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Planning a home birth? Read this first.

An editorial published Friday in the British medical journal The Lancet argues that women have every right to give birth at home -- but only if they've done their homework.

Citing several health organizations' stances on the risks of home births versus hospital delivery and the limited research comparing the two, the editorial notes that while home births may be a bit safer for moms, it's likely that they pose extra risks to babies. Home births are on the rise in the U.S., the article notes, largely because women object to the increased use of cesarean deliveries in hospitals.

The editorial contends that hospitals are the best place for high-risk deliveries. Otherwise, it suggests, "Home delivery is an option for mothers with uncomplicated pregnancies, provided they are advised of the risks involved, have one-to-one midwife care (that includes good resuscitation skills and accreditation by a local regulatory body), and live in a location that allows quick access to obstetric care."

As the editorial points out, the American College of Obstetrics and Gynecology opposes home births. Research published by ACOG July 1 concluded that home births, by dint of insufficient access to medical care, significantly increased newborns' mortality risk.

The Midwives Alliance of North America, a midwives' professional organization, called that study flawed, saying it based its conclusions on shoddy data. A statement attributed to that organization's president Geradine Simkins and posted on its Web site says, "The American public, particularly women in the childbearing years and those who care for them, have a right to high quality research on childbirth. Research literature should not be used to cause undue alarm or limit a woman's choice regarding care providers, including skilled midwives, and place of birth."

In its 2008 policy statement regarding the practice, ACOG asserts that women are entitled to decide where they want to give birth. "Choosing to deliver a baby at home, however, is to place the process of giving birth over the goal of having a healthy baby."

The Lancet adds to that sentiment: "Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk."

The Lancet editorial is bound to raise a ruckus. The Checkup is always happy to host a ruckus. Please share your thoughts below.

By Jennifer LaRue Huget  |  August 2, 2010; 7:00 AM ET
Categories:  Health Policy , Motherhood , Pregnancy , Women's Health  
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Comments

"The Midwives Alliance of North America, a midwives' professional organization, called that study flawed, saying it based its conclusions on shoddy data."

American women need to know that the Midwives Alliance of North America (MANA) refuses to publish the safety data that THEY COLLECTED.

That's right. MANA, the trade organization for direct entry midwives (known as CPMs, as opposed to the more highly educated, highly trained certified nurse midwives, CNMs) spent the years 2001-2008 collecting extensive data. Over the years MANA repeatedly told its members that more extensive safety data was forthcoming, encompassing almost 20,000 CPM attended homebirths. And MANA has announced completion of the data collection and publicly offered the data to others.

So why haven't we seen it? MANA will only reveal the data to those who can prove they will use it "for the advancement of midwifery" and even these "friends" of midwifery must sign a legal non-disclosure agreement providing penalties for those who reveal the data to anyone else. It does not take a rocket scientist to figure out that MANA's own safety data shows that homebirth almost certainly increases the risk of neonatal death, possibly quite dramatically.

CPMs and homebirth advocates are condemning the publication of existing safety data from other studies while REFUSING to release their own safety data. There is simply no ethical justification for withholding homebirth death rates from the American public.

There is nothing that more powerfully demonstrates homebirth advocates contempt for safety and contempt for the truth. MANA knows the death rate at American homebirth. They just don't want anyone else to find out.

Posted by: AmyTuteurMD | August 2, 2010 8:29 AM | Report abuse

First of all, women do not only choose homebirth because of surgical birth.
Homebirth can be more dangerous for babies? Really? Then why is the US presently number 44 in Infant mortality according to this government list? https://www.cia.gov/library/publications/the-world-factbook/rankorder/2091rank.html

