What Are You Wearing to PPROM?

When you hear the word prom, your mind immediately goes to dresses, dancing, and corsages—those awkward high school days when who your prom date was felt as important as who was running for president. And while we would love to relive what we wore and who we wore it with, the PPROM we are here to discuss is premature preterm rupture of membranes (a.k.a. breaking your water before you’re in labor and way before your due date!).

Before we delve into the details of PPROM, let’s take a step back. From the moment of implantation, your plus one spends his or her days and nights swimming in a pool. This pool is in your uterus and is called the amniotic sac. When your water breaks, be it at six months or nine months, it signifies that the amniotic sac has opened and your amniotic fluid (a.k.a. water) is leaking. When this happens at or around your due date, it’s game on. Pack your bags; let’s go have a baby!

And while there is excitement (#babyontheway), there is generally no cause for concern. However, when your water breaks before you have reached the full-term mark (37 weeks), we put on a full-court press to stop things from moving any further. And depending just how early in pregnancy you are, we may pull out all the stops to stop labor from progressing. Preterm delivery can be dangerous: think lung problems, brain problems, GI problems, and beyond. That’s why we will do our very best to stop it.

Because of the what-ifs and the what-cans that often follow premature babies, women with PPROM can anticipate a lot of attention. You, your uterus, and your fetus will take center stage on the labor floor, which will become your new home until the baby is born. And depending on how things go (Do you develop an infection? Does your baby appear to be in distress? Have you reached a safe gestational age for delivery?), the curtain may not fall for several weeks. In short, our goal is to keep you pregnant for as long as we safely can. When it comes to fetal development, days matter. Although the neonatal intensive care units (NICUs) have come a long way, there is no better home for a developing baby than in your womb.

Why your uterus decides to go to PPROM earlier than it should is often unknown. While most cases occur because of an underlying infection, in many cases, we aren’t sure what set the system into motion. However, given that infection is the no. 1 culprit, we will routinely start antibiotics to treat a potential infection and to hold off what might come next (a.k.a. full-blown labor). We will also keep a close eye on your temperature, your white blood cell count, and your baby’s heart rate to make sure that an infection is not arising or, if already present, getting worse. Additionally, if the PPROM occurred at less than about 34 to 36 weeks, your OB/GYN will administer a dose of steroids to help your baby’s lungs reach maturity.

Many of us have had many water-breaking false alarms during pregnancy. The kind when you realize, “Oops, I just peed on myself.” And while it can be hard to distinguish amniotic fluid from urine (for the non-OB/GYNs amongst us), when symptoms like cramping, pressure, and bleeding are present, it is usually the former.

However, the only way to know is to go (we purposely made that rhyme so it sticks in your head!). Going to your OB’s office or the labor floor is the only reliable way to know exactly what that liquid is. And while no one wants to be the boy (or girl) who cried wolf, it is always better to be safe than sorry.

The good news is that most of us won’t show up for the prom early. In fact, only about 3% of all pregnancies in the US are complicated by PPROM. However, women with a previous PPROM are at increased risk for another PPROM. To avoid an encore performance in your next pregnancy, your care might be transferred to a high-risk OB. Such individuals are specifically trained to take care of women with previous pregnancy complications. Furthermore, they may suggest taking weekly progesterone injections, starting at 16 weeks of pregnancy and twice-monthly cervical length checks to reduce the chance of the preterm delivery happening again.

Additionally, if fertility treatments are being used in the future, we strongly recommend that your doctor employ all and any techniques to reduce the risk of multiple gestations. After all, if your uterus had a hard time making it to the end with one, why stress the system with two?

The good news is that while your courtship (a.k.a. pregnancy) may be cut short, the “prom” usually ends on a high note. With early attention, immediate treatment, and a team approach (OB, pediatricians, nurses, and support staff), most babies born following PPROM will do great. And not unlike the prom that they will attend nearly 17 years down the road, while their time in the NICU will be beyond stressful for us as parents and family members, most “kings” and “queens” leave the PPROM none the wiser.

Welcome to parenthood!

Don’t Be So Negative….What Your Rh Status Means for You and Your Baby

There are “blood type” diets, “blood type” personalities, and even “blood types” that are tastier to mosquitos (apparently if you are type O, you should go out and buy some more bug spray!). And while most of us have no idea what A, B, AB, or O mean until we visit our first American Red Cross blood drive, your blood type is actually pretty important in the land of obstetrics. Although most of us don’t think past those three letters (and four groups), the plus or minus that comes after the A, B, AB, and O is equally as important as the letter. The negative or positive denotes the Rh factor. If there is a mismatch between the negative and positives in a pregnant woman, just like those AA batteries you are always in need of, this system won’t work the way it is supposed to.

Let’s start with the simple stuff…

1. There are four basic blood groups; A, B, AB, and O. What distinguishes A from B or AB from O are the antigens (a.k.a. the proteins) on the surface of red blood cells.

