be a bit off, or even off a whole lot. So fast forwarding to the end of pregnancy, we know that a significant number of women face induction pressure when the pregnancy goes past the due date indicated by the medical provider. And in my experience as a doula, many medical providers consider an induction medically necessary on or after 41 weeks. So in practice, in my mind, the due date, particularly in the medical setting, is incredibly important given. This, I imagine that then it becomes really important to prepare for an evidence based pregnancy by tracking our own cycles and preconceptions. So my question is, what in particular is it important for women to track and keep notes on menstrual cycle, Start, End Date, ovulation date, signs of implantation bleeding, etc. Then once we're pregnant, how are due dates normally calculated in a medical setting? Is this calculation method reliable for all women, given that cycle phase lengths vary across women? How can a woman advocate for herself if she feels the due date her provider has given her is inaccurate? This one little number is often the sole deciding factor between a spontaneous labor and an induced labor. It feels so important to get it right, especially for women birthing in a standard obstetric care model. Thank you.

Wow. She did a great job asking that question, because she touched on so many little pieces of it that are really important.

She She laid it all out due dates. If the provider tries to move your due date, I always tell everyone, if they're trying to move it out later, grab it if they're trying to move it up earlier, especially based on ultrasound. But for any reason, refuse. Just refuse. Say, I don't acknowledge the new due date. I'm not changing it, like cover your ears and eyes, and say I'm not listening, because that's it's not going to serve you if they move it up closer. They the fact that they look at ultrasound, look at a baby's weight, which can be all over the place by the end of pregnancy, all over the place. And estimate gestation when a woman herself knows, especially when a woman herself knows when she conceived. It's just not reasonable.

So early ultrasound is far more accurate. So the estimated due dates, that's

only because the range isn't as great as later at birth, a baby could be five to That's right, 12 pounds. That's the only reason it's more accurate. It's the same technology that's that's not inherently accurate, but it's like we're only talking about our ounces in the beginning, not

well, it's not based on weight in the beginning. It's not weight. It's they're measuring a length, a size, and it's, it's a different it's a different variable, it's a different measurement. And it is at early ultrasound.

It's not based on weight later either. It's based on size measurements. Will they determine a weight based on various size measurements? But they did once too. The evidence does support that early ultrasound is accurate for due dates within a two to three days. However, two to three days still makes a difference, and pregnancy is 280 days. That's the regular that's the average length of gestation. But the variable is, when does a woman ovulate based on her menstrual cycle? So she asked the question like, what's the most important thing to know? And what's important to know is your menstrual cycle length? Are you a 21 day cycler, or are you a 35 day cycler? Because if you base your due date using the standard calculation of LMP, or last menstrual period, and you're a 35 day cycler, your due date is going to be way off. The LMP is based on a 28 day cycle. So if you're short or you're long on your cycle, that's really important information to share. Now, if you know the exact day of conception, it's actually ovulation that you need to know. So you could have sex, and then you might not ovulate for four days, and that could throw your due date by four days. So you have to know date of ovulation, and pregnancy lasts 266 days on average from ovulation. Let's say you had sex on Monday, and you obviously ovulate on Thursday. You're not going to conceive on Monday because you haven't ovulated yet, but the sperm can live for five days, so that can throw your day date off, right? So it's not about the day you had sex, it's about the day you ovulated. And if you have a 28 day cycle, you ovulated on day 14. If you have a 32 day cycle, you probably ovulated on day 18. We typically ovulate 14 days before we get our period. I'm just thinking of the old days when women were like, out in the fields doing their work, or in the kitchen baking their pies, and they were like, Ah, I think it's been a while since I got my period, and then suddenly they're gaining weight. And it's like, oh, when is your baby due? Well, we think in spring, right? It's like, right, what happened anyway? If they could hear this conversation, like, ah, but you had sex Monday, but did you ovulate on Monday?

It's, do we overthink it? Uh huh. 100% and I would do it too. I do the same. I you know, I get it.