Look at the countries that are doing better than us...and then go look at their systems of childbirth. 70% of them are using midwives, who are the true experts in normal birth and are providing out of hospital. When a mother is having a normal birth why would you put a surgeon in control instead of an expert at normal birth? Some countries penalize women who chose to have hospital birth rather than home, as they know it is more costly and unnecessary. Other countries homebirth midwives are the main provider and OBs are called in if there is a devistion from normal, or they aredoing homebirths themselves.
Another question I have is why does ACOG have any authority over what is advised as risk? Do they truely practice evidence based practice? If so then why is this evidence not only disregarded but also refuted? It seems as if it has to do with the threat of loss in their income. Midwives who do home births are the lowest paid, and have great outcomes. No Ob would every do the work they do for the amount of money they do it for. Nor would insurance companies be willing to walk away from the Obs who are making money for them. This is really not about safety or women's choices it is all about pocketbooks.
But if you really want to do your homework, then follow the trails to the end. Let's really compare evidence that is coming from well thought out, well generated studies. Or, let's count the unplanned "home births" in with the hospital statisitics. A premie born on the side of the road or in it's parents bed who dies is not got anything to do with home birth. Planned homebirth with a licensed provider has the same risks that any timely normal birth anywhere would have. Even when you are in the hospital and need a c-section STAT you will not get it IMMEDIATELY, that is why ACOG stopped VBACS because they knew it can not happen that IMMEDIATELY. That one word changes everything. A woman being transported into the hospital from a home birth with a trained provider is not just appearing there unannounced. The provider has called in and made known the situation and things are being made ready. Most times there is an IV in and med's are on board, just like they would have been in the time it takes to get ready for an emergency c-section. I really think this country and especially the nay sayers need to be educated about what homebirth is and is not...and then we can have a reasonable discussion. Until then most of what is said in regards to homebirth is based on untruths, fantasy,lack of information and emotionally charged judgment.

Posted by: midwifeanji | August 2, 2010 8:58 AM | Report abuse

My son's pulse dropped significantly during a contraction due to the umbilical cord being wrapped around his neck. I'm curious how a midwife would have approached our situation better than the Obstetrician who got our son out in less than 10 minutes and saved his life.

Posted by: slydell | August 2, 2010 9:17 AM | Report abuse

Well I read this first and I'm still planning a home birth as long as I continue to have a normal healthy pregnancy. I do not want the medical interventions performed in a hospital such as being injected with Pitocin. Why not do an article on how the drugs you will receive in a hospital setting can delay the birth process resulting in an increased risk of cesarean?

Posted by: tink712 | August 2, 2010 9:47 AM | Report abuse

I had a VBAC homebirth seven years ago at age 37. My midwife was a CPM, also an EMT. Had we needed a transport, she would have accompanied me and stayed with me. The birth was amazing, and wonderful. I was calm, in control and relaxed--all the things I would not have been had we been in a hospital setting. I did my homework, followed her excellent advice, got excellent care. She stayed for at least an hour at every checkup and did more than any OB I ever saw. In my state CPMs have alegal status. More regulation for them would not translate into better care, in my opinion. Many CNMs are simply doctor puppets and not allowed to make decisions that they know are in the best interests of the moms and babies. CNMs in stand-alone birth centers have more autonomy, and are supervised by a doctor. I could not use a stand-alone birth center, or have a CNM come to my house because they could not get insurance to do VBAC (which they used to do and are frustrated that they can no longer do because their insurance won't cover it). I am certain that ACOG is threatened by homebirth, unreasonably so.

Posted by: howdydoody1 | August 2, 2010 11:24 AM | Report abuse

Slydell-- my son, who was born in the hospital, had the same thing happen-- wrapped cord and dropped pulse. My OB had me change positions and his pulse went right back up. Then after his head was out, she said "OK, stop pushing while I unwrap the cord," unwrapped the cord, and said "OK, now you can push again." He was perfectly fine, Apgar scores of 10, no C-section required. So I expect that is probably what a midwife would have done.

Also, it's not just the process of birth that is better at home (I was high-risk, or I would have had a home birth); it is also the medical outcomes for the mother. Even if it is true that outcomes are worse for babies born at home, they are medically better for mothers; and pregnant women have every right to place their fetuses' health at increased risk in order to improve their own health. For example, there is some increased risk to a fetus whose mother has pain medication during labor, but no one is arguing that women should not be allowed to have pain medication if they want it.

Posted by: lolar2 | August 2, 2010 12:28 PM | Report abuse

The Lancet editorial's arguments are illogical and fundamentally inconsistent with the existing evidence on the safety of home birth.