2. The symbol, plus or minus, which follows the letter is referring to the presence (+) or absence (-) of the Rh factor. Rh stands for rhesus, and Rh or Rhesus factor is another antigen that is found on red blood cells. Rh antigen is present or + in Rh (+) individuals and absent or – in Rh (-) individuals.

Moving on to a couple of fun facts that will make you look smart at a cocktail party…

3. The most common blood type is O+.

4. The universal blood donor (you can give to anyone) is blood type O-.

5. The universal blood recipient (a.k.a. you can take from anyone) is AB+.

6. You inherit your blood type from your parents, and you will pass your blood type on to your children.

Last, the essential stuff for anyone who has been or will be PREGNANT….

7. Rh-negative women need special attention. If untreated AND pregnant with an Rh-positive baby, they have the potential of forming antibodies against the Rh factor that is covering their baby’s red blood cells. And while this may not be a big deal in their current pregnancy (antibodies are like Rome; they were not built in a day), it will be a major deal in future pregnancies. Therefore, all Rh-negative women should receive a medication called RhoGAM (a.k.a. RhoD or Rh immune globin) during their pregnancy to prevent the formation of these antibodies.

8. RhoGAM is an injectable medication that contains a small amount of antibodies pooled from blood donors…it works to kill off any Rh-positive blood cells lingering in the immune systems of Rh-negative women. Think of RhoGAM as a stun gun to the immune system of an Rh-negative pregnant woman. Basically, it will “daze and confuse” her immune system so that she doesn’t have a chance to make antibodies to the Rh factor her body is seeing during pregnancy. Problem solved. And in the past, this was a big problem that not only cost a lot of perinatal morbidity but also mortality. So kudos to those who racked their brains and “birthed” RhoGAM.

9. When it comes to most things pregnancy, it takes two to tango. Therefore, just because you are Rh-negative doesn’t mean that your baby will be. If your partner is Rh-positive, there is a good chance your little one will be too (and that’s when you have a problem on your hands)! To be safe, all Rh-negative women will be given RhoGAM during pregnancy (remember, we won’t know your little one’s Rh factor until birth). The good news is that the majority of pregnant women will only need to roll up their sleeves and stick out their arms twice, once at 28 weeks and once following delivery. This is because in most cases maternal and fetal blood don’t say, “It’s nice to meet you” until delivery. However, because this introduction may speed up to the third trimester in about 2% of pregnant women, we give a precautionary dose at 28 weeks.

10. Unfortunately, two times may not be the “RhoGAM charm.” If bleeding should occur during the pregnancy or if you undergo an invasive procedure such as a CVS or an amniocentesis, your blood and your baby’s blood might get mixed up. Therefore, to be extra careful, we recommend you get another shot within 72 hours of the bleeding or the procedure.

11. Rh-negative women that are NOT given RhoGAM are at serious risk during their NEXT pregnancy. So while many of us have the “I will deal with that tomorrow” attitude when it comes to things that don’t impact us immediately but can hurt us in the future (think not paying your bills and dealing with your credit score later), you really shouldn’t mess around with RhoGAM. Antibodies to Rh take some time to form. Therefore, while your current passenger might pass through without a problem, the next baby on board could be at serious risk if a woman is NOT given RhoGAM during the current pregnancy. Don’t push this one to the side; this sort of credit your next child can’t afford!

Given that 85% of individuals are Rh+, this incompatibility issue does not come up every day. Simply stated, most moms and their babies are in sync when it comes to Rh status. However, given the serious impact an untreated Rh mismatch can have on a woman and her future children, it is something that we OBs get pretty pesky about. We have to be doubly POSITIVE so that nothing NEGATIVE happens. And while we can’t validate the stuff out there which suggests that As may be “more responsible and patient” while Bs are more “passionate and creative,” we can tell you that your blood type means a lot for your baby (and the babies that you may have to come). That much, we are triply super positive about!

On the Road to Delivery…GBS

While the title may have you doing a double take (and maybe even looking for some directions on how to decode GBS), rest assured, you are not lost out there on the road. You are in your home, your apartment, your office, or maybe even in the car (although hopefully not driving and reading!) hanging with your girlfriends at Truly, MD. But if you are nearing the end of pregnancy, you are probably getting pretty good at navigating the streets between home base and the hospital. And although we may not know the quickest way to get you to the labor floor, we definitely know how to get you up to speed on all things third trimester. First stop: Group Beta Streptococcus (a.k.a. GBS).

GBS is a type of bacteria. And although it may not be on your daily bacteria radar (think strep throat or staph skin infection), it is pretty important to us OBs. GBS took center stage in the OB world of the 1970s when it was identified as a culprit in the land of perinatal morbidity and mortality—that is, newborn illness and death. The newborns of pregnant women with GBS in their vaginal canal who were not given antibiotics during labor were at risk for some pretty heavy hitters. Think sepsis, meningitis, and death. Pregnant women were not immune to the negative effects of GBS. They, too, were at risk for things like UTIs and uterine infections.

