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Miscellaneous Prenatal Information

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Subsections on this page:

History of LEEP or Conization

Does anyone know if there is a recommendation re: following cervical length if a woman has had a full term pregnancy since a LEEP or conization without problems, and is now pregnant again??  Is it recommended to still follow cervical length in this pregnancy??

I think it varies by clinician but I recommend a 'baseline' measurement at 12 weeks followed by a comparison when routine 20wk anatomy scan is performed. If cervix is found to < 3cms and/or a significant interval change occurs, then increased surveillance would be indicated (which would be clinically coordinated based on the individual hx). IMO the most  period is 24-28 and the time when patients with increased risk for associated 'incompetent cervix/PTL' would typically declare.


Determining a threshold for amniotic fluid as a predictor of perinatal outcome at term.
Quiñones JN, Odibo AO, Stringer M, Rochon ML, Macones GA.
J Matern Fetal Neonatal Med. 2011 Nov 17. [Epub ahead of print]

Conclusions: An AFI cutoff <8 cm was associated with an increase in FVI outcomes but had a low positive predictive value for a +FVI. Isolated incidentally found low fluid in uncomplicated pregnancies may not be an indication for immediate intervention.

Low Amniotic Fluid Scam by Gloria LeMay [5/31/10]
True low amniotic fluid at full term is an extremely rare condition which can be diagnosed properly only by doing palpation of the pregnant belly.

A homeopathic remedy for oligohydramnios (or polyhydramnios) is Nat. Mur., which helps to normalize amniotic fluid.

Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome.
Nabhan AF, Abdelmoula YA.
Cochrane Database Syst Rev. 2008 Jul 16;(3):CD006593.

CONCLUSIONS: The single deepest vertical pocket measurement in the assessment of amniotic fluid volume during fetal surveillance seems a better choice since the use of the amniotic fluid index increases the rate of diagnosis of oligohydramnios and the rate of induction of labor without improvement in peripartum outcomes. A systematic review of the diagnostic accuracy of both methods in detecting decreased amniotic fluid volume is required.

Amniotic fluid index rejected for biophysical profile [20 July 2004] - The amniotic fluid index has both low specificity and sensitivity for identifying women with oligohydramnios at risk of cesarean delivery for fetal distress.

Biophysical profile with amniotic fluid volume assessments.
Magann EF, Doherty DA, Field K, Chauhan SP, Muffley PE, Morrison JC.
Obstet Gynecol. 2004 Jul;104(1):5-10.

The AFI offers no advantage in detecting adverse outcomes compared with the single deepest pocket when performed with the BPP. The AFI may cause more interventions by labeling twice as many at-risk pregnancies as having oligohydramnios than with the single deepest pocket technique.

Feb. 7, 2003 (HealthScoutNews) -- A low level of amniotic fluid in the last trimester of a pregnancy, often thought to be sufficient cause to induce delivery, is not reason enough to do so.

 Johns Hopkins researchers who studied the health of more than 250 babies born at 37 weeks of gestation say they found that babies whose mothers had low levels of amniotic fluid were of normal size. And the babies had no greater risk for health problems than babies whose mothers had normal levels of amniotic fluid.

"This study indicates that we don't want to intervene because of a Amniotic Fluid Index (AFI) of less than five if everything else is normal," says study author Dr. Ernest M. Graham, an assistant professor of gynecology and obstetrics at Johns Hopkins University.

Graham presented the results of his study on Feb. 7 at the annual meeting of the Society for Maternal-Fetal Medicine in San Francisco.

Perinatal risks associated with borderline amniotic fluid index.
Banks EH, Miller DA
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1461-3

The researchers conclude that borderline amniotic fluid index merits careful attention and twice weekly antepartum testing.

Does an amniotic fluid index of </=5 cm necessitate delivery in high-risk pregnancies? A case-control study.
Magann EF, Kinsella MJ, Chauhan SP, McNamara MF, Gehring BW, Morrison JC
Am J Obstet Gynecol 1999 Jun;180(6 Pt 1):1354-9

High-risk pregnancies with an amniotic fluid index of </=5 cm appear to carry intrapartum complication rates similar to those of similar high-risk pregnancies with an amniotic fluid index of >5.

Midwifery Today, Autumn, 1999, carries a discussion of the apparent contradiction in these studies and suggests that midwives need to take many factors into account in deciding when to intervene during pregnancy and delivery.

Pregnancy outcomes after antepartum diagnosis of oligohydramnios at or beyond 34 weeks' gestation. [Medline entry]
Casey BM, McIntire DD, Bloom SL, Lucas MJ, Santos R, Twickler DM, Ramus RM, Leveno KJ
Am J Obstet Gynecol 2000 Apr;182(4):909-12

We believe that neither our results nor similar results reported by others necessarily prove that antepartum oligohydramnios requires intervention, Dr. Casey's group writes. They note that the amniotic fluid index measurement is not precise, and that individual physicians have their own thresholds for interventions.

Treatment for Oligohydramnios

Reversal of oligohydramnios with subtotal immersion: a report of five cases.
Strong TH Jr
Am J Obstet Gynecol 1993 Dec;169(6):1595-1597

OBJECTIVE: The purpose was to summarize five cases where subtotal immersion was associated with an increase in the amniotic fluid index. STUDY DESIGN: Five women with oligohydramnios, as defined by an amniotic fluid index < 8 cm, who underwent subtotal (shoulder-deep) immersion therapy are described. RESULTS: The mean pretreatment amniotic fluid index was 4.9 +/- 3 cm. After immersion therapy was instituted, the amniotic fluid index increased an average of 6 +/- 2.2 cm. In three subjects whose immersion therapy was discontinued, the amniotic fluid index fell an average of 4.7 cm. CONCLUSION: Subtotal immersion may help reverse oligohydramnios stemming from uteroplacental insufficiency.

This is the 1st that I've heard of immersion for this purpose, but does it occur in a heated pool? i.e. to increase the vascularity/flow to the placenta? (I may be way off here... like I said, 1st I've heard of any of this...) But it sounds like an interesting concept....Good idea, if it works.....(and they told me to stay out of the hot tub while I was pregnant.....)

Could this possibly be due to lowering of pressure on the cervix? Or pressure on the placental blood vessels? I find this interesting....thank you.

I think it's due to the pressure exerted by the immersion fluid on the body, which raises interstitial fluid pressure, causing it to flow back intravascularly, in essence raising the intravascular volume (i.e., hydration) and causing increased uterine blood flow.

Doesn't everyone have to pee when they stay in a swimming pool for about 20 minutes?

In the Sept/Oct issue of JNM, Michel Odent explains that the mechanism causing the pee-in-the-pool phenomenon is more than just a pressure gradient/increased perfusion thing:

  1. Pressure gradient created by immersion increases venous return to the thorax
  2. Increased intrathoracic blood volume stimulates release by specialized heart cells of atrial natriuretic peptide.
  3. ANP inhibits vasopressin, the water-retention hormone Odent says that vasopressin has an oxytocic effect, starting in mid-pregnancy and continuing undiminished to term, which may explain why immersion may slow labor progress if the laboring woman gets in the tub before active phase.

A similar, though less potent effect can be observed in a patient who is confined to bed rest, where increased venous return from the lower extremities results in greater cardiac output, a higher glomerular filtration rate, and a greater volume of urine output.


From Patty Brennan's Guide to Homeopathic Remedies for the Birth Bag, Fourth Edition:

"Too much fluid will keep the baby buoyant and the uterus overextended, so the baby can just float into an undesirable position.  Too little fluid will likewise be problematic as the breech baby will not have enough buoyancy to turn.  If fluid levels seem to be off in either direction, try the water-balancing tissue salt Natrum Muriaticum.  Suggested regimens for varying potencies are as follows (see what works for you):

    6X 3 times per day for 1 week or
    30C 2 times per day for 3 days or
    200C once per day for 3 days or
    1M once"

Treatise on Polyhydramnios

Validation of Subjective Evaluation of Polyhydramnios

There was a paper out of Omaha about 5 years ago looking at the outcome of Hydramnios (Polyhydramnios is redundant) based on the method of detection. If one could just look at the screen and say "Oh my God, that's Hydramnios", the incidence of fetal poor fetal outcome was high. If the diagnosis was made by doing an AFI and finding it to be over 20, then the incidence of poor outcome was very low. In other words the subjective diagnosis correlated well, but the objective diagnosis had way too many false positives. Hot dog, subjectivity wins out for once.

Thrombocytopenia / Low Platelets

I'm curious to hear what other midwives do for low platelets and their cutoffs for a home birth.

Here's what the NIH says about thrombocytopenia during pregnancy: "About 5 percent of pregnant women develop mild thrombocytopenia when they're close to delivery. The exact cause isn't known for sure."

