Expecting Better

PART 1 In the Beginning: Conception

1. Prep Work

• Fertility declines with age, but not as fast as you might expect is not a magic number cutoff.
• Being obese before pregnancy is associated with an increased risk of complications for both you and your baby. Don’t worry too much about a few pounds here and there, but if you are significantly overweight, weight loss before pregnancy may have benefits.

2. Data-Driven Conception

• Timing matters! Pregnancy rates are high if you have sex on the day of ovulation or the day before, but fall rapidly away from that. It’s possible to get pregnant by having sex as many as 5 days before you ovulate, but it’s a lot less likely. After you ovulate, forget it until next month (you can still have sex, you know, for fun).
• It can take up to 9 months to resume your normal menstrual cycle after going off the pill, but there are no long-term effects on fertility.
• Low-tech ways of detecting ovulation (temperature charting,cervical mucus) are informative, but not 100 percent accurate.
• Higher-tech methods, such as ovulation pee sticks, are pricier butvery accurate.

3. The Two-Week Wait

• Very bad behavior during the 2-week wait could affect your chance of conception, but won’t affect the baby if you do conceive.
• Early pregnancy tests can detect a pregnancy 4 or even 5 days before your missed period, but pregnancy loss is common in this period.

PART 2 The First Trimester

4. The Vices: Caffeine, Alcohol, and Tobacco

• There is no good evidence that light drinking during pregnancy negatively impacts your baby. You should be comfortable with :
• Up to 1 drink a day in the second and third trimesters.
• 1 to 2 drinks a week in the first trimester.
• Speed matters: no vodka shots!
• Heavier drinking could have negative impacts, especially in therange of four or five drinks at a time. This should be avoided.

A Caffeine Primer

Caffeine content varies a lot, and across coffee brands in particular. Here’s a little primer for some of the sources you might use most commonly:

• Starbucks brewed coffee, 8 oz.: 165 mg
• McDonald’s brewed coffee, 8 oz.: 100 mg
• Starbucks latte, 16 oz.: 150 mg
• Black tea, 8 oz.: 14–61 mg, depending on the strength
• Green tea, 8 oz.: 24–40 mg, depending on the strength
• Coca-Cola, 12 oz.: 35 mg
• Mountain Dew, 12 oz.: 50 mg

Caffeine - The Bottom Line

• In moderation, coffee is fine.
• All evidence supports having up to 2 cups.
• Much of the evidence supports having 3 to 4 cups.
• Evidence on more than 4 cups a day is mixed; some links are seen with miscarriage, but it is possible that they are all due to the effects of nausea.”

Smoking - The Bottom Line

• Smoking during pregnancy is dangerous for your baby.

5. Miscarriage Fears

• Around 10 to 15 percent of pregnancies that are developing normally at 6 weeks will end in miscarriage. This rate declines quickly over the first trimester and falls to around 1 to 2 percent by 11 or 12 weeks.
• Older age and previous miscarriage increase your risk.

6. Beware of Deli Meats

Pregnancy Off-limits Food List

• Raw eggs (salmonella)
• Raw fish (salmonella, campylobacter)
• Raw shellfish (salmonella, campylobacter, toxoplasmosis)
• Unwashed vegetables and fruits (toxoplasmosis, E. coli)
• Raw/rare meat and poultry (salmonella, toxoplasmosis, campylobacter, E. coli)
• Smoked fish (Listeria)
• Pâté (Listeria)
• Unpasteurized (raw) milk (Listeria, campylobacter)
• Raw milk soft cheese (Listeria)
• Deli meats (Listeria)

Oster Updated Off-limits Food List

• Raw/rare meat and poultry (toxoplasmosis)
• Unwashed vegetables and fruits (toxoplasmosis)
• Queso fresco and other raw-milk cheeses (Listeria)
• Deli turkey (Listeria)

The Bottom Line

• Don’t worry too much about sushi and raw eggs—they might carry bacteria, but these bacteria are no worse when you are pregnant than when you are not.

Toxoplasmosis infection during pregnancy can be damaging to your baby. The risks are small, and you can cut your risk in half by thoroughly washing your vegetables and by not eating raw or rare meat.

• The most dangerous food-borne bacteria is Listeria. Unfortunately, a lot of sources of outbreaks are random: cantaloupes, celery, sprouts. Avoiding Listeria is very desirable, but may be difficult due to the random nature of the outbreaks. Based on past outbreaks, you would do well to avoid queso fresco and, probably, turkey sandwiches.