Despite its bad-guy tendencies during pregnancy, GBS lives fairly peacefully within the vaginas and the rectums of non-pregnant women. Don’t bother me, and I won’t bother you. Given its Jekyll and Hyde persona, we only start to look for the presence of GBS in a woman during the latter half of pregnancy, when it can really turn into Hyde. To uncover whose vagina/rectum is “covered” in GBS and whose is not, your OB will perform a screening test on you between 35 and 37 weeks. And although it may sound scary, it’s no more than a cotton swab test of the vagina and the rectum. Those that test positive are given antibiotics during labor. Those that test negative are not. Pretty simple.

The ACOG has made it their business to get in the business of all pregnant women when it comes to GBS because, like the old adage says, when GBS is bad, it is very, very bad. Anything that can be done to decrease the bad is a major bonus…cue screening for GBS. The universal screening of all pregnant women has done a very, very good job at stopping most widespread GBS infections in newborns, particularly in the first six days of a baby’s life. In fact, since national guidelines for screening and treating pregnant women who test GBS positive were implemented, there has been nearly an 80% reduction in early onset (the first six days of life) neonatal sepsis due to GBS. Pretty impressive stuff.

Women who go into labor before their GBS test was performed (a.k.a. preterm labor), women who have previously given birth to a GBS-infected newborn, or women who test positive for a GBS UTI during pregnancy are automatically treated with antibiotics for GBS during labor. Basically, in these cases where the risks are high, it’s better to be extra safe and add an extra layer of protection. It’s sort of like extra insurance for a driver with lots of points on his license. While he may never speed or get ticketed again, given that his chances are higher, you want extra protection—we’re not saying we know anyone like this!

For most women, the GBS test comes and goes without a bump in the road. It’s sort of like passing a yield sign on the road. You know it’s there. You slow down somewhat, but you don’t really pay it much mind (we didn’t say that we offered good advice on driving!). Don’t fear the results. Positive or negative, we are pretty good at directing you to the right path. No one gets lost out here on this road; think of us as your GPS for your GBS!

When There Is More Than Your Plus One in Your Pelvis

Pregnancy can be a tight squeeze. By the end, not only are your clothes not fitting, but also your organs seem to have a limited place to hang out. It can be difficult to breathe, sit, stand, and walk. You name it, it’s hard to do it. And if you are carrying more than one (#twins, #triplets), it can be a doubly or triply painful situation. The pelvis and abdomen of a pregnant woman is like Manhattan real estate—it’s limited, to say the least. So, when other “things” have taken up home like ovarian cysts and fibroids, it can be an unpleasant situation. However, before you rush to “sell” them off, listen to what we have to say.

The most commonly encountered uninvited houseguests in pregnant women are ovarian cysts and uterine fibroids. They usually have taken up residence and despite the rent hikes are refusing to move. Sometimes, they can stay put, and sometimes they need to be evicted. Here’s the lowdown on what’s legit and what needs to leave when it comes to cysts and fibroids.

When it comes to cysts, most of the time they can stay. In fact, it’s not uncommon to detect cysts during pregnancy. For many women, it is the first time we have seen a “picture” of their ovaries (say cheese!). The ultrasound is the mainstay for fetal evaluation—most women have at least two if not more ultrasounds performed in their pregnancy. During these exams, the ovaries are not camera shy; we usually get a good look at them. Most flash us a smile and never bother you or us again. We might look for them later in pregnancy to ensure that, if a cyst was present it is stable in size, but we infrequently act to take them out. And the numbers tell us why: adnexal masses (cysts in the ovaries/tubes) are seen in about 0.05 to 3.2% of all live births. Cancer is diagnosed in ONLY about 4 to 8% of these cysts. The bottom line is, they are very, very rare, and therefore we usually need to do nothing more than watch them from the outside.

Most cysts encountered in pregnancy are BENIGN and include dermoids (mature teratomas), corpus luteum, and para (adjacent to the ovary) simple cysts. Because nearly 50 to 70% of ovarian cysts during pregnancy will vanish like the bunny in a magic show, we usually leave them alone (only about 2% will cause you any acute problems requiring surgery). Those that won’t step out of the spotlight and need to come out tend to be larger (>5cm) and more complex (a.k.a. scary looking). They are usually removed in the second trimester, as this is the safest time to perform surgery in pregnancy.

Let’s call an Uber and travel from the ovaries to the uterus (a short trip even with price surging!). Here in the uterus, fibroids are often the most common foe faced during pregnancy. While they are sometimes dealt with before pregnancy even occurs, in most cases they are not. As they are very rarely the sole cause of infertility, most women don’t even know they are there until they are plugging along in pregnancy. Again, that trusty ultrasound that we use to capture your baby’s first pics will often identify fibroids that you never even knew existed. For those with infertility or recurrent miscarriages, fibroids will likely have presented themselves long before pregnancy. However, unless they’re inside the uterine cavity or significantly distorting the uterine cavity, they can usually stay put. Preventative surgery is not so popular.

