A Timely Birth

by Gail Hart
© 2004 Midwifery Today, Inc. All rights reserved.

[Editor's note: This article first appeared in Midwifery Today Issue 72, Winter 2004.]
Photo by Caroline Brown

The timing of birth has major consequences for a baby. Too early or too late
can mean the difference between life and death. Or so we have come to believe;
and it's undoubtedly true at the extreme ends of preterm and postterm birth
dates. Although few babies are born at these extremes of the normal length of
pregnancy, much of our prenatal care is based on bringing babies to birth "in a
timely fashion"—neither too early nor too late. But our understanding of
"timely" is clouded, and some of our methods are self-defeating. By intervening in the natural
timing of birth, we sometimes exacerbate the problems or create entirely new ones.

Normal human pregnancy is approximately 280 days, with a variation of about three weeks.
There may be reason for concern if labor has not begun weeks after the due date, since placental
function begins to slow after some point in gestation. Placental insufficiency can lead to poor
fetal growth and, eventually, damage to the baby's organ systems or even stillbirth. This is rare,
but it is not necessarily connected to the calendar. The placenta can begin to fail at any point in
pregnancy, and part of good prenatal care is monitoring growth and fluid levels so we can act
before the baby's reserves are drained. We induce labor—even advise a cesarean without labor—
if the baby is in trouble, regardless of due dates. It is obvious that a baby is "better off out than
in" if the placenta can no longer nourish him/her or if the uterus has become a dangerous place.

Induction Risks

But induction of labor causes so many problems that it should be a rarity, performed only when
the benefits can be proven to outweigh the risks. Induction multiplies the risk of cesarean
section, forceps-assisted delivery, shoulder dystocia, hemorrhage, fetal distress and meconium
aspiration. It is a major contributor to birth-related expenses and complications in the US. Yet it
is so common that we almost think of it as normal. More than a third of American women were
induced in 1999, and another third had labors augmented with Pitocin. (The FDA says that this is
the lowest estimate and that the true incidence of induction is "widely under-reported.")

Even with early pregnancy tests and ultrasounds, induction of labor remains one of the largest
causes of prematurity. Ultrasonic estimation of gestational age is still an inexact science; the
range of error increases as pregnancy advances. Artifact and technician inexperience can
multiply the inaccuracy. Many practitioners seem unaware of this error range or, alternatively,
are unwilling to second guess a due date "confirmed" by ultrasound, even when the woman's
history and clinical assessment indicate a later due date. Hence, the woman may be induced,
even though the baby is clearly several weeks early. Some people discount the danger of early
induction as long as the baby is within the last month of gestation. But even minor degrees of
prematurity can cause harm. Babies born before full maturity can suffer from breathing
difficulties or transient tachypnea, requiring separation in the hospital. They may be more prone
to meconium aspiration. They are at risk for hypoglycemia and may have trouble maintaining
body temperature. They are at increased risk for nursing difficulties and feeding disorders. They
suffer from colic and digestive disturbances. These "minor problems" can affect the early
bonding experience and make family adjustments more difficult. The incidence of child abuse is
higher with "difficult" babies. As midwives we should aim for our families to experience the best
emotional as well as physical health possible. A timely birth is a good step in this direction!

Preterm birth is rising in the United States. Some of this rise results from misjudged due dates
and the fear of postdates pregnancy. Some reason that the risk of inducing an early baby is lower
than the risk of allowing a pregnancy to continue past due, even when the due date is uncertain.
This might be true if the perceived risk of postdates matched the actual risk. But it doesn't!

Postdates

Postdates, by itself, is not associated with poor pregnancy outcome. Extreme postdates or
postdates in conjunction with poor fetal growth or developmental abnormalities does show an
increased risk of stillbirth. But if growth restriction and birth defects are removed, there is no
statistical increase in risk until a pregnancy reaches 42 weeks and no significant risk until past 43
weeks. The primary "evidence" of a sharp rise in stillbirth after 40 weeks—often misquoted as
"double at 42 weeks and triple at 43 weeks"—seems to come from one study based on data
collected in 1958.(1)

The first question one should ask is whether neonatal mortality statistics from the 1950s should
be compared to modern statistics, since labor anesthetics and forceps rates were very different.
Early labor monitoring was scanty and prenatal monitoring not yet developed. The McClure-
Brown report shows a rise in stillbirth from 10/1000 at 40 weeks to about 18/1000 at 42 weeks.
Yes, that is nearly double. But think about those numbers. Even the beginning point is nearly ten
times the modern mortality rate. Either modern delivery methods are vastly different or
something is wrong with the data collection. This study should be updated by research conducted
at least in this century! Modern statistics show an almost flat rate of stillbirth from 40 weeks to
42, with a slight rise at 43 weeks (all numbers being close to 1/1000).(2)

