#255 | What's Up with Intrauterine Growth Restriction: An Off-the-Record-Style Conversation with Dr. Stu Fischbein

March 6, 2024

In this episode, we welcome back Dr. Stu Fischbein for his third appearance on  Down to Birth Show. We start the conversation by catching up on some of the latest problems occurring on the birth scene including VBACs, aspirin in pregnancy, the monetization of birth, late pregnancy ultrasounds, big babies, and due dates, before we get into the meat of the episode on Intrauterine Growth Restriction (IUGR). Dr. Stu shares a letter from one of his followers regarding her IUGR diagnosis resulting in an induction at 37 weeks for a 4-pound 14-ounce baby,  which launches into a conversation around what IUGR is anyway and the actual risk of IUGR.  Would that baby have been better off staying in utero for a few more weeks? How can you know postpartum if the baby was in fact IUGR? There are so many nuggets of great information dropped throughout this episode. You don't miss this one! And for more with Dr. Stu, catch episodes #111 & #128.

Dr. Stu Fischbein & Birthing Instincts
Dr. Stu on Instagram

#128 | Vaginal Breech Birth with Dr. Stu of Birthing Instincts: Why It's Safer Than you Think
#111 | The Obstetric Model of Care vs. the Midwifery Model of Care: Interview with Dr. Stuart Fischbein, MD

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View Episode Transcript

Most pregnancies don't have a problem. Yet, in OB world, almost all pregnancies have a problem. Somebody's not right. They both can't be true. How many mothers are given a diagnosis of IUGR? At a single visit? How can you diagnose growth restriction, if you're not comparing between more than one data point? Well,

the diagnosis used to be IUGR was less than the third percentile by weight, not by abdomen, or think. And 10th percentile was small for gestational age, but they've sort of they've sort of blurred the lines between those two. They don't care whether it's small for gestational age or age, they don't feel that their intervention has any negativity,

if you're just going because it is so delightful to see your baby. Let's face it, try to talk a woman out of doing an ultrasound. But now you're responsible that you opened up a can of worms, we know if they tell you the fluid levels are low, they're gonna recommend induction. We know if they find a baby, they say is big. And we also know that they're wrong, the vast majority of the time anyway, we know they're going to push a scheduled C section, we know they're going to tell you it's IUGR. Well, now, the best thing you can do is don't get yourself into this mess. Ultrasound has never been shown to make low risk women any safer in decades.

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.

Hi Guys

It's always good to talk to you both.

Always nice to see your smiling eyes. Yes.

Yeah, it feels like just coming to visit family. Yeah.

Where are you these days?

I'm still I live in Southern Utah. Life is good. Right now. On a personal level. I'm very happy to speak I head to North Carolina and then on to Florida to reteach breach, seminars. There. You have one make sure you let us know if you're ever in the Northeast.

Of course, of course, I have nothing planned for the northeast at this point.

But northeast, we could use a reteach breach conference up here. That'd be great.

You know what, every hospital in the country could use a reteach breech.


Yeah, there's so much gaslighting going on about breech birth in the hospitals and funneling people down toward the Cesarean section and me being a lightning rod for stories about that I get people that write me stories about, you know, they're looking for VBAC options because the first baby was section for breach. And they were never given any choices when that when that happened. I just got somebody just read to us the other day a story about bear birth center who basically is now lumping in this is probably going on in a lot of places. There's they're lumping twins, breech and VBAC all together in the high risk category. They're putting VBAC in there. As you know, midwives are not allowed to do these birds, they don't have the extensive training that they need to do. Well, that's back. I mean, what are we talking about? That's, I just have to say I've had over 150 clients have VBACs. Over the years, one single one was with an obstetrician. And I'm talking VBACs, after up to four C sections, after 123, and four, and every single one except for one was with a midwife, at home, or at home. And it's not that those women wanted home births, they felt they had no other option and they were committed to a vaginal birth, they were scared to have homebirths in most cases they didn't want on the first time around. So the second time around, they had even less belief in their bodies. They had more to overcome. But it was it's been quite an observation for me to see that. They ended up realizing by the end of pregnancy, they just couldn't do it with those doctors because they were getting all the red flags and all the signals. So now to take that away from women. Again, we come back to freedom every time.

It's freedom and it's also stupidity and control because VBAC is just a vaginal delivery doesn't require any special skills to do a VBAC. They're saying, well, it might require access to a new operating room. Well, that's really really rare. But yet, that fear is what generates all the anxiety that goes on in the community about VBAC because doctors may in at some point experienced uterine rupture. And therefore, or they're just following orders in their hospital which says to them, you can't do VBACs here. And so because they consider it to be risky, they project that risk onto women and then they lump it in with something like breech and twins, which isn't, is also not that risky, but at least requires some special skills to be able to properly take care of women who have a breech baby or twins where more than 50% of the time, one of the twins will be in the breech presentation. But to clump VBAC in there is simply sort of stupid. It's an obtuse, non thinking way of saying, essentially, like the American College of OB GYN states, in one of their guidelines about influenza and pregnancy. They say this sentence, and I'm not taking it out of context. Pregnancy itself is a high risk condition.

They do not they say that now. ACOG says that they call pregnancy, it's in their influenza, it's in their influenza guidelines. A second sentence in the guidelines, says pregnancy itself is a high risk condition. And then it goes on to talk about that's why you should get the flu vaccine, or that's why influenza can be worse. So they're lumping being pregnant in with having hypertension, chronic illness being a smoker, they're considering it a high risk.

It explains guys why they counsel and look at everything as being dangerous. If that's the philosophy that they have, that pregnancy itself is a high risk condition, then you can see where they're coming from. But that's crazy.

