Time after Time: Recurrent Preterm Birth

Trying to figure out when your little one will make his/her first appearance is a game many of us have played. And while family and even office pools are often centered on birth stats (I’ll take a girl on Tuesday, May 18, weighing 7 lbs., 2 oz.), when the grand finale will actually take place is really nothing more than a guessing game, minus those who have scheduled a C-Section or an induction! No matter how much you like fours or sevens, evens or odds, babies come when babies come. Bottom line, don’t take this bet to Vegas. The odds are not likely to be in your favor, and you probably need to save your money. Diapers aren’t cheap! Just like those who go to Vegas and count cards, we OBs have some ways to “cheat” and figure out who is likely to deliver early, sometimes even weeks before their due date. And although we wish it was because we were all-knowing, it’s really because women who have a history of a spontaneous preterm birth (delivery at less than 37 weeks because of preterm labor or preterm rupture of membranes) are significantly more likely, about 1.5–2X, to be exact, to deliver early in their next pregnancy. In fact, one of the strongest risk factors for preterm birth is a prior preterm birth. Add to that the number of times you delivered early (one vs. two vs. three, etc.) and how many weeks you were at delivery (24 vs. 26 vs. 28, etc.), and you have an even better idea about whose baby will make their debut before the curtain officially rises.

The more times you delivered early and the earlier you were (24 vs. 28 weeks), the more likely you are to be early again. There are other risk factors for preterm delivery, like a history of cervical surgery, UTIs and genital tract infections during pregnancy, smoking, substance abuse, low maternal pre-pregnancy weight, and short inter-pregnancy interval. But none is nearly as strong as a previous history of a preterm birth. Simply stated, a history of preterm birth is the odds-on favorite for a preterm birth in your next pregnancy. So why do we care about when and if a preterm delivery occurs? Sure, we love to win a good family/office pool as much as the next gal, but you can be sure that whether we take home the pot is not what’s perturbing us. What keeps us on our toes is the following: babies who are born premature (a.k.a. early) have a much higher risk of serious morbidity and even mortality, particularly in the first year of life.

Nothing good comes out of an early delivery, except maybe a few less pounds gained and stretch marks formed. Pregnancy was meant to go the distance, that is, 39 weeks, and when it is cut short, bad things can happen to your baby. To prevent a recurrent preterm birth, your OB will be on your speed dial—and you on theirs! We want to know how and what you are feeling. We also like to see your cervix via vaginal ultrasounds every couple of weeks. These checkpoints can clue us into what might be coming (a.k.a. another preterm birth). If things start to change, say, the length of the cervix gets shorter or the cervical opening begins to dilate, we will call “Freeze” and often admit you to the hospital for medication and monitoring. Additionally, women who went early before will usually be prescribed weekly IM shots, which are progesterone injections starting between 16–24 weeks. And while the shots may be a big pain in the butt  —we’re not going to lie; that needle is long!—they are a big player in the prevention of recurrent preterm birth.

Although we can never be sure whose baby is likely to break out of the womb before his/her time is up, we can narrow down the lineup to a few of the most likely candidates. And because we don’t like to make any wrongful convictions, we use the evidence (a.k.a. what happened in your previous pregnancy) to hone in on those who have planned a successful escape in the past. While we may put you on high surveillance (frequent office visits, ultrasounds, weekly injections, and possibly even reduced activity) to encourage this pregnancy to go the distance, it’s a small price to pay for your baby’s safety. While we may not be spot on with the weight and date of your little one, we will be on the money with how best to prevent a recurrent preterm birth. Here, we are not willing to gamble!

A Weighty Issue: the More Pounds, the More Problems

“Eating for two” has long been the slogan that has summed up a woman’s eating habits during pregnancy. Whatever the baby wanted, the lady got! From pancakes to pizza and grilled cheese to goat cheese, it was bottoms up (no matter how big your bottom, your top, or your baby got)! The sky or the sundae was the limit, and weight was not a worry. But pregnancy is no longer bon bons and “baby on board” tee shirts. Food choices are important, and OB/GYNs are making weight gain a weighty issue during pregnancy.

During pregnancy, both you and your baby sort of are what you eat. Long gone are the days of limitless donuts and Doritos. And although cravings don’t need to be curbed, more recent medical data show that they should be curtailed. Additionally, monitoring what you put out as well as what you put in is recommended. Caloric intake and energy output can make a sizable difference in your baby’s size and even his or her future health. In 2009, the Institute of Medicine (IOM) released a new set of guidelines for weight gain during pregnancy. These recommendations are based on your pre-pregnancy body mass index (BMI). So get out your calculator and, ugh, that dreaded scale.

To calculate BMI, you take your weight (in kilograms) and divide it by your height squared (in centimeters); so if you are 5’5 and weigh 135, your BMI would be 22.46. Your next question is: what does that mean? Is 22 a good number?

A “good” number as defined by the IOM is a BMI between 18.5 and 24.9; this is considered a normal weight. The highs and lows go like this…a BMI less than 18.5  is underweight. A BMI between 25 and 29.9 is overweight, and a BMI greater than 30 is obese.