In those women who have fibroid symptoms (bleeding, pain, pressure, etc.) it’s a different situation. You must take care of yourself and your uterus! If the symptoms are mild, we recommend holding off on surgery until you are ready to start trying. Surgery done as close to the time of desired pregnancy will cut down on the risk of recurrence. Although you will need about 3 months’ respite to let your uterus recover, you can pretty much get back on the field in no time (keep this in mind as you attempt to plan out your life).

If your symptoms are major or are causing your infertility, there is no better time than now to act. Don’t wait, as it won’t make your life or your symptoms any better. It will just make you more frustrated and fed up!

Newsflash…if you had a big fibroid removed before pregnancy and your surgeon said they “went through and through the muscle,” you are most likely going to need a C-Section. A uterus that has been sliced and diced, poked, and prodded may not be as strong as one that has never been disturbed. By performing an elective C-Section before labor starts, we can reduce the risk of a uterine perforation (uterus opening at the incision). This makes things way safer for everyone involved!

The reality is that most women with fibroids do just fine during pregnancy. Despite the influx of estrogen and progesterone, most don’t grow, and those that do usually only do so in the first trimester. On occasion, this brief rapid growth can cut off blood flow to the fibroid causing “degeneration” and significant pain.  However, most women don’t even remember that their fibroids are there. In very few cases do fibroids cause serious problems; when they do, it’s the following that we are on the lookout for:

  • Increased risk of miscarriage.
  • Preterm delivery and labor.
  • Abnormal fetal position.
  • Fetal growth restriction.
  • Placental abruption.
  • Labor dysfunction (and the need for a C-Section).
  • Heavy post-partum bleeding.

Even with these potentials on the horizon, removing fibroids in pregnancy is almost NEVER an option. A pregnant uterus has lots of blood. Lots of blood makes surgery very scary, and very scary surgery is nothing that anyone is interested in doing. That means you should wait until pregnancy is over to deal with your fibroids!

Unfortunately for the potential buyers out there (ourselves included!), the market is not about to crash. In fact, most say there is nothing more stable than real estate in the long run. Therefore, don’t move or remove “things” just because you have a plus one or maybe a plus two on the way. Their additional presence may be pesky, but unless there is a major problem pre-pregnancy (bleeding, pain, infertility), let them stay in their rent-controlled apartments. If they start to make too much noise, we have ways to deal with them!

The Lowdown on What to Do When You Can’t Get Anything to Stay Down: Nausea in Pregnancy

Praying to the porcelain god, hugging the bowl, or tossing one’s cookies—whatever you want to call it, vomiting is not fun. In fact, it may be one of the most un-fun bodily processes. Add to that unremitting nausea, and you have got yourself quite a pair. And while this dynamic duo is usually only welcomed after select occasions—a stomach virus, food poisoning, or after a serious night out on the town—in pregnancy, it can be a daily event. The hormones secreted by pregnancy (a.k.a. hCG and estrogen) can make you pretty sick—so sick, even getting out of bed to brush your teeth may seem impossible.

Nausea and vomiting in early pregnancy is VERY common. Nearly 75% of women will feel nauseous or vomit at some time during their pregnancy. However, the extreme cases (medically termed hyperemesis gravidarum) are VERY rare. And although nausea and vomiting in pregnancy can happen to any lucky lady, it is more likely to happen in women who are pregnant with multiples (more placenta = more hormones = more nausea), have a history of hyperemesis in a past pregnancy, have a family history of hyperemesis, are prone to motion sickness, or have a personal history of migraines.

Although persistent nausea and vomiting won’t kill you, it will likely make you feel like you’re dying. You can’t work, you can’t work out, and you can barely move. So, what can you do to give the baby barfing the boot?

First, if possible, start taking a prenatal vitamin at least three months before you conceive. Some prep time can help prevent the nausea that women can experience with prenatal vitamins.

Second, try to limit the time you spend around smells that make you sick (goodbye, garlic!).

Third, trade in three large meals for six small ones. The less you need to digest, the less likely you are to lose it!

Fourth, stay away from spicy and fatty foods, and fifth, shelve any pills with iron.

Last, think about investing in ginger pills. Not only has ginger been shown to be beneficial for your immune system, but studies also show that it may be the secret to curtailing your nausea. And although the medical jury is still out on acupressure, acupuncture, and electrical nerve stimulation to the inside of the wrist, it can’t hurt to try.

When simple measures fail and you are still BFF with your toilet bowl, it’s time to bring out the big guns (a.k.a. medications). Your OB will likely start with something like vitamin B6 or vitamin B6 plus doxylamine. If this doesn’t do the trick, they may amp it up with prescription anti-nausea medications. However, before you go this route, it’s important to have a chat with your OB about what’s coming up and when before you take anything else down.

If this still doesn’t cut it and you’re cutting weight like a wrestler before a big fight, your OB may consider admitting you to the hospital for intravenous nutrition. Severe causes call for serious measures. Nutrition can be delivered through an IV if need be.

