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

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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

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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.

Better Late Than Never: Post-Date Delivery

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News flash: pregnancy is 40 weeks. Divide 40 by four ( ≈ four weeks to a month), and even we math novices know that equals 10. You heard it here first: pregnancy is actually 10 months! We know it’s like they just added a few more miles to the marathon once you thought you’d reached the end, but get out your Gatorade because, for some women, the race won’t end for another two weeks. Definition time: a post-term pregnancy is a pregnancy that is ≥ 42 0/7 weeks. The “start” line is first day of your last period, while a late-term pregnancy is one that falls between 41 0/7 and 41 6/7 weeks. Knowing your exact due date is super important because this will be the basis for all the D dates to come.

As OB/GYNs, we love to talk “dates.” And although we do appreciate hearing about the one you went on last night (did he or she really say that?), we want to focus on the date of your last period. The first day of your last menstrual period is probably the most frequently asked question to a pregnant woman. By the end of your 10 months (ugh, sorry to rub it in), your partner will be able to spit this number out in their sleep, it will be mentioned so many times! The reason we ask it over and over is because it determines what your due date is. It also determines if your baby is growing appropriately, if things are developing on track, and if a delivery must be planned or induced when it should or can be done.

Pregnancy and fetal development are based on “weeks.” You rarely ever hear an OB/GYN define a pregnancy in terms of months; our first and only language is weeks. Weeks of pregnancy correspond to the size and maturity of your baby’s organs, particularly the baby’s lung development. So, we will jump through hoops to make sure that your “dating” is accurate and that we know exactly how many weeks pregnant you are and how old your baby is!

Why some babies show up on time, some early, and some late is often very hard to figure out. There are risk factors for each, but most of the time, it’s sort of the luck of the draw. First-time moms, those carrying a male fetus, and women who are obese more commonly carry a baby past their due date. Additionally, if you went over with your first child, you are more likely to go the distance the second time around.

Other than discomfort and major ankle swelling, why do we care how long pregnancy continues? Well, several studies have shown that both late-term and post-term pregnancies have a higher risk of fetal complications. Factors like low amniotic fluid, stillbirth, admission to the NICU, passing meconium (babies’ first bowel movement) in the uterus and swallowing it (a.k.a. aspirating), and seizures occur at a higher rate in late-term and post-term pregnancies. In addition, the longer they cook, the bigger they get. Pregnancies that are past their due dates are more than two times likely to be macrosomic (a fancy way to say BIG!). You guessed it; a big baby is more likely to get stuck on its way out. This leads to a higher chance for an operative vaginal delivery (forceps or a vacuum) and a C-section.

So, when is it time to call it quits? A lot of this depends on your personal history: your age, how you got pregnant (fertility treatments), your medical history, your previous OB/GYN history (have you had a C-section before) and your baby’s development (size, fluid etc.). Not every delivery plan and timeline fits every pregnant woman. In most cases, labor induction cannot be planned prior to 39 weeks of pregnancy (one week before your due date). This is done to ensure that your baby is as ready as possible to take on the world when he or she makes that first appearance. While most OB/GYNs are okay with labor inductions after 41 weeks of pregnancy (the ACOG gives it the green light), they are almost all on board by 42 weeks. In fact, after 42 6/ 7weeks your baby is not only ready for preschool, but according to the ACOG, it is mandatory evacuation time.

There are ways to “get the party started,” including sex, dancing, a bumpy car ride, spicy foods, nipple stimulation (yup, we just said that), raspberry tea, and something called evening primrose oil (sounds super fancy, but really, it’s just a vaginal tablet). The cervix is the gate to the uterus. It will soften, become thinner, and ultimately open and dilate as labor gets closer. Depending on the readiness of your cervix, some of these home activities can help move the process along. Unfortunately, no matter how badly you want to meet your little one, labor often happens on its own schedule.

Once you hit the magic 40 and nothing is happening, your OB will likely initiate more fetal testing to ensure that the baby is just “chillin’ out” and is not stressed. Make sure to be in constant communication with your OB. The more surveillance you have at the end, the safer both you and your baby will be.

If things seem off (you are not feeling well or your baby is moving less), don’t stay silent. We want to hear from you, even in the middle of the night. Trust your intuition. Moms are usually right!

I’m Pregnant. Now What?

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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

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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-eclampsia. For 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!

Time after Time: Recurrent Preterm Birth

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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

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“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

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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?

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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

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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.