With these numbers in mind, the recommendations are as follows:

  • Women who are underweight should gain between 28 and 40 pounds during pregnancy.
  • Women who are normal weight should gain between 25 and 30 pounds during pregnancy.
  • Women who are overweight should gain between 15 and 25 pounds during pregnancy.
  • Women who are obese should gain between 11 and 20 pounds during pregnancy.

While one size never fits all, there are exceptions to the rule, particularly women who are carrying multiples. If you are doing double duty, you don’t need to double your weight gain, but you do need to put on a few extra pounds. Recommendations are not rules, and even some rules are meant to bend and be broken. Don’t beat yourself up every time you step onto that scale: you are not trying to make weight for a wrestling match. These numbers are a guideline, not a guillotine.

Why do we care so much? Can’t there just be nine months when you are not a slave to your scale? We care because excessive weight gain during pregnancy has been linked to a whole buffet of problems: diabetes during pregnancy, fetal macrosomia, high blood pressure, birth defects, premature delivery, stillbirth, cesarean section, complicated vaginal deliveries, and childhood obesity. The menu of problems is large and continues to grow with more research.

We as OB/GYNs are pressing the issue and pressuring you to watch your weight because really bad things can happen to both you and your baby when you don’t. Last, the more weight you gain during your pregnancy, the harder it is to lose after pregnancy is done. While most of us can’t be Heidi Klum at a Victoria’s Secret fashion show one month after delivery (I mean, really, how did she do that?), how much you gain during pregnancy is equal to how much you will need to lose post-pregnancy. So fill your plate the first time, but resist the urge to go back for seconds. It’s not worth it.

Heads or Tails: What to Do When a Baby Is Breech

Surviving OB/GYN residency is like surviving boot camp. Most of the days blur together, and when you reflect on your days and nights, you can’t believe that you actually survived it. And while you couldn’t imagine doing anything else, you also couldn’t imagine doing it all over again. Along the way, down in the trenches, you make some amazing friends, meet some amazing patients, and learn the most amazing things (how to deliver babies!). There are certain practices and procedures that are drilled into your head so many times, you could repeat them in your sleep. One such practice is checking the “presenting part” on every woman admitted to the labor floor. If this part is not a head and actually a butt or a leg, you’d better move your butt back to the operating room for a C-section, ASAP!

What is a “presenting part”? Oh hello, Doctor, I am Tommy the Tush and would like to present myself to you? Sort of, but not really. The presenting part is the anatomical part of the fetus that is leading (a.k.a. closest to the pelvic inlet of the birth canal). Most babies are going to present head first, or in OB language, cephalic. When the butt or feet come first, we call this a breech presentation. Occasionally, your child can give us the cold shoulder and present with an arm, the shoulder, or the trunk. We call this a shoulder presentation. A baby that is cephalic is most often vertex, which means the crown of the head is first. This is the easiest, most common, and ideal presentation for a vaginal delivery.

Sometimes, although a baby is cephalic he or she is not vertex; a baby can be face, chin, or even brow first. Such cephalic but not vertex presentations can be challenging. Although in some circumstances, they can be delivered vaginally, they can also require a C-section. However, of all the crazy positions a kid can get themselves into, a breech is the most common and the one that shouts “C-section” the loudest and the fastest to most modern OB/GYNs. While it’s usually just a flip of the coin for whose baby will be breech and whose will not, there are some risk factors for a breech presentation: the shape of your uterus, the position of your placenta, low amniotic fluid volume, or a previous breech baby.

Old-school OB/GYNs were no joke—they could deliver a kid headfirst, feet first, hand first, or tush first. Rotating, twisting, and rearranging the presenting part was their every day. However, because data demonstrated that breech babies who were delivered vaginally had a worse outcome after they were born, these practices fell out of favor. They were performed infrequently, and just like anything you do, without practice, there goes performance. Therefore, while the American Congress of Obstetricians and Gynecologists (the governing body of our specialty) does not “outlaw” vaginal delivery for a breech baby, they make a strong statement about which obstetricians should be allowed to attempt such a procedure. They explicitly state that delivery mode (vaginal versus C-section) should depend on the experience of the OB.

If your doctor feels comfortable going for it based on his or her experience, it should only be performed in a hospital that has a specific protocol specifying how this thing should go down (or out). Women who are game to try must have a clear understanding of the potentially increased risk associated with stepping up to the plate.

Why have times and opinions on vaginal breech deliveries changed more radically than our wardrobes? Because in 2000 a large international trial called the Term Breech Trial was performed. In this study, they compared how babies who were breech did following a planned C-section vs. a planned vaginal delivery. And what they found was so powerful that you have a better chance of finding a can of Tab than an OB/GYN who will perform an elective vaginal delivery for a breech baby. Mortality (both during and after delivery) and serious morbidity (seriously bad things happening) were significantly lower in the planned C-section group as compared to the planned vaginal delivery group. The findings in this study gave the red light to most OBs offering planned vaginal deliveries for breech singleton babies.

It’s important to mention that twins are a whole different ballgame and having two on your team will let you enter the vaginal delivery for a breech baby ballpark. Here are the rules…if twin A (the twin that will be delivered first) is head down and twin B (the twin that will be delivered second) is head up (breech) AND twin A is larger than twin B, let’s play ball. You can attempt a vaginal breech delivery for the second twin, a.k.a. twin B.