Although it is very rare for this fight to go the distance, if you find yourself still battling nausea in the second trimester, consider adding an antacid or reflux medication. Often, women start to experience reflux in the second trimester. As your little one grows, so does your uterus. As your uterus grows, the space between your uterus and your upper abdominal organs (think stomach) shrinks. Pressure on the stomach can cause things to come back up (a.k.a. reflux), which can lead to nausea and even vomiting.

In cases where nausea and vomiting start after nine weeks or there are other atypical symptoms (abdominal pain, fever, headache), it’s important to reach out to your doctor—ASAP. Not all nausea and vomiting in pregnancy is normal. Sometimes it can indicate that something serious (appendicitis, kidney infection, kidney stones) is going on.

The good news about nausea and vomiting is that, while it can make you miserable, it usually doesn’t do anything miserable to your body or to your baby. Even when the only thing your stomach can stomach is saltines and ginger ale, your baby will be just fine.

Whether you call it “puking,” “barfing,” “hurling,” or “vomiting,” we call it no fun. But it will pass, and we will do our best to get you through it, one day at a time!

“I’m Ready for My Close Up” – Preparing for Baby’s First “Screen” Test

Pregnancy brings with it a battery of tests – not just those that your doctor requests. Sleep disturbances, food cravings, and fatigue may make some of us want to put a “pause” on pregnancy!

One of the many tests your doctor will recommend is baby’s first “up close and personal” – a screening test to make sure baby’s chromosomes (translation – what holds genetic material) and anatomy is a-ok. #babysfirstselfie.

We talked a bit about screening versus diagnostic testing and invasive versus non-invasive tests in our “Gone Shopping” post (LINK). As a refresher, the goal of this screening test is to identify moms with babies who may be at higher risk than normal for certain abnormalities. But, remember, like using an Instagram filter, a screening test doesn’t give us the clearest picture. If your screening test indicates you may be at higher risk for something fishy, your doctor will recommend a definitive test to make the picture crystal clear. Screening tests are “non-invasive” in doctor-speak, meaning a simple blood draw or ultrasound is usually all you need!

As if there aren’t enough decisions to make in pregnancy, there is a laundry list of different methods to screen for chromosomal abnormalities. Your doctor will talk to you about the pros and cons of each and what he or she usually does or recommends.

To prep for that visit, we’ll break it down for you. Let’s start at the very beginning – a very good place to start!

DOES THE EARLY BIRD GET THE WORM? FIRST TRIMESTER SCREENING:

If you want to start the screening early (think 10–13 weeks), you may get a special ultrasound, called a nuchal translucency, and a blood test to look at two markers.

The pros of the method are that you get risk assessment early. The cons are that sonographers must be certified in nuchal translucency scans, and this isn’t the best test to assess the risk of certain structural anomalies, like spina bifida.

GIMME SOME LEG POWER – THE QUAD SCREEN:

The quadruple (a.k.a. “quad”) screen is a blood test done in the second trimester. The combination of these four blood markers assesses the possibility of both chromosomal and certain structural problems.

To be clear, by “structural,” we mean things like spina bifida or other abnormalities affecting the spine. This is assessed with one of the blood tests available (called AFP), but will also be checked for during your anatomy scan, which happens around 20 weeks.

 

STEP BY STEP – USING THE BEST OF BOTH WORLDS:

By using a combination of blood tests in the first and second trimester along with an ultrasound (in some cases), you can get an assessment of your risk for both chromosomal abnormalities and structural problems. This approach is a bit better at detecting problems, but you have to wait until a little bit later in pregnancy to know.

There are a few ways of using this step-by-step approach – integrated, stepwise, and sequential. Your doctor will help guide you on this decision if you choose this method.

THE NEW KID ON THE BLOCK – CELL-FREE DNA:

Cell-free DNA is the most accurate “cell-fi” available (see what we did there?).

This test looks for DNA from the baby’s placenta (the organ your body grows to feed the baby!). Since it will be different (hey – 50% of baby’s DNA comes from someone else!), the test looks for the baby’s DNA and makes sure the chromosome numbers are correct.

While this NKOB is pretty cool, here are a few caveats to consider:

  • The strong suit of this test is picking out those at high risk for three of the most common chromosomal abnormalities – Trisomy 21 (a.k.a. Down Syndrome), Trisomy 18, and Trisomy 13.
  • This test has been most studied in women at high risk of abnormalities, like moms over the age of 35. So, if you’re not one of those high-risk individuals, you may have a higher chance at a false positive, meaning the test might detect a problem when there is none.
  • This test will not assess risks for certain structural defects, like spina bifida.

GREY’S ANATOMY [SCAN]:

Last but not least, your doctor will likely recommend a detailed ultrasound to look at the baby’s anatomy somewhere around 20 weeks. This is considered a part of your prenatal care checklist that is separate from the above blood tests, but we felt it was worth a brief mention!

This bird’s eye view (we just scratched the surface of each test!) of general screening for the baby should hopefully give you a primer for when it’s time to decide what is #truly best for you and baby. And, remember, you’ll have your best supporting actor or actress (your doctor!) guiding you through this process.