I mean, can we just all open our eyes and sea mammals giving birth all over the Earth every day, like by the millions? I just was sometimes we just have to use our common sense. That's what guided me through so much of my work. When I got into this, or even through my pregnancy, when I didn't understand anything. I just kept asking what all of my ancestors did, what all the other vowels are doing. And when you hear certain things, it just simply is incredible.

No, it's almost like a form of Agra phobia. You know, Agra phobia is afraid to guard afraid to go out of your own house. Yeah, crowds dangers, you know, you can just see the ACOG saying, life itself is a high risk condition. And yeah, you know, theoretically it is every day, there's potential risks. But you can't if you live your life, that way, your life is not going to be very filled with, it's not gonna be filled with joy, very often, because you're always nervous. You're always anxious, you're always that person saying, should should the should the baby be playing with that right now? Is it safe to keep your baby up this late? You're not vaccinating your baby. I mean, it's like it's it. If you want to expunge those people from your life, but you can't because they're usually your relatives. So it's just so easy to pray. pregnant mothers, because they're so protective of their babies, right? They're so their instinct is to be so protective, and they're so vulnerable, they will listen to what anybody says if it means that they're putting their, their baby in harm's way, they're going to buy into whatever is put in front of them. So it's really, it's cruel.

It reminds me of the psychology behind. I think the best slogan ever created by anyone, I think, I don't know, if it was New York lotto or one of the lotteries, it was, hey, you never know. And it's like, okay, you never know, you might win the lottery, but you're more likely to be struck by lightning seven times in your life. So let's talk when you get to six times, you know, but that that was such a brilliant line, hey, you never know, playing with your psychology. And when a woman is pregnant, that's the same message. The same part of her brain is that you never know. But you never know. And then that's what scares her. If it's with you tell her it's one in a million, she'll still think, but I could be that one. And you've got her. Right, but they never tell you the other end of that spectrum, which is when you go to the hospital. You never know what might happen to you because you're in the hospital.

Exactly. Right.

It's like the VBAC scenario when they tell you that, you know, your baby has a 50% chance of dying if your uterus ruptures, which first of all, you know, I don't even know where this statistic came from. But I women are told that. So it's much safer if you have a C section, yet they don't ever explain the risks of either being induced, you know, to prevent uterine rupture or repeat C section, to the baby to you down the line. It's always only the thing that they're trying to get you to do that they're just speaking about. Well, and there's plenty of good literature in the world about if you're a healthy woman with a normal healthy pregnancy. You're much better off staying at home. You have a lot rate of interventions, you have a lower rate of cesarean section, you have a lower rate of induction, you have a lower rate of epidural, you have a lower rate of PCR the lower rate of lacerations, you have a better chance of breastfeeding, you know, I could kind of depression, yes, higher rates of satisfaction, all those things go on. But you never know.

And it's that it's, it's, it's that little piece of the unknown and the mothers, you know, desire to protect her baby at all costs, that that gives you plant that seed of fear in her mind. And that's all they can focus on.

Well, they do that they do that because that's their whole system is steeped in that. I think that there are people that are actually manipulating people with fear. And there are other people, other obstetricians, who are honestly just so indoctrinated into that way of thinking that they're going to tell somebody at 10 weeks pregnant, that we'll you know, you're over 35. So there's a chance that your placenta will give out. So we're going to want to start testing your baby early, and we're going to want to induce you probably by 39 weeks, and you're telling us to woman a 10 weeks, and you're telling it to every woman at 10 weeks who's over 35 Not which by the way, is a stupid rule anyway. 35 doesn't mean anything. But you're telling it to every woman never individualizing your care, never asking the woman what her needs or desires are. And never, you know, you're already setting them up for failure. It's the classic thing that I've talked about many times from the movie Inception where you tell, would they tell them not to think about elephants? Okay, don't think about elephants?

Yeah. Yeah. That's a Tony Robbins thing. Yeah. Like, what do you get what you focus on, right.

And they're only focused on finding something wrong. Every time they want to do something for you. It's a revenue generator for somebody, of course, so the whole system is completely busted. Because they're incentivizing more testing more interventions, they should pay less, because natural, physiologic birth pays the least. So and sometimes it requires the most skill. And that's the skill of absolute doing absolutely requires the most time, that's for sure, at the skill, maybe you skill when you need it. Most of the time, you're not going to need it. But you need to have those skills when you need it. But you're right, it requires time, patience, ability to sit and wait and do nothing, which doesn't pay. So the more we do, the more money we can make. And now it's just become, you know, there's always something it's age over 35, your blood pressure is borderline high. Now, it's just this constant for every woman, your baby's too small. And it this movement toward the baby is better off outside the uterus by 38 weeks than it is in the uterus in they can find a reason for every woman, any woman who enters the system that will come up with a reason why your baby should be born a few weeks early.

Well, when they do when they do ultrasounds on you in the last trimester, especially in the last month or six weeks. They've actually looked at that. And they find that there's a 20, some percent higher rate of induction or cesarean section, simply because you had an ultrasound that you didn't need at 36 or 37 weeks, because they'll find something the fluid will be lowish, the baby's measurements will be asymmetrical. The placenta will be at grade three, oh my god, they'll they'll find something to start with is around the neck.