That's why pregnancy has a window of time of five weeks. That's all within a normal range to give birth to your baby. The only factor that we're concerned about is the basically what we talked about early on in the episode, increased risks beyond 42 weeks. That's all we're worried about. And if you know those risks and you're willing to take them, you have nothing to worry about. Your due date doesn't matter.

The problem with the due date is the provider. That's really the problem.

Problem. Hi, ladies, I had a question about delayed cord clamping and just the umbilical cord in general. So I just had my daughter two weeks ago, and I got to the hospital and she was born really quickly. The midwife hadn't had time to look over my birth plan or anything. And after she was born, just a minute or so after she was laying on my chest, the pediatric nurse came up and went to clamp the cord. And I said, No, we're doing delayed cord clamping. And she said, Yeah, I'm not cutting it or anything. I'm just going to clamp it. And she slapped the clamp on. And I had just given birth, so I didn't feel like putting up a fight, and I was just whatever. So I let it go. And then later, someone told me that the standard is, after the baby comes out, the midwife clamps the core is like down lower, which I was just curious if that is a thing, or if my pediatric nurse just disobeyed my request. And also I was wondering, just with how like rough and careless the nurse seemed, if there's any tactic to putting the clamp on. I hate dealing with the umbilical cord postpartum, and I don't know if my kids have low belly button. But no matter how low I felt the diaper, it always rubbed, and I always worry about it, and I just felt like it was so long, and it ended up falling off after like, four days, which is really soon, I think, because it was rubbing so much. So I was wondering if that is something that you can be more careful about and clamp it really close, or if there's a standard of care for that that it needs to be clamped, not right up against the baby. So yeah, I was just curious. Thank you so much. Bye. It sounds to me like the pediatric nurse doesn't know anything about cord clamping.

It sounds to me like a passive aggressive pediatric nurse, both because this has happened to clients of mine where they said, Oh no, we don't want to cut the cord yet. And they lie there, and they're bonding with their babies, and then after a little while, they look down and they're like, wait a minute, why is the clamp there? And in one case, I'm thinking of one woman who took my class years ago. I still remember her so well. And the nurse was like, what you said, you didn't want to cut the cord. We clamped it. And it's it was so upsetting. It was so passive aggressive, because obviously the goal of not cutting it early is to allow the baby to receive all of his or her blood. And they clamped it, very manipulative. That's terrible. It's the same thing. You might as well have cut it. Of course, you might as well have cut it and then. So that was the first point, I think. But then the second thing this woman was asking was something about midwives clamping it lowered down. Is she saying that when midwives clamp it, it's lower down, so they get a little more blood before they stop all the blood from reaching the baby, which is the goal. I don't get that. I'm not entirely sure that part of it, but she was saying that maybe she would prefer it if the cord was cut and clamped closer to the baby, so that the cord wasn't the residual cord that's left after the cut was not so long in rubbing on the diaper. First of all, it's not a problem if the cord falls off a day four, that is fine. That sounds normal. No, yes. Whenever it's dry and it falls off, it's fine. But I will say that there are things that you can clamp the cord with that are less bulky. So at the hospital, they use those thick plastic binder type things. I can't stand those. They're like, so annoying, and they they're constantly, you know, moving and getting in the way and rubbing on the clothes, and they're cumbersome. At home, we usually use a teeny, tiny, little rubber band that you can't even notice. I had a big old, I think, for my whole birth and my birth center birth, I think they were a big old plastic, let's

see. I don't like those. No, my children all had actually reusable stainless steel ones that you could easily just remove yourself. So I only left it on for maybe 24 hours, and then once I was sure that the cord was dried a little bit and sealed, I just would take it off myself, like my babies had little stainless steel ones with their initials etched into they were 24 karat gold jewels. They had jewels, but really good for you.