There is a creeping overreaction in dealing with postdates pregnancies. It is true that the stillbirth
and fetal distress rates rise more sharply after 43 weeks, but it is also true that less than ten
percent of babies born at 43 weeks suffer from postmaturity syndrome (over 90% show no
signs). We should react to this rise by monitoring postdate pregnancies carefully and inducing if
problems arise. But the rise in problems at 43 weeks does not imply a similar risk at 42 and 41
weeks. Postmaturity syndrome is a continuum. It becomes more likely as weeks progress past the
due date but does not start on the due date. And the risks need to be compared to the risks of
interventions. Induction, as already noted, is not risk free. In addition to the risks of prematurity,
induced labors have higher rates of cesarean section, uterine rupture, cord prolapse, meconium
aspiration, fetal distress, neonatal jaundice, maternal hemorrhage and even the rare but disastrous
amniotic fluid embolism.
Large studies have shown that monitoring pregnancy while waiting for spontaneous labor results
in fewer cesareans without any rise in the stillbirth rate. One retrospective study of almost 1800
postterm (past 42 weeks) pregnancies with reliable dates compared this group with a matched
group delivering "on time" (between 37 and 41 weeks). The perinatal mortality was similar in
both groups (0.56 /1000 in the postterm and 0.75/1000 in the on-time group). The rates of
meconium, shoulder dystocia and cesarean were almost identical. The rates of fetal distress,
instrumental delivery and low Apgar were actually lower in the postdate group than in the on-
time group.(3) This is only one of several studies showing postdate pregnancies can be
monitored safely until delivery or until indications arise for induction. Even the famous Canadian
Multicenter Post-term Pregnancy Trial Group (Hannah) of 1700 postdates women showed no
difference in perinatal outcome among women who were monitored past their due date, as
compared with those who were induced at term.(4)

In some studies, postterm births have shown a higher cesarean rate for suspected fetal distress.
However, when a group of researchers conducted a case-matched review of nearly 300 postdates
pregnancies, they concluded that the increased rate of obstetric and neonatal interventions "does
not appear to be a result of underlying pathology associated with post-term pregnancy." They
suggest that "a lower threshold for clinical intervention in pregnancies perceived to be 'at-risk'
may be a significant contributing factor." In other words, the perceived risk is greater than the
actual risk and can become a self-fulfilling prophecy!(5) When monitoring demonstrates that
fetal growth, activity and amniotic fluid levels remain within expected norms, the baby can
safely wait for spontaneous labor to begin. Spontaneous labor gives the greatest chance for
vaginal birth, even though the baby may be slightly larger than if the mother were induced at 40
weeks.

Preventing Prematurity

Few medical treatments have been proven to truly prevent preterm birth. (Avoiding iatrogenic
prematurity is most effective, of course!) Some of the most promising avenues are readily
available to midwives, and we should share this research with our clients.

The following are some factors shown to be associated with preterm birth and some strategies for
lowering the risks:

Overwork, job fatigue, stress—Women in high-stress jobs or who work long hours on their feet
have nearly three times the risk of preterm rupture of membranes leading to preterm birth. In a
study of 3000 primips, those who worked in "high fatigue jobs" had a risk of preterm premature
rupture of membranes (pPROM) of 7% compared to 2% for those who didn't work outside the
home.(6) Although many women must work until the end of pregnancy, changing to less
fatiguing jobs, if possible, will lower their risk of preterm birth.

Poor nutrition in pregnancy, low weight gain—Low maternal weight gain is the single risk
factor that crosses all racial and economic indicators. A woman with a low prepregnancy weight
and/or a low rate of gain before 20 weeks is at high risk for preterm birth. A balance of protein
and carbohydrates provides the best nutrition. According to the Cochrane Database, restricted
carbohydrate diets may raise the risk of preterm birth without having any effect on the incidence
of macrosomia.

Vitamin C supplements—Low levels of vitamin C have been implicated for several decades as
contributors to prematurity and preterm rupture of membranes.(7) In a study of 2064 pregnant
women, those who had total vitamin C intakes of ‹10th percentile of the average intake prior to
conception had twice the risk of preterm birth due to preterm rupture of membranes (relative
risk, 2.2).(8)

Low levels of vitamin C may also be implicated in the risk of preeclampsia, which leads to
preterm birth, as well as, frequently, induced labor. Researchers tested women for plasma
vitamin C levels. Women who consumed less than 85 mg of vitamin C doubled their risk of
developing preeclampsia (odds ration 2.1). Women who consumed the lowest amounts had
almost four times the risk of those who consumed the highest.(9)

It is theorized that oxidative stress plays a role in preeclampsia, and we are learning that
optimum levels of vitamin C protect against oxidative stress. We don't know yet the optimum
level of vitamin C or the best recommendation for supplements, but it has been proposed that
300 mg to 500 mg is probably needed. Many American women consume less than 85 mg daily!

