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Are We There Yet? When, Why, and How Do We Plan Labor Inductions

5/27/2016

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It seems like there a few longer weeks in a woman’s life than those during the last month of pregnancy. Back pain, swelling of hands and feet, difficulty sleeping, and indigestion are just a few of the complaints I hear near the end of pregnancy. There is also often fatigue and Braxton-Hicks can be regular occurrences.  By this point, women are often uncomfortable and are generally counting down the days (perhaps seconds) until delivery.  “Can I have this baby now?” is nearly a daily question.  So, here is a quick review of the what, when, why and how of labor induction.

How do we induce labor? Any means used to stimulate contractions that result in cervical dilation and ultimately delivery of a baby is considered an induction of labor.  Other than “stripping” or “sweeping” membranes (a cervical exam separating the amniotic sac from the inner portion of the cervix to release prostaglandins), more definitive means of labor induction include synthetic prostaglandins (generally vaginal suppositories), amniotomy (breaking the bag of water), and Pitocin (synthetic oxytocin, the hormone released via breastfeeding and other sources of stimulation).  These last 3 methods are done in the hospital, although stripping of membranes can be done in the office.

When and why do we induce labor?  The answer to when largely depends on the reason for induction, so we can cover both the when and the why here.  As a general rule, elective inductions (ie, I’m tired of being pregnant, get this thing out of me NOW!) occur at 39-40 weeks.  Many insurance companies and Medicaid don’t pay for elective deliveries prior to 39 weeks, and with the lowest risk of injury/death to the baby between 39 weeks 0 days until 40 weeks 6 days, this generally makes sense. Elective deliveries prior to this time may also violate hospital policy, so even if your provider wanted to schedule you sooner, he/she probably wouldn’t be able to do so.

Of course, there are exceptions to the rule.  Catastrophic findings may require immediate delivery regardless of gestational age, and certain medical conditions such as some twins, preeclampsia or high blood pressure due to pregnancy diabetes, and fetal growth troubles can also be an indication for delivering your baby sooner.  Also, if your pregnancy nears the 41 week mark, we generally advise for labor induction due to the slight increase in stillbirth risk that begins at 41 weeks gestation and increases until time of delivery.

Bonus question: If I am being induced, does that mean I will have a cesarean delivery?  The answer to that question is that it depends.  Certainly, if the cervix is favorable (depends on dilation, position, thinning and softness of the cervix), particularly for someone who has had a previous successful vaginal delivery, then the chance would be very low.  However, for a first time mother with an unfavorable cervix, then her chance of cesarean delivery is higher.  The chance of primary cesarean delivery in Idaho is roughly 14%, and this may increase up to between 25-33% depending on the circumstances.  For instance, even though the size of the baby is the same (either it will fit or it won’t), the cervical exam does change over time.  These exam findings may be an indication of how well the cervix will respond to labor induction, which in turn is an indicator of the likelihood of successful induction as well as how long the process is likely to take.  A mother with several previous deliveries may require only an amniotomy and her baby will follow in a few hours, but a first time mother may require a day or more of medical induction depending on her exam findings. 

Rarely does the induction process cause significant enough stress to the baby that intervention is required, but even if contractions begin to come too frequently, there is often a medical treatment to reduce their frequency and decrease the stress on the baby.  For instance, terbutaline can be administered in some cases, particularly with prostaglandin induction.  With Pitocin, the half-life is only about 3-5 minutes, meaning that the effects of either too strong or too frequent contractions usually resolves within that time after stopping the medication.

In summary, labor induction is a complex decision.  Even now, there is continuing research on this topic, and recommendations change frequently, but it remains a reasonable option in many pregnancies.  There are many variables, but if you are interested in labor induction, be sure to discuss your specific medical history with your provider to see if “you are there yet!”