So, that's not particularly helpful. However, there are also hints that toxic chemicals and pesticides can play a role, along with certain viruses.

This might be a good time to make sure you're eating only organic fruits and vegetables, or at least avoid the "dirty dozen":

And if you have toxic exposures in your home from recent home project, it might be a good idea to give the whole house a really thorough airing out at least once a day, maybe when we're having a nice evening breeze?

The Environmental Working Group has lots of great information about sources of toxins in your home, your food, and your personal care products.

The UK puts their NICE guidelines for place of birth online. You can search for platelets, or here is the relevant line:

"Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000 "

Our California state guidelines don't specifically address platelet issues, and they leave a lot of flexibility as long as we discuss risks with the mothers.  Some textbooks say that down to 80,000 is OK if you believe there's nothing going on with autoimmune disorders that would affect the baby.

In the non-pregnant population, it seems that levels down to 50K don't require treatment, and nasty things aren't likely to happen until you get below 20K.  So, the concern is that a very large blood loss could reduce your platelets by half or even worse.

One of my midwife friends works in a hospital, and here's what she says: "We don't have a specific protocol for thrombocytopenia but we would generally a) not worry, and b) repeat the CBC at 36 wks. If she was around 100 at 36 wks then she would need weekly CBCs to see if she's stable or dropping. Real risk of spontaneous bleeding happens when platelets are at <10!  In general, if the platelets remain about 70 and it first occurs in the 3rd trimester, it's just gestational thrombocytopenia and nothing more worrisome.I've never seen a woman go from 130s to under 100, and almost always, the platelets remain in the same range or get better at this point.

In my conversation with an OB last year, she said that anything under 100K should warrant a consult. Had a client who got pretty close (109?) and her anesthesiologist husband was *completely* unconcerned by that number.

I had a gal who's platelets were under the normal range, who I'd helped with her 2 previous births.  I had her work with an OB and she had a hospital birth.  Where I live, women are FAR AWAY from hospitals.  I didn't feel safe.

My homebirth friendly OB said anything under 125 was very concerning to him.

100 is normally the cut off with the LA area Doc's so she is still ok as far as I am concerned. You could offer her a heplock if it makes you feel safer.

Sometimes a manual count gives a more accurate and higher number, since the platelets sometimes clot in the machines.  You can ask the lab for a manual count of platelets.  I've read that platelets testing is most effective with an in house lab such as a hospital, since they do the test promptly and the platelets don't clot together.

This is what an OB in the Santa Cruz area says:  If her platelet count gets below 50K a home birth is not advisable, since she is at risk for spontaneous bleeding especially if she gets below 30K.
If she stays above 50K it is ok to proceed with a home birth.  She has most likely Idiopathic Thrombocytopenia of pregnancy which usually resolve after delivery.

It's much lower threshold than any of the other numbers.

an OB i once consulted with said the same thing

I got the same #s from an OB I know -- 50k.

I also had a client like this. We did bring them up with homeopathy but 50k was also the cut off we were looking at per her ob.

The Mothering Forums have some conversations about thrombocytopenia. Platelets aren't directly related to iron levels (hemoglobin/hematocrit), but if low platelets causes an unusual amount of bleeding at the birth, then you'll benefit from robust iron levels.

Reduced Fetal Movement

Fetal Response to Maternal Hunger and Satiation [Medscape, 2014] - This paper focuses on a novel finding; the description by pregnant women of fetal behaviour indicative of hunger and satiation. Full findings will be presented in later papers. Most participants (74% 14 of 19) indicated mealtimes were a time of increased fetal activity. Eight participants provided detailed descriptions of increased activity around meals, with seven (37% 7 of 19) of these specifying increased fetal activity prior to meals or in the context of their own hunger. These movements were interpreted as a fetal demand for food often prompting the mother to eat. Interestingly, the women who described increased fetal activity in the context of hunger subsequently gave birth to smaller infants (mean difference 364 gm) than those who did not describe a fetal response to hunger. [Ed: It would be very interesting to analyze the correspondence between maternal glucose levels and maternal perception of fetal movement when the mother feels hunger.  It makes eminent sense that a mother's adrenaline goes up when she is hungry, and this gets through to the baby readily, thus increasing fetal movement.  It's also possible that a drop in fetal blood sugar would trigger an increase in the baby's endogenous adrenaline, but this is almost impossible to measure.  Reduced maternal glucose levels would certainly contribute to a smaller baby; it's not clear whether the smaller babies in this study were still in a health range.]

Fetal response to maternal hunger and satiation - novel finding from a qualitative descriptive study of maternal perception of fetal movements.

Bradford B1, Maude R.
BMC Pregnancy Childbirth. 2014 Aug 26;14:288. doi: 10.1186/1471-2393-14-288.

Maternal perception of decreased fetal movements is a specific indicator of fetal compromise, notably in the context of poor fetal growth. There is currently no agreed numerical definition of decreased fetal movements, with the subjective perception of a decrease on the part of the mother being the most significant definition clinically. Both qualitative and quantitative aspects of fetal activity may be important in identifying the compromised fetus.Yet, how pregnant women perceive and describe fetal activity is under-investigated by qualitative means. The aim of this study was to explore normal fetal activity, through first-hand descriptive accounts by pregnant women.
METHODS: Using qualitative descriptive methodology, interviews were conducted with 19 low-risk women experiencing their first pregnancy, at two timepoints in their third trimester. Interview transcripts were later analysed using qualitative content analysis and patterns of fetal activity identified were then considered along-side the characteristics of the women and their birth outcomes.
RESULTS: This paper focuses on a novel finding; the description by pregnant women of fetal behaviour indicative of hunger and satiation. Full findings will be presented in later papers. Most participants (74% 14 of 19) indicated mealtimes were a time of increased fetal activity. Eight participants provided detailed descriptions of increased activity around meals, with seven (37% 7 of 19) of these specifying increased fetal activity prior to meals or in the context of their own hunger. These movements were interpreted as a fetal demand for food often prompting the mother to eat. Interestingly, the women who described increased fetal activity in the context of hunger subsequently gave birth to smaller infants (mean difference 364 gm) than those who did not describe a fetal response to hunger.
CONCLUSIONS: Food seeking behaviour may have a pre-birth origin. Maternal-fetal interaction around mealtimes could constitute an endocrine mediated communication, in the interests of maintaining optimal intrauterine conditions. Further research is warranted to explore this phenomenon and the potential influence of feeding on the temporal organisation of fetal activity in relation to growth.

Decreased fetal movements: background, assessment, and clinical management.
Olesen AG1, Svare JA.
Acta Obstet Gynecol Scand. 2004 Sep;83(9):818-26.

A reduction or cessation of fetal movements (FMs) is frequently reported by pregnant women and causes concern and anxiety. However, the clinical significance of a history of reduced FMs remains unclear, and the assessment and management of these pregnancies is controversial. This article is a review of the literature on decreased FMs found in medline and the cochrane library using the search phrases: decreased FMs, perinatal outcome, FM monitoring, and fetal assessment. Formal counting of FMs by the pregnant woman could possibly identify the fetuses, which are at risk of compromise, thus allowing for appropriate action. However, the benefit of this intervention has not been definitely proven. Cardiotocography, umbilical/uterine artery Doppler velocimetry, and ultrasonography have been used for antepartum fetal assessment in pregnancies with decreased FMs, but the evidence of a clinical benefit is limited. The effects of fetal assessment with vibroacoustic stimulation and biophysical profile are unknown and should be further evaluated. Present recommendations on the management of pregnancies with decreased FMs are based on limited and inconsistent scientific evidence. There is a need for further well-designed studies in order to provide evidence-based guidelines in the future. [Ed: Reductions in fetal movement need some intelligent interpretation.  For example, mothers with anterior placentas often feel much less movement when the baby's limbs are behind the placenta.  And all women may feel reduced movement when the baby's limbs are toward the inside of her body, away from the abdomen.]

A Randomised Controlled Trial Comparing Standard or Intensive Management of Reduced Fetal Movements After 36 Weeks Gestation

Sleeping on Your Back In Pregnancy

What is the correlation with placental location? Most placentas are posterior so that when a woman is sleeping on her back, the weight of the baby's body is on the placenta and possibly directly on the umbilical cord. But lying on the back might not be the safest sleep position for a woman with a placenta on the side or in the front. Why did the study not look at this?

Association between maternal sleep practices and risk of late stillbirth: a case-control study. [full text]
Stacey T1, Thompson JM, Mitchell EA, Ekeroma AJ, Zuccollo JM, McCowan LM.
BMJ. 2011 Jun 14;342:d3403. doi: 10.1136/bmj.d3403.

