What is “Normal?”
Yesterday I shared how my training has caused me to relearn how I think about the term “intervention.” Today I want to share another word that needed to be reframed in my mind – “normal.”
When I first began in the natural childbirth movement, when I heard the word normal I always interpreted it to mean “OK” or “Safe” or “Ideal.” I’m not sure if I had thought of the word that way before my first training, or if I somehow picked up on that meaning through my readings. It was, perhaps, a combination of both. I was too young and inexperienced to ever see something bad or dangerous as normal, and the training encouraged me to continue this line of thought.
The most specific example I can recall would be my thinking about newborns. Perhaps you’ve also had the same mindset about some of these. “Physiologic Jaundice is so common, it’s just normal for babies to be jaundiced. I don’t know why doctors get so hung up about it.” or “It is normal for the newborn to have really low vitamin K levels at birth. They increase by the 7th or 8th day, this is no big deal.” or “They get so hung up on blood glucose levels. It’s normal for glucose levels to be low when you need to eat. Just give the baby the breast and she’ll be fine.”
Today, I look at the things I used to say and wonder how I could be so confident in my statements when I didn’t have a full understanding of all the issues. I also wonder how I always assumed “normal” meant good or safe.
You see, a Type 1 diabetic is going to have high blood sugar levels if they don’t take their insulin – this is the normal functioning of their body because a diabetic does not make insulin so the glucose cannot be metabolized. Yes, this is the normal functioning of the diabetic body, but it is not safe.
“But wait!” you say, “The ‘normal’ newborn is not sick, their body is functioning as it should be.” That is true. But neither is the ‘normal’ newborn body functioning like a one or two week old, an older child, nor an adult. Their body is in a state of transition, and it is this existence in a state of transition that makes these “normals” something worth watching a little more closely.
Before a baby is born, most of the work of the liver is done by the placenta. When the baby is born and separated from the placenta, the liver is just a little behind. It isn’t producing as many of the things needed to help blood coagulate when necessary. It’s ability to form glucose and store glucose are very immature, as are its production of hormones to regulate carbohydrates. It’s ability to conjugate bilirubin is limited, as is its ability to break down any medications.
Closely linked to the function of the liver is the function of the kidneys. Their job of regulating fluids and electrolytes is also done by the placenta before birth. At birth, blood flow to the kidneys does increase, but the filtration abilities are limited – salt stays in while glucose and amino acids leak out. The newborn isn’t very good yet at concentrating or diluting urine to regulate body fluids.
The newborn does a poor job of maintaining body temperature.
At the same time the digestive system is starting to gear up for use. Mucus is being eliminated and the necessary bacteria for vitamin K production are beginning to grow.
What does all this mean? This means the majority of newborns are going to go through these early transitions without a problem. But the newborn is in an delicate position – anything that causes additional stress can overload this immature system quickly. This is one of the reasons the highest rates of death in children under five occur in the first year; and the highest rates of death in the first year are among those less than one week old.
As a midwife, I am trained to watch for these things in all my newborns – not with tests but with my eyes and ears. If something is off, I am trained to investigate quickly to help keep the system in the proper balance during transition. Some of the most common problems look the same or lead to each other in those first hours. For example, if a baby is too cold, the body burns glucose quickly to try to warm the baby which can lead to hypoglycemia. Or a baby who doesn’t feed well may begin to have problems with hypoglycemia, and may also have higher bilirubin levels if they are not stimulating good bowel movements.
While I still accept that this transitional time is normal for a newborn, I no longer pass these first few hours or days off as no big deal. While the baby is transitioning to extra-uterine life, I watch a little closer because this is one time when early detection of a problem makes a big difference in overall health.