Bacterial Vaginosis

Bacterial Vaginosis (BV) has been associated with a two to three times increased rate of preterm
labor and delivery, urinary tract infections (UTIs), premature rupture of the membranes (PROM)
and endometritis.(10) Because about 50% of women show no symptoms, universal screening for
BV was proposed over a decade ago. (Screening and treatment is a current World Health
Organization recommendation.) Screening is simple and there are several effective prescription
treatments. But BV has a tendency to recur and is sometimes resistant to chemical treatment.

However, women may be able to discourage BV with some simple home methods. Numerous
studies have shown that when natural vaginal Lactobacilli levels drop, BV invades. Lactobacilli
inhibit the growth of Mobiluncus, Gardnerella vaginalis, Bacteroides and anaerobic cocci even
in a petri dish.(11) Colonizing (or recolonizing) with Lactobacilli is key to vaginal health.
According to Skarin and Sylwan, "The paucity of vaginal Lactobacillus is pivotal in allowing
overgrowth of many other organisms of the vagina."(12) Lactobacilli grow best in an acidic
environment. A healthy vagina is acidic and naturally resists infection by "bad" bacteria—
including strep.

In fact, pH alone—the acid/alkaline level measured by nitrazine or litmus paper—is a marker for
prematurity risk. Retrospective and prospective studies show that high vaginal pH (a low acid, or
alkaline, state) is predictive of preterm labor and preterm rupture of membranes. Viehweg, et al.
state: "Measurements of the vaginal pH value are able to verify an alkalinization of the vagina
caused by atypical vaginal flora.…In contrast to normal pregnancies there is a relation between a
pathological pH value > 4.5 and consequent preterm birth in pregnancies with preterm
labor."(13) In the Multicenter Bacterial Vaginosis (BV) Trial—a prospective study—21,554
women were screened for vaginal pH and outcome. Women with a vaginal pH of 5.0 or greater
had a significantly increased risk of preterm birth and/or low birth weight.(14)

Several alkaline organisms other than Gardnerella (BV) are implicated in PROM. Women with
high levels of these alkaline-producing bacteria had over 300% increase in rate of PROM. In an
article on pPROM, Ernest, et al. note: "Numerous infectious organisms that change the normal
vaginal milieu have been associated with preterm PROM. Because these organisms alter vaginal
pH, the use of pH was evaluated as a potential marker for women at increased risk for preterm
PROM.…Those with a mean vaginal pH above 4.5 had a threefold increased risk of preterm
PROM as compared with those with a mean pH of 4.5 or lower."(15)

Testing pH level is simple, fast, inexpensive and non-intrusive. Women can do it themselves by
touching a strip of nitrazine paper to their vaginal walls. Nitrazine or litmus paper is available in
most drug stores. The urine test strips used by most midwives also assess pH.

Cultivating Good Bacteria

How can a woman GET an acidic vagina? The old time vinegar douche is an acidic wash and
effective treatment for BV and yeast. Vinegar's mild cleansing action is stronger against
undesirable bacteria than against Lactobacilli, and it has a short residual effect, which helps
encourage rapid regrowth of Lactobacilli. (In pregnancy, a woman should seek her caregiver's
advice and use only a low-pressure, low-level douche.)

An infusion of two tablespoons of hydrogen peroxide kills BV and helps Lactobacilli colonize.
But recent research shows that Lactobacilli themselves are the source of most of the acid
produced in a healthy vagina! They create their own optimum growth pH. "Lactobacilli bacteria,
not epithelial cells, are the primary source of lactic acid in the vagina," according to an article in
Human Reproduction (16)

So... a woman can get an acidic vagina by GROWING the Lactobacilli. How? By planting them
—just like any good gardener!

Researchers are working on a two-pronged approach to using Lactobacilli as a natural antibiotic.

Some are trying to analyze, isolate and replicate the effective ingredient, while others are
working on methods to establish optimum vaginal growth. Pharmaceutical companies want to
create a Lactobacilli super pill, but I think we women should do our own home gardening!

Yogurt—Vaginal Application

Many methods have been advised for colonizing the vagina directly. Wearing a tampon soaked
in yogurt is an old folk remedy used for yeast infections (it works!). The yogurt can be used like
a cream or gently squeezed in with a bulb syringe.