Nick
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A Quick Guide to Nutrition During Pregnancy

5/24/2016

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Picture
Wait a second? You mean you don’t just eat whatever you want (hello chocolate cake, don’t mind if I do...eat it all!) and then just lose all the weight immediately after delivery (7lbs of baby = weight loss of 50 lbs right)?  Unfortunately, releasing your inner child appetites (pun intended) with complete abandon may not be the best choice for pregnancy nutrition, but there are still options to take care of that peanut butter-canned chocolate icing-yellow cake mix craving.  Here are a few suggestions for helping to find that balance below.

Where does pregnancy-related nutrition start? Good pregnancy planning begins with a prenatal vitamin about 3 months prior to conception.  In addition to helping reduce pregnancy-induced nausea, your vitamin should contain 3 main ingredients: iron, for prevention of anemia; folic acid, for prevention of neural tube defects; and DHA, to promote fetal brain development.  Also, there are a few foods to avoid: cured meats, deli lunch meat, uncooked seafood, excessive seafood, unwashed vegetables and a few others. Be sure to discuss with your provider if you have a question of whether a food is safe in pregnancy.

How can I even begin to think about food since I’m puking my guts out?  If you suffer severe nausea early in pregnancy, then begin with smaller, more frequent meals, use of ginger ale, and avoiding trigger foods may be enough to help you manage your symptoms. Often, nausea is worse in the morning, and it may be that you feel totally fine by the afternoon.  If your nausea still persists throughout the day and has begun to affect your ability to eat, then over-the-counter options such as Vitamin B6 and Unisom are safe in pregnancy with appropriate dosage (contact your OBGYN for instructions).  However, if that still doesn’t work, you may need prescription medications.  When you are really sick, you may not gain much or even any weight until the nausea resolves, which is generally by the end of the first trimester, and if that’s the case, it’s often OK. Just remember, even at 20 weeks of pregnancy, your baby only weighs about a pound, so he/she doesn’t require a large amount of calories to support.

So how much weight should I gain during pregnancy?  Yes, I’m either really brave or really stupid to talk about weight with women (the jury is still out), but here is a table with the American Congress of Obstetricians and Gynecologists recommended guidelines for weight gain during pregnancy. So, if you disagree, that’s OK. It won’t hurt my feelings because I didn’t come up with them, and again, these are just guidelines.  For each patient, depending on her medical history and personal desires, there may be slightly different weight-related goals. 






Also, if you are curious as how to calculate your BMI, here is a link to an online calculator http://www.nhlbi.nih.gov/health/educational/lose_wt/BMI/bmicalc.htm


Who cares if I gain 100 lbs during pregnancy?  Some of the biggest risks related to excessive weight gain during pregnancy include larger babies and development of gestational diabetes. Even though big babies are cute, they can be a little tougher for mom to deliver vaginally, and if mom also has gestational diabetes, more of that weight can be located in the shoulders, putting the baby at risk for shoulder dystocia and injury during labor. Those are also risk factors for cesarean section (ie, if the baby can’t fit), and uncontrolled gestational diabetes can increase the risk for birth defects and stillbirth. Not to mention that having pregnancy-related diabetes increases the chances of developing diabetes later in life.

Doesn’t all that weight just go away after delivery anyway?  Well, some of it does. The average baby weighs just over 7 lbs, the average placenta weighs about 1.5 lbs, and the amniotic fluid weighs just about 2 lbs.  So, your mommy makeover begins with about 10 lbs of weight loss before you even leave the hospital!  To get all the way to your pre-pregnancy weight may require a combination of diet and exercise, though, but there is some good news for breastfeeding moms:  moms who breastfeed burn an average of 300-500 calories more per day than those who don’t!

What a bummer right?  Still, that doesn’t mean you can’t satisfy that craving for fried chicken dipped in ice cream gravy now and again.  Just make sure that those indulgences are the exception, not the rule. By maintaining a balanced diet with lots of fruits and vegetables while allowing for occasional treats, this can be your healthiest pregnancy yet, and you’ll be back to your pre-pregnancy self in no time!

Nick

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Nursing Bras: the Good, the Bad and Why so Ugly?

