So you had a cesarean for your first delivery and now you are pregnant again.  One of the major questions you will make with your OB is what type of delivery, vaginal birth after cesarean (VBAC) or repeat cesarean, is most reasonable.  How do you make that decision? If we had crystal ball it would be so easy, but we don’t, so let’s look at all the factors that influence the decision.

Risks to consider

After a cesarean there is a scar on the uterus. That area is just a little weaker than the rest of the uterus.  As the uterus grows and stretches this area gets thinned out and even weaker.  Labor contractions put even more stress on the scar.  All this increases the risk that the scar can break open, or what we term “uterine rupture”.  If the scar ruptures, the blood flow to the baby can be compromised and sometimes cause permanent neurologic problems for the baby, or even death.  The risk of these are extremely low.  Only half of a percent of women laboring after a previous cesarean will have rupture.  Of those that rupture approximately 3 percent (and remember this is 3% of 0.5% total ruptures) will have complications or fetal death.  Because this number is so low, it is reasonable to consider a trial of labor in appropriate patients.

So what makes a patient appropriate?

Things your provider is considering when they are counseling you about a TOLAC include the reason for your cesarean, baby’s weight as well as your height and weight, whether or not have you had a vaginal delivery, and your ethnicity.  All of these can affect the potential success of a TOLAC.  There are online calculators that will give you the chance of a successful vaginal delivery.  Additionally we factor in how many more pregnancies you are considering. The final factor is what do YOU want.  Sometimes in your gut you know how you want to deliver. Realize there is no wrong or right.  Your provider will always guide you away from a overly risky option.

Recovery

Many women fear the recovery with another baby at home.  Surprisingly most women do really well after a repeat cesarean.  Certainly if you labored last time, then had a c-section while you were both mentally and physically exhausted, the recovery of a repeat may seem easier even if you have other children at home.

It’s a big decision and no gut instinct, physician or VBAC calculator can always predict a successful vaginal delivery, all of these tools will guide you into a decision that makes you and you provider are comfortable.  End of the day the goal is a healthy baby and a healthy mom!!

A balanced diet is the best way to get the vitamins and minerals you need for a healthy pregnancy.  However, it is easy to fall short on key nutrients during a pregnancy.  A prenatal vitamin can fill in the gaps.

Here are a few key rules to consider when thinking about prenatal vitamins:

Rule #1: Start the prenatal vitamin before you try to conceive.

Many pregnancies are unexpected some it’s reasonable to consider taking a prenatal vitamin daily even if you aren’t actively trying for pregnancy.  Important events are happening in an early pregnancy before a woman even misses her period and knows she is pregnant.

Rule #2: Find a prenatal vitamin that is cost effective.

It will need to be taken for a year or more as it is also recommended to continue a vitamin while breastfeeding.  Prescription prenatal vitamins are no better than over the counter prenatal vitamins.

Rule #3: Make sure your prenatal vitamin has these critical components:

1. Iron, 27 mg. In the United States approximately 20% of pregnant women are iron deficient. During pregnancy, the body needs to make extra blood to support the health of the mother and fetus. It takes iron to make this extra blood.  Iron is also needed for fetal brain development.  Although gummy prenatal vitamins tend to be easier to tolerate, they do not contain iron.  A separate iron supplement would be needed if you are using gummy prenatal vitamins.
2. Folic Acid, at least 400 micrograms.  Low folic acid levels are directly linked to neural tube defects or spina bifida.  The adequate amount of folic acid needs to be present from conception which is why prenatal vitamins should be started before a woman knows she is pregnant.  It can be challenging to consistently get the adequate amount of folic acid in the food we eat.
3. Iodine, 150 mcg . Many prenatal vitamins do not contain iodine. Iodine is needed for normal maternal and fetal thyroid function as well as fetal brain and central nervous system development.
4. Other important ingredients in your prenatal vitamin that are important for fetal bone, central nervous system and overall growth include:
   • Calcium 1,000 mg
   • Choline 450 mg
   • Vitamin D 600 IU
   • Vitamin A 770 mcg
   • Vitamin C 85 mg
   • Vitamin B6
   • Vitamin B12 2.6mcg
   • Zinc
   • DHA: 200 mg There’s evidence indicating that omega-3 fatty acids (particularly DHA)–a fat found in some types of fish–may play an important role in the development of your baby’s brain and nervous system.
     

There are many medical conditions where the amounts recommended above would need to be adjusted.  For example, taking the prenatal vitamin depends on adequate absorption through your gastrointestinal tract.  If you have certain gastrointestinal conditions or have had gastric bypass surgery, speak with your ob/gyn.  In general, a preconception counseling visit is always a wonderful idea to discuss any woman’s history and unique needs.

I “failed” my glucose test…

You drank that not so wonderful orange (or maybe you go lemon-lime?) drink and got a call the next day.  You “failed”.  What does that mean and what happens now?

During pregnancy the placenta starts releasing a hormone that makes women insulin resistant.  Most of the time the body can still maintain blood sugars in a normal range, but approximately 6% of the time is pushes women over into diabetes. The insulin resistance is typically temporary and resolves after the placenta is delivered.

It is important not to miss the diagnosis of gestational diabetes as there is increased risk to both mom and baby.  Moms have an increased risk of blood pressure problems, preeclampsia or toxemia of pregnancy and long term are at higher risk of type 2 diabetes.  The fetus is at risk of growth problems, birth trauma such as shoulder dystocia, bone fracture and nerve palsy, as well as higher chance of still birth.  Scary as all of these issues are, they are largely avoidable if diabetes is diagnosed and well controlled.