Many strains of Lactobacilli exist. You can purchase acidophilus compounds and special
"probiotics" at some pharmacies and most health food stores. But good yogurt contains live
cultures, is readily available, inexpensive and proven to be effective. In the Tasdemir study,
pregnant women with bacterial vaginosis were treated with commercial yogurt. The yogurt was
administered daily with a 10-ml syringe for seven days and then was repeated after a one-week
interval. All the women showed clinical improvement on the third day of treatment. A month
after the second treatment, 90% of the women had no signs or symptoms of bacterial vaginosis.
The researchers concluded: "Commercially available yogurt may restore the microenvironment
and pH of the vagina," cure BV and "prevent prematurity."(17)

In another study, from Japan, women with BV were treated with intravaginal application of 5 ml
of commercial yogurt. In the initial cultures, 29 strains of bacteria were detected. The women
were evaluated and recultured three days later. There was significant decrease in discharge and
vaginal redness, and the vaginal pH was lowered significantly (acidified). All 14 strains of
Gram-negative bacteria disappeared! The researchers concluded that "the Lactobacillus therapy
was effective in both clinical and bacteriological responses."(18) In other words, improvement
occurred in both the SYMPTOMS and the cultures.

Yogurt—Oral Introduction

But yogurt doesn't need to be planted directly into the vagina, in order to grow there. Several
studies have shown that simply EATING it will result in increased vaginal Lactobacilli! The
Lactobacilli colonize the intestinal tract and migrate to the vagina and urinary tract system.
(Urinary tract infections are also risk factors for preterm labor and newborn infections.)
Researchers say: "The instillation of Lactobacillus GR-1 and B-54 or RC-14 strains into the
vagina has been shown to reduce the risk of urinary tract infections and improve the maintenance
of a normal flora. Ingestion of these strains into the gut has also been shown to modify the
vaginal flora to a more healthy state. In addition, these strains inhibit the growth of intestinal, as
well as urogenital, pathogens, colonize the gut and protect against infections."(19)

In one study, ten women with a history of BV, yeast and urinary infections, drank a Lactobacilli
solution in milk twice daily. The Lactobacilli were molecularly typed for identity. One week
later, the researchers were able to culture the tagged Lactobacilli from the vaginas of every
participant. (And six of the cases of BV were resolved within the week). This is one of several
studies that have proved that the oral route can seed the vagina.(20)

Of course, the quality of the yogurt is crucial. If it doesn't contain live cultures, it's useless! Make
sure it's really yogurt and not simply a form of milk pudding!

These once-alternative ideas have become mainstream. The American Journal of Obstetrics and
Gynecology published an article in March 2003 stating, "Certain Lactobacilli strains can safely
colonize the vagina after oral and vaginal administration, displace and kill pathogens including
Gardnerella vaginalis and Escherichia coli and modulate the immune response to interfere with
the inflammatory cascade that leads to Pre-term Birth."(21)

In sum, cultivating a healthy vaginal "floriculture" can reduce the incidence of preterm birth and
lower the rate of bladder infection and UTIs.(22) A healthy colony of Lactobacilli guards the
mother and baby against yeast and E. coli infections.(23) It also may offer protection against
Group B Strep. Adding live-culture yogurt to the diet—or treating with "probiotics"—is an
effective natural method to treat subclinical vaginal infections. It can also treat intestinal
infections, which may trigger preterm birth. I agree with the conclusion of these researchers:
"The lack of systemic side effects makes it a drug of choice in the treatment of pregnant
women."

No magic pill exists to assure a timely birth—a baby born at its healthiest point in gestation,
neither too soon nor too late. Born ready to breathe, eager to nurse, primed to learn and love.
Good health, good nutrition, good living habits and the avoidance of stress go far to ensure the
baby will thrive until his birth date. As we learn more about normal pregnancy, we gain new
tools to help both mother and baby achieve optimum health. This new research may help tip the
balance in favor of better health—and a timely birth.

Gail Hart graduated from a midwifery training program as a Certified Professional Midwife
in 1977. She was certified by the Oregon Midwives Council and licensed in 1995. She is now
"semi-retired" and no longer maintains her license, but still has a small practice. Gail is strongly
interested in ways to holistically incorporate evidence-based medical knowledge with traditional
midwifery understanding.

