Wednesday, September 26, 2012

National Preparedness Month: Fire Safety for Families

"Preparation through education is less costly than learning through tragedy" 

- Max Mayfield, Former Director National Hurricane Center

September is National Preparedness Month, or as some groups call it, Preptember™.  This means doing whatever you can ahead of time to be prepared for an emergency.

So let's start an occasional series on improving your emergency preparedness.  This will not be a continuous series, but rather a series of occasional posts about various preparedness topics.

No, I'm not a hardcore prepper.  However, I've lived all over the country and have lived through or near several emergencies.  I know that challenging things do happen sometimes, and I've seen that being even minimally prepared can make a lot of difference in survival and/or quality of life during an emergency. Now that I have a family to look after, I'm even more motivated to consider preparedness so that I can protect them as much as possible.

Sometimes preparedness can be intimidating or overwhelming. So, let's do a series of posts focusing on getting started with preparedness, with special attention to preparedness for families.

Remember, emergencies come in all shapes and sizes, just like people.  Some people think that Emergency Preparedness means getting ready for a nuclear bomb or the end of the world, but really, it's far more about being ready for the emergencies you are most likely to encounter.

So let's concentrate first on the most common everyday emergencies, things like house fires and power outages and such. Although it's important to prepare for the bigger disasters, it's often best to start with the things you are most likely to encounter, and then let those preps naturally springboard you into readiness for other things.

Today, let's talk about fire safety preparedness.

Fire Safety

The most common emergency people encounter is a house fire.  According to the Red Cross, "Fires kill more Americans each year than all natural disasters combined." Yet fire is one disaster that many people don't prepare for very thoroughly.

Do you know how to extinguish various types of fires? Do you have several fire extinguishers around your house, including one in your kitchen?  Do you and your older children know where they are and how to use them correctly? (Think "PASS" - Pull the pin, Aim low at the base of the fire, Squeeze the trigger, Sweep the extinguisher from side to side.) 

Do you have a fire escape plan?  Have you talked about what to do and practiced it?  The Red Cross reports that about three-fourths of Americans don't have a fire plan or don't practice one.  But training is important for helping people overcome the panic and chaos that can accompany emergencies; that's why schools have regular fire drills. Families benefit from this too.

Do your children know two ways to escape from every room?  Do they know never to hide in a closet or under a bed in response to a fire, but to exit the building?  Do little ones understand not to hide from firefighters, even though the uniform and mask may look and sound scary?  They need to know that firefighters are there to rescue them, and that the equipment is part of that.

Do they know to crawl on the floor as they exit so they can stay low, under the deadly smoke and fumes?  Do they know to close the bedroom door behind them as they leave to help slow the spread of the fire? Do they know to cover their mouths and noses as much as possible to help reduce smoke inhalation as they exit?

Do your children know to feel the door and doorknob with the back of their hand before opening it to make sure there is not a roaring fire on the other side?  To open the door slowly, with their shoulder behind the door, just in case it needs to be shut quickly again?  Do they know not to use the door if heavy smoke is coming from underneath it?

Do they know how to open the window in their room and exit there if the door is not viable? Have all windows been checked to see that they open easily and that screens/bars can be removed quickly?  If the bedrooms are on an upper floor, do you have emergency rope ladders for getting out of the windows safely?

Do children know to run to the neighbors' house and call 911?  Do they know their address to tell a 911 operator in an emergency? Do they know not to run back in the house for pets or family members, but to let firefighters take care of that?

If fire prevents children from escaping, is there a flashlight or whistle in every child's room so they can alert rescuers to where they are?  Do they know to stuff a towel or clothes under the door and cover air vents to reduce smoke getting into the room? Do they know to wave a flashlight or hang something bright-colored at the window, or to blow their whistle so firefighters can find them and rescue them more quickly?

Do you have an established plan to help family members who may need special assistance, like babies, pre-schoolers, the elderly, or those with special needs? Deaths in house fires occur disproportionately in these vulnerable groups, so it's important to have a plan in place to assist them.

Does your family have a pre-arranged meeting spot once everyone is out?  That way, you will know whether everyone is safe, and if not, you can alert firefighters more quickly to who needs rescuing and where they might be.

All these things are important for children to know if a fire emergency occurs. Remember to practice your family escape plan twice a year, both in the daytime and at night.  Heavy smoke makes it very hard to see and many fires occur at night, so children need to practice escaping in the dark too, not just in the daytime.

Smoke Alarms

 Do you have working smoke detectors?  Do you test and change the batteries regularly (if needed)? Do you have enough smoke detectors for your home's needs?  Are they installed correctly?

Having a working smoke alarm cuts the risk of fire-related death in half.  Yet FEMA reports that about 12% of homes still do not have smoke alarms.  Even in those homes which do have smoke alarms, about a third of the alarms don't work properly, the batteries are dead or disconnected, or there are not enough smoke alarms in the house.  That's a lot of vulnerable people.

You need a smoke alarm for every level of your house, because a fire on the lower level can grow to dangerous levels before its smoke is bad enough to set off an alarm upstairs. In addition, it's best to have a smoke alarm right outside every sleeping area of the house.  Many authorities are now recommending having one in every bedroom in the house.

Sleeping with the doors closed can really help lower your chances of dying of smoke/poisonous gas from fires, and it can delay the spread of fire, giving firefighters valuable extra time to rescue your little ones. However, if you sleep with doors closed, you might want to have a smoke alarm inside the bedroom too, in case a fire started inside the room first.