• The CDC has a very helpful general source for information about food outbreaks: http://www.cdc.gov/foodborneburden/index.html. If there is another cantaloupe-related outbreak, you’ll probably hear about it there first!

• If you do get sick, call your doctor.

The Bottom Line

• Mercury is bad for your baby. Omega-3 fatty acids are good for your baby. Fish contain both. Your best option is to try to pick fish with a lot of omega-3s and not a lot of mercury.

• The worst thing you can take from the mercury advice is the idea that you should avoid fish. Fish are great! People who eat a lot of fish have smarter kids on average, even with the greater mercury exposure. Try to pick smart, and learn to love sardines!

7. Nausea and My Mother-in-law

DIY Bendectin

• 10 mg of vitamin B6 (you may need to cut up a larger pill) plus
• Half a tab of Unisom
• Take together, before bed, for relief of morning nausea.

The Bottom Line

• Some nausea is normal and is probably a good sign about pregnancy.
• Vomiting every day for weeks is more than the average person experiences.
• Treatment (in order): (1) small meals, (2) vitamin B6 + ginger ale, (3) Vitamin B6 + Unisom (a.k.a. Bendectin), (4) prescription drugs.

8. Prenatal Screening and Testing

The Bottom Line: Part 1

• First trimester screening can detect about 90 percent of Down syndrome cases.
• The success of this screening varies with age, from around 82 percent in women age 20 to almost 98 percent in women over 40.
• False positives also vary with age, from 3 percent for someone in her early twenties to 50 percent for someone in her midforties.

The Bottom Line: Part 2

• Miscarriage risks from CVS and amniocentesis are indistinguishable, making the earlier-in-pregnancy CVS test the clear winner.

• A reasonable estimate of procedure-related miscarriage risk from CVS is about 1 in 800 but…

• …most studies are not large enough to allow us to reject the claim that there is no increased risk from this procedure.

9. The Surprising Perils of Gardening

• Changing the cat litter is fine (make sure you wash your hands after)…

• …but gardening is associated with an increased risk of toxoplasmosis. It should be avoided.

• Dye away! Concerns about hair dye are overblown.

Getting too hot during your first trimester—be it from a fever, a hot tub, or some type of superhot yoga—can lead to an increased risk of neural tube defects like - spina bifida.

• Some airplane travel is completely fine. If you work on an airplane you might consider a modified schedule.

PART 3 The Second Trimester

10. Eating for Two? You Wish

• What you put on you have to take off (at least if you want to get back to pre-pregnancy condition). Most women are able to do this, although it takes a few months (don’t pressure yourself).

• Impacts of weight gain on child weight later are extremely small if they are there at all.

The Bottom Line on Weight

• On average, if you gain more weight, your baby will be larger. If you gain less weight, your baby will be smaller.

• Both very large and very small babies face additional risks, although too-small babies face greater risks. If anything, you should probably be more concerned about gaining too little weight than too much.

• But, mostly, chill out.

11. Pink and Blue

• If you want to learn your baby’s sex before birth, you can do so through CVS, amniocentesis, or ultrasound.

• There’s no affirmative evidence that fetal heart rate or other old wives’ tales do a good job of predicting gender.

• You cannot increase your chances of a particular gender by changing the timing of sex before conception.

12. Working Out and Resting Up

The Bottom Line

• General exercise during pregnancy is fine. Not exercising during pregnancy is also fine. By and large, you should feel comfortable continuing to do what you are already doing.

• Kegels prevent urinary incontinence and quite possibly improve your pushing ability in labor. Do them.

• Prenatal yoga is definitely worth trying. Although the studies are not large, they do show some large effects. If nothing else, perhaps you will improve your self-actualization.

The Bottom Line

• Unisom is safe to take. Ambien is also probably safe, but the evidence is a bit more mixed.

• Most evidence suggests that restrictions on back sleeping are overblown, although one recent study disagrees. Concrete guidance is limited.

13. Drug Safety

• You should feel comfortable taking anything in pregnancy categories A and B.

• You should avoid anything in categories D and X (exceptions would be made for Category D drugs that treat very serious illnesses; this is doctor territory).

• For drugs in Category C, try to get a better idea of the safety evidence (either from your doctor or from the appendix here).

PART 4 The Third Trimester

14. Premature Birth (and the Dangers of Bed Rest)

• Survival outside the womb is possible (although not likely) as early as 22 weeks. Survival dramatically increases with continued gestation after this point. By 28 weeks, more than 90 percent of babies survive, and by 34 weeks it’s 99 percent.