Before you get all bummed about your baby’s current position, take a deep breath. Most babies move all over their roomy apartment (your uterus) for the first five to six months of pregnancy. By the late second trimester, most babies will be head down and stay head down. In fact, only about 3–4% of babies will be breech by the end of their pregnancy. Your OB will check your baby’s position around 34-36 weeks. If your little one is head up, this is the time to talk about what can be done medically to turn things around. An external cephalic version (ECV) is a procedure that is often offered to women with breech babies who would like to attempt a vaginal delivery. It is usually performed at about 37 weeks. We wait until the last minute for two reasons:

First, we want to give your stubborn one as much time as possible to make the move for themselves, and second, if we are successful at moving the baby into the head-down position, we don’t want them to flip back up! Most women are candidates for an ECV, and while it won’t work on everyone, unless you need a C-section for another reason, you can consider an ECV. Women who have had other children, have a posterior placenta, and have a good amount of amniotic fluid are more likely to have success with the procedure. All that pushing, poking, and turning works about 50% of the time. The average success rate is reported in the medical literature at 58%, with a range of 35–86%. Some doctors may offer pain medication and muscle/uterus relaxers to not only make the procedure more pleasant but also increase the chance that it works.

However, you should know the procedure is not without risk. The baby may not like all the poking and prodding, and therefore, heart rate monitoring should be performed during and after the procedure. In some rare cases, an emergency C-section may be needed if the baby is really unhappy with the ECV attempt. We strongly recommend the ECV only be performed on a labor and delivery ward where actions can be taken in the event of an emergency.

Other non-Western medicine tricks include maternal position (forward leaning inversions, headstands, pelvic thrust), acupuncture, and moxibustion. The latter is a technique whereby an herbal (moxa stick) is burnt on an acupuncture point on the body. If your baby just won’t see the light, no matter how many tricks and methods you and your OB employ, don’t sweat it. C-sections can ensure your headstrong child enters the world safely on his or her own two feet!

Epidurals, Episiotomies, and Elective C-Sections: What Are the Essentials for a Good Labor?

From the moment you pee on the stick and see the two lines, the smiley face, or the word pregnant, your mind starts to run wild. Is this for real? Will it be good? Could this really be happening? After dropping about fifty more bucks at the drugstore by taking another three to four tests to confirm what the first showed (trust us, we’ve been there!), the idea of pregnancy and motherhood begins to settle in.

Through deep breaths and calming thoughts, you start to envision what the next nine months will look like. Cravings, nausea, fatigue (sometimes extreme), bloating, spider veins, acne, back pain, and maternity clothes…bring it on! And although you can handle almost any of pregnancy’s curve balls—and there are many—the unknown surrounding how that baby will actually make his or her entrance into this world is probably the most nerve racking. Will there be endless hours of pain where you spend every contraction cursing your labor team (gotta love the movies!), or will it be a peaceful few hours rocking back and forth to the iPod playlist you carefully selected? Whichever it winds up being, you can almost be sure it won’t be what you imagined. It will deviate from your birth plan or your non-birth plan, no matter how hard you will it not to.

Amidst all the unattractive parts of pregnancy, there will be the most attractive things you have ever experienced. You will feel your baby kick. You will listen to your baby’s heartbeat, and you will watch your baby grow. You will think a lot about your future, both immediate and distant, and try to imagine what your days, nights, and years will look like. (Spoiler: the nights will be long, and the sleep, short!) While you can’t know when or how everything will happen during labor, you can take those sleepless nights preparing for a variety of possibilities. By educating yourself (through reputable sources—shout out to Truly, MD!) and talking to your doctor or midwife, you can prepare yourself for what might come. There is a lot to learn and a lot to consider, so we will give you the abridged version.

Epidurals are not your enemy; in fact, they are sort of your fair-weather best friend. (Labor isn’t so long!) Despite all the pros, unfortunately, for some reason there is a lot of negative hype around epidurals, such as:

  • They will cause a C-section.
  • They will hurt your baby.
  • They will cause permanent back pain.

These are simply not true. While epidurals have been demonstrated to increase the second stage of labor (a.k.a. how long it takes you to push that kid out) and increase a woman’s need for labor augmentation (Pitocin), they have not clearly been linked to increased C-sections.

Data show that timing may be the issue, and getting your epidural too early (defined as < 4cm) may be what increases the risk of a C-section. So while we will do our best to coach you through those early contractions sans an epidural, in our opinion, next to the pill, epidurals may be medicine’s best gift to women. Think of any other medical situation where it would be okay for a woman to have intense pain and no pain control. We can’t think of one! So don’t try to be a hero. If the pain is too much, it’s okay to cry mercy. We promise this doesn’t make you a failure. While pain-free labor seems pretty amazing, we would be remiss not to mention that there are some negative side effects with epidurals (headache, temporary weakness/numbness, fever, low blood pressure, rash). However, in general epidurals are incredibly safe and in our opinion a total lifesaver!