References:

1. McClure-Browne, J.C. 1963. Comparison of perinatal mortality rates versus gestational

age through the past three decades. Postmaturity, Am J Obstet Gynecol 85: 573–82.
2. Eden, R.D., et al. 1987. Perinatal characteristics of uncomplicated postdates pregnancies.
Obstet Gynecol 69(3 Pt.1): 296–99.
3. Weinstein, D., et al. 1996 Sep–Oct. Expectant management of post-term patients:
observations and outcome. J Matern Fetal Med 5(5): 293–97.
4. Hannah, M.E., et al. 1992 Jun 11. Induction of labor as compared with serial antenatal
monitoring in post-term pregnancy. A randomized controlled trial. The Canadian
Multicenter Post-term Pregnancy Trial Group. N Engl J Med 326(24): 1587–92. PMID:
1584259
5. Luckas, M., et al. 1998. Comparison of outcomes in uncomplicated term and post-term
pregnancy following spontaneous labor. J Perinat Med 26(6): 475–79. PMID: 10224605.
6. Newman, B., et al. 2001 Feb. Occupational fatigue and preterm rupture of membranes.
Am J Obstet Gynecol 184(3): 438–46. PMID: 11228500
7. Woods, J.R., Jr., et al. 2001 Jul. Vitamins C and E: Missing links in preventing preterm
premature rupture of membranes? Am J Obstet Gynecol 185(1): 5–10. PMID: 11483896.
8. Siega-Riz, A.M., et al. 2003 Aug. Vitamin C intake and the risk of preterm delivery. Am
J Obstet Gynecol 189(2): 519–25. PMID: 14520228
9. Zhang, C., et al. 2002 Jul. Vitamin C and the risk of preeclampsia. Epidemiology
13(4):409–16. PMID: 12094095.
10. McCoy, M.C., et al. 1995 Jun. Bacterial vaginosis in pregnancy: an approach for the
1990s. Obstet Gynecol Surv 50(6): 482–88.
McGregor, J.A., and J.I. French. 2000 May. Bacterial vaginosis in pregnancy. Obstet
Gynecol Surv 5(5 Suppl 1): S1–19.
11. Skarin, A., and J. Sylwan. 1986 Dec. Vaginal Lactobacilli inhibiting growth of
Gardnerella vaginalis, Mobiluncus and other bacterial species cultured from vaginal
 content of women with bacterial vaginosis. Acta Pathol Microbiol Immunol Scand [B].
94(6): 399–403.
12. Ibid.
13. Viehweg, B., et al. 1997. [Usefulness of vaginal pH measurements in the identification of
potential preterm births]. Zentralbl Gynakol 119 Suppl 1: 33–37. PMID: 9245123.
German.
14. Hauth, J.C., et al. 2003 Mar. Early pregnancy threshold vaginal pH and Gram stain scores
predictive of subsequent preterm birth in asymptomatic women. Am J Obstet Gynecol
188(3): 831–35. PMID: 12634666.
15. Ernest, J.M., et al. 1989 Nov. Vaginal pH: a marker of preterm premature rupture of the
membranes. Obstet Gynecol 74(5): 734–38. PMID: 2812649.
16. Boskey, E.R., et al. 2001 Sep. Origins of vaginal acidity: high D/L lactate ratio is
consistent with bacteria being the primary source. Hum Reprod, 16(9): 1809–13.
17. Tasdemir, M., et al. 1996. Alternative treatment for bacterial vaginosis in pregnant
patients; restoration of vaginal acidity and flora. Arch AIDS Res 10(4): 239–41. PMID:
12347751.
18. Chimura, T., et al. 1995 Mar. [Ecological treatment of bacterial vaginosis]. Jpn J Antibiot
48(3): 432–36. PMID: 7752457. Japanese.
19. Reid, G., and J. Burton. 2002 Mar. Use of Lactobacillus to prevent infection by
pathogenic bacteria. Microbes Infect 4(3): 319–24. PMID: 11909742.
20. Reid, G., et al. 2001 Feb. Oral probiotics can resolve urogenital infections. FEMS
Immunol Med Microbiol 30(1): 49–52. PMID: 11172991.
21. Reid, G., and A. Bocking. 2003 Oct. The potential for probiotics to prevent bacterial
vaginosis and preterm labor. Am J Obstet Gynecol 189(4): 1202–28.
See also Elmer, G.W., et al. 1996 Mar 20. Biotherapeutic agents. A neglected modality
for the treatment and prevention of selected intestinal and vaginal infections. JAMA
275(11): 870–76.
22. Reid, G., and J. Burton. op cite.
23. Andreeva, P., and A. Dimitrov. 2002. [The probiotic Lactobacillus acidophilus—an
alternative treatment of bacterial vaginosis]. Akush Ginekol (Sofia) 41(6): 29–31.
Bulgarian