Getting Ready

My due date of Labor Day (September 7) is quickly approaching, which means I’m 38 weeks now.  It’s been nice having these last couple of weeks to be on maternity leave, mostly because I no longer sleep through the night.  As I mentioned before, I keep waking up early in the morning, often for no good reason.  I don’t necessarily need to pee, I’m not any more uncomfortable than I was earlier in the night, but for some reason I find myself more awake.  From that point, turning in bed takes more effort so that may wake me up more, or if the little guy happens to be moving a lot, then that can also wake me up further.  Pretty soon I’m getting hungry, and then I can’t go back to sleep until I’ve gotten up and had a snack.  If I sleep through to 6 am, it’s a triumph.

Since his head is down, I haven’t quite figured out if he’s “raising the roof” with his hands, twisting his head or what, but occasionally I’ll feel him moving around my cervix, and it’s really uncomfortable.  So far, I’ve been pretty lucky with the pregnancy symptoms.  If I put on my maternity belt, I can go for a 2-mile walk around my neighborhood, complete with hills.  Without the belt, I feel like I need to pee right away.  But for normal daily activity, I don’t need the maternity belt.  It’s great to have more time to exercise consistently.  I went swimming for the first time in forever, and I’ve also had a chance to do my prenatal yoga DVD that I only used once before this week.

I have unfortunately been getting swollen feet daily, and thanks to the hot summer weather, wearing my compression leggings is usually not practical.  I’m a fan of dresses for summer maternity wear, because you don’t have the extra layer from maternity pants.  I was previously able to get away with wearing some non-maternity stretchy dresses, but now most of them are too short thanks to the bigger bump.  Elevating my feet at night means waking up with less swelling, but it is a bit awkward to elevate your feet when you’re already sleeping on your side.

Just a couple days ago, my left hip would occasionally give and hurt briefly while putting weight on that side.  Yesterday, I noticed my pubic bone area hurts if I cough, sneeze, or move in certain ways.  I guess my pelvis is loosening up in preparation for him to come through.  So far I’ve been enjoying my chill time, but perhaps soon I’ll be like many of my patients- very uncomfortable and tired of being pregnant.

I can’t say I’ve felt the urge to do the nesting thing.  The way I see it, decorating would be more for us than for the baby.  As long as we have all the necessities for when he arrives, I don’t feel the need to do more.  There are a lot of other things I’d rather spend time doing.  Right now, the crib is full of baby stuff and is being used as a storage space.  I figure that’s fine since we have a bassinet that he can sleep in initially.

I even wondered about the necessity of washing his things before he uses/wears them.  When I buy clothes from the store, I will wear them once or twice before washing them.  I did a quick search online, and I don’t know if this is true, but various people reported that they use chemicals to make the baby clothes look nice in the stores, so that stuff can irritate baby’s skin.  I also noticed that a lot of the labels said to wash before wearing.  So I went ahead and washed the newborn to 3-month sized clothes, as well as the blankets and such.  It’s funny seeing all the little clothes and knowing we’ll have a little guy to fit into them soon.

At this point, we have all the essentials ready (I think), and his movements are unmistakeable.  Things definitely feel more real than they did earlier in the pregnancy when his arrival seemed so far away.  We are curious to see what he looks like, and excited to meet him.  With that said, there’s still an element of not quite being able to imagine that in a few short weeks, life will be very different.  Even though I know logically that it’s going to happen, it’s still hard to completely envision it.  My friend who had her first baby 2 months ago said she still can’t quite believe she’s a mom.  I can’t imagine the shock for people who have their babies unexpectedly prematurely.  Ready or not, he’ll be here soon!

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Protecting the Perineum

Little Willie has made it to 37 weeks, which is considered full-term, but we are now finding that there are mild risks to being born before 39 weeks.  So we don’t perform elective C-sections or inductions without a medical indication before 39 weeks.  I’m hoping he wants to stay in my uterus until 39+ weeks for selfish reasons- so that I get a little more time before he comes.

Now that I’m on maternity leave, I was hoping to have a chance to look into some of the less medical aspects of labor and delivery.  Today I wanted to focus on the voodoo around preventing perineal/vaginal tears during the delivery.  The perineum is the part from the vagina to the rectum.  This part tends to tear the most, and is where we use the grading system for the extent of the tear (1st degree is good, 4th degree means it tore all the way to the rectum) but many women can get tearing elsewhere in the vagina and vulva.