CONCLUSIONS: This is the first study to report maternal sleep related practices as risk factors for stillbirth, and these findings require urgent confirmation in further studies.

Women advised to sleep on side to help prevent stillbirth [BBC - 11/20/17]

Someone recently mentioned to me that when a pregnant woman sleeps on her back it disturbs the body's ability to get oxygen to the baby. It sounded very odd to me. Has anyone heard anything like this or that any particular sleeping positions interfere with the flow of oxygen or are bad for the fetus?

If a woman sleeps on her back she is cutting off blood circulation from the large artery that runs along the back...  Being on one's back for very long can be very uncomfy for a pg woman

Actually, I think it is the inferior vena cava.  And yes, by sleeping on the back a woman can cause the blood flow to be diminished.

That being said, I don't tell my ladies one way or another.  They usually tell me.  Many women just cannot lie on their back.  But some find that they always wake on their back and they are concerned because the books say they shouldn't.  I tell them not to worry about it because if it bothered the babe, it would bother her and she just plain would/could not do it.

A woman in late pregnancy, when she lies on her back, can cause some compression of the vena cava-the main vein going to the trunk of the body.   For some, not all, this causes discomfort and a feeling of lightheadedness due to constriction of blood flow.  If you are constricting blood flow from that area, you are also slowing all circulation in the area, so you would also be possibly cutting some circulation of oxygen to the uterus, I imagine.

I think for most women, though, it is something they will feel themselves and be uncomfortable with if it is a problem for them.  Even slightly elevating the shoulders or being slightly to one side can alleviate this, if she still wants to be on her back.

I agree that it makes sense to keep a laboring woman off her back.

But is there really any evidence that sleeping on your back causes any harm to the baby?  Some of my clients are inveterate back sleepers, and they feel SO guilty about it.  I have done some searches and not found any research about this, which is what I tell them.

I also figure that if their sleep position is causing circulation problems, they're going to wake up with swelling in their feet and legs, which would be a good reason on its own to change sleep positions.

I think of this issue as one of those "old midwives' tales", and I'd love to see any actual research on the subject.

I agree.  While Supine Hypotension can be a problem during labor, it is really not an issue before that time.  Common sense tells you that if a woman has circulatory interruption before labor, she will experience symptoms - i.e. dizziness, edema, nausea, etc. - what I lovingly call "the beached whale" symdrome.....and she will change positions to eliminate that feeling.

During labor, however, with the demands of the uterus, the supine position can aggravate the compression of the inferior vena cava, and drop the blood supply available to the contracting uterus.  So, avoid the position- simple solution to obvious problem..  NO laboring woman would ever assume the supine position voluntarily, because she would shortly feel the above mentioned symptoms and change positions so she could breathe, and work more efficiently.

Over the years, I have seen research on Supine Hypotension during labor, but never before labor.

I believe that if you are one of the ones who has that O2 deprivation you will know it because you get either faint or sick to your stomach.  Some of my ladies can't sleep any other way, and I say their baby will tell them if it doesn't like that particular position.  There CAN'T be a rule, an absolute.  What did women do (and still do) when they didn't have someone to tell them all these "musts"?   They figure it out. Right?

The link between sleeping on your back and trouble for the baby can clearly be inferred from the data which does exist. If we know an awake mom can have supine hypotensive syndrome (and the data is clear, then why would she NOT have it when she sleeps? The mechanism still exists and I can't think of anything about 'sleep" which would change that..

I say it's probably better to sleep on their sides, but if they were made as back-sleepers then that's probably what's best for them. Our particular bodies are our best guides for what's best.

And the condition only occurs pretty late in pregnancy when many women aren't at all comfortable sleeping on their backs any longer.

But.. I also tell them how easy it is to prevent any potential problem. All one has to do is get a slight tilt to the pelvis -- so a little pillow, or folded blanket or soft towel wedged under one hip does the job. Easy fix. No worries.

Swelling in the legs isn't a reliable indicator of supine hypotensive syndrome. It's not that type of circulation. It's a lowering of the blood pressure
which can affect placental flow and fetal heart rate (we see this often when moms labor on their backs because we are monitoring then). There shouldn't be any effect on swelling of hands or feet.

I tell folks no to worry too much about it, because the affects are mild in most people -- not existent in some people -- and are only extreme in a minority of people. But it's so easy to sleep comfortably in other positions -- or even on the back with a little pillow on the side -- that I think it's worth recommending. But if moms can't or wont do it -- I have no worries.

OK, I broke down and looked in PubMed:

Influence of compression of the inferior vena cava in the late second trimester on uterine and umbilical artery blood flow.
Ryo E, Okai T, Kozuma S, Kobayashi K, Kikuchi A, Taketani Y
Int J Gynaecol Obstet 1996 Dec;55(3):213-8

CONCLUSION: The inferior vena cava is compressed in the majority of pregnant women in the second trimester, and the compression may affect the uterine artery blood flow but not the fetal circulation.

Semi-Fowler's positioning, lateral tilts, and their effects on nonstress tests.
Moffatt FW, van den Hof M
J Obstet Gynecol Neonatal Nurs 1997 Sep-Oct;26(5):551-7

CONCLUSIONS: No statistically or clinically significant differences were found in nonstress tests between the three groups. Lateral tilting did not shorten test time. Results do suggest that hemodynamic changes can occur in 3rd trimester women who are in semi-Fowler's position without a lateral tilt. Lateral tilting of gravidas in semi-Fowler's position during nonstress testing is thus supported to avoid hypotensive symptoms.
Maternal and fetal effects of the supine and pelvic tilt positions in late pregnancy.
Kinsella SM, Lee A, Spencer JA
Eur J Obstet Gynecol Reprod Biol 1990 Jul-Aug;36(1-2):11-7
Neither the left or the right pelvic-tilt position was associated with a significant change in leg blood flow or maternal heart rate compared to the supine position. A possible 'sluice' effect in the placental circulation was not confirmed, as fetal heart rate and umbilical Doppler resistance did not change in any position. . . .  Leg BP and Doppler ultrasound measurements of uterine artery resistance may not be adequate measures of the effect of posture on uteroplacental perfusion.

And . . . just when you thought it was safe to sleep standing up:

The oscillating 'vena cava syndrome' during quiet standing--an unexpected observation in late pregnancy.
Schneider KT, Bollinger A, Huch A, Huch R
Br J Obstet Gynaecol 1984 Aug;91(8):766-71

While studying the lung function of pregnant women at term in four different postures, we were surprised to note marked cyclic accelerations in the heart rate in two-thirds of the women when in a standing position. . . . About 70% of the fetuses showed reduction in the long-term variability, increase in fetal heart rate or periodic accelerations. Although no woman fainted during quiet standing, the maternal circulatory changes were consistent with those seen in the classical vena cava syndrome.
But it is safe to sleep on your belly!!!  All I can say is that these researchers have never been pregnant!

Effects of maternal prone position on the umbilical arterial flow.
Nakai Y, Mine M, Nishio J, Maeda T, Imanaka M, Ogita S
Acta Obstet Gynecol Scand 1998 Nov;77(10):967-9

"The maternal prone position can provide complete relief of uterine compression of the large maternal vessels. "

From Physiology in Childbearing by Dorothy Staples:

"Aortocaval occlusion - The alternative name for aortocaval occlusion is supine hypotensive syndrome.  Bevis (1996) believes this is misleading as the fall in blood pressure is a late sign nd reduced placenta perfusion will have occurred before the drop in maternal blood pressure.  a reduction in venous return and a fall in cardiac output are produced by the weight of the gravid uterus pressing on and partly occluding the inferior vena cava.  It will occur whenever the woman lies supine in late pregnancy.  If fetal distress is present the interference with placental circulation will increase the severity of hypoxia.

"Prevention - If the woman has to lie supine the sequence of events can be avoided by placing a folded blanket or a small rubber wedge under the mattress to tilt her body 15 degrees to the left.  Modern operating tables and delivery beds have this function built into their design.  Enkin & Wilkinson (1997) reviewed the use of lateral tilt during CS but found the data to be poor.  However, they stated that low Apgar scores were fewer and neonatal pH measurements and oxygen tensions appeared to be better if lateral tilt was used.  [This is from the poor research.]"


Hypertension, Habitual Snoring, and Adverse Pregnancy Outcomes [6/23/14] - Pregnant women with hypertension are at high risk for obstructive sleep apnea, a condition that often goes undiagnosed. . . . Because the association was so pronounced, the authors urged all pregnant women who snore to be tested for obstructive sleep apnea. In addition, they noted that obstructive sleep apnea is a condition that is believed to cause or promote hypertension.

Hot Tubs/Saunas/Spas/Thermal Stress

Summary of the issues: avoid hot tubs in the first trimester, and then use common sense in enjoying them in the second and third trimesters.