For women who don't have "high risk" pregnancies, the slightly increased neonatal risk of a home birth over a hospital birth is very similar to the increased neonatal risk from attempting VBAC vs. elective repeat Cesarean section, a choice which ACOG has recently stated should be an informed one and not denied to women by institutional policy. For more information on this and the limitations of the meta-analysis that presumably led to the Lancet editorial, please see: http://commonsensemd.blogspot.com/2010/07/vbac-and-home-birth-evaluating-evidence.html

Posted by: linkenny | August 2, 2010 12:49 PM | Report abuse

There are certainly risks to BOTH home birth and hospital birth that should be weighed. Hospitals can lead to c-sections, other medical interventions, and infections.

If you use a hospital and a nurse-midwife you can probably get your insurance to pay. Go to the hospital at the LAST POSSIBLE MINUTE (that your midwife says is safe). The clock starts counting the minute you arrive at the hospital and you will not be allowed to labor more than 24 hours at that point before a c-section is performed--but they don't care how long you labored at home. And in the hospital, once they make you put on a fetal monitor you won't be able to move around or hang out in the shower, so labor will become far more uncomfortable. They may not let you eat or drink, either.

Even with a midwife I ended up with a medicalized experience the first time, but avoided a section (barely) thanks to the midwife. The second time, I was very careful in choosing my nurse-midwife and I also hired a lay midwife to help me at home and accompany me to the hospital. Birth is far too important to be left to the assistance of husbands who don't know what they're doing, staff nurses who pop into the room every once in awhile, and MDs who just show up for the last few minutes and might decide to do a section at the drop of a hat.

I can't imagine why a woman would try to make it through childbirth without a midwife, yet obviously the vast majority do so.

Posted by: rnegrete | August 2, 2010 2:38 PM | Report abuse

women and their bodies....what a freak show.

tell you what - there are still some good reasons for not trying a vaginal birth, but of course, what woman of 4'7" will actually sit down and face this music without a man-doctor-body hating attitude?

none.

My 'ex blames ME for having her get the cesarian birth on both kids.

let me tell you that this was WAY past wishful thinking on her part; she was not the average stature of a woman and THAT - not me - is the reason the kids weren't delivered vaginally.

BUT OF COURSE ITS EASIER TO BLAME MEN, ISN'T IT?

He body was simply NOT build for childbirth.

Despite that - she, along with your sisters would have my children's baby brains damaged just for HER pleasure to say she did it.

the facts of a 4'7" woman are not the same as the facts for a 5'7" woman.

but did she lighten up?

Nope - Its all my fault.

This is what I take fault for: marring her.

not a good idea.

Posted by: pgibson1 | August 2, 2010 2:48 PM | Report abuse

I had my last child at home. He was born with the cord around his neck and not breathing on his own. My midwife gave him some mouth to mouth, a few compressions and oxygen. Today he is a fun loving, ahead in development 7 month old. If you have done your research and hired someone who is a trained professional, you have done the best you can to cut risks. This goes for home birth and delivering at a hospital with an OB.

Posted by: dcgirl4 | August 2, 2010 3:13 PM | Report abuse

I had my daughter with the help of a team of dedicated midwives at Loudoun hospital. (Loudoun Community Midwives.) I thought it was the best of all worlds. When an OB needed to intervene, one was immediately available, yet I still had the care of my midwife from beginning to end.

Posted by: mjp3md | August 2, 2010 4:02 PM | Report abuse

Wow, there's a lot of vitriol and misinformation being spouted on here. I already got into a discussion/disagreement with my cousin over the Lancet editorial and a BBC report about a Dutch study. My cousin is a big proponent of at-home births and the use of midwives. To be clear, I do not oppose at-home births -- my disagreement with her was that I believe that it is important that everyone be given the fullest set of facts/data on the subject in order to make the most informed decision. In contrast, she, like some of the anti-hospital people on here, would rather malign the data and simply declare the data wrong (kind of like global warming deniers) rather than accept reality.

So, let's sum up a couple things here. For the person who thinks it is acceptable for a mother to put her comfort above her baby's health, you simply have a different set of principles than others. I cannot change your mind any more than you could change my mind. Just be aware that, in modern times in the Western world, giving birth is considerably more dangerous for the baby than the mother.