So that one part, that's a good one. One part of that meta analysis that I believe you're referring to, is focusing on big babies. And when you do the research, one in 12, women approximately one and 12, about eight and a half percent of women have quote, big babies, I refuse to use the word macrosomic. My babies would both qualify, I think it's a bogus term. And I'll never use that with legitimacy. But one in 12 have babies over 814. And when they give late pregnancy ultrasound to women, they tell not one and 12. They're looking at big babies, they tell one in three, that they have big babies. And that research showed that those women were heavily coerced into scheduling C sections, the vast majority of the time and induction the rest of the time. None of them were just told, Well look at that you've got a big baby Good For You go home and enjoy. We'll see you when you go into labor, none of them. And then all those babies were born those suppose had big babies. The average weight of those, quote big babies was under eight pounds. And the conclusion of that study was that a care providers perception of a big baby is more dangerous than a big baby because what it showed was far higher maternal complications 4% versus 17% and so on and so forth. Everything was worse in the category where they suspected a big baby as compared to women like me who simply had big babies, those were much safer births.

And they use, they use the idea that a big baby will lead to like, it'll get stuck or there'll be a shoulder dystocia. And it's like, well, yeah, but that's not true. First of all, there's very little correlation between having an eight or nine pound baby and Shoulder Dystocia. Secondly, that's why you're an obstetrician. If there is a shoulder dystocia, you're trained to handle the shoulder dystocia. But Shoulder Dystocia has become like a like screaming fire in a crowded theater. You know, you mentioned that to somebody and you said it earlier to her, she said, if you can scare a woman about her baby. She's going to err on the side of caution, which is another phrase that that bliss and I like a lot because what that really means is that you're making a mistake, to be cautious. But it sounds like small babies are at risk of shoulder dystocia as well. It isn't just the big babies that gets stuck at the shoulders. It has a lot to do with a lot more to do with maternal position and baby's position than the girls. Epidural epidurals Yeah, being on your back, not being able to be upright and moving and allowing your baby to optimally navigate the pelvis.

Right. And these are all things that are done to women. Not necessarily for women, a small small percentage of women need interventions, but most women do not. But the medical model doesn't understand that. Because as I've said, 1000 times all that matters to them, really, when you boil it down is a live baby in the bassinet. And how the baby gets in that bassinet is not their concern. And what happens to that baby, that mother and that mother's future babies at that moment is not their concern. They may on a personal level feel that way. But the medical model doesn't feel that way the medical models and assembly line, it's you know, there's lots of analogies, it's a hamster wheel, and they can't get off, and everyone who comes in is treated exactly the same. You're asked the same questions, you're drawn the same Bloods, you're peeing in the same cup, well, hopefully different cups, you're paying and you're peeing in a cup, you're changing into a hospital gown, you're asked to be on your back, you're put belts on your belly even doesn't matter if you're coming in for your fifth baby, and you feel like pushing, or you're coming in for your first baby, or your 38 or your 22. They treat you all the same. And now that and now that we have a system, which is going away from individual practitioners, to shift mentality to the laborers mentality, there's very little relationship that goes on between them. So you have the very unconnected. And then you'll also have the idea that a lot of doctors are not very happy with the system as it is, but they feel helpless to do anything about it. And when you're unhappy, and you're working a shift, and you meet somebody who doesn't conform to your way of thinking, it's very hard to be nice to them. Because you don't have the patience for it, you're just working your shift, and you don't know this person, and this person is telling you, you know, that's not what the literature says are there, they're contradictory. They're contradicting you and you're tired, and you've been up and you have, again, you have no relation to this person. So you end up having these conflicts that you see all the time. It's really rare, from my experience in both worlds hearing from a woman who writes into me that I have this conflict with my midwife. It happens, but nowhere to the extent because midwives and their patients have relationships. And when you have relationships, you work it out, or you find out early on that this isn't a relationship for me. And, you know, they say that finding a midwife is like dating, you want to find somebody that's compatible for you and, and somebody that that listens to you and that you feel comfortable and doesn't raise as you guys like to say the red flags. And you can do that in the midwifery model, but the medical model, you get whoever's on call. And I
will say that I think midwives in the medical model are more like the doctors than they are like midwives just from observation.

Because they've been groomed by the system. They're indoctrinated into the system. And now they have to start kind of following the protocols and policies of the hospitals. But you know, there is there's actual evidence out there to show that continuity of care is a major factor in the safety of birth, that women who have continuous care with the same provider throughout pregnancy and birth have less intervention and safer bursts yet. And also, you saw you talked about midwives in the hospital. It's happening to midwives at home a lot too, because because a lot of them will depending on how they're trained because some of the midwifery schools now are becoming more and more medicalized. And so they're coming out even the CPM or what we Call heirlooms, licensed midwives. And and then depending on what state they're in the the tyranny of the of the regulatory state is such that it scares the crap out of midwives because they want to help this woman but they, they're putting their career and potentially their freedom on the line because the state has a policy that was put in place by people who really don't understand birth. lobbied by people who have no financial incentive to keep birth medicalized and in the hospital. And so you end up with states that say, Oh, you can you midwives can't do this without Doctor consultation. Or you can't take care of somebody at 36 weeks and six days if she's in labor, or you can put up your home birth if you go past 42 weeks and a very high percentage of women go past 42 weeks in the care of home birth midwives. It's, you know, women who take care of themselves there will nourish babies go late. There's one of my own friend Nancy Waner, who's the the expert in Leanback. She had three women one July, they were all VBAC moms, they all went past 42 weeks, all in the same month. I mean, it's really not uncommon. And it's so unfair to the to the mother, to have that fear like this dramatic opposing birth looming over her if she simply goes past 42 weeks, and then the midwife is rendered totally helpless over this situation, the midwife ends up doing things she wouldn't normally exactly sweep like cervical sweeps, which I have a letter from somebody here about a cervical sweep and all the problems that cause or castor oil or other things that they would not normally do. If are fetching medical records, or fucking medical records, they're taking matters into their own hands, because they're faced they're they're put into one unethical situation, which is going to lead to others than those women are going to look to take their power back and say, Well forget this, I'm not going to abandon this woman I've had a relationship with all these months, when I can simply fudge the due date. But that's what this leads to. Because like you said, Stu, that these decisions are made by those who don't know, the first thing, they're in this position of oversight, they don't know the first thing about birth, they shouldn't be in those positions to make those decisions.