Hot topic #2 on the L&D floor. Put your scissors away, because episiotomies (a cut along the perineum to increase space) are no longer standard practice. The routine use of episiotomies is sort of an old-school practice (reference to it can be found in the medical literature for over 300 years!). Historically, it was done to help expedite the pushing process, more space presumably equaling more speed. It was also thought to decrease the incidence of bad tears and future leakage (a.k.a. your dependence on Depends!). But the studies demonstrated that the proof was missing from the pudding. Most evidence showed that the benefits of routine episiotomies were sparse and in more of doctors’ anecdotal experiences (let me tell you about what I’ve seen!) more than evidence-based. Medicine moves faster than a NASCAR racer in the final lap of the Daytona 500; research is the fuel driving the process. Routine episiotomies are out of gas; restricted use is preferred and is the current practice.

Zodiac signs, numbers, days of the week, and months are all important. I mean, if you deliver a Taurus as opposed to an Aries you could be up against a bull versus a ram. But despite your love of certain signs, elective anything when it comes to labor should be carefully considered. Scheduling C-sections and deliveries to fit between scheduled appointments, commitments, and important events has become a popular trend. The “Cesarean delivery on maternal request” (the PC way to say “no medical reason to go under the knife”) encompasses about 2.5% of all births in this country (about 1.3 million births per year). Simply stated, if this is what you want you are clearly not alone. But before you go under the knife, we ask you to consider the potential downsides of this seemingly benign procedure.

While the most common surgical procedure performed on women in the US is a C-section, they are most certainly not risk-free. A C-section is still surgery. You will be in the hospital longer; your baby has a higher chance of respiratory problems. Squeezing through the birth canal squeezes the fluid out of the lungs, while taking the “easy way out” does not allow the fluid to come out, and you are at higher risk of problems in your next pregnancy. Think of it this way: when you fall and cut your knee, you usually get a scab. The area heals, but often a scar remains. As long as it isn’t on your face, you can pretty much deal! Well, when a C-section is performed and the uterus is cut, it (just like your knee) will scab and eventually will heal. But even in the hands of the best OB, it is not uncommon for scar tissue to form on the uterus. Scar tissue on the uterus may be hard to see, but trust us, it is not a pretty sight. While cosmetically, you won’t have a problem (only your OB sees your uterus!), scar tissue can negatively affect your future pregnancies in a pretty big way. Placental implantation problems, uterine rupture, and even the need for a hysterectomy can all occur the next time around.

And in this case, the motto “The more, the better” does not apply. The more kids you have, the more C-sections you will likely need and the worse the situation can become. A planned “C” will decrease your urinary leakage (cough, sneeze, laugh, oops!) in the first year after delivery, but after that, the playing fields between elective C-section and vaginal delivery are pretty much equal. (Basically, we all will be peeing on ourselves at the same rate.) So while it seems simpler, cleaner, and easier, we again remind you that it is surgery, and surgery has risks. Think before you sign up. Read, ask, consider, and investigate.

Flashing alert…we are talking about the elective-not-in-labor C-section, NOT the “I’ve-been-in-labor-for-24-hours-and-pushing-for-four,-and-this-kid-won’t-come-out C-section!” Or this baby is breech and won’t turn C-section.  Trust us, we are not knocking C-sections or those who have them; being awake while somebody is operating on your belly is more than admirable. If you wind up needing a C-section, don’t sweat it. You are no less of a woman, a mom, or a tough chick because you couldn’t push your baby out from below. It’s your voice, your body, and your baby. And as long as you are at least 39 weeks pregnant (one week before your due date or more), you can request an elective-not-in-labor-just-because-I-want-it C-section!

We’ve seen women who swore off epidurals like the devil begging for them and women who signed up for elective C-sections walk onto the labor floor 10cm and pushing. You just never know how it will go. Have an idea what you want—midwife or OB, doula or partner, C-section or vaginal delivery—but be ready to accept the exact opposite. You can print it 100 times, in color and in bold, but it likely won’t change what happens on that fateful morning, afternoon, or evening. In the words of our girl Elsa, “Let it go.” More important than the perfect story or the kickass photo ops is safety (yours and your baby’s).

Hours of painful contractions can blur your ability to reason. That’s what your trusty OB/midwife is there for. Sure, we’ve probably been up with you, but sleepless nights are par for the course for an obstetrician (coffee is our best friend!). Even the best of stories and plans often needs editing. And while chapters 1–10 may not be a New York Times bestseller, it’s the last page that matters most: a healthy mom and a healthy baby. The rest are just words on a page!

Funny Math: How Due Dates Are Calculated for Pregnancies Conceived after Fertility Treatments

Does anyone recall sitting in math class and just staring at the blackboard thinking, “Nope, I just don’t get how X + Y * A = B.” Sure, you nodded to get Mr. Novick off your back, but in reality, you had no idea how he arrived at that answer. And while algebra and amusing are rarely used in the same sentence, that guy seemed to be doing some funny math! Much the same can be said about how we fertility doctors date (a.k.a. tell how pregnant you are and when you are due) pregnancies conceived with fertility treatments.

Most pregnancies (ART excluded) are dated based on the first day of a woman’s last menstrual period. And although you are technically not pregnant in the first approximately two weeks of the menstrual cycle (a.k.a. the follicular phase), you are growing the egg that will ultimately become half of your baby. Because the majority of menstrual cycles range between 25–35 days, the math usually works out. But when pregnancies are conceived with fertility treatments, the lead time (a.k.a. egg development) can be VERY variable. Weeks and even months may be added to get an embryo implant ready. For this reason, if you used fertility treatments to conceive, you can’t simply add a few days to your last menstrual period to calculate your due date. You may need some creative counting and a good doctor to get things sorted out.