Test buttons on smoke alarms should be pressed monthly to be sure the alarms are still working. If your alarm starts "chirping", replace the battery in it immediately. You should also vacuum around smoke detectors periodically to keep cobwebs and bugs from interfering with them.

Batteries should be replaced about once or twice a year; many authorities suggest the Daylight Savings change day for this ("change your clocks, change your batteries!").  If you don't want to be bothered with changing the batteries regularly, buy the type of smoke alarm that has long-lasting lithium batteries (which should last 10 years).  They are more expensive, but it might be worth it to you.

The smoke alarm itself should be replaced about every 10 years, even if it seems to work, because it can get less sensitive to smoke with time. [I did not know that!]

You can read more about smoke alarms here and here.  If cost is a factor, remember that many areas have programs for getting free or low-cost smoke alarms.  Call your local fire department for more information.

Fire Prevention

Of course, the best thing to do is to avoid a fire altogether.  Prevention is the first step to fire safety preparedness.

The kitchen is the source of most home fires.  Good safety practices for preventing fires in the kitchen include never leaving anything on the stove unattended, turning the handles of pots away from the edge of the stove, keeping combustibles like kitchen towels away from the range, and not wearing loose sleeves when cooking.  In addition, have a kitchen fire extinguisher nearby, within easy reach.

Grease fires are particularly dangerous.  Keep pot lids close at hand for quick smothering of grease fires, sliding it on sideways so you don't get burned.  If you can't find a pot lid that fits, put a cookie sheet on top in order to deprive the flames of oxygen.  Next, turn off the heat source and wait for everything to cool completely before removing the lid.

NEVER pour water on a grease fire or transport it anywhere, or you will likely make the grease fire spread! And while baking soda can help smother a small grease fire, flour can actually ignite and make it worse. Covering a grease fire is really the best option for putting it out quickly, because you deprive it of the oxygen it needs to function, and you don't take the chance of using the wrong substance or not having enough to do the job.  (Of course, if in doubt, get out and call 911.)

Things you can do to prevent fires elsewhere in the house include:
  • having a good sturdy screen on your fireplace
  • not overloading electrical plugs
  • watching for frayed or worn cords
  • not running electrical cords under rugs or across doorways
  • not putting combustible materials near a heat source like baseboard or space heaters
  • having your chimney inspected and cleaned each year
  • disposing of fireplace ashes safely
  • cleaning lint from the dryer each load, and having the hose/vent cleaned regularly
  • being particularly cautious with portable heaters 
  • never leaving candles unsupervised, and using them in tip-proof containers
  • never smoking inside the house and making sure cigarettes are disposed of safely
  • keeping clothes and other combustibles away from water heaters
In addition, many fires are started by children experimenting with flames, so spend time educating children about fire safety.  Keep matches and fire materials stored high, out of the reach of young children.  Make sure they know about "Stop, Drop and Roll," which can save lives if clothes catch on fire. If they find a match or lighter, make sure they know that it's not a toy, and that they need to alert a trusted adult about it.

You can read more about fire prevention here and here.

Summary

Fire (and its associated smoke and poison gases) is the second most common cause of accidental death in U.S. homes.

Sadly, small children are twice as likely to die in a fire as the rest of us.  If you have a family, it's especially important to lower your chances for a devastating fire and to know how to respond if one does occur.

The best way to survive a fire emergency is by preventing one in the first place.  Pay attention to general fire safety around the house. Do a fire hazard hunt, and talk to your children about preventing fires.

If a fire occurs despite precautions, a good early-alert smoke alarm greatly improves your chances of survival. The majority of fire fatalities occur in homes without smoke alarms or where the smoke alarms were not working, so check the batteries in your smoke detectors regularly or buy the kind that don't need replacement often.  Update your alarm every 10 years.

In addition, have a fire safety plan in place.  Teach your children how to get out safely, how to alert rescuers to their presence if trapped, and establish a family meeting spot. Make sure your family is ready by running home fire drills about twice a year. These are critical for safety if a fire does occur.

Adapt your precautions as needed for your own situation.  People in high-rise apartments or manufactured homes may have different needs than those in single-family homes, and those who have family members with special needs (hearing impairments, mobility challenges etc.) may need special adaptations in their plans. Be flexible and make adjustments as needed.

Hopefully you will never experience a fire emergency, but if you do, having a plan in place could help save your lives.

Our Experience: How does my family measure up to all this? Well, even the most prepared family has things they can improve on, which is part of the lesson of preparedness.  We are no exception.

 At our house, we've done a decent job with fire prevention and family escape plans.  However, we need to practice our fire drills in the dark, test our smoke alarm batteries more regularly, vacuum around our smoke detectors periodically, have our chimney inspected, and have our dryer vent hose cleaned.  And my husband needs to stop leaving the kitchen when he's cooking something on the stove!

 After much thought, we recently decided to add more smoke detectors.  We felt our existing ones might not be placed optimally to get an early alert while asleep so we are adding ones in each bedroom.  We also added carbon monoxide detectors, because this is another deadly emergency that can be escaped from with good alarms.

 How's YOUR fire safety preparedness at your house?  Any other hints to add to the ones here?


Fire Safety Resources
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Tuesday, September 18, 2012

Childbirth Education Experiences in Women of Size


Readers, I need your input and stories.

I've been asked to write an article for childbirth educators on how they can make their classes more size-friendly for plus-sized women. I have a number of ideas, but I'd like to solicit your feedback on this too.