NOTE - Exposure to heat is only a problem if it raises your body temperature.  In general, if the water temperature is at or below normal body temperature, then it will not cause any problems, so pregnant women can still enjoy warm baths.  If the water temperature is too warm, then you will start sweating to try to cool down; if this happens, then you're too hot, and you need to cool down the bath or get out of the water.

Doppler flow measurement of uterine and umbilical arteries in heat stress during late pregnancy.
Vaha-Eskeli K, Pirhonen J, Seppanen A, Erkkola R
Am J Perinatol 1991 Nov;8(6):385-9

"The effect of a moderate heat stress (20 minutes 70 degrees C) on uterine and umbilical artery blood flow was studied . . . The fetuses of healthy pregnant women are not compromised during or after moderate thermal stress."

In language that most people can understand, this means that if you spend 20 minutes at 158 degrees Fahrenheit (which is really, really  hot, even hotter than El Paso, Texas!), your baby will still be fine.  Even assuming that this was dry heat (the least stressful on the body because the woman's perspiration would cool her down), this is still very, very hot.

From a practical point of view, you can note that this level of heat stress caused an increase in the woman's pulse of 26 beats/minute on average.  A conservative approach to using hot tubs would be to check your pulse, and if it increases more than 20 beats/minute after 20 minutes, get out and cool down a bit, and then get in and enjoy yourself some more!

Maternal heat exposure and neural tube defects.
Milunsky A, Ulcickas M, Rothman KJ, Willett W, Jick SS, Jick H.
JAMA. 1992 Aug 19;268(7):882-5.

CONCLUSIONS--Exposure to heat in the form of hot tub, sauna, or fever in the first trimester of pregnancy was associated with an increased risk for NTDs. Hot tub exposure appeared to have the strongest effect of any single heat exposure.

 Fever During Pregnancy Linked to Birth Defects [2/24/14] - The researchers conclude that they "found substantial evidence to support an adverse impact of maternal fever during pregnancy." They suggest that future studies be conducted prospectively, assess longer-term health outcomes, and consider timing, duration, and extent of fever.

Limitations of the study include the consideration of elevated maternal temperature and not the underlying cause of it (type of infection).

Prolapsed Uterus

One of my clients called reporting something coming out of her vagina. I went and saw her and yup, it was her cervix. She is 13 weeks.

This should resolve when the uterus grows 'up and over' the pubes @ ~16-18 wks (depending on maternal habitus/uterine growth) Meanwhile, avoid any activities which have potential valsalva, I'd substitute some? of the Kegels for the knee-chest posture prn, watch for UTI d/t potential urinary retention.

Sea Pearls Sea Sponge Tampons can be used to support a prolapsing uterus.

Retroverted Uterus/Incarcerated Uterus

Retroverted Uterus more likely to become incarcerated in second trimester.

Malposition of the Uterus from Medscape

Incarcerated retroverted pregnant uterus is very uncommon, indeed many practitioners do not believe it exists.  I wonder how many miscarriages are due to this. (I have no opinion, I really just wonder).

Anyway, what happens (according to the theory that I learned in a medical setting, which may be different from what midwives know) is that the fundus of a retroverted uterus gets trapped in the posterior portion of the pelvis and the uterus, as it expands, pushes against the urethra and obstructs the bladder.  It can also put lots of pressure on the rectum and the nerves in the pelvis.  This pressure can result in miscarriage, or the pregnancy can continue, expanding the anterior wall of the uterus--a very uncomfortable and unnatural condition.

I saw two cases of this in residency.  My first clue was having a hard time finding the cervix during a speculum exam--it was very anterior and pointing posterior (imagine that the uterus is bent 90deg at the junction between the body and the cervix).  Bimanual exam confirmed a firm mass in the posterior pelvis--unmistakably the pregnant fundus.  Fetal heart tones could not be heard with the uterus in this position.  I can't believe I have forgotten the exact details of these two cases--I know one miscarried and one had a full term baby.  I think OB reduced one and I reduced the other.

To reduce the uterus:  Place the woman in knee/chest position and push hard on the fundus.  In addition, you may wish to place a tenaculum on the cervix so you can pull it towards the perineum.  I have felt the satisfying "plunk" of the uterus moving into the pelvis and then been able to hear heart tones.  I have also read about somehow using the same position, then introducing a flexible sac containing mercury and allowing this weight to more gradually reduce the uterus.

Bicornuate Uterus

While apprenticing, I assisted with an Amish woman with a bicornate uterus through three pregnancies, and know of the outcome of her first and fifth pregnancies as well.

First pregnancy ended up in spontaneous abortion at 16 weeks.

Second pregnancy was a term breech presentation at home. uncomplicated.

Third baby born vertex at home at about 34 weeks gestation, no complications, precipitous labor, we missed the birth by about 7 minutes. Bicornate uterus was discovered during fundal massage in fourth stage of labor.

Fourth baby, came at about 34 weeks in footling breech/sort of transverse position with umbilical cord dangling down around the presenting part. Transferred to hospital at 8cm, BOW intact, Baby born vaginally w/o complication within 10 minutes of arrival at hospital.

Fifth baby born by C-sec, at 30 weeks with abruptio placenta.

[from ob-gyn-l]

She has conceived 2 more times, and carried to term uneventfully twice. She now is thinking about a 3rd child." I've told her my gut feeling is that she would have another uneventful pregnancy, but that she still is at a higher risk of prematurity, although probably not as high as the literature says given her clinical history.

I've got a nice review--"Reproductive Potential of the Anomalous Uterus," Phillip Patton and Miles Novy. Seminars in Reproductive Endocrinology 6 (2):217-233, May 1988. 92 references.

It classifies the Mullerian anomalies into 5 categories and looks at the literature on each. Unfortunately, for many categories including bicornuate uterus, it doesn't specifically address SUBSEQUENT pregnancies, though the individual articles might.
Table 4 (reprinted without permission)--Pregnancy outcome in the bicornuate uterus

authors #pts #preg AB rate% PTbirth% Term% Surv%
Buttram 110 313 35 23 42 57
Capraro et al. 38 137 30 14 56 61
Heinonen et al. 44 98 28 22 50 63

The references above are:

The review also mentions cerclage treatment to reduce pregnancy loss.

Those references include:

My impression is that the more pregnancies they have, the more the uterus is "stretched out". Thus, they make their risk smaller and smaller spontaneously.

I have a student/client with a bicornate uterus who is 29 weeks pregnant (1st pregnancy). Preterm labor is being well-managed (has stopped) with bedrest, oral terb, & cerclage (at 14wks/1cm). Having made it this far, she is now thinking ahead to delivery, and what problems she may have then.

Her OB has mentioned she is at increased risk for uterine rupture of the "non-pregnant" horn during labor/delivery. He himself admits he cannot give her percentages for this happening, but that it has happened to one of his patients with a bicornate uterus. But then, he also admits, that he has had very few patients with bicornate uterus, so his experience is limited.

Her OB will remove the cerclage at 36 weeks. He has mentioned scheduling a c-section to prevent rupture, but my client is concerned that this is too drastic a decision without more information.

Leave her alone. The delivery will be natural. One is always astonished to see how many unicornuate or bi uterus are unknown before delivery.

I agree 100%.

I agree, she may deliver vaginally at term with no problem. I assume you will take the cerclage out at 38 weeks or so?

I have had two of these patients, both delivered vaginally. They were watched closely for pre-term labor, one had it; the other didn't. Neither had a cerclage, although I considered it and checked the literature. Couldn't convince myself to do it.

I concur completely. I have never heard of a rupture of the non-pregnant horn. It doesn't even make sense, since that is the thicker and hence stronger horn.

If he is concerned about rupture, then why not treat her as a VBAC. I have read reports of rupture of a uterus without previous surgery, but I have never seen one. I have to think that they are very unlikely (but not impossible). It seems that his approach is somewhat coloured (that's the Canadian spelling) by his past experience (as it is for all of us). I would be just as concerned about an abnormal presentation (breech, shoulder, cord). I would think she should be given the option of vaginal delivery in a setting where immediate C/S is possible.

If she presents in labor with a vertex presentation, I would let her labor like anyone else.

