I get this question a lot from my patients during their postpartum visit.  “So, I just had a baby and would like for my kids to be close in age- when is the best time to have my next baby?”
In the medical literature, this is called “birth spacing” and there have been lots of studies that have looked at ideal timing between pregnancies. 

1. What is optimal time to wait between pregnancies?  If you are <35 and healthy, the ideal time to wait before planning your next pregnancy is 18-24 months and less than five years.  If you are over the age of 35, as fertility decreases at this age, the ideal interval may be closer to 12 months.  Remember these numbers do not apply to a miscarriage.  Most people with a first trimester loss are safe to start trying during the menstrual cycle following their loss.  However, you should consult with your doctor as they would be aware of your medical and pregnancy history and would be able to help you plan accordingly. 
2. What are the risks of spacing a pregnancy closer than the recommended intervals?  Studies have shown that pregnancy within 6 months of a live birth increases the risk of premature birth, placental abruption, low birth weight, anemia, and congenital disorders.  Very closely spaced pregnancies often do not give mom enough time to recover from pregnancy and breastfeeding, as this can deplete your folate and iron stores, and which is why they are at higher risk of being anemic. 
3. What are the risks of waiting too long? Long intervals between pregnancies can affect fertility and can increase the chance of developing preeclampsia.  Moms over the age of 35 have increased risks of preeclampsia, hypertension, diabetes, problems with the placenta and stillbirth.  There is also a higher chance of having a baby with a chromosomal issue.
4. What is different if I had a c-section?  If you have had a c-section, waiting at least 6 months is preferred in order to allow the uterus to heal and decrease the chance of uterine rupture.  Most physicians also require a minimum of 6-12 months between pregnancies if you are considering a vaginal birth after cesarean (VBAC). 

Planning your family can be tough.  Even if you have the perfect plan in mind, there’s no guarantee that your body will cooperate, but by keeping the above guidelines in mind, then you can help make your pregnancy safer and more likely to result in the outcome you (and your provider) are hoping for:  healthy mom and healthy baby 😊

Dr. Pam

For many moms-to-be, the focus is on getting pregnant, but once that happens, there isn’t always great information on what to expect during labor.  As the end of pregnancy looms, some expectant mothers don’t have a clear idea of exactly the next step is going to be.  So, here’s a quick overview looking at the end of pregnancy and delivery.

​When should I expect pregnancy to end?  Full term for pregnancy is beyond 37 weeks, and your due date is at 40 weeks.  We offer induction for patients who haven’t gone into labor spontaneously by their due date because we can begin to see an increase in the risk of stillbirth and need for cesarean section in pregnancies beyond a certain duration.  In fact, the ARRIVE trial suggests that we may even see a reduction in risk for cesarean section with inductions as early as 39 weeks.

How does this labor thing work? 
There are 3 main stages, and the first stage of labor has two parts.  Latent labor, or the beginning of contractions, can last anywhere from hours to weeks.  This process involves the cervical change from closed (0cm) to 4-6cm.  For some women, these contractions may not be noticeable until near the end of latent labor whereas for others, there can be significant discomfort and even frustration if the intensity of contractions increases without cervical change.  Active labor starts between 4-6cm and often progresses around 1cm per hour or sometimes even faster.

The second stage of labor begins following full dilation (10cm).  This stage involves pushing and delivery of the baby.  The second stage of labor can last anywhere from one contraction with pushing (usually a mom who’s done this before) to as many as 3 hours for first-time mothers in certain situations.

After baby gets here, the last stage of labor is delivery of the placenta.  This generally happens shortly after the delivery of the baby, although in some cases the delivering provider has to manually extract the placenta by placing his/her hand into the uterus to remove the placenta.

What conditions would cause the need for intervention for either my baby’s health or my health?  Sometimes, an intervention can be as simple as adding Pitocin to help labor progress.  Since prolonged labor can result in increased risk for intrauterine infection, abnormal heart rate for baby, low oxygen levels for baby and increased need for cesarean delivery, we like to see contractions reach a level of intensity that will continue to cause the cervix to dilate.  Sometimes, the pushing process can cause a lot of stress on the baby, and in this case, operative vaginal delivery (vacuum or forceps) may be indicated.  Also, while we prefer to allow the vaginal tissue to stretch to minimize tearing, an episiotomy (cutting the vaginal tissue) may be required to speed the delivery of a baby in distress.  A cesarean delivery is generally reserved for when all other options have either been tried or are not appropriate.  Some reasons for cesarean delivery can include a baby that is too big to pass through the bones in mom’s pelvis (i.e. mom has been pushing for a long time without having the baby move closer to delivery), a heart rate pattern for baby that suggests waiting for the entire labor and delivery process would increase risk of harm to the baby, or if mom’s cervix stops dilating despite having adequate contraction strength from the uterus.