No, they were so much better though. No, it's funny that, but I really didn't know about those. Trisha and I had a home birth. Myself and a birth center birth, and I think in both cases, and you were at my home birth, you weren't the primary midwife. You were the supporting midwife. But still, I believe I had that big, clunky plastic thing. We were using the cheap plastic, yeah, because we're like, yeah, you know why? Because we could no longer get the beautiful stainless steel ones. Really no silverettes. There's a new project for you. Yes, make an umbilical cord clamp. That's such a good point. A reusable, sterilizable umbilical cord clamp. And women can bring them to their own bursts, because you can't take those plastic ones off. You have to wait for the cord to fall off. Right? These little silver clamps, I could just release it when I was ready.

I mean, I've seen birth videos where it's like just a little string and it's really you

can do or you can do cord burning. They don't put anything on what does

that mean? That sounds really dramatic. Cord burning, like setting the umbilical cord on fire. Yeah, I have never been at a birth where it's done, but it is practiced, it is done. But, you know, I was joking when I said setting the umbilical cord on fire. Can you tell, literally, what is no, what is what literally? Is it? I was joking. It is literally burning the cord. What? Yes, you put a flame under, severing it with a flame, severing it with a flame, and then the smoke goes in the air, and the baby, like you all just smell this burning in the air.

It's like a candle burning in your home. That's not a big deal. You put, you light a candle, you put it under the sounds kind of cool, and you burn it. It's and it's very ceremonial. I've actually never seen it done, though, but you also, you know you have to wait a little while to do that, so your midwife have to be there with you for a little bit. It's not like it's done in the first few minutes after birth. Like in the hospital, they want to get that clamp on, cut the cord, be done, get rid of the placenta, close up shop.

Hi. My name is Liz. I am a mom of two. I'm based in New Jersey, and I had a question, hopefully for the podcast, I would love to know what your thoughts are. So I as I said, I have two children, and with my youngest, my second, I had a two vessel umbilical cord, which is also known as a single umbilical artery. I was wondering, would you consider this reason for induction? My midwife allowed me to wait until my due date, but I was induced on my due date because of that umbilical cord abnormality, and unfortunately, it ended in a C section, which was the last resort after a long failed induction. It turns out the baby was presenting asynclitics. So would you say that induction made sense for a two vessel cord baby, or was it likely not necessary? This is always something that I wondered. So thank you in advance, and I hope to hear the question answered on the show, bye. Bye.

Okay. Gosh, we get a lot of two vessel cord questions due date, right? She was induced on her due date. But this seems to be coming up quite a lot. So this must be the two vessel cord. Must be one of those things out there right now, like IUGR big babies, where everybody just it's a good excuse to push for induction. We do know that there are some increased risks with the two vessel cord. So can you explain a two vessel cord? What the normal usual is, and then what it means to have a two vessel cord?

Okay, so what it means is that you typically have two arteries, in one vein, three vessels, in a cord and in a single vessel or in a two vessel cord, you have one and one. So the incidence of a two vessel cord is generally around 1% it is more common in multiples in pregnancy. So maybe that's why we get so many more questions on this, as we have a lot of multiples, I think multiples there's just on the rise because of fertility treatment. Yeah, I think that's so. So it's, um, it's more prevalent everywhere, which means it's more prevalent in our population. And we talk a lot about twin birth and support natural twin birth. So I do think that we have a population of people anyway, nonetheless, there are slightly increased risks to a baby with a two vessel cord, most babies will absolutely have no effect from this, but because you are missing one of the arteries, there is the risk of IUGR, intrauterine growth restriction, a slightly increased risk of stillbirth. And it is just one of those things where I think it's like, you know, for providers to just kind of throw that induction card out there, it's a good reason to say, let's get you on the induction induction schedule. You have a two vessel cord. This is a variation of normal that may benefit from your baby being born early. We've already let you go to full term. Why wait another day? Do.