As much as we love numbers, we can only count so high! Therefore, to make sure we are getting this equation right, we use pregnancy wheels (a fancy way to say pregnancy calculators) to figure out when you should plan to meet your plus one. Whether it be the day you ovulated, the day we performed your IUI, or the day your IVF ET was done, we can figure out exactly how far along you are. Given that the numbers will be less than transparent, it’s important to get a due date calculated by your fertility doctor before posting “We are expecting…coming March 24th” on your Facebook page. Additionally, you want to pass this info on to your OB and any other practitioner that participates in your care—they need to be in the know about when you will be ready to go!

Dates are not only numbers to an OB. We don’t break them, we don’t forget them, and we certainly don’t change them (unless we have a really, really good reason). They not only dictate when pregnancy-specific tests should be run (think genetic screening, diabetes screen, and GBS screening) but also when a fetus has what it takes to take on the world. Fetal lungs weren’t built in a day. In fact, they weren’t even built (for most babies) in nine months. They require those dreaded extra four weeks (remember, pregnancy is actually 40 weeks!) to get fully ready for a deep breath in and a deep breath out.

When most of us hear those words “You’re pregnant” (particularly after years of trying), we start to think about the end. And while it’s almost like planning for mile 26 before the race gun has even gone off, your due date is a big deal. But no matter how dynamite it is to know when D-Day is, your due date is NOT dynamic. It’s pretty dead set, especially after doing fertility treatment. IVF, IUI, and all the like leave little to the imagination. There is no questioning when your insemination or transfer was performed. Be mindful of these dates and the difference in how your due date is calculated after doing fertility treatment. While we love the web (#trulyMD), we want you to be careful when searching it for your due date. Make sure to use an IVF or fertility treatment calculator. This will save you a lot of calendar crossouts and changing-of-the-date chaos.

Ten Tips for First-Time Moms: What to Do in That Last Month!

Take everything we say in this post with a grain of salt. Most of it has minimal medical basis and maximal learn on the job-type tips. Pregnancy can be amazing and awful all at the same time—yes, we just said awful and pregnancy out loud together!

When you head into the home stretch, the physical pain usually gets worse, as does the anticipation and anxiety, especially if it’s your first time at the rodeo. First, all the emotions you are feeling are totally NORMAL. We totally give it up to Brooke Shields, who broke barriers by sharing her postpartum experiences. It’s important to know that joy is not the only emotion you’ll be feeling at the end of pregnancy and the beginning of mommyhood…

Here are our top 10 pre-delivery tips.

  1. Get groomed.
    While we are not telling you to run from the nail place to the waxing place and back to the hair salon, we are telling you to treat yourself! Make time for you before the baby arrives. A spa visit and some good R&R is the best way to do it. Besides, who doesn’t like to be pampered?
  2. Make a delivery playlist.
    Labor is not called labor because it comes and goes in the blink of an eye! Much to the chagrin of the family members camped out in the waiting room, it can be a LONG process—especially for your first! We recommend bringing along some good music, downloading some good movies, and maybe even packing a good book. Nothing takes your mind off things like laughter and light tunes.
  3. Plan a dress rehearsal.
    It’s never a bad idea to map out the best route to the hospital. Know where you are going and how to get to the labor and delivery floor. While it may seem silly to make a dry run, it will likely ease anxiety when game time comes. On that note, it’s also not a bad idea to have your “costume” (a.k.a. overnight bag) ready to go. The last thing you need when those contractions start is to be searching for your favorite sweatpants!
  4. Breast milk vs. formula.
    We are NOT here to pass judgment or tell you which is better for you or the baby. In our opinion, what works best for you will work best for your baby. But if you do think that you want to give this breastfeeding thing a whirl, make friends with a good breast pump, and a find a good lactation consultant (or someone in the know). This will help you prepare for what’s to come and increase your chances of getting the milk flowing.
  5. Bag the birth plan?
    We get it…you know exactly what music you want to be playing, exactly where you want your partner to be sitting, and where the baby should be placed right after delivery. And while having a birth plan is important, be FLEXIBLE with your bullet points. For sure know if you want an epidural, if you want a doula, and if you want a vaginal delivery or a C-Section—but unfortunately, labor and delivery don’t follow a plan. Be prepared for things to deviate from the script…the show will still go on!
  6. Know who you want to be there at the final push!
    Who you want to hold your legs and wipe your forehead is a very personal decision. Don’t be bullied by parents, your in-laws, or your friends—only people you want in the room should be there. It’s okay to want privacy during your special moment.
  7. Eat your heart out!
    While we want you to be careful about how many pounds you add during your pregnancy the night before you go into the hospital (if being induced, having a C-Section or as labor is starting), we recommend going all out in the food department. Treat yourself to a decadent dinner with your significant other. You will not only need the energy to push, but you will also want to enjoy the last moments of being kid free.
  8. Be mindful of unsolicited advice.
    Everyone is an expert when it comes to all things pregnant, and they are not afraid to share it. While most mean well, the advice can become moderately annoying. Listen to what you want to, and shut out what you don’t want to hear. Your doctor and medical team have probably done this several hundred times; they have got you covered and know what’s best.
  9. Accept the unacceptable.
    So many times, we hear women saying through tears and sobs, “This is not how I planned it. I feel like such a failure.” Unfortunately, no matter how hard you try to control what happens on D-day, you can’t. Nature doesn’t care if you dreamed of delivering in a bathtub in the dark with classical music in the background—if your baby’s heart rate drops, you’re having an emergency C-Section under the bright lights, no questions asked. The number-one priority is your and your baby’s safety; trust us, when you hold that baby in your arms, the plan will be nothing more than a moment in the past.
  10. It’s ok to want to quit—at least several times a day.
    Motherhood is the only job you don’t get to call in sick to, you don’t get to resign from, and you don’t get fired from. You can’t clock out, and you don’t get a paycheck. But even with all the exhaustion, the frustration, and the anxiety, it is the most amazing experience you will ever have. Labor is TIRING. Pushing is HARD. But quitting is not an option—you are stronger than you know.