Yeah, one of my major pet peeves about the whole tyrannical regulatory system is that the same bodies that educate you, as a midwife or as a as a resident, and OB GYN, and then you come out and you take a bunch of testing and you then you get licensed to practice. But then they tell you how to practice. It's like, I'm licensed to be a physician, I, you guys have approved me through years of residency training or midwifery school, to be competent, to be able to make good decisions, and then I come out and then you don't let me make decisions. You tell me how to practice. It's very frustrating, because because there are people that want to practice, very rigid, follow every ACOG guideline, every CDC guideline, and there are women who want those kinds of practitioners. But there are other people that want to individualize. And we want to listen to what the woman wants and her desires and maybe be a little more flexible. And the regulatory bodies say we can't even though we went through all this training, they've taken the bait, Bayes, whoever they is, think they know best for all women, and all the people practicing. And so they're going to make one size fits all because it's about control. And when you want to control something, you need to have, you need to control it. Because you you, you hate the idea that people are individuals. And that's that is a big problem with the system. That's why I said at the beginning, you come into the hospital, your your the questionnaire they're asking you guys is the same questionnaire. If you came in with a appendicitis or gunshot wound, they'd be asking you the same questions. How many stairs you have in the house? Where did your grandmother die from? Do you have any tattoos or piercings? I mean, does this really matter to a pregnant woman coming in labor? But no, you have to do it. Because somebody in a cubicle in the Administrative Office service management says we have to do the same thing all the time to all all people. And this is where the system completely breaks down. And that's why we ended up with dissatisfaction rates that are extremely high C section rates over over 1/3 of women having C sections, induction rates of 3040 50%. In England, they just their stats just came out of England and they have less than 50% of women went into spontaneously. I think it was 43%. They're following our model when they have lower maternal mortality, like everything else. They're right. They're all better but I always feel like the trend is the other countries become more like this. I know they just start modeling are for example. So one thing that I'd love to get your take on Is the unquestionable trend in IUGR, intrauterine growth restriction. This is something I never heard about in the first 15 years that I did the work that I do. And now we hear about it constantly. And I just would love to get your take whether you're hearing about it all the time, I assume you are. And, you know, just the whole difference between bad and small for gestational age, Trisha has commented on it a bunch of times, and we've touched on it in a few episodes. But what's the lowdown on this?

Let me start by reading you a letter that I got this morning. Oh, okay. I do want to get into it. Because the the definition of IUGR is fuzzy. Yeah. And you can use the definition any way you want. And if you want to get people to be induced and stuff, then you'll use a definition that is rather liberal for if that's the word I can use for that, but this is a letter from Justine and she says by Dr. Fishbein, this kind of stuff. I get, like, all the time.

Oh, yeah, we do to wondering if you can give me your opinion. I have a I have a mama having her second baby. So this is a practitioner midwife. I have a mama having her second baby with me at home this year. And her first was IUGR you and I can agree most cases vigr, overdiagnosed and overmanaged. But she's aware, it was recommended to her to take a baby dose of aspirin for this whole second pregnancy to prevent a second IUGR baby. First of all, maybe they asked her questions about her baby. Maybe they asked her why the baby was supposedly to diagnosis IUGR when this was recommended to her by some MFM. But I suspect the MFM here's IUGR with first pregnancy, baby aspirin was second pregnancy. No makes it a notch even checking to see if the IUGR was an accurate diagnosis. That's let's continue. Okay, so she says the Justine says My gut tells me that it's not necessary. But I told her I would consult with an OB and see what they say any thoughts would be greatly appreciated. So I wrote back. This was this morning, actually, you are on target with the over calling of IUGR. Do we know what her first baby Wait, how many weeks was she? Why baby was IUGR if it was IUGR. The default most obese is to intervene without investigating. And they think aspirin is innocuous anyway. So they think that by giving an aspirin aspirin is like the it's like the snake oil. It cures what ails you? And they give it no matter what and they think it's innocuous. And whether it is or it isn't. It's an intervention. And we don't know what the use of aspirin will do to the mom or that baby or that baby 10 years from now or 20 years from now. Because no one looks, no one cares. It has done some good things as you said, it does reduce the risk of recurrent preeclampsia in some women a 27% decrease risk, which actually isn't that great.

The absolute risk is even lower. It's really low. The absolute risk is very low. But also, yeah, you're right. They haven't studied that enough. And I can't believe how they do treat it as a doc Yes. But they do know that moderate to high levels of aspirin are not safe. And you always have to wonder if there's anything that isn't safe with moderate to high levels. How do we assume that low is necessarily safe? We don't know where that that needle starts to move where suddenly you're in unsafe territory and to take anything daily for almost a year is really quite as quite a significant recommendation medically.

At least it's cheap.

That's, that's true. They're not making money off the aspirin.

No, they're not making money off. Okay, but they're making money off their surveillance. So yes, yes. It's

the psychology of prescribing. It's the psychology of letting her think something is wrong. It's the psychology of control.

It's the idea that if there is something that we can do that's potentially harmless to reduce the risk of late pregnancy complications, we're going to do it because it's also liability. Okay,

so here we go. So she writes back, and she says the baby was four pounds, 14 ounces at birth, and that was a 37 weeks in two days. So if you consider a baby's on the smaller side, but if you would have let her go another two and a half weeks, that baby would have been close to six pounds, or maybe five weeks and she would have a seven pounder. Right? So

is a six pound baby at term growth restriction is in the normal range. If you look at it, it's greater than the third percentile, but it's SGA. But it's not necessarily IUGR. Correct?