Doing It at Home: Labor and Delivery in Your Bedroom

When most of us think about the birth of our baby, we ask questions like Who do I want in the room? Which doctor/midwife do I want at the delivery? and Will I have a bowel movement while pushing (don’t stress if you do; it’s super common)? Until recently, very rarely did the question At home or in the hospital? cross our minds. However, over the past few years, home birth has gained some serious followers.

More and more women are opting to deliver their baby in their bedroom rather than in birth centers or hospitals. In fact, rates of home birth were up from .79% in 2004 to 1.3% in 2012. Fear of C-Sections and the medicalization of birth (monitors, medications, and modest autonomy) have collectively driven women out of hospitals and into their homes. While there are certainly benefits to home births (minus the cleanup factor—labor can be quite messy), there are some major downsides as well. Here’s what to consider if you are considering a home birth.

First, deciding to deliver at home is a BIG, BIG, BIG decision that should not be made alone. While we get that women have been delivering babies for centuries, things can still go wrong, very wrong and very fast. That’s why it’s super important that you speak with a medical practitioner (OB/GYN or midwife) to make sure that you are a good candidate for an at-home delivery. According to the ACOG, the following women are on the no-fly list when it comes to at-home births: a previous C-Section, babies who are not head down (medical term: fetal malpresentation), and multiple gestations (more than one baby in their uterus at one time). It is just way too risky.

Second, if you are good to go for it at home, make sure you are not alone. Seek out a midwife who is licensed and experienced in doing home births. You want to make sure that this is not their first rodeo. Knowing when to throw the towel in and trek over to the nearest hospital is essential.

Third, have a good idea of your surroundings. And while we aren’t referring to the nearest grocery store, we are referring to your local hospital. Being close to a medical facility can be the difference between a horrible and heroic outcome.

Why do we care so much? Well, we care about you and your baby’s safety—big time. And although most home births go off without a hitch, when compared to hospital deliveries, home births carry a significantly higher risk of bad outcomes. A large study that was recently published in the JAMA (the Bible of all good medical research) showed that death, neonatal seizures, and neurological impairment were nearly 2.5 times more likely to occur when babies were delivered at home as opposed to in the hospital. Additionally, mothers who delivered at home were more likely to need a blood transfusion. But to be fair, the data wasn’t all down on home births. Women who delivered in a hospital were way more likely to have their labor augmented (a.k.a. enhanced with drugs like Pitocin) and have a C-Section.

As doctors, we have opinions…lots of them. Most of these are rooted in research, data, and years of medical education and training. But despite our degrees, we are not dictators. We are, in many ways, nothing more than trusted advisors. Therefore, while we can give our advice and render an opinion, we can’t tell you what to do. That’s up to you. You take the information we give you and with it make an educated and informed decision.

But we’re not going to lie; on this issue, we side with the ACOG and truly believe that the safest place to deliver a baby is in the hospital or in an accredited birth center. In our opinion, the potential downsides of the at-home birth far outweigh the potential downsides of the hospital birth. And while bad things can happen anywhere, we would rather you go where they happen less.

We also get that the labor and delivery of a child is one of the most intimate experiences in one’s life. You want what you want. We know; we were patients, too. Our advice is to find a practitioner (OB or midwife) whose vision for labor and delivery is close to yours. While on D-Day what you expected while expecting and what happened may be very different, at least you are staring from a place of togetherness.

Labor is as unpredictable as the weather in the tropics. Things can change faster than you can imagine. Get ready to roll with whatever rolls in…it will allow you to weather the storm safely. Make sure you have a life jacket and safety net (a.k.a. good medical practitioner on your side) should the seas get rough.

I’m Pregnant. Now What?

Month after month of unhappy faces, single lines, and not-pregnant responses… When you finally see a smiley face, a double line, and/or (likely and, because most of us take about 20 tests to make sure it’s right) a pregnant message, you almost pass out. After the excitement, shock, and joy subside, anxiety, confusion, and uncertainty set in. What do I do now? And while we may not be on your speed dial, we can share with you a few of the pointers we point out to those that are!

First things first, take a deep breath. There is a lot that will happen over the next nine months, and you want to try and remain as calm as possible. (Good energy is transferred through the placenta!) After a few good, deep breaths, a bunch of OMGs this might actually be happening, and a call to your plus one (or best friend), the next step is to purchase a prenatal vitamin (if you aren’t already on one). Generic or brand, it really doesn’t matter. You just want to make sure that your body is chock full of nutrients and essentials to start nurturing that little one. If you haven’t already been taking one, there is no need to stress. You have not caused any damage or done any harm.

Additionally, if you have had a few cocktails, colored your hair, or partook in any activities that are off limits during pregnancy, don’t sweat it. The first weeks between ovulation and early pregnancy are what we OB/GYNS call the “all-or-none” interval. Your actions will either have absolutely no impact on the pregnancy, or they will result in a non-pregnancy/miscarriage type of situation. Simply stated, there will be no long-term effects on the fetus!