If vertex, allow labor. As it has been said - we don't know how many of these are never diagnosed because they conceive spontaneously, labor and deliver spontaneously. If non vertex, I would hesitate about version, but I have tried and have taken care of one (undiagnosed as uterine duplication because needed no procedures) who (yes its anecdote and meant as such) that was followed by a lay midwife, taken to two other places for attempted version, known to be footling breech, went into labor spontaneously at 42 weeks, known to have had a fast labor with her first baby, the lay MW went to her home (out in the boonies) found her to be 8 cm, then rushed her to our hospital 'cause we were closest (she would usually use another hospital). Since footling breech and neither I nor my partners had prior rapport with her and it was footling, I did do a C/S. She thought we were great and came to us for her next pregnancy with a successful VBAC. I've taken care of another with complete duplication - First pregnancy in side A with normal labor and delivery. Second pregnancy in side B - She had a First Stage that was like a "first" labor (first for that uterus) and a Second Stage that was like a "second" labor - the vagina and perineum had given birth before. Neat people with interesting stuff mom nature did to them, keeps us thinking and on our toes for all the variations we see.


See also: Well Woman / Uterine Fibroids

Treatment of Uterine Fibroids with Complementary Medicine By Lewis Mehl-Madrona, M.D., Ph.D.

Adverse obstetric outcomes associated with sonographically identified large uterine fibroids.
Shavell VI, Thakur M, Sawant A, Kruger ML, Jones TB, Singh M, Puscheck EE, Diamond MP.
Fertil Steril. 2012 Jan;97(1):107-10. Epub 2011 Nov 17.

RESULT(S): Compared to women with no fibroids or small fibroids (≤5 cm), women with large fibroids (>5 cm) delivered at a significantly earlier gestational age (38.6 vs. 38.4 vs. 36.5 weeks). Short cervix, preterm premature rupture of membranes, and preterm delivery were also significantly more frequent in the large fibroid group, and were associated with number of fibroids >5 cm in diameter. Blood loss at delivery was significantly higher in the large fibroid group (486.8 vs. 535.6 vs. 645.1 mL), as was need for postpartum blood transfusion (1.1 vs. 0.0 vs. 12.2%).
CONCLUSION(S): Women with large uterine fibroids in pregnancy are at significantly increased risk for delivery at an earlier gestational age compared to women with small or no fibroids, as well as obstetric complications including excess blood loss and increased frequency of postpartum blood transfusion.

Transcatheter Uterine Artery Embolization for the Treatment of Symptomatic Uterine Fibroid Tumors [Medscape registration is free]

Uterine Artery Embolization for Uterine Fibroids  [Medscape registration is free]

Uterine Vessel Coagulation Method Shows Promise in Treatment of Fibroids [Medscape registration is free]

Uterine Fibroids - Natural Medical Protocols

Integrative Medicine articles about uterine fibroids:

Stress Reduction for Relief of Fibroids & Endometriosis by Susan M. Lark M.D.

Uterine Fibroids by David L. Hoffmann B.Sc. (Hons), M.N.I.M.H.

Uterine Myomas (i.e., Uterine Fibroids) - Translated with commentary by Bob Flaws, Dipl. Ac. & C.H., FNAAOM

Uterine Fibroids  from Naturopathy Online

Lewis Mehl-Madrona, M.D., Ph.D talks about a study they're conducting about uterine fibroids at Shadyside - "We have a study under way on complementary medicine treatment of uterine fibroids, which has three components. Guided imagery or visualization is one; Chinese medicine with acupuncture and nutritional modification and herbs is the second treatment; and the third treatment is a kind of deep tissue body therapy primarily related to the pelvis and We have a study under way on complementary medicine treatment of uterine fibroids, which has three components. Guided imagery or visualization is one; Chinese medicine with acupuncture and nutritional modification and herbs is the second treatment; and the third treatment is a kind of deep tissue body therapy primarily related to the pelvis and abdomen.

About Uterine Fibroids from Women First Healthcare

Uterine Fibroids from MEDLINEplus.

Fibroid Pain During Pregnancy

I have a friend who's experiencing terrible pain from a necrotic fibroid that grew along with her pregnancy.  (She's now about 16 weeks.)  She's getting OB care, and they're considering surgery, but, for now, she's taking Motrin for the pain. (OB said she could continue this until 35 weeks.)

We were talking about non-pharmaceutical pain relief, and we talked about warm baths, and it occurred to me that a TENS unit might provide some pain relief.

Does anyone know anything about TENS use during pregnancy? Any thoughts on safety?  Placement of the electrodes (same location as for labor?)

I cared for my daughter-in-law with a twisted fibroid stem in pain. A homeopath recommended colecynth 30x that cut the pain before she got home and although' the fibroid grew until about 26/40 wks. she never had a problem.

I'm here to suggest hypnosis.  This is a very safe and effective option for pain relief; no negative side effects and many positive effects: pain relief,  constant availability, self empowerment,  a skill with a broad range of  applications that the woman takes with her through the rest of her.

I understand the pain she is going through as I had a necrotic fibroid myself. I did find that pain was well controlled with Tylenol #3. The codeine is not that bad for the baby and it made things easier for me. Without proper pain control she just might go into prem labor........from
the irritable uterus. Alcohol could also help.  Be assured that the pain will eventually go away probably about 30 weeks, but in the meantime she needs to get the pain under control!

I am looking for information on fibroid tumours during pregnancy or more specifically what I might expect the impact of fibroids to be postpartum. I have a client G3P1 who has a fibroid located in the fundus of her uterus. My concern is postpartum hemorrhage.

What size is the fibroid?

I'm not sure. I got the impression it was 2-3 inches in diameter when picked up by u/s last pregnancy. This seems big to me but I have no experience with these at all. I can't palpate it but will try more carefully next time. It was picked up by u/s last pregnancy. I wonder if it would be worthwhile for her to have an u/s now?

a 2-3 inch fundal fibroid should cause no problems at all with PP bleeding. The ones to worry about are those grapefruit sized ones, which are obvious on abdominal exam (I suppose if they were posterior you might not feel them). If she is s=d and you can't feel irregularities, I would not worry.

Gemmotherapy recommendations for uterine fibroids (from Dolisos):
European Ash (Fraxinus excelsior) Buds 1DH: 50-100 drops 3 times per ay t help relieve uterine congestion
Raspberry (Rubus idaeus) Young Shoots 1DH: 50-150 drops 3 times pre day to help with hormonal equilibrium

"SEQUOIA GIGANTEA: Prostatic hypertrophy and adenoma, uterine fibroids. " from GEMMOTHERAPY - DRAINAGE

Shrinking Fibroids with Pycnogenol

One of the studies that I haven't had time to do any serious work on lately is the use of pycnogenol, a natural proanthocyanidin extract from such sources as grape skins and pine bark.

The study will get done within the next two years, but until then, I can tell you that since there are no other nonsurgical possibilities, it's worth a try. If it works, she'll probably have about 50% shrinkage at the end of 3 months, 75% at six months, and 90% at a year. They'll probably never go away with pycnogenol but may well become symptom free. And three months isn't too long in the grand scheme of things to be doing intermittent cathing if you can save a surgery from it. As a side benefit, once we have big enough numbers, we may be able to show significant anti-cancer effect from this extract.

If she uses it, do me a favor, please, and report the details to me so that I can incorporate the data point. Dose is 1 mg/lb body weight/day.

Umbilical Hernia

Client pregnant with her 10th baby, has an umbilical hernia which protrudes about 3 1/2 inches most of the time but when she lies down she can move her stomach in such a way that it goes down to about an inch.  She is 38 weeks pregnant.  The hernia is not bothering her now but it bothered her quite a bit at the beginning of pregnancy.  She is planning to have it surgically corrected some time after the birth.

To our questions:

  1. Should this herniation be supported during pushing at all and how?
  2. Could it be damaged during pushing?
  3. Is there a position that would be most advantageous for this woman?
  4. Are there exercises or any way that she can work toward strengthening her herniation?  Have made copies of information from Elizabeth Noble's Essential Exercises for the Childbearing Year.

I've seen these handled three ways:
One -- mom holds her hands over the area when she pushes
two -- mom wears a "wrap" during labor
three -- it is simply ignored.

The outcome has always been the same -- no problems with either approach.

 I do  think mom should be advised to refrain from heavy-duty pushing.  She's a multip and if she wanted could probably deliver without any pushing at all -- or only the most gentle pushes. I think it'd be advantageous to "breathe" the baby out. Since she is high parity, she probably won't have more than a couple second stage contractions anyway.

Can't see how the maternal position could be relevant to anything.

I wouldn't advise trying any sort of exercise during pregnancy.

PS -- these are actually pretty common. I've seen some pretty good sized ones -- especially in high multips. I don't think I've ever heard of any problem with them -- has anyone?

I don't think they carry the same risk of intestinal protrusion as other types of hernia sine the peritoneum covers the area quite well.

I have only seen one umbilical hernia in a pregnant woman. and it didn't need any support. this mom had three babies with it till she got around to getting it fixed. didn't seem to bother her once she was 6 1/2 months or so.