Correct. And it may even not even be SGA because it may not have another factor another factor. So she says at the ultrasound and are 32 weeks or abdominal circumference as measuring small under the fifth percentile.

All right, what is this plane,

the rest of her growth was on track length was above average of I recall, I don't even know they do length in utero, but an overall numbers combined her out of the in the 25th percentile. So if you add in the head, the head circumference, the femur, and the abdomen, the baby was in the 25th percentile, yet she was deemed IGR because the abdomen was smaller. So she was called asymmetric IUGR. But there's no evidence here that they, you know, look for any other indication was there oligo hide rhamnose the overuse of color Doppler flow is one of my bugaboos. But was there any problem with the blood flow in the Bateman babies middle cerebral artery, umbilical artery or the mother's uterine artery? Or Were any of the ratios that they look at? Probably not. But yet they, I'm again, I don't know that they just went into she was born at 37 weeks into I gotta believe that she was induced. Okay, so she goes on and says mama did get a low positive test for one type of antiphospholipid antibody. But the next test in a couple months later was normal. So she doesn't have antiphospholipid antibody syndrome, which is a whole nother discussion another day. The child is normal now at age two. Child was normal at age 02. But But does the does the curve the Hadlock curve that they use for ultrasound to determine take into the account the genetics of the parents? People shaking your head so that that's good for radio, but no, it doesn't. It doesn't.

Plus, we know that there's there's a huge amount of inaccuracy between ultrasound techs in measuring these lengths. I mean, how are we really? Can we really accurately measure an abdomen? No.

I mean, yeah, there's a there's an error, there's an error in the scan. But IUGR is not simply something that goes by a number. Right? The question is, How is the baby growing over? All right. And what I consider to be more worrisome is a baby that's, say, at the 50th percentile at 30 weeks, and at 36 weeks is that the 14th percentile and drop in a baby that's an eighth percentile at 20 weeks, eighth percentile at 30 weeks, sixth percentile at 36 weeks, that baby's growing beautifully. It just happens to be on the small end of the bell shaped curve. And by the way, just to remember what a bell shaped curve is shaped like, shaped like a bell, right? We're not all supposed to be in the middle there must write outliers within the curve must be. So when they when they say, well, the baby's environment is fine. The baby's head and femur are fine, but the baby's abdomen little small. Okay, fine. So if you're worried about the baby's growth falling off a little bit, you have to deliver that baby. No, you could watch that baby. So many mothers are given a diagnosis of IUGR at a single visit, how can you diagnose growth restriction, if you're not comparing between more than one data point? It has to be over time to be considered restrictive. You can't plot a curve with one point. But that's happening to so many mothers one time one visit you have IUGR we're scheduling your induction next week, or or we're going to bring you in twice a week. And we're going to charge you you know, several 100 hours a visit to come in twice a week. And then we'll we'll we'll allow you to go to 39 weeks. That's what they'll say will allow you to go to 30. But we don't want you to go past 39 weeks. Well, why not? Why would you not allow them to a password? Well, the rate of school was right, well, not if there's not any, I'll tell
you why they're afraid she's gonna go into labor on her own. If they go any longer than that. The odds just get too darn high. What I wish they would do and what I hope is coming in the future is instead of this IUGR diagnosis being based on now first only to know once a baby is born. Well it looks like that one actually did have it. Well, it looks like that one didn't really have it. Oh, well, we did our best. I feel like the second step should be saying to the mother, let's talk like, Do you smoke? Do you have a history of smoking? Do you have an autoimmune disease? Do you have risk factors? Have you smoked pot? Are you doing drugs? Let's talk is there something else? What's your diet? Like? What are you?

How much did you weigh when you were born?

Yes. How much did you weigh when you were born? Exactly. But I feel like that's the direction this needs to go because that can actually point to whether there is risk. We don't just look at IUGR in and of itself. But is IUGR indicative of a risk that there is some disease in her body or some poor caretaking. But if there isn't, if there's neither, then what is the risk of IUGR that this baby is just absolutely going to stop growing. Well, that's like you both said, then we watch. We go to this idea. There's this idea, I think in their mind that it's safer to induce and have the baby be born by 3738 Definitely by 39 weeks, then to risk the extra weeks of pregnancy, that that that is a greater risk. I see these babies that were induced that 37 and 38 weeks weighing five and a half pounds, and these mothers who are now disappointed in their birth experience, and now, they can't breastfeed their baby, because they were born too soon. And they're too small, to, you know, have the efficiency that they would otherwise have if they had a couple more weeks of gestation.

Now they're born in a crisis situation. That's what we're doing to these mothers and babies as they're born. It's not like Oh, phew, now the baby is out, like Hello. Well, if you were so concerned about this baby being small, now what are we doing that the baby is out? Now we have to focus on feeding the baby and building up the baby. And we know they're gonna be born with a breastfeeding issue.

So they're saying feeding formula. I know with twins that when you induce twins that 36 to 37 weeks, which is often recommended in the medical model, not not in ours. You may decrease the risk of stillbirth by a tiny percentage and that stillbirth risk is is blown way out of proportion, it's still far less than one half of 1%, even at 40 weeks with twins, who have are uncomplicated. But if as compared to if you have twins going to labor at 39 weeks, the ones that are induced the 36 to 37 weeks have a three fold greater risk of going to the NICU than if you let them go to 38 or 39 weeks? Well, again, three fold is a is a relative risk number. As people know, when we talk about you talk about it. You know, you actually the actual risks, the actual risk is, is moderately high in a hospital setting that has a NICU. Because what's the point of having a NICU in a hospital setting it's to get babies to fill it up. That's what's going on. And here's here's, here's an interesting thing about the diagnosis of IUGR. A lot of maternal fetal medicine doctors will use the diagnosis of less than the 10th percentile. Right? Yeah. Which is not a diagnosis that I was taught. Doesn't make sense to me. Because here's a good question for those math whizzes out there. How many babies are less than the 10th? percentile?