But there really isn't the research to show that there are better outcomes. There are some increased risks. So you may again be in that position of going more frequently for biophysical profiles, making sure that the group baby's still growing well. But as long as the you know, perfusion to the baby is normal and there are no signs of compromise, then I don't think that you need to be induced. The reason for induction is because that there is an increased risk of IUGR and stillbirth with a two vessel cord. I don't know the exact incidence of that off the top of my head, but that would be why they would push for induction. Now, she did mention that she had to have a C section because her baby was a synclitic at 40 weeks. Okay, so asynclitic means that the baby's head is presenting slightly off center. So we want the baby's head to be centered as it, you know, puts pressure on the cervix and moves down through the pelvis. If it's slightly off center and tilted like the ear toward the shoulder, then that head diameter is bigger and doesn't fit so well. So sometimes, when we induce too early and we haven't allowed the baby to get into proper alignment for physiologic birth, we have asin clinic presentation, and then we put Pitocin on top of that, and the baby doesn't necessarily have time to make its maneuvers because we're forcing those contractions. So her intuition and her, you know, her, her sense of this, I think, is right, that she was induced at 40 weeks, and she had a C section because of an asynclitic presentation she may have, if she was left undisturbed, she may have gone to 41 weeks, 41 and a half 42 and that may have given her body and her baby more time to get properly positioned.

Hi, my name is Kate. I'm a longtime listener of the down to birth podcast, and I was recently pregnant with my first baby. So I live in the state of Virginia, and I learned quickly when I started to dig into home birth here and finding a midwife that midwives here do not have legal access to medications or legal permission to administer medications. This applies to antibiotics, RhoGAM, oxygen, Pitocin, all of those things that you all have mentioned on your show midwives having in case of emergencies or when they need them. So I was wondering if y'all could address maybe the people who are going into their home birth without guaranteed access to these things, there is a way to get them that you have to find and pay for a visit with a hospital, nurse midwife or doctor who's willing to prescribe you those things for use at home, which, as you can imagine, is very difficult to do. So I'm planning my home birth. I'm very excited for my home birth. I've talked to my midwife, and they are pretty much forced to treat almost everything with verbal medicine. They do send people to doctors to get antibiotics, to get rhogams, to get things like that, but it is very difficult, and because of that extra difficulty, I know a lot more people probably decline who would benefit from those things. Thanks for everything you guys do.

Gosh, I wish we had her, mean Hayes Klein on the call for this one.

She'd love to jump on and talk about this. So the issue is in some states and not others, midwives have access to these necessary, potentially life saving interventions or drugs like Pitocin in the case of postpartum hemorrhage, right? So what we're learning is in some states that's not even legal for a home birth midwife to have Pitocin on her to stop a hemorrhage.

Well, I think that's actually the case in a lot of states, in states that allow, in states where CNMs do home birth, that's probably more common that they have that on them. But yeah, this is all the various laws and licensure that are trying to prohibit providers from doing midwives from doing home birth, and patients from choosing home birth, your clients from choosing home birth. So just to be clear, they're going about that by making a less safe environment for women to birth at home. That's how they're going about this. Yes, saying, while it's still legal, let's give these midwives access to everything they need to keep these families safer, exactly that's on that's unconscionable. And why am I surprised? I'm not. You shouldn't be surprised. The reason that the part of what makes what makes home birth more safe is the ability to manage emergencies. And if we don't have those medications, we cannot manage those emergencies, things, things like rogam antibiotics for GBs. I mean, those are, those are non emergency things. You can get those by going to a doctor's appointment. We know already with GBs, other ways of, you know, reducing the risk of infection. But when we're talking. Talking about postpartum hemorrhage, which is the leading cause of death in maternal mortality for women in pregnancy to deny midwives access to that medication is wrong. I mean, it's just wrong. You're just, you're just preventing women from being able to have their safest home birth. And you know, refusing women care if they transfer to the hospital, refusing the midwife to have access and to collaborate with the OB when they have to transfer care. I mean, these are all things that are making home birth less safe. We can make home birth as safe as any birth by supporting access and supporting collaborative care and supporting continuity of care. So her question is, was, basically, should I feel okay having a home birth if my midwife doesn't have access to these medications? That's a hard question. I mean, for the non emergent things like antibiotics and Vitamin K. That vitamin K? Yep, I would think that her midwife probably has a way to get access to medications for postpartum hemorrhage, maybe oxygen for the baby. But you know, this is a this poses a larger question of, what is safe birth and safe is relative. Is birth, is giving birth necessarily in the hospital safe versus giving birth at home without these medications, is which one's safer? Like there's increased risk in the hospital, there's increased risk at home without these things.