Anecdotally, my colleagues and I have noticed that some vegetarians have poor tissue.  What we mean by this is that some women get the normal perineal lacerations after a vaginal delivery.  When we are performing the repair, their vaginal tissue is very fragile and tears easily, and doesn’t stitch up well.  Sometimes the sutures keep tearing and pulling through the tissue and it’s not helping stop the bleeding, so I’ve had to just pack the vagina with vaginal packing, which is kind of like gauze in tape form.  It provides pressure to help tamponade the bleeding.  I think it goes to show that if some women aren’t having adequate protein sources in their diet, it can affect the quality of their tissue.  This also affects tissue for C-sections as well, and it’s actually more scary if things are hard to suture during surgery.  This definitely biases me towards staying Paleo and eating good quality meat.

I’d recently heard about a balloon that some people use to help stretch the perineum and vagina prior to delivery.  I have no idea how well it works, but it’s called the Epi-No, and is a balloon that you inflate daily in the vagina to gradually stretch it.  It costs about $140:

http://www.epi-no.co.uk/about-us/

I previously mentioned a book I got called Gentle Birth Method by Dr. Gowri Motha.  I have found her entire regimen to be unrealistic for most- you’d have to make it a full-time job to do everything she recommends.  Even the dietary recommendations alone of avoiding too many carbs, particularly wheat and sugar, have been tough for me.  I do agree it’s probably best to do so to discourage the baby from getting too big to push through one’s pelvis, but I haven’t been able to curb my pregnancy cravings to that extent.

In addition to that, she has recommendations based on one’s personality/body type, and for me she recommends avoiding spicy foods and garlic, acidic foods like tomatoes and citrus, and cheese which I find difficult.  Add to that recommendations for exercise, herbs/supplements, massage and body treatments, and self-hypnosis practice for labor.  Honestly, unless you live in England and are able to go to her center, aren’t working full-time and don’t have any other children, I feel like it would be damn near impossible to follow all of the recommendations.

With that said, there are some helpful tips in the book.  First off, I do appreciate that she stresses that as a physician, she knows that there is a time and place for an epidural and C-section.  She cautions women not to get so bent on having a medication-free vaginal delivery that they lose sight of the real goal- safe delivery of their baby.

In terms of reducing perineal tears, she recommends perineal stretching exercises.  Though a woman can do it herself, it’s much easier for her partner to perform it on her (gets kinda hard to reach down there with a full-term belly).  It involves pressing on the perineum repeatedly at the 4 o’clock, 6 o’clock, and 8 o’clock positions.  It’s done 6 times at each location as the woman is exhaling, and gradually the finger can be inserted deeper in the vagina and two fingers can be used as the perineum stretches.  Gauze soaked in her perineal massage oil can be placed prior to the exercises to help prep the area.  As opposed to buying a $140 balloon, I figured it’d be worthwhile to try the perineal stretches if I can maybe avoid excess tears.

In the course of my Google searching, I came across this great site written by a midwife:

http://midwifethinking.com/2010/08/07/perineal-protectors/

It’s very thorough, and in addition to the Epi-No balloon and perineal stretching, she mentions other factors that can affect tearing during vaginal delivery.

Someone previously commented (see the Stress in Pregnancy entry) asking about birthing positions.  In my training in Western medicine, I can’t say I’m very familiar with alternative birthing positions.  I’ve pretty much delivered everyone in a hospital bed on their backs, maybe rarely on their side.  So honestly, it would throw me off to try to deliver a patient on all fours.  Also, in most hospital settings, women tend to get epidurals so they are limited in their mobility.  The midwives we work with in the hospital are much more familiar with the other positions for pushing and delivering.  According to the site above, delivering on the side or all fours is associated with less tearing.

For me, I’m planning on playing things by ear.  It would be nice if things go well and I can handle my labor without an epidural, but I’m not ruling it out.  It would also be nice if my labor remains uncomplicated and a midwife is taking care of me, in which case I can discuss positions.  Most likely due to convention, I’ll end up delivering in the standard position on my back, and I’m hoping between my diet that includes quality protein sources, the perineal stretches, and having a controlled delivery of the head, that I can reduce tearing.  I’m also aware that a lot can happen on Labor & Delivery, and things rarely go according to plan.