In articles like these, it's good to start off with some real stories from women of size.  Storytelling is useful in bringing home advocacy messages in an emotionally powerful way.  So for those of you who have been pregnant and have taken a childbirth education class (of any sort*), please tell me about your experiences as a woman of size, both positive and negative:

  • How were you made to feel welcome (or not)?
  • Did you feel you had any special needs or concerns as a women of size in the class?  If so, were they met?  
  • Was the equipment/environment friendly for a larger person? 
  • Did you feel pointed out or ostracized as a woman of size?
  • Do you feel you could have asked specific questions about your concerns as a woman of size, either privately or during class?  
  • Were you given any list of resources that might address the needs of diverse people in the class (lesbian women, single moms, women of size, etc.)?

If you haven't been pregnant (or haven't been to a childbirth education class), think about what you would like in such a class as a woman of size:

  • What special needs might a woman of size have in a childbirth ed class?
  • How can a childbirth education teacher make the class more size-friendly?  Consider classroom design, chairs, equipment, images, films, mobility and positioning concerns, content about nutrition and exercise, breastfeeding information, etc. 
  • How can a childbirth educator help women of size feel more welcomed, respected, and listened to? 
  • What resources specific to women of size should childbirth educators know about? 

For example, let me share a few stories from my own experiences:
One thing that was a problem for me in my first pregnancy was the lack of information and resources available for women of size.  There were no maternity clothes or nursing bras in my size in that city then, and no one had any clue about how to help me find any. It would have been helpful if my childbirth educator or care provider had been able to give me a list of resources for pregnancy in women of size.    
One of the most trying things for me as a fat woman who practices Health At Every Size® principles was the nutrition diary. After years of having every stinking thing I ate nit-picked and judged, I found freedom in returning to a more natural, intuitive way of eating. When extensive food diaries were expected in childbirth classes, that was very stressful for me. Would they even believe what I wrote? Did they think I was lying when junk food wasn't in my diary?  Would they have hyper-restrictive standards for me as a woman of size? I honestly found food journaling quite an ordeal. I can only imagine how triggering it must be for women with eating disorders.   
There was also very little information about breastfeeding when well-endowed. The football hold was never mentioned in my breastfeeding class, and it was only through The Nursing Mother's Companion that I realized that this might be helpful for well-endowed women. If I hadn't learned about the football hold, breastfeeding would have failed for us, because the cradle hold did not work for me.  Childbirth educators need to remember breast diversity and address different positions and techniques.
These are some of the experiences I remember being challenging in the childbirth education classes I took over the years.  Most teachers were welcoming to me as a woman of size, much more welcoming than some of the doctors and midwives I saw, but still, there were a few things that could have been improved.

How about you? What were your experiences?  What things could have been improved in your classes?  What would you most look for in a class if you were to take one?  What advice would you give to childbirth education teachers about making their class size-friendly?

I'm also interested in hearing about the childbirth ed class content that was most useful to you in general, not just as a person of size.  For example, one of the best classes I ever took was one where we did an extensive labor rehearsal with our partners, rotating through various laboring positions and coping techniques for a prolonged period of time.  This brought those techniques out of my intellectual memory and into my muscle memory, making them easier to remember and utilize in labor.

How about you?  What was the best or most useful thing you learned in class?  What do you wish they had done more of?  What was not useful?

[You can share your comments and ideas either via a direct email to me (kmom *AT* plus-size-pregnancy *dot* org), or in the comments section of this post. Please understand that if you comment here or send me an email, you are giving me explicit permission to quote you as needed.  If you don't want me to quote you, please say so.  If you are okay with being quoted, please use a name that is okay for attribution.  Finally, remember that I retain the right to use, not use, or edit any story as needed.]

Thanks for your help.  Birth workers (including childbirth educators) are hearing the message that women of size deserve more respectful care.  Here is our chance to spread that message even more.

*What kind of childbirth ed class did you take?  A hospital class?  A Lamaze class?  BirthWorks?  Hypnobirthing?  Birthing From Within? Bradley? Others? 
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Tuesday, September 11, 2012

The Dangers of Estimating Fetal Weight Near Term

Here's a new, interesting study that shows that the routine practice of ordering a fetal weight estimate near term can have negative consequences.

Background: Many care providers order an ultrasound to estimate the baby's weight when the mother is near term, even though research shows this is not a very accurate way to predict the baby's weight.  

Women with babies predicted to be big often are pressured to schedule a planned cesarean to avoid the possibility of shoulder dystocia (shoulders getting stuck, causing injury to the baby), despite little research to show that a cesarean improves outcome.

Or they are encouraged to induce labor early "while the baby is smaller," even though research shows that this actually may increase the risk for cesarean.

Here is a new study that shows that even just doing the fetal-weight ultrasound in the first place may increase the risk for cesarean.

Why?  Probably because knowledge of the results (and nervousness over fetal size) changes the behavior of the care provider so that they have a lower surgical threshold during labor.  

This is particularly an issue for women of size. Even though the majority of "obese" women do not have big babies at all, we do tend to have bigger babies on average than "normal" weight women.  This makes care providers nervous. And since many believe that fat women eat mostly junk food or are practically diabetic anyhow, this increases their fear of big babies even more. So many providers routinely order ultrasounds to estimate fetal weight near term in the pregnancies of obese women.

In this most recent study, 50% of all pregnant women had an ultrasound that calculated Estimated Fetal Weight (EFW) within a month of delivery. Those that did had a higher cesarean rate than those who didn't, especially those whose babies were predicted to be big by EFW.