Now, for the Lancet editorial, it's important to understand that it was not calling for banning at-home births. It simply wanted women to be aware of the risks involved and particularly wanted women to understand that safe at-home births require that you meet the following criteria:
1) A low-risk pregnancy
2) A trained/certified mid-wife who is attending ONLY you
3) A short distance to the nearest hospital

The third criterion is actually quite important. In the Dutch study, which found that at-home births were as safe for babies as at-hospital births, 1/3 of women who started at home ended up moving to the hospital. Think about that: ONE-THIRD of the women had to move to the hospital due to difficulties with their birth. The babies ended up being fine, according to the study, but clearly, it was critical that a hospital not be too far away. By the way, the Dutch have a high rate of at-home births and believe it is quite safe.

The problem with this issue is that, on both ends of the spectrum, you get people who are ideologically driven, rather than evidence-driven. We should ALL look at well-conducted studies, examine the studies' conclusions and flaws, and try to draw the best possible interpretation of the findings as they apply to our lives. Most of all, we should use ALL the evidence to inform women to the highest degree possible -- i.e. not trying to shunt them in one direction or another.

Posted by: rlalumiere | August 2, 2010 4:08 PM | Report abuse

- Slydell: Did you have pitocin? An epidural? An epidural just placed when his heartbeat went down? Were you in bed? Did your doctor help you turn over? Put you on hands and knees? Put oxygen on you? Pitocin and epidurals are notorious for causing stress to the baby. If mom doesn't have a lot of amniotic fluid, the extra crush from the pitocin-induced contractions can squish the cord when it wouldn't normally have done that... say, in a homebirth, for instance.

And, important to know the cord is around the neck in *30%* of births. We see it all the time and it is rarely, *rarely* ever an issue. We just slip it over the baby's head. No cesarean necessary for that.

- pgibson1: My, my... a tad angry, are we? Thought I'd point out that women who are 4'7" *all over the world* have babies -vaginally- every single day. While blame might not be appropriate on her part, it is also not appropriate for you to blame her body, thinking/saying it is deformed or incapable of delivering a baby vaginally. You very well could be incorrect.

- rlalumiere: I am *clear* in my consents and in discussions with clients that it is *indeed* safer to deliver in the hospital if a catastrophic event occurs, both for mother and baby. We can't do cesareans, we don't have blood and we don't have teams that specialize in a variety of areas.

However, women wanting a homebirth are not just wanting it because of the ambiance; they are weighing the risks of not being in the hospital for something tragic versus being in the hospital and loaded down with technology and drugs that often have no scientific proof of working... and it isn't uncommon for that very technology to *create* the "tragic" circumstances hospitals are there to "save."

Risks and benefits. With full disclosure, absolutely.

Posted by: navelgazingmidwife | August 2, 2010 6:38 PM | Report abuse

1) Yes, I do prioritize my life and physical and mental health above that of my unborn fetus. Thank you very much. I think it would be criminal to orphan the children I have already brought into the world for one not yet in it.

2) The problem is as discussed the ACOG study sited in the Lancet is a badly done study and propaganda for ACOG not real science.

3) Even with all the bias of ACOG and their statistical manipulation all they could find was a slight increase in neonatal mortality. They admitt there is decreased infant MORBIDITY at home.

Morbidity means non-fatal illness.

So I'm being irresponsible if I choose the birth setting (home) that has the least chance of my death, my being injured, my infant being injured?!!

PS - The increased deaths in the Washington State study were all do to congenital defects.

Posted by: sheepdoc | August 2, 2010 6:57 PM | Report abuse

As usual, the truth probably lies somewhere in the middle of all of this :D

I think women should have the right to choose a homebirth...but if I had done so, I'm fairly sure my first child would not have survived. My second might possibly have done so, but I would not have survived the experience.

So, y'know, I'm all about the hospital births. But there's no question there are things that could be changed about hospital births to make the experience better all around.

Some hospitals (hi, Shady Grove Adventist!) are doing some great renovations and have already had some things like hot tubs and such.

And, of course, a lot depends on your OBGYN and their opinions on things, so if you do your research ahead of time, the experience will go better.

Posted by: marag | August 2, 2010 7:57 PM | Report abuse

"The Lancet adds to that sentiment: 'Women have the right to choose how and where to give birth, but they do not have the right to put their baby at risk.'"

Forgive me for basically lifting my comment directly from Rixa Freeze, PhD, but a post of hers on her blog, Stand and Deliver, addresses this whole line of reasoning better than anything I've ever seen anywhere on the matter.