What can I do to prepare for delivery?  I’d suggest making sure that you and your partner know how to get to the labor and delivery area of the hospital, especially after hours as some doors may be closed during the middle of the night.  If your significant other takes you on the “scenic route” to labor and delivery, you may not appreciate the detour.  I’d also suggest getting a bag together of the things you might want in the hospital for a several day stay.  If you’re not sure what to pack, you can check out a sample packing list here:  https://www.tetonobgyn.com/blog/what-to-pack-for-the-other-labor-day4298355  Lastly, knowing the reasons to go to the hospital are very important.  If you think you might be in labor (generally painful contractions every 5-7 minutes for an hour, although you can always go if you’re not sure), if you think your water has broken (even if you’re not in labor), if you’re concerned that your baby isn’t moving normally, or if you have heavy vaginal bleeding (more than a pad per hour), then you should go to labor and delivery.  You don’t have to call for permission in any of those cases as sometimes we can be busy in a delivery and not able to immediately return a call.  We don’t want you waiting on us to call back while you have your baby in the bathtub.  Just head to the hospital, let the nurses know what’s going on, and they will start an assessment while they get in touch with us.

While a list like the one above can’t take all of the uncertainty out of your labor and delivery course, it can provide a little more information about what can happen and what you might expect.  As every woman is unique, so, too, is her pregnancy.  Please be sure to discuss any concerns you have with your provider, and we hope that you have the perfect labor, delivery and new baby for you 😊

Dr. Nick

We always strive for our patients to have an uncomplicated easy vaginal delivery with minimal tearing and discomfort.  However, sometimes a c-section is necessary to get both baby and mom safely through the labor and delivery process.  Some reasons for a c-section include the following: fetal distress in labor, problems with the placenta, position of the baby in the uterus, the cervix stops dilating or the baby stops moving down through the pelvis….
For many moms having their first c-section, a lot of times this is the first major surgery they have ever had.  They have lots of questions but have very little idea on the best way to get through the recovery.  Here are some tips that we hope can help you through the process.

1. Use a belly band:  So, both hospitals will provide you with a belly band if you have had a c-section; if you don’t get one right away- just ask your nurse for one.  When you are walking and moving around this will really provide you with the back and abdominal support you need to make the recovery process easier. 
2. Use a pillow when contracting your abs!  Anything that works your abdominal muscles, like coughing and laughing, can be pretty painful after a c-section.  We recommend placing a pillow on your abdomen before coughing and laughing to provide some support and help ease the discomfort your will feel when using your abdominal muscles. 
3. Make sure you stay on top of the pain!  I’ve seen lots of patients try to tough it out and not take pain medication because they did not like the way it made them feel.  For the first 3 days, it is very important to use these medications to help with the pain.  Initially we want your body to focus on healing, not on fighting pain.  Everyday will get better, and once the pain has improved, then you can decrease the amount of pain medication that you are taking.
4. Don’t compare your recovery to others.  I always hear family members talk about how they had a vaginal delivery without an epidural and toughed it out or stopped taking pain medication 1 day after the c-section.  Don’t let other people get to you.  This is not a contest.  If your family and friends are not being supportive, then you may have to consider temporarily limiting their access to you and the baby.  This time is about your recovery, not theirs!
5. Do what you can to prevent constipation before it happens!  Make sure you drink as much fluid as you can.  Usually we will provide you with a stool softener after your deliver. Recovering from a c-section and constipation can make you pretty miserable- we are there to help if you are struggling. 
6. Breastfeeding is hard, especially if you have just had a c-section!  This is a very anxiety provoking process for most new moms, especially if they had an unanticipated c-section.  Your milk probably has not come in and you are pretty sore from your c-section and your baby is not latching on- this is a pretty classic scenario.  Take a deep breath, utilize the nursing staff and lactation consultant and don’t fret- your milk probably won’t come in until the moment you’re are discharged.  Please let us know if you are struggling and need help.  If you decide breast feeding is not for you- that is ok- we are here to provide support, whatever your decision may be!

For most new moms, pregnancy is just the beginning of the baby challenge, and especially for those recovering from a cesarean section, the newborn time can seem even more daunting as you recover from surgery.  Please let others spoil you and take care of you while you are healing.  Try to take advantage of friends and family if they are available.  Utilize their help with the baby, meal planning, cleaning and whatever else they may offer and try to get some sleep!