The rate of EFW ulstraounds is probably even higher in obese women.  How does that then affect our cesarean rates? It is likely another example of management variables that result in increased cesarean rates in obese women.  Yet this is a management variable that can be modified.

An ultrasound to estimate fetal weight near term does not improve outcomes and is a risk factor for an increased cesarean rate.  


References

Am J Obstet Gynecol. 2012 Jul 9. [Epub ahead of print] Estimated fetal weight by ultrasound: a modifiable risk factor for cesarean delivery? Little SE, Edlow AG, Thomas AM, Smith NA.  PMID: 22902073
OBJECTIVE: The purpose of this study was to investigate whether knowledge of ultrasound-obtained estimated fetal weight (US-EFW) is a risk factor for cesarean delivery (CD).
STUDY DESIGN: Retrospective cohort from a single center in 2009-2010 of singleton, term live births. CD rates were compared for women with and without US-EFW within 1 month of delivery and adjusted for potential confounders.
RESULTS: Of the 2329 women in our cohort, 50.2% had US-EFW within 1 month of delivery. CD was significantly more common for women with US-EFW (15.7% vs 10.2%; P < .001); after we controlled for confounders, US-EFW remained an independent risk factor for CD (odds ratio, 1.44; 95% confidence interval, 1.1-1.9). The risk increased when US-EFW was >3500 g (odds ratio, 1.8; 95% confidence interval, 1.3-2.7).
CONCLUSION: Knowledge of US-EFW, above and beyond the impact of fetal size itself, increases the risk of CD. Acquisition of US-EFW near term appears to be an independent and potentially modifiable risk factor for CD.
Am J Obstet Gynecol. 2009 Mar;200(3):340.e1-3. Overestimation of fetal weight by ultrasound: does it influence the likelihood of cesarean delivery for labor arrest? Blackwell SC, Refuerzo J, Chadha R, Carreno CA.  PMID: 19254597
OBJECTIVE: We sought to determine whether the overestimation of ultrasound-derived estimated fetal weight (EFW) is associated with increased diagnosis of labor arrest. STUDY DESIGN: This is a historical cohort study of nulliparous women with term pregnancies who underwent bedside ultrasound examination for EFW before labor induction. Labor outcomes of women with EFW overestimation > 15% the actual birthweight were compared with those with EFW not overestimated. RESULTS: Overestimation of EFW occurred in 9.5% of cases (23/241). The rate of cesarean delivery (CD) for labor arrest was higher for those with EFW overestimation (34.8% vs 13.3%; P = .01) even though there were no differences in length of the induction duration. After adjusting for confounding factors, EFW overestimation remained associated with CD for labor arrest (odds ratio, 4.8; 95% confidence interval, 1.5-15.2). CONCLUSION: Our finding suggests that an overestimation of EFW may be associated with a lower threshold for CD for labor arrest.
Am J Obstet Gynecol. 1995 Oct;173(4):1215-9. Fetal macrosomia: does antenatal prediction affect delivery route and birth outcome? Weeks JW, Pitman T, Spinnato JA 2nd.  PMID: 7485323
OBJECTIVE: Our purpose was to determine whether clinical or ultrasonographic prediction of fetal macrosomia influences subsequent delivery route and birth outcome in a clinical setting where macrosomia is not considered an indication for cesarean delivery. STUDY DESIGN: The hospital records of 504 patients delivered of infants weighing > or = 4200 gm between October 1989 and March 1994 were reviewed. Statistical comparisons were made between patients in whom fetal macrosomia was predicted before delivery (n = 102) and those in whom it was not (n = 402). Cesarean delivery, shoulder dystocia, and birth trauma rates were the variables of interest. RESULTS: Cesarean sections were performed in 52% of the "predicted" group deliveries and in 30% of the "not predicted" group (p < 0.01). The increased cesarean delivery rate in the predicted group appeared to be related to an increased incidence of labor inductions (42.5% vs 26.6%, p = 0.005) and a greater proportion of failed inductions. The proportion of patients delivered by cesarean section without a trial of labor was similar in the predicted and not predicted groups (14.7% vs 10.2%, p = 0.21). There was no significant differences in the incidence of shoulder dystocia or the occurrence of birth trauma. CONCLUSIONS: The antenatal prediction of fetal macrosomia is associated with a marked increase in cesarean deliveries without a significant reduction in the incidence of shoulder dystocia or fetal injury. Ultrasonography and labor induction for patients at risk for fetal macrosomia should be discouraged.
Eur J Obstet Gynecol Reprod Biol. 2002 Oct 10;105(1):20-4. Clinical and ultrasonographic weight estimation in large for gestational age fetus. Weiner Z, et al. PMID: 12270559