• Delaying birth after the onset of labor is difficult, but usually can be done for a few days. Delaying even just a day or two can have large impacts on survival by allowing you to be moved to a more advanced hospital, and giving time for steroid shots to improve the baby’s lung function.

• There is no evidence that bed rest will prevent preterm labor. Avoid it.

15. High-Risk Pregnancy

PLACENTA PREVIA

Placenta partially or fully covers the cervix

Possible consequences

Vaginal bleeding with potential for significant blood loss

Preterm birth

Possible management/treatments

Need for Cesarean delivery

Vast majority resolve on their own

Follow-up ultrasound after initial diagnosis to confirm

If condition continues to term, Cesarean delivery typically around 36–37 weeks

PLACENTAL ABRUPTION

Placenta detaches, partially or fully, from the wall of the uterus

Possible consequences

Painful contractions and vaginal bleeding with potential for significant blood loss

Preterm birth

Fetal growth restriction

Need for Cesarean delivery

Possible management/treatments

If full term, treatment is delivery

If preterm, management varies with degree of abruption

If there is concern about the fetal or maternal condition, delivery may be indicated even if the baby is preterm

GESTATIONAL DIABETES

Diabetes diagnosed during pregnancy

Possible Consequences

Possibility of a very large baby, which leads to:

Obstetric risks—need for instruments or C-section

Fetal/neonatal risks—stillbirth, shoulder stuck in delivery, metabolic problems

Possible managment/treatment

Glucose monitoring and control through diet and exercise modification, or with medications if needed

RH ALLOIMMUNIZATION

Baby has positive blood type, Mom has negative

Possible Consequences

If the maternal body is exposed to the fetus’s Rh(D)-positive red blood cells, antibodies are produced that can cross the placenta and flag the fetus’s red blood cells for destruction

Can result in severe fetal and neonatal anemia and hyperbilirubinemia

Possible managment/treatment

Rhogam shot given at 28 weeks and after delivery—a simple triumph of modern medicine

CERVICAL INSUFFICIENCY

Painless dilation of the cervix

Possible Consequences

Can cause second trimester miscarriage or very preterm birth

Possible managment/treatment

Cervical length screening, progesterone treatment, or need for a cerclage—putting a stitch in the cervix to keep it closed

FETAL GROWTH RESTRICTION

A fetus that is small and not reaching its growth potential. Risk factors may include smoking, malnutrition, placental problems, or intrinsic fetal problems.

Possible Consequences

Very low birth weight, preterm birth, stillbirth or neonatal death, metabolic and breathing problems

Possible managment/treatment

Continual evaluation of fetal growth, behavior, amniotic fluid, and blood flow in fetal vessels

May need early delivery when the baby would be better off outside the womb than inside

PREECLAMPSIA, ECLAMPSIA, HELLP SYNDROME

Related disorders that involve high blood pressure, with an increased amount of protein in the urine. “Occurs after 20 weeks of pregnancy. Possible symptoms may include headache, visual disturbances, abdominal pain, and sudden weight gain.

Possible Consequences

Eclampsia is a complication of preeclampsia that involves seizures

HELLP is a complication that results in hemolysis (destruction of red blood cells), elevated liver enzymes (liver dysfunction), and low platelets

Death of mother or baby if not treated

Possible managment/treatment

Evaluation includes assessment of blood pressure, blood tests, urine collection for protein measurement, and how well the baby is doing and growing

Magnesium sulfate +/- blood pressure medications are used to prevent seizure or stroke

Treatment is delivery of baby and placenta

Delivery preterm may be needed in severe cases

PLACENTA ACCRETA

Abnormal invasion of the placenta into the wall of the uterus.

There is increased risk of having this if you have placenta previa or have had prior Cesarean deliveries.

Possible Consequences

Massive hemorrhage at the time of delivery, especially if not diagnosed prior to delivery

Possible managment/treatment

Delivery by Cesarean section, immediately followed by hysterectomy

16. I’m Going to Be Pregnant Forever, Right?

• No one has ever been pregnant forever.

• The majority of babies arrive within a week on either side of your due date.

• Cervical checks are predictive of coming labor (although not perfectly); ask about effacement in addition to dilation to get a more complete picture.

17. Labor Induction

• Best option: go into labor on your own.

• Prebirth fetal monitoring is a good idea, but beware of false positives.

• Fluid monitoring. Two easy ways to avoid false positives: (1) stay hydrated, and (2) ask your doctor to measure the deepest vertical pocket rather than total fluid volume.