​Dr. Pam

​Ever wonder why your fried and marinated foods taste so good?  A big part of the richness and flavors you love come from the oils you cook with.  That being said, just like adding a pound of butter to your popcorn, we wouldn’t necessarily endorse cooking or preparing your food in a vat of oil either.  Moderation is always helpful with any cooking oil, but if you’re looking for a comparison, here’s the scoop on some of the most common cooking oils:

1.  Olive oil – a good standby with lots of monosaturated fats.  These “good fats” have been linked to a Mediterranean diet, which has in turn been shown to have some cardiovascular health benefits.  That being said, it does have a low “smoke point,” making it good for cooking, dipping or sautéing, but probably not ideal for baking. 
2. Canola oil – high in polyunsaturated fat as well as high in smoke point with less flavor makes it a good choice for baking or frying.
3. Coconut oil – obviously a super-healthy choice, right?  Actually, it probably isn’t.  While some studies have linked coconut to everything from loss of belly fat to improved cholesterol, it turns out that if you look more closely, the studies were in fact touting the benefits of medium-chain triglycerides (MCTs).  Even though you can make MCT oil from coconut oil, it generally only composes about 15% of the coconut oil.  That’s kind of like calling a Snicker’s a healthy food option because it has peanuts.  Also, typical coconut oil has a very high saturated fat content (about the same as lard), and this type of fat has been linked to heart disease.
4. Avocado oil – composed largely of monounsaturated fat and with a naturally buttery flavor, this is a very versatile cooking option.  It’s high smoke point also allows for a variety of cooking techniques.  That being said, it is a bit pricier than some of the other cooking options.
5. Nut oils – hazelnut oil combines monosaturated fat and vitamin E, but even though its high smoke point allows for many types of cooking, don’t use it unless you want to add a pretty pungent nut flavor.  Macadamia nut oil has a slightly less pronounced nutty taste, so it can be used for grilling and salad dressings.  It also packs a combination of omega fatty acids to promote heart health.  Peanut oil is often used in stir-fry, and has a relatively even balance of poly- and monounsaturated fats.
6. Corn oil – commonly used for frying and cooking, it contains a combination of monounsaturated and polyunsaturated fats similar to olive oil, but it may be even more effective at lowering cholesterol and blood pressure.
7. Palm oil – given it’s high percentage of saturated fats (over 50%), it would generally be advised to consider other oil-based options.

So, there you have it:  a quick rundown on some common cooking oils.  The bottom line is to remember to avoid any types of trans fats, limit saturated fats, and, again, use these oils in moderation.  Even one serving of olive oil has over 100 calories, and even though there’s a lot of “good fat” in it, you’d still be consuming 14 grams of fat with each tablespoon!  So, pick your oils carefully and happy cooking!
Dr. Nick

In this day and age with two working parents, its so easy to stop by the frozen aisle in your grocery store and grab a quick-frozen meal for dinner.  I never thought much about it or felt that it was a potential health hazard.  However, a recent study out of France shows that frozen dinners (which are considered “ultra-processed foods”) are not only dangerous to your health but also increases your risk of early death!
Ultra-processed foods are foods that are “manufactured industrially from multiple ingredients that usually include additives used for technological or cosmetic purposes.”  They are consumed in the form of snacks, desserts, or ready to eat or heat meals.  The study examined the health and physical habits of 45,000 adults over a two-year period and they found a 14 percent higher risk of early death for each 10 percent increase in consumption of ultra- processed foods.
So, what about frozen foods makes it so unhealthy?

1. Added Starch: Many frozen foods have added starch to keep the frozen foods tasting fresh.  Starch is just extra glucose and all this extra sugar increases the risk of developing insulin resistance and eventually diabetes. 
2. Added Trans-fat: Frozen foods are usually full of trans-fat.  Foods that have a lot of trans fat contribute to raising cholesterol and putting you at an increase risk of heart disease. 
3. Added Salt: Salt is a well-known preservative.  Most frozen foods contain more salt than what you would add if you made the meal out of scratch for immediate consumption.  This can increase your cholesterol and your blood pressure.
4. Lots of preservatives: there are lots of other preservatives that are added to frozen foods to improve the texture and keep them tasting fresh.  Many of these have not been well tested by the FDA and most manufacturers don’t need permission to use these preservatives. 