5/17/2016

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1. Do I really need a nursing bra?
f you are planning on breastfeeding your baby, you are likely going to need some nursing bras.  Getting access to the girls with a normal bra and a fussy baby can be rather difficult.  A good nursing bra is designed to provide you with good support, extra room when your milk comes in, and the ease to open in the front with one hand.


2. Do they really have to be that ugly?
Most nursing bras, especially the seamless ones are very plain and basic.  After 9 months of pregnancy and  a rapidly changing physique, most women look forward to being able to see their toes and some semblance of normalcy. Looking and feeling attractive for themselves and their partner is very important.  However if you have ever been to a Victoria's Secret in search of a nursing bra- guess what? They have hundreds of racerback bras but not a single nursing bra! It's like all of a sudden the purpose of your breasts are work, and somehow this is incompatible with sex appeal and being more than your baby's mother in the eyes of your significant other.

3. Ok, so while what is available in retail stores can be boring and ugly, there are some better options available online. 
In the last couple of years there are a growing number of companies that are committed to beautiful and sexy maternity and nursing bras.  Youlingerie, Cake Lingerie, Belabumbum, and HOTmilk( yes that is the name of the company) to name a few have some items that combine the functionality of extra fastenings and comfortable linings with beautiful colors and lace.  You Lingerie is a U.S. based company that has more affordable maternity bras than its European/ Australian counterparts.  The only issue with purchasing online is you cannot be fitted in a store and will have to measure yourself.  bravadodesigns.com has a video and bra size calculator on their website that can be very helpful.  

4. What should I look for in a nursing bra?
You should probably get fitted for a nursing bra at 8 months of pregnancy.  This is the size your breasts should be at approximately 8 weeks post birth when your body has learned to regulate its milk supply.  A lot of women make the mistake of purchasing nursing bras with extra room in the cup. This is not necessary as most good nursing bras will have stretchy fabrics on the top of the cup, which will allow for movement in the breast as it produces milk.  Your nursing bra should also have four hook and eye fastenings for added comfort, wide non slip shoulder straps, cups that open and close with one hand, and an opening that will provide plenty of room for your baby to feed comfortably. 

5. Should I get a sleep bra? 
Sleep bras are a transitional bra style that are great for nighttime nursing or at home nursing when comfort is key.  Most importantly, your breasts will likely leak milk at night, so you may feel more comfortable having your breasts supported at nighttime.  Nursing tanks are also another option as they offer good support and are perfect for layering under your favorite non nursing tops.  Make sure they have quick release clasps or pull aside cups. 

Pam
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Exercise in pregnancy: Too much, or not enough?

5/10/2016

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How much exercise is recommended during pregnancy?
Believe it or not, the American Congress of Obstetricians and Gynecologists (ACOG) still recommends 30 minutes of activity and exercise on most, if not all, days of the week. Why is staying active important? In addition to helping with mood, energy, posture and overall health, exercise also helps to improve sleep quality (best to take advantage now, before your baby gets here). It can also prevent/treat gestational diabetes and can improve back pain, bloating and constipation.

How do pregnancy-related changes in the body affect my exercise routing?
One of the biggest changes is related to hormonal changes that relax the ligaments supporting the joints. This increase in joint mobility may cause a slight increase in the risk of injury. Also, as the baby grows, the extra weight in the front of the body can affect balance, which can make you more likely to fall as your pregnancy progresses. This change in the center of balance is one of the causes of back pain later in pregnancy.

What kind of exercise is safe in pregnancy?
Studies have shown the baby tolerates 30 minutes of even strenuous activity as performed by both active and generally inactive mothers-to-be.  Walking, swimming, aerobics and cycling are all safe during pregnancy, although outdoor cycling should be avoided if you are unfamiliar with the balance necessary to avoid falling. If you were running prior to pregnancy, you can often continue during pregnancy with a few modifications to your regimen. In fact, my mom actually ran all the way into the third trimester while pregnant with me, and she tells me I’m perfect :)

What activities should be avoided?
Apologies to our hockey-playing moms, but contact sports and sports with a high risk of falling such as gymnastics, water skiing and horseback riding should be avoided.  Even more unfortunately, down-hill skiing should generally be avoided not only to reduce the chance of falling but also because of the risk of hypoxia at higher elevations. It is advisable to avoid “hot yoga/pilates” as well.  Lastly, scuba diving should also be deferred until after pregnancy due to concern for decompression sickness that results from pressure changes around the body.