OBJECTIVE: To examine prospectively the effect on pregnancy outcome of a management protocol, that adds ultrasonographic weight estimation in fetuses suspected clinically as large. STUDY DESIGN: Prospective follow up study of all singleton deliveries during a 1 year period. All patients underwent routine clinical estimation of fetal weight. When clinical estimation of fetal weight was > or = 3700 g, patients were referred for ultrasonographic estimation of fetal weight. When the latter was > or = 4000 g the patient was informed about the risks of birth trauma. Cesarean section was recommended only when > or = 4500 g. Ultrasonography was repeated every 4 days when possible. Predictive values of clinical and ultrasonographic estimations of fetal weight for diagnosing macrosomia, defined for the purpose of this study as 4000 g or more, and their effect on the rate of cesarean sections. RESULTS: Five hundred fifty-five (14.4%) out of 3844 singletons were estimated as 3700 g or more. Only 315 fetuses had ultrasonographic estimation of weight within 3 days of delivery. The sensitivity of clinical and ultrasonographic prediction of macrosomia was 68 and 58%, respectively. Cesarean section rate in newborns weighing 4000 g or more was 22% when macrosomia was clinically suspected compared to 11% when it was not (P<0.05). In fetuses estimated ultrasonographically as 4000 g or larger the cesarean section rate was doubled (50.7% versus 24.9%, P<0.05) compared to those estimated as smaller than 4000 g, although actual weight of 4500 g or more was recorded in 10.6 and 8.5% of these groups, respectively. There were no cases of shoulder dystocia in macrosomic babies when macrosomia was not detected by ultrasound compared to two cases of shoulder dystocia (2.7%) when macrosomia was detected by ultrasound. CONCLUSION: Antenatal suspicion of macrosomia increased the cesarean section rate while the associated improvement in pregnancy outcome remains questionable. The contribution of ultrasound, added to routine clinical estimation of fetal weight, was clinically insignificant apart from a further increase in cesarean section rate.
Arch Gynecol Obstet. 2008 Sep;278(3):225-30. Epub 2008 Feb 26. Suspected macrosomia? Better not tell. Sadeh-Mestechkin D, et al.  PMID: 18299867
OBJECTIVE: To evaluate the management policy of delivery in a suspected macrosomic fetus and to describe the outcome of this policy. STUDY DESIGN: For this prospective observational study we followed the management by reviewing the medical records of 145 women and their infants. The study population included women at term admitted to the obstetrics department with suspected macrosomic infants, as was diagnosed by an obstetrician and/or by fetal sonographic weight estimation of > or =4,000 g. The comparison group (n = 5,943) consisted of all women who gave birth during the data collection period. RESULTS: Induction of labor and cesarean delivery rates in the macrosomic pregnancies (actual birth weight >4,000 g) of the study group were significantly higher when compared with the macrosomic pregnancies of the comparison group. When comparing the non-macrosomic to the macrosomic pregnancies (actual birth weight </>4,000 g) of the study group no significant difference was demonstrated regarding maternal or infant complications. The sensitivity, specificity and positive predictive value of the methods used for detecting macrosomia were 21.6, 98.6 and 43.5%, respectively. CONCLUSION: Our ability to predict macrosomia is poor. Our management policy of suspected macrosomic pregnancies raises induction of labor and cesarean delivery rates without improving maternal or fetal outcome.
Am J Obstet Gynecol. 2006 Sep;195(3):657-72. Epub 2006 Apr 21. Shoulder dystocia: the unpreventable obstetric emergency with empiric management guidelines. Gherman RB, et al.   PMID: 16949396
OBJECTIVE: Much of our understanding and knowledge of shoulder dystocia has been blurred by inconsistent and scientific studies that are of limited scientific quality. In an evidence-based format, we sought to answer the following questions: (1) Is shoulder dystocia predictable? (2) Can shoulder dystocia be prevented? (3) When shoulder dystocia does occur, what maneuvers should be performed? and (4) What are the sequelae of shoulder dystocia? STUDY DESIGN: Electronic databases, including PUBMED and the Cochrane Database, were searched using the key word "shoulder dystocia." We also performed a manual review of articles included in the bibliographies of these selected articles to further define articles for review. Only those articles published in the English language were eligible for inclusion. RESULTS: There is a significantly increased risk of shoulder dystocia as birth weight linearly increases. From a prospective point of view, however, prepregnancy and antepartum risk factors have exceedingly poor predictive value for the prediction of shoulder dystocia. Late pregnancy ultrasound likewise displays low sensitivity, decreasing accuracy with increasing birth weight, and an overall tendency to overestimate the birth weight. Induction of labor for suspected fetal macrosomia has not been shown to alter the incidence of shoulder dystocia among nondiabetic patients. The concept of prophylactic cesarean delivery as a means to prevent shoulder dystocia and therefore avoid brachial plexus injury has not been supported by either clinical or theoretic data....