So if you go back to I believe it was episode 178 which was our third episode with civil rights attorney Hermine Hayes Klein. She's fantastic, and we've had three great episodes with her. That was the whole premise of that most recent episode we did with her, in which there's this endless debate what's safer hospital versus home birth, and those numbers are often manipulated, and we talk about that a little bit in that episode, but her key point is it's very important to recognize that those good statistics are happening in countries where midwifery care is supported by the hospital system, so that if there is a transfer, they're ready to take that midwife and take that birthing mom in that they can support what the midwives are doing at home, and that's not how it is in the US. And this is a perfect example of how it looks like they're looking for that end statistic of worse outcomes to prove their point. But they're really not supporting midwives and families in some states, I guess, for her specific question, I would say that if you were going to give birth at home without access to any of these medications, no oxygen for the baby, no medications to manage postpartum hemorrhage, then I would consider proximity to the hospital and access to the hospital as a key factor in whether I had a home birth or not. If you're hours from a hospital, I you know, would take that into consideration. If you're closer and a transfer is easy, then that makes it safer.

Alright, let's get to quickies.

Okay. How can I combat early pregnancy headaches, other than sleep and water,

eat more frequently. Don't let your blood sugar get low. That's the main trigger of headaches in early pregnancy is low blood sugar, and that happens really easily, so eat at least every two to three hours, smaller meals more often. How do I talk to my OB about aging placentas not being a thing?

You don't need to talk to your OB about this. Their mind is already made up. If they were interested in this, they'd be listening to our podcast episodes with Rachel Reed, or they'd be doing the research on their own. So the question isn't how to convince them. They have to convince you of things. You just have to do your your research, make up your mind and then manage your doctor. That's all you have to do. Create your boundaries and manage your doctor. You're not there to convince anyone of anything. It's actually the reverse next that's all perfect, all right, is 26 weeks too late to switch from a birth center to a home birth midway? Oh, of course, not at all. That's early switch go. I've had couple switch

from one provider to the next after 40 weeks. Wow, coming to mind right now. In fact, one of them messaged me today on Instagram. Wow, yeah. So no, you got plenty of time. Is it a red flag to spend eight plus hours in a birth center after a car crash and only see the midwife one time? Wow, that sounds concerning, so she was involved in a car crash, went to the midwife's office to have the baby checked. I'm sure. I'm just assuming this is the story, and waited was there for eight hours to be monitored, only seen by the midwife one time, I would say, yeah, that's concerning, because that just. Indicates that they are over booked, understaffed. I mean, that's a long time to leave you.

I mean, maybe she was hooked up to some kind of monitor, and there really wasn't much to be done, though. And maybe it's not the nicest but maybe it's not negligent care either, because there was probably like, a nurse watching the monitor or something.

Yeah, you still think you'd to be seen by your midwife more than once in eight hours, a hug or a stroke of the head, something, please, something, yeah. I mean, it's a it's a precautionary sign.

I mean, the only question is, how did it feel? Really right?