The GBS Test

As of today, I’m officially on maternity leave!  In California, you can start it at 36 weeks, but I decided to work into my 36th week.  I’m glad to be done now, especially because for the last few days, I’ve been waking up at 5 am for no good reason.  Maybe I’m mildly uncomfortable, but there doesn’t seem to be a reason like needing to pee that wakes me up.  I just find myself more awake with a very active mind.  Not so great going into a full workday without a good night’s rest, but I guess I’ll be dealing with that when I head back to work postpartum.  I’m hoping for at least a couple of weeks of some chill time to relax and take care of things before Little Willie arrives.  As my husband puts it, it’s the last vacation…of my life.

Last week, I had my GBS test done.  GBS, or group B streptococcus, is a bacteria that commonly colonizes our bodies.  According to my go-to resource UpToDate, 15-40% of pregnant women are colonized with GBS.  In my experience, I wouldn’t say 40% of my patients test positive, but since we test everyone, I see it frequently.  We perform GBS screening for all pregnant patients at 35-37 weeks’ gestation with a swab of the vagina and rectum.  Anyone who screens positive automatically gets penicillin (or another antibiotic if allergic) in their IV when they are in active labor or break their water.  This is done to help prevent GBS infection in the babies, and is done routinely nationwide, per CDC recommendations.

Some women are found to have the GBS bacteria in their urine on a routine urine exam with their initial prenatal labs.  They are considered to be colonized, so they will automatically be treated on Labor & Delivery.  If a patient had a previous baby who became sick due to GBS, then we will automatically treat them with antibiotics.  Also, since preterm babies are more susceptible to illness due to GBS, we automatically give antibiotics to patients in preterm labor to help prevent it, since most of these patients haven’t had the swab done yet.

Initially, when this was getting started, they were treating the pregnant women based on risk factors.  But in the end, they found that testing everyone and treating the positive women (unless they were having a scheduled C-section) significantly reduced illness due to GBS in the babies.  In the early 1990s, before this was implemented, the rate of early-onset GBS was 1.5 per 1000 live births according to the CDC.  By 2010, after universal screening and treatment were implemented, the rate fell to 0.24 per 1000 live births.  There is also late-onset GBS infection that occurs 7+ days after birth, and antibiotics in labor unfortunately haven’t decreased those rates.

So what happens if a baby gets sick with GBS?  They can get sepsis, which means they can have a generalized infection throughout their bodies.  The severity can range, but they can develop septic shock and have long-term consequences.  They can also develop pneumonia or meningitis due to GBS.  Bottom line is that it can be very bad.

With that said, during the pregnancy I’d been thinking about this.  Yes, I know that GBS infection is bad and I certainly wouldn’t want that to occur to my baby (or anyone else’s).  And I tell all of my patients about why we screen and the importance of getting the antibiotics in labor if they are positive.  But the fact is that it’s still rare.  Back in 1981 when I was born, my mom wasn’t tested, and most of us did just fine.  What I’ve been more concerned about is that there’s probably a lot we still don’t know about the effects of all of these antibiotics in labor.

Those of us in the Paleo community are probably more aware than the average American about this issue.  Our natural flora- the normal bacteria that occur in our bodies, mostly our digestive tracts, play an important role in our health.  Taking antibiotics and throwing off that normal bacterial balance likely has negative implications.  Problem is, that research is still developing and isn’t as robust as the data above on GBS infection.  Mark Sisson has discussed it previously on his Mark’s Daily Apple site:

http://www.marksdailyapple.com/the-problems-with-antibiotics-more-fallout-from-killing-your-flora/#axzz3itNRv69U

As an OB/Gyn, I see this a lot with vaginal yeast infections.  Women take antibiotics for a urinary tract infection (UTI) or the like, which then kills the bacteria in the urine, but also the normal bacteria in the vagina.  That causes the yeast to grow, causing the vaginal yeast infection.  Antibiotics are necessary and good when one really has an infection.  The issue is that many times people take antibiotics that end up not being needed- like maybe they thought they had a UTI, but in the end they didn’t.  I have some patients who are really frustrated with recurrent vaginal yeast infections, and often we are not able to pinpoint why they keep getting them.  I can’t help but wonder if their eating habits are to blame, but I can’t just tell everyone to go Paleo.  And that might not even work.  I do encourage them to reduce sugar and junk food, and to consider probiotics in the case that they keep getting infections and don’t otherwise have any explanation.