"Let's follow this logic down its slippery slope to the final, authoritarian end:

* No epidurals or pain medications except for surgical births, because they add medical risk with no medical benefit (no one has ever died from the sensations of labor, but there are a host of risks--from minor to deadly--from epidural anesthesia and IV narcotics).

* No elective inductions.

* No elective cesareans.

* No home births (if you believe there is increased risk to the baby).

* No hospital births for low-risk women (if you believe there is increased risk to the mother and/or baby from standard hospital and obstetrical practices).

* No VBACs because they have a slightly increased risk to the baby.

* But no repeat cesareans because they are riskier for the the mother and sometimes the baby as well...So if you have a cesarean, you are not allowed to have any more children, since both VBAC and ERCS carry risks, and risk to either mother or baby is not acceptable. After all, the most important thing is a healthy mom and healthy baby.

See how ridiculous this is becoming?"

There are risks no matter where one decides to give birth. BIRTH HAS RISKS, PERIOD. What is up to every woman to decide is what set of risks she is comfortable taking.

P.S. pgibson1, what a thoroughly . . . . odd way to publicly process your ex-marriage.

Posted by: Dou-la-la | August 2, 2010 8:50 PM | Report abuse

*sigh*
Sheepdoc, you decided to be like one of the people on the extreme ends who pushes an ideology rather than letting the evidence guide her. On a side note, if you're baby is born, it is no longer an "unborn fetus". In fact, the whole purpose of this discussion is the idea that people want their baby to live and be healthy and free from any childbirth-related injuries, etc, as well as the mother. So, let's refrain from engaging in a discussion that appears to be veering rather close to some sort of pro-choice/pro-life debate.

Now, the Lancet cites a meta-analysis published the American Journal of Obstetrics and Gynecology. The study was NOT performed by ACOG (societies do not normally conduct studies). In fact, it is a meta-analysis conducted by researchers at the Maine Medical Center. That you call it "propaganda" reveals that you have no interest in evidence -- you simply care whether a study supports your pre-determined belief. When something supports your position, you'll take it as a properly conducted study full of good evidence for your beliefs. When it doesn't support your position, it becomes a "badly done study and propaganda". Moreover, without any evidence, you insist that the study shows "bias" and "statistical manipulation". Clearly, you are no scientist or even an objective person and have no interest in letting the evidence guide you.

If you had bothered to keep an open mind while reading the study (something I strongly doubt you did), you would have noted several things that you probably would have liked. Among others:
1) Home births were associated with less frequent premature births, less frequent low birthweights, and less frequent assisted ventilation.
2) Home births were associated with fewer medical interventions such as epidurals, episiotomies, and caesareans.
3) Home births were also associated with fewer infections and lacerations.

Some of these may be due to pre-existing differences between the groups -- e.g. fewer epidurals and maybe even caesareans could easily result from the fact that women having home births are probably more resistant to such interventions. Nonetheless, the overall set of results listed here (plus even more in the study) are quite positive for home births.

HOWEVER, the biggie remains: Neonatal death rates were double in the home birth group. If babies with birth defects were excluded, the rates were triple. This is not good for your ideology, though fine for us who are driven by data. Perhaps you can call double or triple a "slight" increase, but for an objective description of a study, it's best to avoid such terms as they can be rather misleading.

On a final note, there were NO maternal deaths in the meta-analysis. That means that, across the 550,000 births in the 12 studies, not a single woman died. So, please stop this nonsense about you dying and leaving an orphan behind.

Posted by: rlalumiere | August 2, 2010 8:59 PM | Report abuse

My first birth was in a birthing center. My second, due to complications, was in a hospital. My next, which will happen in the next 3 weeks will be at home, barring complications.

I hope to God I don't have to go to the hospital. Hospitals are terrible at assisting natural childbirth. They haven't the faintest clue what they are doing and they do not inspire confidence in anyone who has done it before. They can't wait to get an epidural in you so they can render you a non-participant in the process as quickly as possible.

It's lovely that ACOG and Lancet are condescending to tell me I have their permission to give birth where I want to. As if I cared.