While the “all or none” gives you a get-out-of-jail-free card, you do want to start to alter your habits. Hang up your love of unpasteurized cheeses, your obsession with tuna (that one was hard for us, too!), and your passion for cold cuts. While you can still eat cheese, tuna, and cold cuts, the quantity needs to be reduced and the way they are cooked slightly altered. For example, cold cuts should be warmed before eating.

But don’t obsess about what you are eating in those first few weeks. Nausea is at its peak during this time, and whatever you can keep down is all you and your baby needs. Don’t stress if only grilled cheese, bagels with butter, and saltines are all that you are craving. Your lack of greens, veggies, and fruits won’t harm your little one. Your tastes will change shortly, and you can stock up on good things at that time.

It’s also a good idea to buy yourself a water bottle and make sure you are constantly sipping. The changes in blood volume that occur during pregnancy can make you dehydrated pretty quickly. To avoid that “Oh no, I am going to pass out” feeling, drink lots of fluid. And while we are on the drinking subject, it’s totally cool to continue with caffeine. A cup or two a day is definitely not a no-no. Furthermore, the occasional glass of wine, flute of champagne, or bottle of beer is not a big deal. While there is no safe amount of alcohol that can be consumed during pregnancy, a few drinks (over the nine months, not one day!) is certainly not going to do any damage.

From food, we transition to fitness. For all of you die-hards out there, pregnancy does not mean you have to hit pause on your fitness habits. Exercise in pregnancy is totally okay. You may need to tailor your exercises and taper the intensity, but staying active is A-ok. With that being said, the only things we are not fans of are the activities performed in 100 degree-plus heat (e.g., hot yoga). That temperature is not only going to seriously dehydrate you but also may not be so good for your baby’s developing organs. It is always a good idea to let your exercise instructor know that you are expecting. Most studios/fitness clubs have done a good job at training their teachers on how to modify and be mindful of moms to be.

After food and fitness, most women usually want to know about sex and personal grooming. Here’s the deal: sex is okay. Unless you start bleeding, there is really no reason to go on pelvic rest (aka- no sex). If bleeding should occur, we usually recommend resting (no sex, no exercise, and nothing in the vagina) until you are blood free for about 48 hours. After that, it is okay to give it another go. Most bleeding after sex is from the cervix or from the development of a tiny blood clot around the placenta, neither of which routinely cause a miscarriage.

In terms of personal grooming, continue pushing forward: bikini waxes, manicures, pedicures, facials, and massages are all good. Hair coloring is the only questionable practice on the list. We usually suggest sharing your news with your colorist and asking him or her to switch to a more suitable dye for pregnancy.

And finally, we arrive at family (a.k.a. whom should you tell and when). The telling part is totally up to you. While we always recommend that our patients share their news whenever and with whomever, remember that a positive test does not equal a baby. You may not want your 300+ Facebook friends to know that you just peed on a stick and saw a smiley face. However, you probably do want to tell your parents your sister and your BFF should anything go wrong and you need support. In general, most women wait until the one-third mark (about 12–13 weeks) before telling their employer and their Instagram. But bottom line is that this is a personal decision. Do what is right for you.

Make friends with a good Internet source (like Truly, MD!), buy a good book, and make sure you like your OB. He or she will serve as a guide during the next several months. You want to be comfortable and confident with your baby team. If someone or something is not working for you, kick them off, quickly! Your OB/GYN is like the coach of this team, so if you are not jiving with the coach, start looking for another team captain. This game is a big deal. These nine months, even for those of us who are not pregnancy lovers, are sort of sacred. There are only so many times in women’s life that they will be pregnant. So relish the good stuff—the first time you hear your baby’s heartbeat, the first time you feel movement, the first time you see your baby on the ultrasound, and the first time you hold your baby. You are in for a lot of firsts. Let us be the first to say congratulations on your pregnancy!

Under Pressure! Pre-Eclampsia

Pregnancy increases your pressure in a whole bunch of ways. For all of you ladies who have ever waddled through your home cities on hot days, you know that the pressure in your feet, your legs, your fingers, and your hands is way more than just some mild swelling. It can get so bad that some women can’t wear their shoes, their rings, and even their watches; it’s no joke. And don’t even get us started on the bladder situation. It’s hard to go anywhere without knowing where the nearest bathroom is. But the pressure that we are going to address in the next few paragraphs is that of your blood pressure and a condition unique to pregnancy called pre-eclampsiaFor those of you who either didn’t have this problem, didn’t know anyone who suffered from this condition, or have never been pregnant, you might be thinking PRE what? Your eyes are glazing over, and you are considering closing your computer. Stop! Pre-eclampsia is a very serious condition, and although we don’t expect to make you into board-certified OB/GYNs in the next several minutes, you should know what it is, what symptoms to look for, and when you need to shake a leg to the labor floor.

