Welcome to my blog, which speaks to parents, professionals who work with children, and policy makers. I aim to show how contemporary developmental science points us on a path to effective prevention, intervention, and treatment, with the aim of promoting healthy development and wellbeing of all children and families.

Tuesday, October 29, 2013

What might redefining "term pregnancy" mean for parents and babies?

So far the discussion on the policy change by the American College of Obstetrics and Gynecology (ACOG) has focused on the implication for timing of delivery. While previously babies had been considered "term" at 37- 42 weeks, the new policy defines term as 39-40 weeks. Babies born at 37-38 weeks are considered "early term" and those born at 41-42 weeks "late term."

The main consequence of this policy change is an official recognition that babies at 37-38 weeks are still not optimally mature for delivery.  The main objective of the policy is to "expand efforts to prevent nonmedically indicated deliveries before 39 weeks gestation*." In other words, doctors should not electively induce delivery or perform c-sections before 39 weeks. An article in Time magazine on the subject refers to a recent study showing an increased incidence of medical complications in what are now officially "early term" deliveries.

But given my interest in the parent-baby relationship and its impact on healthy development after birth, I had a different take on the significance of this change. Many babies born at 37-38 weeks are not induced or delivered by c-section. For a range of reasons, most of the time not an identifiable one, a mother may spontaneously go in to labor at 37 weeks. And, in contrast to the babies in the above study, the vast majority of these babies do not end up in the neonatal intensive care unit. They are in the regular nursery for the typical 48 hour stay.

My hope is that the policy change will focus more attention on the vulnerabilities of these babies.  The important question is,  "What is the implication for these babies who are not at optimal states of maturity, yet are cared for along side the now "term" babies and treated by professionals as if they are no different?" I put this question to a colleague of mine who is a hospitalist in a major teaching hospital in Boston. Her full time job is to care for newborns and parents following delivery and up to discharge in the regular nursery.

Personally I think this more nuanced classification of who the "full-term" baby is will be important for the parents and other professional who are supporting and teaching the family in the early weeks of life - eg. nurses in the well nursery, lactation consultants and medical providers.  Currently, unless a baby is under 37 weeks, they are all seen as fairly similar in their capabilities with differences being attributed to temperament or "personality" rather than gestation maturity.
There's a continuum to observed physiological parameters that may not be appreciated or fully noticed when babies are lumped together as full-term between 37-42wks; these include degree of sleepiness, subtlety of feeding cues, amount of energy reserves, ability to regulate state changes, muscular tone to name a few.  All of these impact the newborns' behaviors; especially feeding which is a primary focus for parents with their newborns.

Understanding that their infant's capabilities are related very often to his/her gestational age will reassure parents about their own capabilities as they learn to observe/make sense of their new infant's behaviors/cues with a more informed/understanding eye and less self-blame when trying (or struggling) to feed or to calm or to awaken their newborn.  

As my colleague wisely points out, what it looks like in real life when a baby is not "optimally mature," is that the baby may be difficult to arouse,  cry more or in general be more challenging to care for. Much of a new parent's sense of competence comes from successfully feeding her baby. If the baby's challenges with feeding are not identified and linked to his early gestational age, a parent may experience feelings of frustration and failure. She may abandon breast feeding or slide in to depression as she struggles to meet the needs of her baby.

In previous posts, I have referred to a wonderful tool, the Newborn Behavioral Observation System, that offers the opportunity to identify a baby's unique strengths and vulnerabilities.  This video of a brief excerpt of the NBO with a 3-day-old infant shows the newborn's tremendous capacities for communication. The NBO offers the opportunity to look at these qualities in a systematic way.

My hope is that now that the ACOG has officially identified these "early term " babies as vulnerable, professionals who interact with these families will offer parents the opportunity to identify possible challenges and develop strategies to manage these challenges, which with care and attention will resolve in a short time as the baby matures.

*Gestational age refers to the number of weeks since a mother's last normal menstrual period.

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