I have run into this situation twice in the past couple of years.  I used a wide abdominal binder on these ladies during labor for support.  The same kind one would apply after abdominal surgery.. Cost about $13 through a surgical supply house.  Might only be available by prescription, but you could rig one up with material.  The fancy ones are stretchy elastic with velcro closures, and I always carry a couple of sizes with me for my moms with pendulous abdomens.  Sometimes will help guide the head into the pelvis.

Beta Thalassemia or Thalaseemia Minor

We have many women with beta thal trait. They  really do quite well, and no special care is needed. You will never correct the anemia if it is due to beta thal.  These women should have the normal amount of iron that other pregnant women get.

Here is a good "one stop shopping" website on hemoglobinopathies.

Abnormal Paps or ASCUS in Pregnancy

Management of ASCUS with High-Risk HPV Present in Pregnancy [Medscape registration is free]

Molar Pregnancy

About Molar Pregnancy

If you read the above carefully, you realize that molar pregnancies can co-exist with normal pregnancy, so hearing a heartbeat doesn't rule it out, AND . . . this one kind of blew me away . . . choriocarcinoma can develop after a normal pregnancy, but is easily ruled out by a negative pregnancy test.

So . . . what does all this mean in terms of providing responsible (ethically and legally) midwifery care?

HCG levels with first lab work to rule out molar pregnancy, with or without normal pregnancy?

If done early, should they be repeated later in pregnancy to confirm fallen levels?
Varney's suggests 100 days post-LMP if molar pregnancy is suspected.

Postpartum pregnancy test - how many days?  Or would low HCG levels in mid pregnancy be sufficient.

Anyone know ACOG recommendations on all this?

I've had 2 molar pgs in my career.  The deal with them is, if the pregnant mom doesn't know until, say, quickening, or, fhts heard with fetoscope, the situation can get more malignant.  Early diagnosis is important which is why I try to see clients at 11 weeks to listen with a Doppler. 

I understand the importance of early diagnosis of molar pregnancy, but I'm uncomfortable with frightening moms into routinely allowing me to use a doppler when they're otherwise opposed, especially when it's to try to detect such a relatively rare occurrence.

And, of course, I find myself asking what you do if you aren't able to pick it up with the doppler.  Do you send all clients for a "real" ultrasound if you haven't heard FHT by 11 weeks? (Or maybe you have an U/S machine in your office?)

Do you have any ready references for the increased risk in waiting an additional 8 weeks for other positive signs of pregnancy?

I will use this information to inform my clients and expand the ever-increasing universe of informed consent choices.

Wouldn't it be a reasonable compromise to get HCG levels with initial labs?  A normal HCG level would rule out molar pregnancy without exposing the baby to ultrasound.

Bleeding Nipples

I'm working with a woman who is bleeding from the nipples. It is a bit watery, but very much blood and she says that if she wears a sports bra it goes through that and her shirt in a day, so this isn't a small amount either.  Her doc has never heard of this and so she was sent to an specialist who had never heard of it. She will get a mammogram after the birth, but I am thinking that it must be a tumor, but in both breasts?  Have any of you ever heard of this?

I had a lady doing this with her first baby last year.  Had done some breast pumping during labor and got lots of bloody discharge, and she said that had been going on for awhile.  I took her to see a specialist pp and he said it was normal.  But if it didn't clear up in days to come back, but it did clear up and she breast fed.

Bleeding from the breast is rare and could be several things.  Of course the mom should be referred to a physician in case she did have something serious going on or even a benign intraductal papilloma, but I would ask if she had had any breast trauma such as wearing breast shells or trying to express colostrum.

Sometimes the reason for the bleeding is not known.  Chele marmet calls this "rusty pipe" syndrome.  It is most common in first-time moms. It usually resolves itself and in no way interferes with breastfeeding.

Sometimes bleeding is due to warty type growths in the ducts.  They are not really tumors and do not preclude breastfeeding.

I am a La Leche League Leader and have some information about blood from the nipples.

  1.  It is usually harmless and due to broken capillaries.  It usually occurs in first time mothers in both breast (though one breast bleeding is also common) and is not associated with pain or soreness.  Most women who have experienced this report that the blood clears within a three days of lactation beginning.
  2. Another cause can be fibrocystic disease and intraductal papillomas.  The intraductal papillomas will be felt as a small lump in the breast and usually occurs in only one breast.  It will clear up on its own without treatment on most occasions.
  3. It is SAFE to nurse a baby under any of these circumstances!  If the bleeding doesn't stop after two weeks postpartum, it should be checked by a doctor but the baby can continue to nurse throughout.

Ptyalism (Excess Salivation)

If it helps to know that there's a benefit to profuse salivation during pregnancy, it is that it helps to keep your teeth and gums were in excellent shape!

She has tried the suggestions of limiting starchy/acidic foods, small frequent meals, gum, upping water consumption, various teas. Does anyone else have something along these lines to suggest as a way to help out with this problem?

Often sucking on hot (atomic) fire balls helps.

Those tiny little sherbet pip sweets helped one woman I know of for the excess saliva.

Any thoughts what to do with pregnant women with constant salivation?  Have a 18 week OB who must carry a cup to spit in because she has such excess salivation. (Much as I hate to admit this, I find this absolutely disgusting....although I know she has no control over this, I just hate spit. It's hard to even write this!!!!)

One of my OBs suggested an anticholinergic drug which he uses for over active bladder, and which has particularly nasty dry mouth as a side effect, but we are both reluctant to use this in pregnancy.

So how about midwifery remedies?

Some say that eating celery helps.  This is recommended by Traditional Chinese Medicine.

Has she tried one of the really drying type of mouthwashes? (Listerine comes to my mind!) Also, have you talked to a dentist about ideas? Homeopathy might also have some remedies.

Keeping mints or hard candy to suck on sometimes helps as adjusting starches in the diet (usually lessening).  Astringent mouthwashes are recommended, but my ladies haven't reported that this helped for very long.  I wonder if comfrey tea would help.  It usually helps to balance mucous membranes - if they're too wet, dry them up; if too dry, help make them moist.

In the book, "Natural Healing for the Pregnant Woman," the homeopathic remedy Tabacum (I'd never heard of it) was recommended for "profuse salivation."  It is recommended to take a 6C or 30C potency every 15-30 minutes for 3 doses, then one to four times daily.

I had this with all three of my pregnancies and have had a few clients experience it also.  It is usually concurrent with not just nausea but vomiting and dehydration.

My only relief was B6 shots.  In between I kept Kleenex or paper towels in my mouth to absorb the "fluids" :-). (I still don't like the word SPIT.)  Of course - I was too sick to go out and about - so no one else, outside of family, was really offended.  When my husband was going though a checkout at the grocery store with my 6 year old, the gal asked what all the Kleenex were for.  "Oh, my mom's pregnant!", my daughter pronounced!  I'm sure that kept the checkout gal wondering :-)  Anyway - I feel for the gals with ptyalism - it's kind of a vicious circle thing.

Older Moms / Age Issues / Advanced Maternal Age (AMA)

Attached are the articles, I think are most helpful in answering these types of questions (what can we do to maximize good outcomes?)

As I mentioned in the AIM talk, there are a number of problems with these types of broad based studies

The risks associated with advanced age include:

Abruption, previa, low birth weight, preterm birth, perinatal mortality (IUFD and neonatal mortality)

The absolute risks are modest  - for instance the perinatal morality in those >45 in the Jacobsen paper are 1.4%. The table (hazard ratio) from the Reddy paper is chilling >8/1000 pregnancies in those >40. in this paper the risk increased in those >37 weeks

 Important to keep in mind, that most women will not have this outcome but when you compare it to those aged 20-20 (0.5%) it is statistically different.

If you look at low birth wt (and we know these babies are at a higher risk of IUFD) – again the risks are modest (Aldous – from WA state).

There is no study proving the efficacy of antenatal testing, but I do believe that is helps avoid CD, and IUFD.

UCSF recommendations for antenatal testing are attached

CnattingusS1992_JAMA-AMA_Perinatal outcomes.pdf
Fet Guide '09 short.pdf

In one of DeLee's books he makes the observation that elderly primips do as well as younger primips as long as two conditions are met:

1. the woman is in general good health with no underlying medical conditions (heart disease, hypertension, diabetes etc.)

2. the primip who got pregnant "easily" can generally expect a better outcome than the woman who conceives with difficulty. If a woman takes years to conceive, then we have to wonder about her hormonal function. If she marries late and gets pregnant in the first year, it proves she probably has normal functions.

Older Moms Take Heart: You May Be More Likely To Live Longer [6/28/14] - Women who had their last child after the age of 33 had twice the odds of "exceptional longevity" — defined as living to about 95 — as did women who had their last child before age 29 . . . [Ed: My theory is that the baby's stem cells get back into the mom's organs and revitalize them.]