Pre-eclampsia is unique to pregnant women and newly post-partum women. It is a disorder that occurs in the last half of pregnancy and is characterized by new onset high blood pressure (a.k.a. hypertension) and protein in your urine (a.k.a. proteinuria). While it may be the first time you are looking at this word, it is actually not so uncommon. About 5% of pregnancies are affected by pre-eclampsia. Women who are having their first baby, are older, have a personal history or a family history of pre-eclampsia, have pre-existing medical problems (kidney disease, diabetes, obesity, a history of elevated blood pressure), or who have multiples are more likely to get pre-eclampsia. Why it happens is a bit unclear. While we know it involves both maternal, fetal, and placental factors, which ones, how much, and when they develop are still unclear. We do know that placental development early in pregnancy is probably a big contributing factor. The diagnosis is usually made in one of two ways—either you get picked up “coincidentally” when your doctor checks your blood pressure at a routine visit OR when you call with the scary symptoms.

The symptoms are pretty specific and usually cause your doctor, midwife, and/or nurse to quickly check your blood pressure and then check you into the hospital. Blood pressures are usually somewhere between the 140/90 to 160/110 mm Hg range—and trust us, this is not a place that you want to score high. The higher the blood pressure, the more severe the situation. (Same goes for the amount of protein in the urine; more is not better here!) To make the pre-eclampsia cut, your top BP number must be greater than 140 and the bottom greater than 90. In terms of the protein situation, you must have equal or greater than 0.3 grams in a 24-hour collection. (Yup, get out your bucket, and start peeing. We want all the urine you make for one whole day!) Other common symptoms include headache, blurry vision, flashing lights, abdominal pain (specifically in the center or the right upper abdomen), nausea and vomiting, shortness of breath, chest pain, and change in mental status (a.k.a. fuzzy thinking). If we feel pretty sure that you are headed for the pre-eclampsia party (elevated blood pressure, protein, and/or symptoms), we are likely going to send you an invitation to the labor floor. Regrets are not accepted. Here, you will find your place card with your room number on it. You will probably be sitting here all night! We will send some bloodwork on you to see how serious the situation is.

Just like most things, there are degrees of pre-eclampsia (mild to severe). We use your blood pressure, your urine, your symptoms, and your blood work to help us decide where you fall. Those that land at the severe table will not be leaving this party anytime soon. They will also likely not be leaving the hospital pregnant. Severe pre-eclampsia is often an indication for delivery. When a baby is delivered (at how many months/weeks pregnant) and how a baby is delivered (vaginal delivery vs. C-Section) are dependent on the severity of pre-eclampsia and the status of both Mom and Baby. When the baby comes out, the blood pressure usually comes down (or pretty shortly thereafter). Therefore, the best treatment for pre-eclampsia is delivery. However, while we are getting that baby to make its big debut, we have to protect you from seizures (no longer pre-eclampsia but now eclampsia) and other really unpleasant things. That’s why we give IV Magnesium. While the magnesium in many ways can be a miracle worker, it can make you feel many things other than good. You will feel hot; you will itch. You will be out of it; you will feel loopy. You will feel like you are having an out-of-body experience. It is not fun, but it is necessary. In most cases, we will also give you medications to lower your blood pressure. It will be a full-court press to protect you from the bad stuff associated with pre-eclampsia.

Most cases of pre-eclampsia occur after 34 weeks of gestation (about 8.5 months); however, some cases develop earlier. However early or late it comes, to be pre-eclampsia, it cannot come before 20 weeks (5 months) of gestation. And staying on the subject of timing, when you have had it once, you are more likely to have it again (and possibly) earlier than you got it last time. Unfortunately, there is no way to prevent the big P from making a return performance. Although newer scientific evidence shows that we can reduce the chances somewhat by giving aspirin, the data are not definitive. The data are even looser when it comes to things like extra calcium, anti-oxidants, vitamins C and E, and fish oil. Some say it can reduce the chances of having a repeat pressure performance, while others say it will do no more than a placebo pill.

We make a big deal out of pre-eclampsia because it is the real deal in terms of poor pregnancy outcomes. In fact, worldwide, about 10–15% of all pregnancy-related deaths are from pre-eclampsia and its nasty side effects (kidney failure, brain bleeds, strokes, heart muscle damage, liver failure/rupture, fluid overload in the lungs, seizures, and placental abruption). And in OB we have two patients (Mother and Baby), and pre-eclampsia does not spare either. It could cause serious problems for your plus one as well (growth restriction, low fluid, preterm delivery, and death). Pre-eclampsia can cause a precarious situation and therefore deserves our prompt attention.

Whenever we hear the word pressure, our brains automatically go to that Billy Joel song “Pressure.” You can hear those lyrics and that piano chord almost immediately. And with the opening vocals, up goes your blood pressure. You start thinking about all you have to accomplish in one day. It seems impossible! And the words of another musical great, David Bowie, remind us that we are always “Under Pressure”: pushing down on you/pushing down on me. But while normally these tunes pull you up a hill as you jog or are entertaining you on a car drive, when you are pregnant and your pressure rises, you can’t simply hum away the symptoms. Pre-eclampsia is not a song that can be changed or skipped; it’s here to stay. So make sure to share your symptoms and your medical history with your OB. We can rework this play list to make it something we can all listen to!