• Non-stress test. Advice: just keep clapping

The Bottom Line

• Tea, oil, sex—all duds at starting labor.

• Acupuncture evidence is mixed.

• Nipple stimulation works, and so does membrane stripping (but don’t do this last one at home).

PART 5 Labor and Delivery

18. The Labor Numbers

• Labor times vary a lot. Average dilation time is 1 to 2 centimeters an hour after active labor starts.

• There are three major categories of labor problems: (1) dilation is too slow, or stops altogether; (2) baby gets stuck, and (3) baby is facing the wrong way, making it harder to push.

• Emergency C-sections are a good option to have, but a C-section should not be your first choice…

• …unless your baby is breech or (probably) if you’ve had a C-section before.

19. To Epidural or Not to Epidural?

Epidural and Baby

• Positive Impacts: None identified (although that’s not the point!)

• Negative Impacts: Increased chance of unnecessary antibiotics

• No Differences: APGAR score, fetal distress, baby poop before birth, baby time in NICU

Epidural and Mom

• Positive Impacts: Better pain relief

• Negative Impacts: Greater use of instruments (forceps or vacuum in delivery), greater use of C-section for fetal distress, longer pushing time (15 minutes), higher chance of baby facing up at birth,* greater use of Pitocin in labor, greater chance of low maternal blood pressure, less able to walk after labor, greater chance of needing a catheter, increased chance of fever during labor

• No Differences: Overall C-section rate, length of dilation period of labor, vomiting during labor, long-term backache

• Only marginally significant

The Bottom Line

• Epidural is very effective pain relief.

• But it increases the chance of some complications for the mother.

20. Beyond Pain Relief

Oster Birth Plan, Bullet Point 1

If water breaks before contractions start, our preference is to wait 12 hours and induce if labor has not started. Unless necessary, digital vaginal exams should be avoided during this period.

Oster Birth Plan, Bullet Point 2

• I will be drinking water and clear fluids during labor.

Oster Birth Plan, Bullet Point 3

• Our doula, Melina, will be with us during labor.

Oster Birth Plan, Bullet Point 4

• Intermittent (ideal) or mobile fetal monitoring

Oster Birth Plan, Bullet Point 5

• If labor progression is slow during active labor, our preference for augmentation is (in this order): (1) amniotomy (breaking water) and (2) Pitocin

Oster Birth Plan, Bullet Point 6

• No routine episiotomy

Oster Birth Plan, Bullet Point 7

• Pitocin in the third stage is fine if necessary/recommended.

The Bottom Line

• Broken water: Induce if labor doesn’t start on its own within 12 hours.

• Eating and drinking during labor: Probably should be allowed, although most hospitals still will not let you have solid foods, and you probably aren’t going to want them anyway. Do bring some Gatorade to keep your energy up.

• Doula: Having a doula decreases the chance of a C-section and of using an epidural. Recommended.

• Continuous fetal monitoring: There’s no evidence it’s effective. If intermittent monitoring is available, do that.

• Labor augmentation: Labor can progress slowly, and does for many women. The 1-centimeter-per-hour rule is probably a bit optimistic. But there are limited downsides to augmentation; both breaking the water and use of Pitocin tend to speed up labor without increasing C-section rates or other complications.

• Episiotomy: Not a good idea.

• Pitocin after birth: Useful in preventing postpartum hemorrhage. Recommended.

21. The Aftermath

The Bottom Line

• Delayed cord clamping: a good idea if the baby is born before 37 weeks. If the baby is full term, it’s up to you to trade off the (possibly) higher risk of jaundice with the lower risk of anemia.

• Vitamin K shots: effective at preventing bleeding, and the claims that they increase the risk of cancer are unsubstantiated.

• Eye antibiotics: probably not necessary if you don’t have an untreated sexually transmitted infection, but legally mandated in most states and without any obvious downside.

• Cord-blood banking: very unlikely to be useful for your family given current technology. Future technology is difficult to predict. Public cord-blood banking is worth considering.

22. Home Birth: Progressive or Regressive? And Who Cleans the Tub?

The Bottom Line

• If you don’t want any pain medication, there are some pros to home birth. There are fewer C-sections, less instrument delivery, easier recovery for Mom, and less tearing.

• If you haven’t done this before, there is about a 30 percent chance you’ll end up in the hospital anyway.

• Some studies suggest that mortality risks are higher with home birth, others do not. Risks are low in any case.

• If you do decide to go this route, make sure you choose as experienced a midwife as possible, ideally a certified nurse-midwife, who has had nursing, midwifery, and infant resuscitation training.