By the way, I wouldn't be giving birth at home if I wasn't firmly convinced that it was safer for uncomplicated births. I've read all the scientific literature. As usual, MDs couldn't design a decent scientific study if their life depended on it. So I resent their accusation that I, or any other homebirther, would put the safety of our child above anything else. Their data doesn't remotely support that conclusion because none of these studies are properly controlled. And, FYI, if my baby is ever at any risk, I'll suck it up and deliver at a hospital just like I did my second.

Hospitals are pros at turning uncomplicated births into complicated, dangerous ones. It makes them more money, I suppose, and saves them the inconvenience of having to wait for babies to come in their own time -- usually during the middle of the night and not 9-5 Monday-Friday, as doctors would prefer.

The rate of C-section in this country is an obscenity, and none of these studies factor in the increased risks of ruptured uteruses and death of the infant in subsequent pregnancies because of their over-use of the procedure. Without considering that, it's hypocritical for them to claim that mothers are somehow endangering their children by avoiding hospitals and their excessive C-sections.

I'm not putting my health and safety at risk just because some hospital's malpractice insurer thinks they are more likely to win a lawsuit if the doctor cuts me open at the slightest provocation.

Posted by: MichelleF1 | August 3, 2010 12:50 AM | Report abuse

If the newborn death rate were truly tripled at home birth, there would be good reason to avoid it. However, most of the posts I've read have not bothered to analyze this study, but simply regurgitate the conclusion, without evaluating its methodology or its facts.

Although the study is not set to be published until September, I was able to obtain an advance copy and read every study included in the metanalysis. I list the conclusions of each study, and discuss the findings at: http://www.themidwifenextdoor.com/?p=930

Please don't accept what's fed to you as "fact" without analyzing it for yourself.

Posted by: birthsense | August 3, 2010 10:53 PM | Report abuse

Are we all forgetting this little thing called the Constitution? Statistics and flawed studies and money-hungry agendas aside, the bottom line is we all have the the right to healthcare autonomy. It is unfortunate that something so black and white is dismissed by our law-makers as evidenced by our lack of decision-making ability when it comes to giving birth. Nobody should dictate where a woman is to give birth but the woman. Period. The world does not have to agree with her and the world will not have to deal with the consequences, she will. We have choice in whether or not to carry a pregnancy to term, how insane that we cannot (in many areas, mine included) choose where to birth. Please.
By taking away our human rights we are now denied access to quality care and may be unintentionally increasing risk where there would normally be very little.
I have a history of precipitous labor, less than 3 hours, and nearly had an unplanned homebirth with my 2nd child as a result. Due to my distance from the hospital I chose to give birth at home with my third child. I was incredibly lucky to have found a CPM who could get to me right away. I delivered in under 2 hours safe and sound in my home....illegal in my state. Had I chosen the legal option, a hospital birth, I would have likely delivered in my home unassisted or in a car, and risked mine and my baby's health. Had I not been able to find a CPM what would have been the best option? They all would have sucked. Don't tell me what to do and don't pretend you care more about me and my baby than I do.

Posted by: homebirthRN | August 4, 2010 2:29 AM | Report abuse

slydell - my daughter was born at home - with the cord wrapped twice around her neck. After her head was delivered, my midwife told me to keep pushing even after the contraction stopped, the rest of her come out in less than 5 seconds, she unwrapped the cord and all was well. Apgar of 9, no need for breathing help.

navelgazingmidwife-"However, women wanting a homebirth are not just wanting it because of the ambiance; they are weighing the risks of not being in the hospital for something tragic versus being in the hospital and loaded down with technology and drugs that often have no scientific proof of working... and it isn't uncommon for that very technology to *create* the "tragic" circumstances hospitals are there to "save."" I totally agree. I chose to give birth at home because I am a puddle of jell-o in the face of a doctor - I do what they tell me regardless of what I think it the right course of action. I knew that my midwife - having seen hundreds ,if not thousands, of normal, natural births would tell me if something was WRONG, not just inconvenient for the hospital or the doctor. I firmly believe that I would have had a c-section if I were at a hospital because it was "taking too long". And yet, at home, I was allowed to do what my body needed to do, no rush, no pressure. And it did exactly what it needed to do! Healthy baby!


Posted by: jennyrose00 | August 4, 2010 9:20 AM | Report abuse

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