10%. tempered? It doesn't take a math whiz, or 10% of baby's growth restricted? No, no.

Right. So it doesn't add up. It's again, common sense wins. What did you learn back in the day, you were an obstetrician for 20.

I learned that all medicalized too Oh, yeah, I would have been doing what these people are doing.

More rhetorical. Now. Now it's more of this catch all the 10% thing?

Well, the diagnosis used to be IUGR was less than the third percentile. But not by abdomen or by, by, by the weight charts. And 10th percentile was small for gestational age, but they've sort of they've sort of blurred the lines between those two. And since they all they care about is getting the live baby in the bassinet. They don't care whether it's small for gestational age or age, they don't feel that their intervention has any negativity. That's because they don't even counsel you about the downsides of induction. I mean, they may, but they couch it in such a bias that, that they're telling you that while it's the farm, it's the lesser of two evils. And therefore this is something that you should do. But they don't tell you the risks of Cytotec or the risks of Pitocin instead of oxytocin are the risks of the discomfort and the fact that you need to be monitored, and then you won't be allowed to eat, and that you have probably will end up with an epidural, which will then disconnect you from your baby, and then baby will not like it, and the baby will get into stress. And we'll have this thing called category two fetal heart rate tracing, which no one really understands. And the baby will be diagnosed with fetal intolerance to labor. And they'll do a C section and they'll come and get a baby out that's screaming without cause of nine and nine. And they'll say, Gee, thanks, aren't we great? We solved the problem. We got your baby out guys of nine and nine, and the mother will believe it. Stew. What was that fleeting, cynical comment you made earlier about the goal of one? Which one? The one where you said the goal of the neonatal intensive care unit is to fill it. Can you comment on what you were indicating there and what you're saying, it's a profit center of the hospital. It's a profit center for the hospital because we've heard from so many women who can't get their babies out. Once they're in, they can't get them out. And it's days and days when we need more observation. Well, now the baby has to do this. The baby fails one test and they get five more days. And now we need to wait for the baby to poop again are now and it's days and the couples go out of their mind with anxiety and they feel trapped. They really start to have notions like they're never gonna get their baby. Terrible what they're doing.

The policies are set up to find a way to keep the baby in the NICU like even the car seat policy, baby as they have to sit in the car seat for what 60 minutes or 30 minutes whoever. Some people live six minutes from the hospital but they have to be in the car seat and if they fail it then they have to be in there for another 24 hours.

I had a mom have to stay three more days because of that.

I mean What what are you leaving AMA, right? You leave against medical, and then you have to deal with the fact that they'll call Child Protective Services. That's that's insane.

They won't let you leave with your baby in a car seat. So now you're leaving with your baby in your arms and you're walking home. I mean, if they see it with your baby in the car seat, they're gonna stop you. It's so difficult for the mothers who have had NICU babies to make the transition from the NICU feeding schedule to a physiologic breastfeeding schedule, it's so ingrained in their brain, how, you know, this baby has to feed a certain amount every three hours, not more than eight times a day, not more than this amount. And in exactly this amount, when breastfeeding works, nothing like that. And they can't let go of the idea that they don't know how much their baby's getting at every feeding. Because they've been they've, they've been so afraid of the time in the NICU, that the baby's not eating enough or growing enough or their babies too small, or it's just really traumatizing. And just like, you know, the OB is only concerned about the healthy baby in the bassinet after. And in the NICU, they're only concerned about the baby growing in meeting their their goals while they are staying in the NICU. Nobody is thinking about what happens to that mom and baby when they leave the hospital. It's just like, Okay, bye. Good luck.

Yeah, it's also the fact that they believe that that baby is that they care more about that baby than the the parents do. Exactly. As if, as if and you have to realize, again, this whole thing boils down every aspect of our life. But specifically, the medical system boils down to money. And there's no money. If a woman has a homebirth for the hospital. There's no money if a woman comes in and says I don't want an epidural, I don't want an IV. I don't want my blood drawn. So they coerce you into thinking that you have to have your blood drawn? Well, if you have to have your blood drawn, then how come women at home can birth without having their blood drawn? How does that even work? And, you know, if you have to have an IV, or at least just a saline lot, you know, we have to have access, just in case, what was the term you guys use at the beginning of the podcast? Wasn't just in case it was Yeah. Hey, you never know. Oh, you never know. Right? I gotta write I want to write that down. So yeah, so you have to have an IV because you never know. And then you can't really eat anything. Because God forbid, you might get anesthesia, general anesthesia, which is one of the 100,000 births, and you might vomit. And that's even where, and therefore we can't feed you. And that's something out of the 1950s that still sticks around and you know, some hospitals again, somehow they're changing, and they changed the policy. They changed that in 2015, the American Association of Anesthesiologists or the American Academy have, they changed that in 20, November of 2015. They said, Oh, look at this, lo and behold, they were 70 years late, they said lo and behold, women can eat in labor. And since then hospitals have hardly made any change at all. And the vast majority of American hospitals, they're still telling women that they can't of course you can women listening, you can eat whatever you want, you have the freedom to, but they're uninformed. It's really scary. We don't and this is the thing, we always have to question ourselves like, are they unethical? Or are they ignorant? I had a couple years ago, who after learning about delayed cord clamping in my class that came back to the next class and said, Cynthia, we spoke to our doctor about wanting to do delayed cord clamping and the doctors response was, What do you mean, you want to wait until the cord stops pulsating? If it stops pulsating, it means the baby is dead. Can you believe this? I mean, and all I've been left to wonder I do is Did the doctor truly not know either one is unforgivable. He's either he's either that unethical and manipulating them, or he's that ignorant and doesn't deserve anyone's business?