Pot and Pregnancy: Is It Okay to Puff When Pregnant?

Marijuana use has become fairly widespread. Pot, hashish, ganja, dope: it’s all over. The legalization of marijuana in many states across the country has made lighting up as acceptable as having a drink; people can routinely be seen puffing in public in places like Colorado and Washington. In fact, to date, 23 states and the District of Columbia have legalized marijuana in some form (medicinal and or recreational use). Many more states have decriminalized the possession of small amounts of marijuana; taken together, pot is now fairly prevalent. It’s no longer something sold surreptitiously on a street corner. Given this, use during pregnancy and the postpartum period (specifically while breastfeeding) has become a more commonly asked question. So we are here to answer the question: can you toke during any trimester?

As you probably predicted (sorry to be a buzzkill for those who are fans), put your lighter down. Marijuana use in pregnancy is not kosher. Legal or not, it’s most definitely not legit in pregnant women. Cannabis sativa (Latin for marijuana) is the most common illegal drug used during pregnancy. About 2–5% of pregnant women report using it during pregnancy. (And if this is the number of patients admitting to it, think about how many more people are not copping to it!) In fact, about 50–60% of marijuana users continue to use during pregnancy. Whether you think of marijuana as the gateway drug to evil or the contrary and celebrate its legalization, you should realize it’s not okay in pregnancy or while breastfeeding (even when being used for medicinal reasons).

Animal models designed to test the impact of marijuana use in pregnancy have shown that the active ingredient in marijuana (tetrahydrocannabional, THC) does cross the placenta. Studies show that use during pregnancy can disrupt normal brain development. Children who were exposed to marijuana in utero had lower cognitive function, impaired visual-motor coordination, and lower scores on tests of visual problem solving. Furthermore, prenatal marijuana exposure was associated with decreased attention span and behavioral problems.

While brain development, behavioral problems, and attention span may be affected, the impact of “smoking up” during pregnancy has not been linked to structural anatomic defects (birth defects and other abnormalities in organ development). Additionally, there does not appear to be an increased risk of infant mortality among mothers who used marijuana during pregnancy. Lastly, the data do not demonstrate a consistently higher risk of preterm delivery or growth-restricted babies (medical term for small babies).

It is also important to remember that, while pot can be ingested (a.k.a. pot brownies), it is most commonly smoked. Smoking, whether it is marijuana or cigarettes, results in the release of really bad toxins. Newsflash: the levels of such toxins in joints is actually several times greater than in tobacco smoke. While this is not meant to be a prescription for eating rather than smoking your marijuana, it is important to remember that you are doing double negative duty to your baby on board when you smoke pot.

The data on breastfeeding and marijuana use are sparse. While THC has been observed in breast milk, the effect of its use on breastfeeding babies is limited. Given this, we recommend abstaining until nursing is fully completed. Simply stated, TLC does not equal THC! In addition, while marijuana is prescribed for select medical reasons, it should not be used for such purposes during pregnancy. According to the FDA, there are “no approved indications” for marijuana use during pregnancy and lactation.

If you happened to puff while pregnant but you didn’t know you were pregnant, it is not an indication for termination. Be honest with your OB/GYN about what happened so that the appropriate assessment can be taken. Whether it’s legal in your state or not, we are not here to lecture or lionize you for your personal practices when you’re NOT pregnant. However, when you’re pregnant or breastfeeding, we are here to say you should most certainly lay off the pipe. No matter how chill it makes you, it is not cool in pregnancy!

Heart Rate, Shmart Rate: Pregnancy and Exercise

There may be no greater taboo topic (other than who you voted for and what God you believe in) than pregnant women and exercise. Finger pointing, whispering, and gasps are the norm when a visibly pregnant woman hops on a treadmill. For some, it evokes the same feeling as a pregnant woman who smokes a cigarette. “How can she do that; doesn’t she know she’s hurting her baby?” No major fitness brands cater to pregnant women, and clothing lines for the pregnant athlete are scarce. It’s close to being off limits. News flash, world: the data on no exercise for pregnant women are old and no longer relevant. It’s time to turn things up and break a sweat. Here’s why.