The duration of labor in healthy women.
Albers LL.
J Perinatol. 1999 Mar;19(2):114-9.

RESULTS: The mean length of the active-phase, first stage was 7.7 hours for nulliparas and 5.6 hours for multiparas (statistical limits of 2 standard deviations from the mean were 17.5 and 13.8 hours, respectively). The mean length of second stage was 54 minutes for nulliparas and 18 minutes for multiparas (statistical limits 146 and 64 minutes, respectively). Variables associated with longer labors were electronic fetal monitoring, ambulation, maternal age over 30 years, and narcotic analgesia. Morbidity was not increased in longer labors.

Expectation of pregnancy outcome among mature women.
Porreco RP, Harden L, Gambotto M, Shapiro H.
Am J Obstet Gynecol. 2005 Jan;192(1):38-41.

"When controlled for parity and plurality, mature women over 45 years conceiving largely through ART with donor eggs can expect newborn outcomes similar to younger women cared for in the same setting of a high-risk maternal-fetal practice."

Pregnancy blues worsen with age [10/12/04] - Older mothers are more anxious during their pregnancy and less likely to have the social support younger mothers enjoy, a study has found. But they are also less starry-eyed about parenthood, and will perhaps make better mothers for it.

Delayed childbearing--are there any risks?
Roberts CL, Algert CS, March LM
Med J Aust 1994 May 2;160(9):539-44

The risks associated with pregnancies in women over 35 are primarily related to pre-existing medical conditions such as hypertension.  Overall health appears to be more important than age.

Midlife Mommies - A treasure chest of resources for first-time moms over 35. We offer info on business, health and fitness, in addition to providing a place to tell your personal story.

Do obstetric complications explain high caesarean section rates among women over 30? A retrospective analysis
BMJ 2001;322:894-895 ( 14 April )

Please, I want to hear your stories of your oldest clients, and how they did. Good births, problems, SAB's, etc.

My experience of older mothers giving birth at home has been very positive.  Just staying away from a hospital improves their chances of having an ecstatic birth. I'm interested to know what their job history has been.  Women who have been airline stewardesses, x-ray technicians, firewomen, Kinko's employees, etc. may be at higher risk for birth defects because they have been exposed to radiation or chemicals.  If there is no history of work related pollution, I have only found one thing consistent with over 38 yr old mothers and that is "The older the woman, the cuter the baby."

I assisted a woman this summer that was 45yo, g6p4 ages 24, 13, 9, 6yo. 1st forceps breech, 2nd C/s for active HSV, 3rd induced ybac, 4-sab, 5-ybac at home (got tired of docs and hospitals looking for problems) 6-sab, 7 6mo after sab. very supportive and same husband with last 3 children . excellent diet. Living 40 miles from the closest hosp. She had her 1st 2 visits at the local clinic with FP docs, who strongly recommended hosp birth d/t age and distance to hosp and refused referral for HB. She and here family were well aware of her risk factors, they also were aware of the risks of going to the hospital for routine birth with her "risk" factors. she used a lot of herbs throughout, chiro care for her back, she was in a lot a back pain at the end. she was totally receptive to transferring to hospital/docs at the earliest signs of problems. she gained the most she had of all preg, and felt her yrs at the end of preg. 9 hrs latent, 4 hrs active, 20min pushing. 17min3rd followed by 450-500cc bldg. (I saw my partner inadvertently put a lot of tension on the cord right after birth which probably may have contributed.) Mom and babe are great!

My oldest mom was 46 when she gave birth to her sixth child. She was a nice Mormon woman, had a pretty decent diet, no major health problems other than being over weight. It seemed like her biggest problem was feeling overwhelmed with having yet another child somewhat unexpectedly. Her pregnancy was uncomplicated, and she gave birth at home without any problems.

Another mom I cared for, who is a friend of mine, was 45 when she gave birth to number 6 also. She had a number of SAB's prior to her last pregnancy, with no history of earlier SAB's. Her husband had had a vasectomy which had been reversed as they decided they wanted one more baby! The SAB's began occurring after the reversal, and it took about 3 years before she was able to conceive and carry to term. She felt pretty tired and run down in the last pregnancy, and mostly scared of losing the baby, but the birth and postpartum was uncomplicated.

The oldest first time mom I took care of was 43. Other than having many anxieties that I don't see as much in younger women, she was fine. She did develop a severe type of gestational pruritis (I don't remember which type as there are several -- I was not her primary care giver) that made it difficult to sleep or get comfortable at all. She had a normal vaginal birth, and had no real difficulties. She had a second baby about one year later and was induced, I believe, because the itching problem made her so miserable. She had no birth complications but did have problems with breastfeeding afterwards, related I suspect to meds in labor.

The highest parity mom I have cared for is 8 now. I am not sure what you are looking for. I have the impression over the years that parity may make more of a difference as moms get older than the actual age........

Let's see, you want good stories for primips 35+?

This is a bit clinical sounding, but I wanted to give you some numbers to show primips over 35 can have "normal" births.  However, as you can see there was significant intervention compared (ie, arom) to what we, as natural birth advocates, would like to see.

As far as the length of their labor from about 3cm and relative ease:

38 yr old = 5 hrs/arom/epidural
40 yr old = 15 hrs/arom/epidural
36 hr old = 7 hrs/arom/epidural
35 yr old = 5 hrs/augmentation/epidural
36 yr old = 6 hrs/augmentation/non-medicated
37 yr old = 13 hrs/arom/epidural
36 yr old = 6 hrs/non-medicated
39 yr old = 6 hrs/narcotic
40 yr old = 6 hrs/augmentation/spinal during pushing
39 yr old = 5 hrs/augmented/non-medicated
37 yr old = 6 hrs/non-medicated
38 yr old = 7 hrs/narcotic
35 yr old = 13 hrs/induction/narcotic
35 yr old = 9 hrs/induction/epidural
38 yr old = 9 hrs/induction/no meds
36 yr old = 14 hrs/epidural
36 yr old = 9 hrs/augmentation/epidural

I never thought any thing different due to their age.  I find that if the woman is generally healthy, has a good mind set, and frequent exercise is a factor, I don't see much difference if their labors.  I find that sedentary life style and mind set are the biggest factors for difficult births in my book.  Just my 50 cents worth.

I purposefully left out the complicated births, but there were only 6 that went much longer and became complicated due to fatigue, intervening or natural phenomenon. Far less of them than what I listed above.

Last year I looked after a 43 year old primigravida who was a GP. We both did a (not particularly rigorous) search of the literature and too found inconsistent results. Neither of us could find any good quality research to support the use of a high risk label being applied to a primigravida on age alone.

She had a Registrar give her a full run down of all the 'risks' and suggested an elective LSCS at 38 weeks to be on the safe side. My client listened to his advice and considered her options but in the absence of any other complications went on to have a quick (OP) birth at home with no complications and a speedy recovery.

In fact my colleagues and I look after many older primigravida (I guess we would class that as 40 and over) with several women being 42 or 43. What has surprised us has been the trend that these women, if low risk in all other ways, appear on the whole to have very quick and 'easy' labours. Clearly our clientele are not a cross section of older primigravida but we have wondered what influences this.. a healthy lifestyle, social support, preparation (plus time and money for this) or just a weaker pelvic floor (not our own observation - that of a client!)

Oldest mom was 47; oldest primip was 44.  I've heard of a few at 50.  Never heard of any problems (my few  moms in their forties have done great)

Polycystic Ovarian Syndrome (PCOS)

Polycystic Ovarian Syndrome Association

PCOS increases risks associated with pregnancy and birth. If the mom's hormonal levels are aberrant enough, that placenta just doesn't get properly situated and that can lead to the other problems down the road that, statistically, are more common in women with PCOS - PIH, pre-eclampsia, abruptio, etc.  Abnormal placentation can lead to additional problems during the birth.  Also, PCOS is an inflammatory condition (most will have elevated CRP values) and that inflammation probably also contributes to the increased incidence of the above diagnosed conditions.

Large/Heavy Women and Birth (The Clients, not the Midwives)

See also: WaterBirth for Large Women

Study Finds Strong Link Between Pre-Pregnancy Obesity, Infant Deaths [1/20/16] - Pre-pregnancy obesity is strongly associated with infant mortality, and compliance with weight-gain guidelines during pregnancy has a limited impact on that mortality risk, according to a study published online in the journal Obstetrics and Gynecology. [Ed: Takeaway message: there's tremendous benefit in reducing weight BEFORE becoming pregnant.  In particular, carrying the extra weight contributes to blood pressure and blood sugar issues during pregnancy.  However, it's not healthy to lose fat during pregnancy since fat contains stores toxins; losing the fat releases the toxins into the mother's bloodstream and thus into the baby's.]