Well, what about the what about the doctor who says, well, we can't hand you the baby because the baby can't be above the level of the placenta, because the blood will flow out of the baby back into the placenta. And there's one of those one where that's actually on, somebody caught that on video where a Dark Doctor was saying that to think about that for a second, if you have a placenta previa, and you stand upright, all pregnancy, your baby will have no blood.

They've done the research on this, it's strongly pulsates against gravity. And it's ridiculous that we even had to do the research. But they did do the research on it. It's proved it, it goes against gravity as luck just throughout the body. And it goes right into the baby's liver. And the idea that it can flow back into the mother, it's in the baby's liver. It doesn't just flow back. So where are these doctors come up with these ideas? Do they just like you said, you said Are they either intentionally doing this or they just ignorant? Part of me believes both and part of me believes they're delusional. They create some scenario in their mind or they did when they were a resident and implants in their brain, and they cannot navigate around it or it's what it's the consensus around them. They heard another doctor say it or they either heard it at a conference or they heard it somewhere and then every But he just practices by consensus, whatever he said, I'll say, and because the mother's believe it, and by it really easily, it kind of just gets you moving on to the next thing, you know, you only have seven minutes for an appointment. So if I can tell her something that she's gonna just believe really easily, then I can end the discussion and move on to my next appointment. So here's, here's a good question for you guys back to the IUGR thing is what does a woman do when she's told that her baby has IUGR by her physician, or by the maternal fetal medicine doctor that her physician routinely sends them to? You know, when I was growing up, maternal fetal medicine doctors were consultants, who took care of problems when they when they were discovered by their OBS. Now, they become essentially a routine part of prenatal care, that almost no OB will, we'll know, pregnant women will make it through a pregnancy even perfectly normal one, without being at some point referred to a maternal fetal medicine doctor, even if it's just for the 20 week scan. And once they get sort of into that system, there are things that can happen. So what does a woman do when she's given this one time ultrasound and said, Wow, I think your baby might be growth restricted? She can't really, I mean, how does she seek a second opinion in the system where everyone thinks the same? What does she do? What do you guys recommend? They see Cynthia is good chomping at the bit there.

I'm chomping at the bit. Because of that meta analysis we referenced earlier with respect to low fluid levels and big babies, and because of this IUGR trend, and it is a trend, it's not that it doesn't ever happen, but it is a very powerful trend. I think the best advice for the vast majority of women is Think long and hard. Before going for a third trimester ultrasound. Why are you doing it? If you have a reason? This is what I tell my clients if you have a reason to do it. For example, you were in a car accident, I had placenta previa really close to the cervix, they need to clear it. You have a breech baby like we, my husband, we just did that episode in October on my birthday, my husband manually, breech baby, but before that, with the with the help of an expert midwife, it's kind of a long, funny, unusual story. But we knew where the placenta was, we knew the cord wasn't an issue, when you have a reason to do it. Yes. Now, it makes sense. But if you're just going because it is so delightful to see your baby, let's face it, try to talk a woman out of doing an ultrasound because it's so awesome to see the baby. But now you're responsible that you opened up a can of worms, and now you got yourself into a mess. And now how are you going to get yourself out of this mess? We know if they tell you the fluid levels are low, they're going to recommend induction. We know if they find a baby they say is big. And we also know that they're wrong, the vast majority of the time anyway, not that that's linked to worse birth outcomes anyway, we know they're gonna push a scheduled C section, we know they're going to tell you it's IUGR. Well, now, the best thing you can do is don't get yourself into this mess. Every woman before us since the beginning of time got through this without ultrasound, ultrasound has never been shown to make low risk women any safer in decades. So you're asking us how to get out of the mess. All I can say is let's try to not get into it in the first place. I think it's very simple.

If you if you do end up with a third trimester ultrasound, which so many mothers do for this better, any reason that they are convinced that they need it, Dr. Seuss, giving me the money sign? Yes, they make money. If you just if you get a diagnosis of IUGR, ask for time, do not accept a single data point as a diagnosis of IUGR. Ask for more time, see what happens over time that ask what the true risk is of reevaluating this in a week or two.

And move on find out also a little bit more if you can about the person that you're up. First of all, as you guys always say, make a good choice in your first in your OB that you're picking to begin with. Don't pick somebody just because they've been doing your Pap smear for 10 years. They see how you feel the red flag issue, but also find out who that doctor uses for their maternal fetal medicine and do some investigating long before you ever have to go there find out about that group. You know you it's sometimes hard to do, but you can start to investigate that group and find out and don't most pregnancies don't have a problem yet in OB world almost all pregnancies have a problem. There's there's a disconnect somewhere in in there. Somebody's not right they both can't be true. And I would lean on the fact that most pregnancies don't ever and if you if they even put their hands on you and use a tape measure which is surprising how many obese don't even do that any Maybe they go right to the ultrasound machine, because it's right next to the exam table. And a woman, a woman knows her body really well. And she knows when her baby is growing or when things don't seem right, or the baby's movements have changed. So if they take the tape measure at 35 weeks, and you're measuring 34 centimeters, that's perfectly fine. Right? 33 is perfectly fine. But if it two weeks later, you're still 33, then that might be something worth checking into. But ultimately, babies shift positions fundal height is very, it's not subject to the height doesn't have a high specificity. Let's put it that way. So it doesn't, doesn't really tell you a whole lot. I mean, it's sort of a clue. But don't let them tell you that I think your baby's small because it's one or two centimeters behind. And that's a reason to do that ultrasound that Cynthia said earlier, we should really be careful about taking the recommendation because doctors have a power over you that they can convince you that you need to have these tests done. And the fact of the matter is, it's linked to worse birth outcomes. This isn't just us all on a bandwagon to say, always go for the most natural thing possible. In all instances, this is what is linked to safer outcomes for mother and baby. And that's why we take this position. As I wrote in one of my published articles, this isn't just about vaginal birthing for the joy and gratification of it, though that should not be discounted. This is because it is the safer approach to birth.