Exercise is Excellent for Everyone. Young, old, pregnant, and postpartum, exercise is a good thing. Physical activity has a positive impact on almost every organ and organ system in your body: hearts, lungs, brains, and bones. It also is a major weapon in the war against obesity, which we are currently losing big time as a country. Additionally, those of us who move on a daily basis not only look better but also feel better. (The chemicals that bring you up are released into the brain during and after exercise. They will keep you flying high for many hours post-workout).

Exercise in pregnancy achieves all of the above benefits, plus some others. Women who get to the gym when expecting should expect a lower chance of gestational diabetes, macrosomic (large) babies, high blood pressure, and excessive weight gain. And we OB/GYNs are not the only ones endorsing exercise in pregnancy. The US Department of Health and Human Services recommends that healthy pregnant and post-partum women participate in at least 150 minutes per week of moderate-intensity aerobic activity. They are also cool with women who like to take it up a notch, which means those who engage in vigorous-intensity aerobic exercise can keep it up.

While we are not telling you to go out and achieve your PR in the marathon or train for an iron man (or woman!) in the dead of summer, we are telling you to get out, get active, and stay fit. You will have to make modifications in your regimen. You will have to share your big news with your fitness instructor. You will have to stay extra hydrated and wear loose, breathable clothing. But if given the all clear by the OB, you won’t have to sit on the sidelines.

In pregnancy, our bodies change big time (no brainer). But it’s not just that belly that we acquire; it’s also a shift in the point of gravity, laxity of the ligaments/joints, increase in blood volume, and decrease in vascular resistance. The last two are what can make you feel lightheaded and your legs swollen. Be conscious of these differences. Your awareness will keep you out on the track, in the studio, or on the mat longer.

Not every pregnant woman can bike, spin, or lift weights. Some pregnancies are more complicated, and the pregnant woman can’t exercise ad lib. For this reason, it’s important to be as open and honest with your OB/GYN about what you want to do as you would with your trainer as to what you want to build. We need to know what you’re doing so that we can tell you what is okay to do.

There are certain medical conditions (restrictive lung disease, severe anemia, heart disease) as well as specific obstetrical conditions (incompetent cervix, placenta previa after 26 weeks, premature labor) where exercise is prohibited. In addition, if you were a couch potato before pregnancy, it’s probably not the best idea to start doing boot camps once you pee on the stick. A more gradual progression into exercise is probably the way to go.

No one really knows where that magical 140 (maximum heart rate for a pregnant woman) number came from. We have searched textbooks (both online and in print) to find out why this number?? We got nothing good! And that’s because it was never based on any real data. The new recommendations from the American Congress of Obstetricians and Gynecologists on Eexercise and Pregnancy no longer stipulate that heart rate be used to assess how hard a woman is working when she is working out. We now recommend using “ratings of perceived exertion” to monitor exercise intensity (a 15-grade scale; very, very light → very, very hard).

Using the “talk test” is another way to measure exertion. (We prefer the “sing test”: can you sing the song playing on your iPhone?) Although we don’t want to hear you belting out the lyrics to “I Will Survive,” we do want to know that you will survive this workout class. If you can sing or talk, you can breathe, and if you can breathe, your baby is getting oxygen—and then you are all good.

Exercising in pregnancy has been viewed as selfish. Here’s what they say: Women who exercise care more about their bodies than their babies. Women who exercise are vain and self-centered. Women who exercise are not good mothers-to-be. This is downright bogus and simply BS. Studies show that babies actually like exercise just as much as their mothers do. While their heart rates increase, their birth weight does not decrease. In fact, babies born from mothers who exercise see benefits, from their brains to their bodies to how they are birthed (C-Section vs. vaginal delivery).

Exercise is good for both parties, mother and baby. While we may not be there to run beside you during this pregnancy, we can offer you a few parting pieces of advice:

  • Make sure to stay cool (don’t exercise in a 100-degree basement!).
  • Make sure to stay well hydrated.
  • And make sure to stay well nourished, with adequate caloric intake.

Other than that, lace up your sneakers, clip into the saddle, or roll out those yoga mats. It’s time to get moving!

Achoo…F-F-F Flu! The Flu Vaccine and Pregnancy

Break out the tissues, start brewing the tea, and swallow that Echinacea, because winter is coming! No, this is not an episode of “Game of Thrones,” but a chill is in the air. When the temperatures drop, anxiety over the flu rises, as does our consumption of vitamin C. Hand washing becomes an obsession, and coughing or sneezing without covering one’s face is the biggest faux pas. Despite what may feel like a lot of hype, the flu is the real deal, especially for women who are pregnant.

Because the flu can be way more than a one-day couch-lounging event, any method to prevent catching it is of the utmost importance. In addition to good hand washing and sanitary practices, the flu vaccine can significantly reduce one’s chance of getting the flu. Given changes in the immune system and respiratory system, pregnant women are at increased risk for not only getting the flu but also getting the flu with a vengeance.

Along with the muscle aches, runny nose, and headaches, pregnant women are at a much higher risk for all the negative and serious complications that come with the flu: ER visits, hospital admissions, intensive care stays, and even mortality. Simply stated: the flu and pregnant women do not mix.

Because of this oil-and-water situation, it is crucially important to receive the flu vaccine once it becomes available, no matter what trimester or “pre” trimester you’re in. The flu vaccine in pregnancy is at the top of every OB’s list, so it should be at the top of yours as well.