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Monday, September 3, 2012

Canning: Pecking About Pectins

Different brands of pectin; image from pickyourown.org 

We've been talking about canning and preserving as an end-of-summer change of pace for the blog.  Today, let's talk about pectins.

Previously, we talked a little about things that keep people from trying canning, which are usually safety fears or just pure lack of knowledge about how to can.

We reminded everyone that high-acid fruit jams, processed in a boiling water bath, are a very safe form of canning, unlikely to harm anyone because spoilage would be obvious (mold or a fermented smell). Thus, jams are a great place for beginners to start.

We also shared some resources for learning how to can, good books and websites for canning, online tutorials, and how to find canning classes in your local area.

One question that often arises in canning is the difference between the different types of pectin, and that can definitely be confusing.  So let's try to break it down a little bit now.

What is Pectin?

Pectin is plant fiber that is used as a thickening agent for jams and jellies.  Here is one website's summary:
By definition, pectin is a structural heteropolysaccharide found in the walls of plants that forms a colloidal system when combined with water. In simpler terms, pectin is a soluble fiber that forms a gel when you add water to it. Some plants have more pectin in them, some less. Apples and citrus fruits have the highest concentrations of pectin in them and are oftentimes the sources for what you will find on the shelves at your grocery store.
Knowledge of the uses of pectin has been around for a long time, as discussed here:
Jams and Jellies have been produced for many years, at least since the 18th Century. Recipes were published in the "London Housewife's Family Companion" of 1750 which described jellies made from apple, currant, and quince, all fruits rich in gelling pectin. 
Pectin was first isolated in the 1820s, and shown to be the key to making jams and jellies.
Gradually, people mixed pectin rich fruits or fruit extracts with fruits which do not set jams well - strawberry with gooseberry or with red currant, for example. Extracts of apple peels and cores were also used for "difficult to set" jams. 
Commercial jam producers sought further supplies of pectin source materials. In Germany, apple juice producers started to dry the pomace residue left after pressing juice for sale to jam makers, who would cook the pomace in water with or without fruit juice to make a jellying juice. 
The first commercial production of a liquid pectin extract was recorded in 1908 in Germany, and the process spread rapidly to the United States, where a classic patent was obtained by Douglas (US Pat. 1.082,682, 1913). This was followed by a rapid growth of the pectin industry in the United States, and also somewhat later in Europe. 
In recent years, the centre of production has moved to Europe and to citrus-producing countries like Mexico and Brazil.
There are several different types of pectin and each works a little differently. The main two types of pectin are high methoxyl pectin and low methoxyl pectin:
The high methoxyl pectin needs acid and sugar for it to work and is most commonly used for traditional fruit preserves. Low methoxyl pectin needs calcium present for the gelling process to work, which makes it better for low or no sugar preserves.
This is a crucial difference, so let's discuss it a bit more.

High Methoxyl Pectins

High methoxyl pectins are the kind most people probably think of when they think of canning.

High methoxyl pectins are easily found in most supermarkets. Common brands are Sure-Jell, Ball, Certo, MCP, and many others.

Different brands have differing processing requirements.  If you are going to make a recipe from the box, follow the recipes in that brand's box only. Don't swap brands because recipes are formulated specifically for that brand and its unique requirements.

Dry and liquid forms of high methoxyl pectins are not interchangeable either.  Each has their own advantages, and which you use is mostly personal preference. Certo is the most common liquid pectin you'll find, but Ball also makes a liquid pectin which some people prefer.

There are also rapid-set and slow-set high methoxyl pectins. The difference is in the Degree of Esterification (DE). The rapid-set ones have a high DE and are used for products where you want chunks of fruit suspended in a gel, as in marmalades. Slower-set ones have a slightly lower DE and are good for clear jellies.  

One disadvantage to high methoxyl pectins is that they need sugar to set up (jell), and therefore you can't alter the amount of sugar that's in the recipe.  The recipe has been tested to see just how much sugar is needed to make the jam set up properly, so if you lower the sugar amount you will get runny jam.

Another nit-picky detail about high methoxyl pectins is that they are very finicky about changes to a recipe.  If you try to make a double batch of jam, they won't set up well.  Definitely make two separate batches rather than double a recipe.  Also don't tweak the ingredients very much; a little bit of change in spices can be tolerated, but anything more will probably also affect the ability of the pectin to set up.

High methoxyl pectins need inordinate amounts of sugar.  Usually the sugar concentration required is above 55 percent, meaning that there is more sugar than fruit in the recipe, causing the jam to be super-sweet.  Many people (including me) don't like this.

No, I'm not trying to lose weight, and no, I'm not diabetic, but this is too much for me.  My sweet tooth is absolutely overwhelmed by the sweetness in some of these full-sugar recipes, and I don't think that much sugar is good for your body.

If you are like me and want to lower the amount of sugar in your jams, consider a low methoxyl pectin instead.

Low Methoxyl Pectins

Low methoxyl pectins are less commonly used and harder to find. However, they offer far more flexibility in the amount of sugar that's required, which is increasing their popularity quickly.

Low methoxyl pectin is made by subjecting high methoxyl pectins to a de-estrification process. High methoxyl pectins have a DE of more than 50%, and low methoxyl pectins have a DE of less than 50%.

A low DE means that low methoxyl pectins are responsive to calcium ions, unlike high methoxyl pectins, which lets them jell food differently.  Canning with low methoxyl pectin involves adding calcium in order to activate the jelling properties of this pectin.

This is the biggest difference between the two pectins.  High methoxyl pectins jell due to the interaction between the pectin, sugar, and acid, while low methoxyl pectins jell due to interaction with added calcium, thus requiring much less sugar.

Sure-Jell makes a low methoxyl pectin (available in the PINK box) in addition to its high methoxyl pectin (available in the YELLOW box).  In the Sure-Jell pink box, the calcium has already been added to the pectin powder and stabilized with dextrose, so the cook doesn't have an extra step in the canning process.

Many people like the low-sugar Sure-Jell because that extra step is done for them. However, Sure-Jell's "low sugar" recipes still use quite a bit of sugar ─ about 3 cups of sugar for every 4 cups of fruit.  Many people would like to use even less. So they turn to Pomona Pectin instead.

Pomona Pectin is the brand of low methoxyl pectin that will best accommodate low sugar recipes.  This type is "amidated" through an additional processing step, which lowers the degree of esterification even more. Because of this, it is even more responsive to calcium for jelling, rendering the amount of sugar irrelevant except for taste.

Thus, cooks using Pomona Pectin can use as much or as little sugar (including no sugar at all) as they prefer.  Most jammers end up using somewhere around 1/2 - 1 cup of sugar for every 4 cups of fruit with this pectin, but you can vary the amount of sugar used according to your taste, which is a flexibility no other pectin has.

In addition, since the jelling properties are not dependent on sugar, you can also use different types of sweeteners, like honey, maple syrup, fructose, agave, fruit juice, etc. Or you can use artificial sweeteners like Stevia if you need to watch your carb intake super carefully.  For diabetics, people with PCOS, or people with cane sugar allergies, this flexibility is huge.