That's talking about low risk pregnancies.

Exactly, which is very clearly Yeah, that we could go off on a tangent about the definition of low risk pregnancies that were that is not all breaches are the same. Not all diabetics are the same.

Not high risk. Oh, yeah. advanced maternal.

So the term high risk itself, just it actually inflicts risk, because once you label somebody with a label, again, it's don't think about elephants, right? There's one of my classic things is a 20 week scan where they find that everything's perfect. But there's a single and a woman's had a normal ni PT test. So the PT, on invasive prenatal testing, it's a blood test, it's done between like 10 to 12 weeks, it shows you baby doesn't have any of the major trisomies can tell you the sex of your baby, that sort of thing. And then at 20 weeks, she has a perfectly normal ultrasound except they see a isolated, isolated echogenic left ventricular focus, which is a tiny little calcification in the heart. As an isolated finding, it means absolutely nothing. And the OB May the MFM or the ultrasound tech might even say, this doesn't mean anything, but we want to see you back in six weeks just to be sure that it's gone. So what is the woman taking home from this perfectly normal ultrasound? There's something wrong with my baby's heart. Yeah,
she's not going to sleep for six weeks, six weeks, he's secreting cortisol, adrenaline, and stressing and Googling, and, and visualizing the outcome she doesn't want, which is also linked to how you know this is also what happens in life, what we visualize is also more likely to occur. And that's dangerous in itself. It's like all the doctors who Schedule C sections at 20 weeks because the baby is quote, breach at 28 weeks, let's just not take any chances and get that C section scheduled in case that baby doesn't turn head down. Why even telling someone that that the baby is breech at 20 weeks is an issue. And then she's convinced her baby will stay breech and I swear there's a correlation. The problem with the current medical system is that these things are not going to be easily changed. You're not going to easily change the mentality of those people stuck in it. So they're not going to suddenly think to themselves, why am I telling this lady she's breached? 38 weeks or 28 weeks? I mean, then that's even the problem. I mean, I could tell her baby's breech. And she said, and a lot of babies are breached, the third of babies are breech at 28 weeks, it doesn't mean anything. They're not going to suddenly start to counsel women differently. Why? Because they don't know anything to because they don't have the time in their model to do it. So this is a this is a been a major bugaboo of mine that I've seen, because of my experience of living in both worlds and actually being that kind of physician for the first few years that came when I came out of residency, you know, being very medicalized and interventionist, leaning, and then gradually backing away. But it took me a long time to do that. It's not going to happen in the medical model. There's too many pressures on the practitioners to conform to whatever the system wants to say. So that's, people need to know ahead of time, if you're going to go to a medical dies, doctor, you're going to have to deal with some of these things. So make good decisions about choosing somebody who feels good to you and whether or not you can afford it or not sometimes going outside of your network, or sometimes going outside of your state or sometimes having concurrent care You know, avoid the things that are scary. This is your pregnancy. And it's your baby, not the hospitals, not the M. FM's. And you know, occasionally they're right. And if you have trust in your doctor, then you'll believe them when they tell you there's a problem. But if you don't have trust, and I don't know how, nowadays how anybody has trusted the medical system. I don't write, don't trust, anything that I read. That comes out of the CDC, or the FDA, or a cog. I have to look at it really critically. Sometimes they're right and it's usually about it and not in something innocuous. It's not usually about something controversial. When it comes to controversial stuff, they're almost always wrong. And if somebody is consistently wrong, why are you continuing to trust and the medical model has been consistently wrong, and treating everyone as if, like a cog says, pregnancy itself is a high risk condition. But you have to find a way to make this an enjoyable experience, because it's better for you.

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.

Recording already we haven't even done anything yet. I know I do that. So I'm afraid I'll forget. I'm not doing anything. Don't worry. Someone like you. We're going to start just chatting. I'm so afraid that I'll just never click the button so I just chop it out. How are you doing?

Yeah, that happened to listen I once and that was enough, right?

There's some mistakes you make once in life.

Yeah, yeah. I'm good. I'm actually quite good. You were so good on The Daily Show. I don't understand like you just spoken perfect sound bites? Did you get nervous?

Yeah, but not as much as you think you didn't look at? Yeah, it was like 200 people in the live studio audience to us. It was well, first of all, Michelle was very gracious and easy to easy to deal with. I got to meet her in the green room about an hour before and, and so that and then my daughter was in backstage with her coworker and and it's, again, it's a topic that I had no idea what she was going to ask me. So Wow. And she started right off with a fear question. And that was sort of that caught me off guard for like two seconds. And then and then once it starts coming out, you know, it's something that I know so well. That it gets going but yeah, you're nervous. You're nervous and you forget you say things a little differently than you would have said them otherwise are you afterwards you kick yourself because you didn't.

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About Cynthia Overgard

Cynthia is a published writer, advocate, childbirth educator and postpartum support specialist in prenatal/postpartum healthcare and has served thousands of clients since 2007. 

About Trisha Ludwig

Trisha is a Yale-educated Certified Nurse Midwife and International Board Certified Lactation Counselor. She has worked in women's health for more than 15 years.

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