Additionally, research shows that the babies whose mothers received the flu vaccine while pregnant have a lower chance of developing the flu as an infant. The flu vaccine is not approved for use in babies younger than six months; therefore, the best way for these babies to receive protection is through their mothers (antibodies against the flu will pass from mom to baby through the placenta and protect the baby for up to six months of age). Simply stated, the best way to prevent and protect both you and your baby from being sidelined in a serious fashion from the flu is to receive the flu vaccine at the outset of the flu season.

The flu vaccine USED to come in two formulations, a shot and nasal mist.  The nasal mist was NOT safe in pregnancy (it was live weakened virus).  But the CDC pulled this version from circulation as it was not found to be effective.  So currently, all formulations are safe before, during, and after pregnancy.

There has also been some controversy on the use of thimerosal, a mercury containing preservative used in some vaccines, and autism.  There is no solid scientific data to support a link with thimerosal causing autism in children born to women who used these vaccines.  Thimerosal-free formulations of the flu vaccine do exist but the ACOG and CDC do not necessarily recommend pregnant women use only these formulations.

Bottom line: if you are not getting the vaccine from your OB/GYN, make sure to share your big baby news with the healthcare provider who will be administering the vaccine.

Getting the flu while pregnant is no joke. While it’s totally normal to be extra cautious about what you eat, take, or do while pregnant, the flu vaccine gets the double thumbs up.

Come Out, Come Out Wherever You Are: Ectopic Pregnancy

A positive pregnancy test brings with it big-time butterflies, big, bright smiles, and a big bag of unknowns. But very rarely does it bring the big question “Wow, I wonder if this pregnancy is located in the right place.” We all just sort of assume that, when we find out we are pregnant, the pregnancy is within the uterus. Unfortunately, this is not always the case. Pregnancies located outside of the uterus, better known as ectopic pregnancies, are not uncommon (and unfortunately never viable). In fact, about 2% of all pregnancies are located outside of the uterus. Bottom line, ectopic pregnancies are a big deal, and if misdiagnosed, can cause a big problem.

While it’s hard to find anything positive to say about ectopic pregnancies (they are a serious foe for any OB/GYN), the good news is that most ectopic pregnancies pick the same hiding spot…again and again and again! The majority of ectopic pregnancies can be found within the fallopian tubes (about 97%).

The remaining spots where ectopic pregnancies like to hide include the ovaries, the cervix, the abdomen, C-Section scars, or the uterine cornua (the uterine horn). Unfortunately, even when ectopic pregnancies hide in the same place, they are not always immediately visible. When they are small, they can escape even the shrewdest of physicians. It is for this reason that we use both pregnancy levels (hCG), weeks of pregnancy, symptoms (pain and bleeding), and the ultrasound pictures to determine if there is a pregnancy hiding where it shouldn’t be. During this “come out, come out wherever you are” phase, it is important to stay close to home and be in constant communication with your OB/GYN. Keeping us posted will allow for a speedier end to this game of cat and mouse.

Another key player in the ectopic hiding game is knowing who is most likely to have an ectopic. Identifying those at risk allows us to send out the search party early (a.k.a. watch a woman who has risk factors for an ectopic the moment she tests positive for pregnancy). Such risk factors include women who have a history of an ectopic pregnancy, previous surgery on one/both of their tubes, a history of PID, STDs, infertility and/or infertility treatments, smoking, or previous pelvic/abdominal surgery. They serve as hints or flashing red lights for OB/GYNs when patients complain of vaginal bleeding and/or abdominal pain in the first weeks of pregnancy.

Knowing what might be lurking outside of the uterus allows us to keep our eyes open and our minds ready to act. Intervening early in the game (when the ectopic pregnancy is small) can minimize the damage that an ectopic pregnancy can cause.

Once an ectopic pregnancy has been discovered, we move pretty quickly to make sure it doesn’t go back into hiding. We initiate treatment immediately and act fast to put an end to this problem. Treatment can be medical, surgical, or in some cases, simple observation. Which is right for you depends on many factors: a woman’s medical and surgical history, the size of the ectopic pregnancy, the pregnancy hormone level, how far along the pregnancy is, and the symptoms one is feeling. After analyzing these factors, the decision to administer methotrexate (the medical treatment) or undergo a laparoscopy will then be determined.

Make sure you have a thorough discussion with your MD about why he or she has selected the specific treatment plan. Although your pregnancy may be hiding, you should not be kept in the dark about what’s going on inside of your body and why a certain treatment is being used.

Ectopic pregnancies are no joke. If untreated, they can lead to massive bleeding and even death (#1 cause of death in pregnant women in the first trimester). It’s because of this that we OB/GYNs get very worked up over even the possibility of one and will stop at nothing until they are found. We will send blood tests on you every two to three days, bring you in for multiple physical exams, and even ask you to undergo repeat ultrasounds to help us figure out where the pregnancy is and how to make it go away. While the follow up can be annoying, it is essential.

In this game of hide and seek, it’s important that we play together (patient + physician) on the same team. Ultimately, no hiding spot is immune from an ectopic. As a united front, we find it quicker and make sure it doesn’t go back into hiding. So let’s uncover our eyes and start searching!