So back to the GBS- the rates of GBS infection was 1.5 out of 1000 live births before the days of universal screening.  It’s very bad when it occurs, but it’s rare.  And if 15-40% of pregnant women are testing positive, that’s a lot of women who are getting prophylactic antibiotics that they don’t need.  The problem is that we don’t know who is who.  We don’t have a good way of predicting which of those positive moms are going to have sick babies, so that’s why we treat everyone.

My concern if I tested positive and got the prophylactic antibiotics was that it would change my normal flora, as well as my baby’s.  And that could have potential negative consequences.  I thought about declining the prophylactic antibiotics in case I was positive.  That would have raised some eyebrows amongst the staff I work with.  And of course, I’d be gambling and taking the risk that my baby might develop a GBS infection- not something my husband and I take lightly.  In the end, I’m not sure what I would’ve done.  I was relieved to test negative and not have to make that decision.

Stress in Pregnancy

I’ve mentioned before that I’m a huge fan of the Headspace meditation app.  I find it to be very well-designed, and makes it much easier and fun for me to meditate on a daily basis.  They have sessions on various topics such as stress, sleep, relationships, even creativity.  I was very excited that they recently introduced a new session on pregnancy- worked out perfectly for me, timewise.  The sessions evolve during the course of 30 days, and involve visualizations for yourself as well as focusing on the baby.

Per the narrations, the basis of the sessions is that it’s beneficial for you and the baby to have a more calm, positive mindset and that stress is bad for you and the baby.  While I don’t disagree with that, it did get me wondering- how much do we really know about how bad stress is for the pregnancy?

Like most things in pregnancy, I figure it’s hard to study.  You can’t exactly split a group of pregnant women, subject half to significant stress and half not and see what happens.  I’m not one to go searching through all the evidence, so I went to two of my go-to sources.  One is UpToDate, a website many of us clinicians subscribe to that gives us current evidence and recommendations from experts.  It’s generally reliable, and most of us use it as a higher-level Google.  The other resource is ACOG, the organization that oversees us OB/Gyn docs in the US and gives us practice guidelines (how to manage patients based on the current evidence).

According to UpToDate, there is evidence that stress is associated with preterm birth.  They say that major maternal physical and psychological stressors, including anxiety and depression, can activate the HPA axis (involved in the stress response), and it’s been associated with a slightly higher rate of preterm birth.  One study showed that women who had depression early in pregnancy had a higher rate of preterm birth, and there was a “dose-response” effect, meaning that the worse the depression, the more it was correlated with preterm birth.  They talk about the various mechanisms thought to be related to this, and even have the graphic below.

UpToDate

Pathogenesis of preterm birth

Image
HPA: hypothalamus-pituitary-adrenal; ACTH: Adrenocorticotropic hormone 16-OH; DHEA: 16-hydroxydehydroepiandrosterone; E1 – E3: estrogen, estradiol, estrone; CRH: Corticotropin releasing hormone; Cox-2: Cyclooxygenase 2; PG: Prostaglandin; MLCK: Myosin light chain kinase; PROM: Premature rupture of membranes; PGDH: Hydroxyprostaglandin dehydrogenase

Don’t ask me to explain it in detail, as I’m certainly no expert in it.  Bottom line is, stress apparently causes certain factors to be released, which are then thought to cause physiologic changes that lead to preterm labor and preterm birth.

ACOG doesn’t specifically have any articles on stress and pregnancy that I found.  When I looked at their practice bulletin on preterm birth, they didn’t mention stress as a risk factor.  Unfortunately, there is a lot that we still don’t know about preterm birth, or we’d be better at preventing it.  The biggest risk factor is if one has had a prior preterm birth.  There are other things, like underlying infection that have been correlated with preterm birth, but then again treatment hasn’t been shown to prevent preterm births.  Some cervical procedures, like conization of the cervix which is performed to remove cervical dysplasia (advanced precancerous changes), were traditionally thought to increase risks of preterm birth, but they also wonder if there are other factors that contributed to the dysplasia in the first place that also put one at risk for preterm birth.  There are some behavioral factors like smoking and substance abuse that increase risks.