What about strength training?
Lifting and resistance exercise is generally well-tolerated by those who have been participating in strength training prior to pregnancy. As long as the expectant mother understands how pregnancy will affect her body and is able to perform the exercise with safe form, she can often continue her routine while making accommodations as needed.  That being said, lifting that might cause the weights to be dropped on the baby or mom and/or loss of balance should be avoided.

How do I know if I’m doing too much?
We generally advise a target heart rate less than 160 beats per minute.  If you experience regular contractions, vaginal bleeding, rupture of membranes, dizziness and headache, chest pain, trouble breathing BEFORE exercise, muscle weakness affecting balance, and calf pain/swelling.

Generally, speaking activity is well-tolerated by women who are pregnant, and in fact, it should be encouraged for expectant mothers.  However, there are some absolute contraindications to exercise during pregnancy such as heart/lung disease, incompetent cervix/cerclage, twins or higher gestations, persistent vaginal bleeding, abnormal placental implantation, premature labor, ruptured membranes, anemia and pregnancy-induced high blood pressure among others.  To help plan your healthy and active pregnancy, talk to your OBGYN today!

For more information on exercise in pregnancy, check on the link below as a maternal-fetal medicine specialist (high-risk OB) offers further insight.

http://fox13now.com/2016/04/28/this-utah-mom-did-crossfit-until-the-day-before-she-delivered-her-baby/

Nick
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Pregnancy Myth Busters: Volume 1- Gender Prediction

5/3/2016

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1.       The fetal heart rate can tell me the gender of my baby right? At least once a week I have a patient ask “since the heart beat is more than 140 it must be a girl.”  And of course my response is well 50% of the time it will be a girl.  Multiple studies around 18 weeks’ gestation have shown that there is unfortunately no correlation between fetal heart rate and the gender of the baby.  We do notice that the fetal heart rate between 6 and 13 weeks is usually at or above 160 and then normalizes to 120-160 thereafter.  So while this is a popular question in gender prediction quizzes, there is really no correlation between the gender and the fetal heart rate.
2.       Everyone thinks I’m having a boy because my belly looks like a basketball or everyone thinks I’m having a girl because my belly looks like a watermelon.  This idea that the shape and height of your belly can indicate your baby’s sex just isn’t true.  While most people think carrying a pregnancy high is indicative of a girl and carrying it low means it must be a boy, the way you carry is really determined by other factors.  The shape and height of your belly is really determined by your muscle tone, position of the baby and most importantly your uterine tone.  For most women they will carry their first pregnancy higher and subsequent pregnancies lower as their muscle and uterine tone has been affected by previous pregnancies.
3.       Since your morning sickness is so bad you must be having a girl.  One popular pregnancy myth is that if a woman has severe morning sickness then there is a higher chance that she is having a girl. The reasoning is that pregnancy hormones tend to be higher when having a girl.  Several studies did find that women who required hospitalization for severe nausea/vomiting in pregnancy had a slightly higher chance of having a girl.  However, my bet would still be on the ultrasound in determining gender. 
4.       If you crave sweets you’re having a girl! If you crave salty foods you’re having a boy!  Most women experience food cravings during their pregnancy.  While these cravings are most likely the result of hormonal and metabolic changes that take place while pregnant, some believe that the baby’s gender can be determined based on the types of craving a woman is having.  Unfortunately, there is no correlation between pregnancy cravings and gender but it is still a lot of fun to take the gender prediction quizzes online and keep friends and family guessing until the results of the ultrasound are back!
 
Pam

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