However, the trade-off is that the calcium needed is not pre-added to Pomona, so you have to make a calcium-water mixture beforehand and then add it near the end of jamming. This calcium water thing seems strange if you've not used it before, but it's really not a big deal. Here is information about using calcium water from the Pomona website:
What are the ingredients in the monocalcium phosphate powder that comes with Pomona’s Pectin? The monocalcium phosphate powder that comes in its own packet when you purchase Pomona’s is a food-grade rock mineral source of calcium made up of two minerals, calcium and phosphorous. The food industry uses it as a yeast nutrient in baking, an acidulant in baking powder, and a mineral supplement. 
What is calcium water? Calcium water is a solution of some of the monocalcium phosphate powder that comes with Pomona’s Pectin and water. 
How do I make calcium water? Put 1/2 teaspoon white calcium powder and 1/2 cup water in a small, clear jar with a lid. Shake well before using. Store in the refrigerator between uses. Calcium water lasts a number of months. These same instructions are on the directions and recipe sheet that comes with Pomona’s Pectin. 
How long will calcium water keep? Calcium water should be stored in the refrigerator. It will last a number of months. When you take your jar out of the refrigerator, look at it before you shake it. You should see white powder settled at the bottom of the jar and clear water above that. If you see any other colors in the jar, discard the calcium water.
There is a bit of a learning curve involved in using Pomona Pectin. Personally, I found that the directions included in the Pomona box were very confusing for a first-timer.  It took us a while in our canning class to figure their directions out, and even our teachers were a little confused by some of their phrasing.  But eventually we figured it all out.

If you learned to make jam using high methoxyl pectins, it's confusing at first to switch to a different order of mixing things (you add the pectin to the sweetener first, not the fruit, or it will clump). You also have an extra step, adding the calcium water).  However, the advantages that Pomona offers outweighs the confusing directions and the extra steps.

For example, Pomona claims its pectin lasts indefinitely if stored properly. High methoxyl pectins don't keep well, and if you use last year's box, your jam may not set up properly. This means the storability of Pomona is a big advantage.

Another advantage is the "tweakability" factor. You can make double batches with Pomona, unlike with high methoxyl pectins, and that can be a huge time-saver. You can also add a certain amount of extra ingredients without messing up the pectin's action...just add a little extra lemon juice to keep the acidity factor high. And if your jam turns out too stiff or too runny, you can go back and tweak the jelling action.

All these things, plus the flexibility to use less sugar or different types of sweeteners, makes Pomona the first pectin choice of many experienced cooks.  It's definitely a brand to check out if you do much jamming, or if you prefer the taste of fruit over the taste of sugar.

Do keep in mind that if you are using less sugar, there will be less volume in the final product. Also, the lower the sugar, the softer the jam set tends to be, if that makes a difference to you.  But most people are more than happy to trade off these issues for the many advantages of Pomona.

Pomona Pectin can be hard to find in regular supermarkets, although most natural food stores carry it.  You can also order it directly from Amazon, or you can get it through Pomona's website.  Many food co-ops also carry it, and so do many farm-oriented stores.

Because of its many advantages, it's well worth the trouble to find and learn to use this less common type of pectin.

Do You Have to Use Pectin?

I'm sure some people are wondering whether you absolutely need to have pectin in order to make jam. Of course not; people made jam long before commercial pectin was around, But pectin does make your life a bit easier, which is why it's so popular.

Different fruits have differing amounts of pectin in them, so some don't need extra pectin to set up.  For example, apples, cranberries, currants, gooseberries, quinces, and citrus fruits have a lot of natural pectin and often don't need anything extra.

Most berries, peaches, and apricots, on the other hand, have very little natural pectin. But even low-pectin fruits can make a decent jam if you cook them long enough, add a lot of sugar, and add a little acid (like lemon juice).  The problem is you have to stir them in a hot steamy pot for quite a while, usually in the middle of the hot summer. Boiling for a long time also reduces the amount of nutrients in the fruit and the amount of jam produced.

Thus, many people elect to use pectins as a way to make jamming faster and cooler, and as a way to keep the jam more nutritious and less caloric. Others prefer to make jam without the shortcut of added pectin, feeling that the flavor is richer that way, even if the jam is a little runnier. It's all about your preferences.

You can find instructions for making jam without pectin here.  The trick is to use a certain amount of fruit that is a bit underripe (has more natural pectin), but not so much that the flavor is compromised.  Another option is to add apple juice instead of water when cooking, or to add other high-pectin fruits to the jam.

If you are going to make jam without pectin, it's important that you know how to recognize when it jells properly, as the amount of cooking time will depend on the ingredients used, the ripeness of the fruit, the water content of the fruit, your elevation, etc.

So the cooking skill-set needed for no-pectin jams is a little higher, but it can absolutely be done.

Can You Make Your Own Pectin?

Some people don't want to use commercial pectin, either because it is cheaper to make your own, or because they object to the processing that commercial pectin goes through.

Commercial pectin is made mostly from citrus peels or apple pomace (what's left over after juicing apples).  New pectins are being developed from sugar beets and even sunflowers, but citrus peels (and apple pomace to a lesser extent) are the most common sources for commercial pectin.

If I understand the process correctly, hot dilute acid is added, the results are separated and filtered, and alcohol is used to precipitate out the pectin.  The product is washed and dried and made into a powder.  This becomes the high methoxyl pectin we see in most supermarket brands.