I think it is easy to forget that frozen foods are still ultra-processed foods.  I always thought of frozen foods as freshly prepared foods that were just frozen- kind of like when your friends bring you freezer meals after you had a baby.  Unfortunately, frozen foods bought at the store have lots of preservatives, additives and extras that you did not likely anticipate.  So, before you stop by the frozen aisle to buy dinner for the family, remember that despite all the fancy packaging and healthy claims, these quick-fix options can increase your risk for hypertension, diabetes and even early death.  The best choice is to buy fresh ingredients and cook the meal yourself.  You know exactly what is in the meal and can tweak the sugar and salt amount to your own dietary needs.  Not to mention, busy moms can still freeze the leftovers for later 😊

Dr. Pam 

For most couples getting pregnant is simple and easy.  They just get pregnant and don’t have to go through expensive infertility testing and years of praying and hoping for a successful pregnancy.  For others it is a difficult struggle.  While there are many reasons couples may suffer from infertility, one of the biggest hurdles that prevents them from getting pregnant is the financial aspect.  Infertility treatment is expensive and not covered by most insurances.

So, I get this question a lot from patients struggling from infertility.  If you are going to dip into your personal savings or take out a loan to start a family, what makes more financial sense IVF or adoption? 

Let’s start with IVF.  Let’s just review what IVF is first.  The infertility specialist will extract some of your eggs and then add your partners sperm in a laboratory outside of your body and then at the appropriate time place that embryo in your uterus.  Now, what does IVF cost?   On average, one IVF cycle will cost somewhere between $10,000-$15,000.  Of course, the variation in cost is also dependent on the reason for infertility and a lot of other parameters.  Now this in no way guarantees you a baby.  However, the technology is improving every day and the success rate is rather impressive at certain facilities.  A good percentage of youngish (early thirties) healthy women will likely get pregnant by three cycles.  

My patients that pursue IVF frequently get asked- why not just adopt?  Well for one it is way more expensive than the average person realizes.  The average adoption in the U.S. costs between $27,000-$30,000.  The average adoption overseas can cost as much as $58,000-$65,000.  Most patients have this perception that adoption is cheaper until they have already invested in the process.  And again, just because you spend this money, there is no guarantee that you will get a baby.  Another consideration with adoption is time.  Even under the best of circumstances, adoption can take years to bring a child home.  

Another less well-known option that is much more affordable than IVF or traditional adoption is embryo adoption/transfer.  When couples go through IVF, they usually end up creating more embryos that they can use.  So, thousands of embryos sit in a lab and go unused.  With this procedure, couples with infertility will use donated embryos and just have them placed in their uterus at the appropriate time.  The cost of this procedure is about $3,000-$5,000.  

The decision on how to expand your family if you suffer from infertility is very complex.  It is important that you educate yourself on your personal fertility.  If the cause of infertility is known, treatment will likely be a lot more successful.  Know and research different options on building your family before deciding whether it be IVF, adoption or even foster care.  If electing to try IVF or embryo transfer, be sure to research your local infertility specialists and make sure you know their pregnancy rates.  The best programs out there will have a high pregnancy rate and a lower number of embryos transferred.  We are fortunate to have two options here in town:  Idaho Fertility Center and Reproductive Care Center.  If seeking adoption (and there are definitely many children who would benefit from these services), then be sure to research and find a reputable adoption agency.  Your needs may vary depending on the area from where you are hoping to adopt a child.  Whatever you decide, good luck in finding the best option for you to bring the newest member of your family into your home :)

​Dr. Pam

As fitness wearables become more commonplace, many people may assume that if I wear my new gear and take my steps, I will instantly begin to look just like (insert your favorite fitness model’s name here).  I mean, it sounds simple.  Take 10,000 steps per day, burn an extra 500 calories per day, or 3,500 per week (the amount in a pound of fat), and then you’ll just walk any extra weight right off.  Unfortunately, as many people have discovered, that’s not exactly the case, and here’s a few reasons for these fitness setbacks:

1. Your actual body composition differs from the weight used in this calculation:  These metrics are for a 180 lb person who travels 5 miles in 10,000 steps and burns roughly 100 calories per mile.  So, if you only weight 120 lbs, then you’d really only burn about 300 calories over the same 5 miles.  Also, if your stride is too short to travel 5 miles in your 10,000 steps (ie perhaps you’re a bit more petite than allows for long enough strides to reach your 5 miles), then you may also miss out on hitting your burned calories goal.  Also, even at rest body composition can play a role in your metabolism with muscle burning 7-10 calories per pound per day whereas a pound of fat may only burn 2-3 calories per day.  Thus, even if you hit the 500 calories from the 10,000 steps, you may still not see results if you have a higher fat to muscle ratio as your baseline metabolic rate (calories burned at rest) is slower.  Also, as you lose weight, the amount of effort to burn the same calories in exercise increases while your basal metabolic rate decreases. 
2. Say you weigh exactly 180 lbs and your body composition exactly matches that of the test subjects.  Intensity in your travel may also affect the number of calories burned.  Walking at a 4mph pace (or a mile every 15 minutes) would put you on track for 500 calories burned.   So, it takes roughly an hour and fifteen minutes of walking to burn those 500 calories.  Say you increased your pace to 6mph (a mile every 10 minutes).  You could look to burn 444 of those 500 calories in just 30 minutes, or with only 3 miles of effort instead of 5 miles.  Add another 4 minutes of running, and you’d match the 500 calorie output in just 34 minutes instead of an hour and fifteen.  Alternatively, if you walked more slowly than 4mph, then it would take a longer time to burn 500 calories, so you’d need to extend your walking time to reach your goal.
3. Gender also plays a role in metabolism.  For instance, following puberty, most men began to increase their lean body mass as testosterone levels increase, whereas for women, we don’t see such a surge in lean muscle as testosterone levels are naturally lower than for men.  That being said, participation in activities, such as weight lifting, that increase lean body mass may cause a slight increase in metabolism
4. Age can also play a role.  As we age, we may begin to see a decrease in muscle mass over time.  This can be due to participating in less weight-bearing and strength-training activity, dietary changes and also that maintaining lean mass may become a little more difficult due to simply being older.  In addition to the loss of muscle mass from the changes listed above, the parts of the body responsible for metabolism begin to wear down.  While staying active and paying attention to diet can help offset these changes, the bottom line is that the whole pizza you could eat without gaining an ounce at 20 will make you gain weight at 40.
5. Speaking of diet, one of the biggest misconceptions about exercise is that once done, you can now eat whatever you want.  You know the extra 500 calories you burned?  Check out the number you’re putting back in your post-workout smoothie.  Or in your post-workout splurge at whatever fastfood you might be treating yourself with.  It’s so easy to “treat” yourself with more calories than you burned exercising, not too mention more vigorous exercise often makes us hungry, so we tend to eat more than when not exercising anyway.

The bottom line is that there’s no easy way to lose weight and stay fit.  Those who tend to have the most success make changes that they can live with long term.  Results from a crash diet and daily intense workouts will only last as long as your motivation.  Ultimately, you will gain the weight back.  If you hate running, then you won’t keep doing it.  If you find that you love hot yoga and long walks with your dog, then do that.  If you’re eating 500 calories a day and are always hungry, then you can’t do that forever, and the weight will come back.  It's the same with diet pills you take for a few months and then have to stop for heart health.  Switching out healthier recipes for foods you already love to eat can be something you can allows for not feeling deprived while making positive progress.  The bottom line is that more calories have to be expended than consumed for weight loss to happen.  Gradually eating more healthily and learning to be active in a fun way are changes can allow for lifelong success.
Dr. Nick

Looking for a little more motivation to keep up with your New Year’s health goals?  New data from the American Cancer Society suggests that being overweight or obese increases your risk of both developing and dying from cancer.  As many as 8% of all cancers and 7% of all cancer deaths are thought to be caused by excess body weight, even if you’re otherwise healthy.

There is a clear association between obesity/being overweight and endometrial cancer, (menopausal) breast cancer, colon cancer, esophageal, renal (kidney) and pancreatic cancer.  There may also be a link to ovarian, cervical, gallbladder, liver, multiple myeloma, and non-Hodgkin lymphoma as well as aggressive prostate cancer (while prostate cancer is not a concern for women, it may affect your partner).  Even for normal weight women, having increased belly fat is associated with the development of cancer. 

Why do researchers think this happens?  It seems like “healthy” and “obese” may not go together after all, as obesity can have negative effects on immune function, inflammation, and hormone.  These changes can impact not only overall health but may play a role in the development of certain cancers.  For instance, excess estrogen production from adipose (fat) tissue can change the flow and length of the menstrual cycle, and this unopposed estrogen is associated with the development of endometrial cancer.  This same mechanism may contribute to some types of breast cancer as well.

Even a small amount of weight loss may be helpful for decreasing cancer risk, and, of course, there is a reduction in heart disease and diabetes.  Weight loss can also be helpful in bringing some predictability back to the menstrual cycle without the need for hormonal birth control to regulate bleeding. 

Given all of the benefits above, not to mention an improved sense of overall wellbeing, now is the perfect time to start making and working toward your own health goals for 2019.  Whether that’s to take an exercise class, run an 5K or just lose those pesky (fill in the blank) pounds, we hope that this information can help provide some motivation.  Good luck living your best 2019!
​
Dr. Nick