So that we don’t miss anyone that might have gestational diabetes, the first orange drink test “failure” is set at a low enough level that it will catch everyone that has it.  The problem with the low cut-off is that it also catches a lot of people that do NOT have diabetes.  This is what we define as a screening test. So the next step is the diagnostic test to weed out the “false positive” results.  We do this through a longer, 3 hour test.  I will be honest- it is not a fun test.  Our office will give you instructions to carb load for a few days prior to the test.  This sounds counter-intuitive because we just told you your body may not be able to process carbs and now we want you to to eat extra carbs.  The reason behind this is that this gives the pancreas the best chance to prepare for the extra sugar load of the second drink.  The day of the actual test you will come to the lab fasting and get a blood test, drink another lovely orange drink, then get a blood sugar test every hour for 3 hours.  It’s long.  It’s boring.  You are pregnant and hungry.  So again- we know it’s not a fun test, but it is really important.

No one wants gestational diabetes.  But with appropriate testing and treatment we can work together to make sure that at the end of  the pregnancy you have a healthy baby and a healthy mama.

In this age of COVID-19, it is easy to be overwhelmed by all of the news reports and social media posts out there.  It is hard to tune out all the bad news we are given as well.   Recently, patients have been concerned about news reports of increased risks for miscarriage due to COVID-19. The reports refer to a recent article published in the Journal of American Medical Association (JAMA).  The article is a case study of a pregnant woman in Switzerland who tested positive for COVID-19 and unfortunately suffered a miscarriage at 19 weeks of pregnancy.  Testing attributed the loss to a placental infection with COVID-19.

This case is tragic, and we cannot disregard the experience of this patient.  It’s important to note, however, that it is a single case report, and does not indicate that every pregnancy is at risk for the same outcome. Because COVID-19 is a new virus, we are still learning about its effects in pregnancy. Despite the information presented in the JAMA article, the CDC advises that based on current information, pregnant women seem to carry the same risks for serious illness with COVID-19 as non-pregnant adults.

Even under normal circumstances, pregnancy and the postpartum period is a time of physical and emotional change.  Navigating these changes during a global pandemic is certainly challenging.  Your OB provider can help to explain information reported in the news, and hopefully give reassurance amid the uncertainty.  Above all, pregnant women should follow social distancing guidelines.  It is important to avoid people who are sick or have been exposed to the virus, clean and disinfect frequently touched surfaces daily, and wash your hands with soap and water or hand sanitizer frequently.

In the age of smart phones and Google, it’s no surprise to me that my patients walk into our office with a wealth of information.  Search “pregnancy” on the iPhone App Store and you’ll get hundreds of results.  We’ve taken the time to review some of the available pregnancy apps and here are some of my favorites (and the best news is that they are all free!).

1. Period Tracker

Whether you’re planning for a pregnancy or trying to track your irregular bleeding patterns, Period Tracker keeps track of it all.  It tracks your period and ovulation cycles every month and is very easy to use.  It keeps track of your menstrual interval (the time from the start of one period to the start of the other) and predicts when you should get your next period.  This can be helpful for vacation planning too!

2. Sprout

Like many of the other pregnancy apps, Sprout customizes to your pregnancy after you input your due date.  It is unique in that it offers amazing 3D images of how the baby is developing from week to week.  Included in this app is a contraction timer, weight tracker, and baby kick counter.

3. My Pregnancy Today

This is a newer app which is gaining popularity quickly.  It offers suggestions for how to keep yourself in the best possible health during a pregnancy in addition to images of the developing baby, what to expect in the weeks to come, and a due date calculator.

4. Contraction Monitor

In the midst of wondering “am I in labor?” this app is here to help keep track of contractions.  Not only does it keep track of contraction frequency like many of the contraction apps, it allows mom to rate the intensity of the contraction and keeps track of how long contractions are lasting.  This is very helpful information to provide to your health care provider when you think you’re in labor.

5. Baby Names

This app offers thousands of ideas for naming your baby.  If you’ve waited until delivery to start thinking of about a name, this offers lots of ideas in the palm of your hand.  It’s also a fun app to keep you busy when you’re waiting in line.

*It’s important to know that most apps are created for fun and are not approved by medical professionals.  If you have questions or concerns based on the information you’re reading online or on an app, be sure to discuss it with your health care provider.

In the third trimester of pregnancy, all  women will notice the onset of daily hiccups from their babies in utero.  Why is this?  Is it normal?

It is perfectly normal and reassuring of a normally developing nervous system.  The nervous system begins to mature in a fetus around 26 weeks gestation and , as a result, a series of reflexes begin to become apparent in the growing baby by 32 weeks.  The term hiccup (or hiccough) originates from the Latin meaning “to gasp”.  Hiccups are actually a reflex caused by involuntary contractions of the diaphragm and rib muscles that result in a sudden inspiration and closure of the glottis (AKA “voice box”).   These reflexes, hiccups included, persist through the third trimester and generally disappear when the baby is around 3 months of age.

When a fetus has a hiccup, the muscles involved with breathing contract and it is suspected that this exercises the breathing muscles before the baby is born.    As the nervous system is maturing, a fetus will have several episodes of hiccups every day.

So, next time your feel those sudden intermittent little spasms in your uterus in the third trimester, be reassured that your baby is maturing normally and exercising the little breathing muscles in preparation for taking his or her first breath in the first moments of life.