And has, have you felt that way again? Since it's kind of like a fluke, it's kind of like if you give birth with like a doctor or midwife, and you feel like you love them so much, and you feel like they cared about you so much, and they see you six weeks later, and they're like, you had a boy, right? You're like, what? Right? You wouldn't come into thinking of me and my baby every day. Yeah, that's these little moments can really sting. Okay, are little bumps on my newborns face? Normal? Very likely. Yes. I mean, newborn skin is so full of little bumps and color discolorations and rashes are so common, and newborns, their skin is very sensitive, so absolutely and by three weeks of age, don't forget that newborn acne is a real thing. Yeah, usually clears by five weeks, and they always say, don't schedule your newborn photos between three and five weeks, because it happens to all of them. How do your boobs change as you get closer to delivery? They don't actually change that much. They can get a little throughout pregnancy. They can get a little by the end, yeah, think a little bit. I mean, they sort of change throughout pregnancy. Your nipples get darker, your breasts get fuller, things become more sensitive. But there isn't like this massive change right before delivery, right there is on the fourth day when your milk comes in. That is massive. That is a massive change. Can water birth increase the risk of urinary tract infections? No, ma'am, and people will tell you that it can, or people will tell you that it increases the risk of infection overall, and it does not. So don't buy that. If you don't sleep train, will the baby eventually sleep the right number of hours? Yes, yes, without a doubt.

Yeah, by college, they'll be sleeping all the time.

Just wait till they're teenagers, they're exhausted, they'll get plenty of sleep. Yeah, I

mean sleep training, though, there's an aversion to the word training, and I don't love it either, but like developing good sleep habits with a baby can serve you and your baby really well. It's not just a function of how many hours they get, but how much restful sleep you're all getting. Anyway, yeah, it's a hard question to answer. Honestly, I don't know what to say to that.

I don't think you have to sleep train if you're having major sleep difficulties and something feels really abnormal, then you could look into some sleep support, yes, but you don't have to train them in order to get them to sleep the right number of hours. Okay, what are your thoughts on cold plunging for detoxing six weeks postpartum, I am breastfeeding as well.

That's bold. It's great for the immune system. It's great. But how on earth is that practical? Are you going to do a cold plunge? Maybe she has a cold, cold plunge. Maybe she does what do you think of that in front of her house? I think that if it feels right to her and her body feels ready for that, it's similar to like returning to exercise when you feel ready, go. Start slowly. Don't try to sit in a cold pool for five minutes. Maybe you do 10 seconds, you build up to 30 seconds, you build up to a minute, as long as it feels okay to your body, it's fine, it's not going to hurt anything.

Would you do it? And I wouldn't do it under any circumstance. No, I would. I would like to, I try to, I try to make the water in the shower cold. Sometimes I've started doing that. I finished every shower with a cold, cold.

Oh, I started cold. I can't finish cold.

Oh, no, you have to do the only way around. It's starting at cold is miserable, but it was miserable, no, because you're hot then, and then the cold actually feels okay. But then you finish the shower and you're shivering, whereas the other way, you end up nice and toasty warm.

I get so cold so easily. You know that about me? Yeah, but when I do a cold finish to my shower, I am never cold when I get out. Not at all how I feel so invigorated. Oh, wow. It's super healthy. Okay, try it that way. All right, switch. My water doesn't get that cold. It's like my best opportunity is, that's really part of the problem. It doesn't get come to my house. Oh my gosh. Your house comes from hundreds of feet down in there, but it's so cold. Ours doesn't get that cold. Actually. It's not hundreds of feet down the ground. It's not that cold, but because it sits in the pipes on the surface, it is really cold. Now, are we done? That's it. All right? Happy, healthy, thriving, prosperous, beautiful, healing. New Year to you and your loved ones and to the to the Earth at large.

Happy New Year, everyone.

Thank you for joining us at the Down To Birth Show. You can reach us @downtobirthshow on Instagram or email us at Contact@DownToBirthShow.com. All of Cynthia’s classes and Trisha’s breastfeeding services are offered live online, serving women and couples everywhere. Please remember this information is made available to you for educational and informational purposes only. It is in no way a substitute for medical advice. For our full disclaimer visit downtobirthshow.com/disclaimer. Thanks for tuning in, and as always, hear everyone and listen to yourself.

Hey, there to my two favorite East Coast birth ladies. It's Lee calling you from Kauai, Hawaii, where this evening and most evenings, I am incredibly grateful for the fact that our night skies here are so clear there is no ambient light, and the stars are always so special. Blessing to you, and much, much thanks for all you do. Aloha.