So how do I approach the topic in real life?  July was a brutal month work-wise, working nearly 60 hours a week consistently the whole month.  I can’t say my mindset was exactly Zen as I’d be finishing yet another long work day.  But am I worried that this is going to significantly affect my pregnancy?  No.

My patients often worry about the stress in their lives affecting their pregnancies, and I think it’s generally unnecessary.  While I wouldn’t advise volunteering for combat and voluntarily going to a war zone, most of us experience normal life stressors throughout the pregnancy, and that’s fine.  That’s life.  I can’t imagine that from the caveman days to now, that women have ever been able to get through 9 months of pregnancy without normal life stressors.  And sometimes my patients have more significant stressors- some of them have lost family members during their pregnancy.  Do they all go into preterm labor?  Nope, their babies do just fine.

As a doctor, my goal is to make sure that my patients don’t need a higher level of care for what’s going on.  If they are significantly depressed or anxious, then they may need to see a therapist or psychiatrist.  I certainly wouldn’t want their underlying condition to affect their behaviors, such as eating or substance use, which would then affect the pregnancy.

I do agree that there is potential benefit in working on handling stress levels, such as meditating and exercising.  But rather than doing that, many of my patients worry that their stressful work situation is going to affect their pregnancy, and then they come to me asking for notes for work.  While work modifications are reasonable for patients who have physical pains and limitations, I do think some women are misguided when they think they need to modify because of “stress.”  One extreme example is a patient who works as a school bus driver, driving 2 hours in the morning, and 2 hours in the afternoon.  She felt like this was too much, and asked to reduce her hours.  This is the kind of behavior that will make your doctor roll her eyes and complain about you behind closed doors.

My thoughts are to do what you can to handle your normal life stresses while you’re pregnant.  Meditation is a good use of your time if you are so inclined, but it’s not for everyone.  If there are significant issues going on, they need to be taken care of.  But worrying about how much your normal life stressors are affecting your pregnancy is unnecessary and just increasing your stress.  You have enough to worry about in pregnancy; make this one less thing.

You look so small for 34 weeks!

I’ve been hearing that a lot in my pregnancy.  Which is a compliment, and nice to hear.  Certainly better than, “Wow, you sure you’re not having twins?”  I know that I’ve been gaining a healthy amount of weight in the pregnancy, and that things are going fine.  So I’m comfortable and happy with how I look.  The only person who thinks I look big is my mom- a couple weeks ago, she commented on how big my abdomen was getting.  She wondered if she got that big with me and my brother.  I have no doubt that she was bigger at term than I was two weeks ago.  It’s just easy to forget when it’s been over 30 years.  And I think she’s just so used to seeing my normal non-pregnant body, that it seems like such a huge change now.

The other day, I was saw a woman walking way ahead of me down the hall in the hospital, and noticed the uncomfortable waddle.  As I scurried past her, sure enough there was a pregnant belly attached to her front.  I thought to myself how relieved I was that I can still walk just fine, with no significant discomfort.  I think it has helped that I haven’t gained excess weight, though of course many women have pregnancy-related pain despite normal weight gain.

I do find, though, that even the seemingly innocuous comments from people about pregnant women’s size can cause worry in my patients.  Every so often, a patient will tell me that people have been commenting on how small she looks, and that she’s worried her baby is too small.  I reassure her that her fundal height (the measurement from her pubic bone to the top of her uterus) is normal, and therefore there’s nothing to worry about.  Ultimately, everyone carries differently.

And on the other hand, if people make comments in the other direction, that of course will make women self-conscious as well.  Hopefully most people aren’t insensitive enough to purposely make a comment that a pregnant woman looks big, but perhaps it can happen inadvertently.  Maybe they volunteer how far along they think the woman is, and it ends up being way off.

For me, I don’t mind that people tell me I look small for my gestational age.  I won’t lie- it’s nice to hear.  It’s the equivalent of any woman being told she looks thin.  But the fact is, comments in either direction can make women worry.  So hopefully people are mindful of that.  And also, it helps for the pregnant woman herself to try not to worry about comments so much.  Ultimately, her doctor will let her know if there’s anything to worry about with the baby possibly growing too small, or if the patient is gaining excess weight.