High-methoxyl pectins (DE usually 60-75%%) are subjected to a de-esterification process using acid in order to hydrolise some of the ester groups and create low methoxyl pectins (DE around 20-40%). For the very low methoxyl pectins like Pomona, hydrolysis using ammonia converts some of the ester groups into amide groups, creating the amidated low methoxyl pectin that is needed for low/no sugar pectins.

All of this sounds complex and off-putting but is generally considered very safe. Still, if you object to all this processing or simply want a cheaper, more easily available pectin, you can make your own pectin at home from underripe apples or crabapples.  Directions can be found here, here, or here.

Remember that the result will be a high methoxyl pectin, but one that may result in a less firm gel than commercial pectins. You will need to use a lot of sugar (and some acid) in these recipes, need to have the skill to recognize when the proper jelling stage is reached, and be accepting of a slightly runnier product.  But making your own pectin is definitely do-able; it's what most of our great-grandmothers did.

Final Thoughts

Well, there you go, more than you ever wanted to know about pectin!

Turns out, pectin was way more interesting (and way more complex!) than I thought it was going to be when I started. What I thought was correct was often incorrect when I did a little more research. And I found that there are an awful lot of strong opinions out there about pectins.

However, what it boils down to (!) is that there are two main types of pectin. High methoxyl pectins needs lots of sugar and some acidity to jell, and low methoxyl pectins need calcium to jell and are thus great for jams with less sugar.

You can use commercial pectins, make your own, or create a jelling effect by cooking the fruits for a long time, but there is little consensus about the "best" type of pectin.  It all depends on what you want out of a pectin, what you are making, what fruit you are using, how sweet you like things, what sweetener you want to use, what gel consistency you want, and your opinions about how pectins are made.  The key is to experiment and find out what you prefer.

Some people prefer their jams super-sweet and cooked.  If this is you, high methoxyl pectins are probably your best choice. Sure-Jell in the yellow box, Certo or Ball liquid pectin, or Ball regular pectin are all brands that work well for full-sugar jams.

Some people want to use less sugar but don't want an ultra-low sugar jam.  Low methoxyl pectins like Sure-Jell in the pink box, Ball's Low or No Sugar Pectin, or Pomona Pectin are the best for this, and they all result in great-tasting jams that are still plenty sweet.

If you want very little sugar in your jam (or prefer a different type of sweetener), then an amidated low methoxyl pectin like Pomona Pectin is the way to go.

Most people I know who do a lot of jamming prefer Pomona, frankly, because it's so much more flexible than the other pectins. It's harder to find, but seems well worth the effort. However, any type of pectin works very well and results in a good product.

You can also make your jams without any added pectin. I would like to try this at some point so I know how to do it, but generally I prefer not to cook jams that long.  The flavor is too overcooked for my taste, and the jams too sweet.  But many purists prefer this style.

If you are feeling adventurous, make your own pectin!  I've never done this either, but I like the DIY aspect of it, and it's a good skill from an emergency preparedness point of view. I will try this at some point so I know how to do it, but it probably won't be my main kind of jamming unless it needs to be.

Personally, I prefer the low methoxyl pectins.  I've had great luck with Sure-Jell in the pink box; it was very easy for a beginner to use and the results were really tasty.  I'm experimenting now with using Pomona Pectin in order to reduce sugar content even more in my jams.  I really like the flexibility it offers over other pectins, so I think I'll probably use it more as I do more canning.

If you are a beginner and feeling totally intimidated about the whole process, I suggest you start with the pink box Sure-Jell Strawberry Freezer Jam recipe so you have an easy first experience with jamming and don't have the added intimidation of water-bath canning. And the flavor of this jam is soooo good, it makes great Christmas gifts...if you can bear to give it away!

Then when you have had your first successes (and have gotten addicted to homemade jam!), try some of the canning recipes that use a boiling water bath.  Truly, it's not that hard, and you're not going to poison your family.  Plus the results are delicious and don't have to be frozen!

As a fellow beginner, I would also remind you that you don't have to preserve everything under the sun. People often feel intimidated by the Canning Queens out there and can't envision spending that much time and effort. Just because some people spend tons of time on canning doesn't mean you have to. You can preserve food just as much or as little as you prefer.  

Start small and see how it feels, then if you like it, expand into different fruits, techniques, and pectins as your time allows.  Take a class and learn new techniques if you prefer to learn by watching and doing.  Experiment with new recipes. Allow yourself to make mistakes and remember that you don't have to be an expert overnight.

I promise, you don't have to be Betty Crocker or Susie Homemaker to learn how to can. I'm about as far from a Domestic Goddess as you can get, but I've found canning quite rewarding, not to mention delicious and nutritious. Give it a try!

 *What are your favorite jam recipes?  Tell us about them and share a link to the recipe!

 **Pectin Trivia: High methoxyl pectin is also being used as a treatment for some cases of high LDL cholesterol, as it inhibits the absorption of cholesterol from foods.  It's a common ingredient in anti-diarrheal meds as well.  There is also some evidence that modified citrus pectin (MCP) may reduce the risk of tumor metastasis, especially in prostate cancer and perhaps breast cancer and melanoma.  However, all this is preliminary and far from well-proven; always consult your care provider before trying anything new.  I just thought it was interesting that pectin might have some medicinal benefits too.

 ***Update October 2018: I now have added a guide to Remaking Runny Jams. If you have a batch of jam or jelly that does not set up and gel, try some of the techniques in this post. 

Further Canning and Pectin Information

 General Canning Information
General Pectin Information
Pectin Info for Science Geeks
Info on Making Low-Sugar Jams
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