Excessive gestational weight gain and obesity increased cesarean delivery risk in both adolescent and adult pregnancies, according to a study of 1,034,552 Ohio births where analyses were limited to 309,935 singleton live births in term primiparous women. Researchers found:

• Cesarean delivery increased by 31% with excessive weight gain compared with Institute of Medicine (IoM)-recommended gestational weight gain (22%)

• Cesarean delivery increased overweight (31%), obesity (41%) compared with normal body mass index (BMI).

• Compared with adults, teens have 47% lower primary cesarean delivery risk.

• Excessive gestational weight gain increased risk in adults by 50%.

Citation: Beaudrot M, DeFranco EA, Elchert JA. c Obstet Gynecol 125:2S, May 2015. doi: 10.1097/01.AOG.0000463524.12783.be [Ed: I wasn't able to find this reference in PubMed.]

Exami-Gowns - OB/Gyn gowns available up to 4X sizes.

Excessive Weight Gain During Pregnancy Impairs Breast-Feeding Ability [Medscape registration is free] - This article suggests that the elevated levels of progesterone supplied by fat in the body may reduce milk supply.  However, it also suggests that more attention to a proper latch and baby and maternal position may reduce this problem.  Personally, as a midwife, most of the breastfeeding problems I've seen have been in women who are on the thin side - they may not have enough fat to support breastfeeding hormones, or they may already have body image issues that make it difficult for them to appreciate their breasts as a source of nutrition and comfort for their babies.

Plus-Size Pregnancy Website - Kmom's site

Baby Becoming  - Clothing for the Big, Beautiful, Pregnant and Nursing Woman.   Charlotte is proud to be the Pregnancy Advocate for NAAFA. (National Association for the Advancement of Fat Acceptance) PHONE: 401.658.0688 or 1-888-MOMMY10 (1-888-666-6910)     FAX: 401.658.3008

King Edward Memorial Hospital in Western Australia is considering opening a specialized antenatal clinic for obese women, which they define as weighing more than about 265 pounds.  (It's not clear whether this is pre-pregnant weight or admission weight.  I think it's admission weight, since much of the concern is about the hospital staff having to lift heavier moms, presumably those who have epidurals and aren't able to move themselves.)

Where can I find maternity fashions for plus size women?

Is Weight a Contraindication for Homebirth?

A Dad Talks about His Wife's Experience as a Large Woman

I would especially appreciate any words of encouragement that any of you could offer to me as a healthy, but overweight woman (with normal blood pressure and no family history of GD). I'm on a mailing list for overweight and pregnant ladies, but they seem to embrace the medical establishment and there seem to be a frighteningly high number of c-section and induced births on that list. Is there anyone on this group who could share with me a story of a plus-sized homebirth?

I'm on a midwife email list where the subject of heavy women having babies has come up more than once. Our assessment is that the medical system is discriminatory toward overweight women and treat them as walking disasters with no willpower. The experience of most midwives is that overweight woman who are healthy and take care of themselves during pregnancy have no more problems during labor and birth than anyone else. Your perception that overweight women have higher C/S rates is based in fact - it's true. I truly don't think that should be happening. It's known that obese women (perhaps as opposed to large-framed, heavy women) have a higher incidence of gestational diabetes and high blood pressure during pregnancy, but that doesn't mean that EVERY, or even most obese women will have these problems. I advocate a lot a attention to diet during pregnancy, a low weight gain, lots of activity, and a positive attitude on the part of the woman and her support people. There shouldn't be any reason why you can't look forward to a rewarding homebirth!

Kliegman, R.M. & Gross, T (1985). Perinatal Problems of the Obese Mother and Her Infant. Obstetrics and Gynecology. 66(3), 299-305.

This article used wt. greater than 200 lbs prior to pregnancy or during pregnancy as its definition of obesity and did not consider height. It is a literature review. More gestational diabetes was found in obese moms. A, the risk of pre-eclampsia was increased. There was also a higher incidence of twins. Fetal macrosomia was more common but when obesity was defined as more than 50% of the ideal wt for height, there was similar Csection rates as for the general population. Even when moms did not gain much wt. during the pregnancy, the incidence of low birth wt., and IUGR was reduced by 50%. Perinatal mortality was improved or at the least equivalent to compared to that of non-obese moms.

Feelings about Being Naked and Bodily Emanations while Birthing

Junk Science about Obesity and Childbearing - I was moved to write this subsection after reading an article that smacks of junk science:  Big Moms, Big Problems - For Obese and Overweight Women, Pregnancy Ups Risks To Selves, Babies By Suz Redfearn [2/22/05]

Big Babies

Some babies are genetically inclined to be big.  Often, the mother is a taller, broader person, too, so the baby is proportional to the mother's frame.  Sometimes the baby takes after a very large father, even though the mother's frame is on the smaller side.  In that case, the mother may benefit from herbs to prepare her uterus and cervix to be ready for action as soon as baby throws the switch, when the baby's head is still very flexible.  And position is especially important in these cases.

However, some women are growing bigger babies because they have poorly controlled gestational diabetes or borderline blood sugar issues.  These are the worrying cases, not so much because of the baby's size, in and of itself, but because the blood sugar issues interfere with the mother's body's preparations for labor and birth.  The uterus may not be ready to function properly when the baby is ready to be born.  Then, as the days pass, the baby's head starts to harden so that it may have trouble entering and coming through the pelvis when labor does finally begin.  The labor may also be dysfunctional so that it goes on for many days without any good progress.

Perceptions of fetal size influence interventions in pregnancy, study finds [10/8/15] - The study in the Maternal and Child Health Journal found that only a fraction (one in five) of the expectant mothers who were told their newborns might be large actually delivered babies with excessive birth weights - a condition known as fetal macrosomia, or a birth weight of more than 8 pounds, 13 ounces.

We all know how some people like to scare Moms with the Big Baby theory.  What I LOVE to mention to my families, is what a huge benefit it is to have a Big Baby.  (let's turn the tables her ladies and look at the glass half full instead of half empty)  I say things like:  Oh big babies are great because we never have to worry about a prolapse of the cord, the head is nice and big and round and fills up the pelvis so beautifully, there's no cord slipping past your baby's head;  how great that you have a big baby, it is so much less likely to have a problem with being asynclitic;  your body knew exactly what is was doing when it was growing this baby, you are avoiding so many problems with the floating baby syndrome that nurses love to use as another negative comment.  (all of my babies were high until I was ready to push).   Your body gets to produce more relaxin, the hormone which softens the pelvic structure to make it more flexible for baby, and we all know that more hormones will aid in the entire labor process.

THESE WOMAN ARE LUCKY TO BE HAVING BIG BABIES-------and we need to tell them that.  Sorry for yelling, but I LOVE big babies.  Moms with big babies in my experience have an EASIER TIME.  Yes, I said EASIER........

Fetal Arrythmias

Had it in June.  Momma wanted to get level II u/s with MFM docs. All was well.  Didn't hear it again until the end of labor just when I was starting to get concerned about the baby.  All was fine, baby born not long after I heard the arrhythmia episode.  Baby now 7 weeks old.

Many years ago now we had a client whose baby had an arrhythmia , that I heard with a fetoscope , baby was fine, normal nursed.... But at 18 months he tipped head first into a mop bucket was rescued quickly enough in his rural home and air evaced to the hospital where he checked out fine as far as the drowning went but they found a heart anomaly that needed surgery, so any more I want these babies checked out, not necessarily immediately cuz we would be seeing signs and symptoms of a baby not doing well but at some point in the first month.

The few times I've consulted with our back up doc about fetal arrythmias, he usually says "stop listening so long that you have a chance to hear it!".  We have never had to risk out of OOH for it (or send to MFM) and most of the time it resolves spontaneously either before labor or after birth.  I agree with the caffeine - also d/c cold meds, etc.

Pregnant Belly Noises

Anyone have any experience of 'abdominal clicks / sounds' in pregnancy?  I have a client who's 30 weeks, 4th pregnancy, describing loud clicks emanating from abdomen, loud enough for husband to hear in same room, not like hiccoughs, several at a time, associated with fetal movements.  Any thoughts?

This is the first time I have EVER had confirmation that this can happen!  I thought it was just me!!

When I was pregnant, I sometimes heard exactly what you describe - loud 'clicks' coming from my tummy.  They could be heard across the room, sometimes.  My mum heard, my DH heard - even the dog heard - but when I mentioned them to HCPs they just looked at me as if I was mad, and said things like 'you must have imagined it', or, it was your stomach growling - which it wasn't - not like that at all.

I have never had any idea what caused the clicks.  To me, they sounded like bones creaking, only more a 'click...click...click' - but there was an almost 'electronic' squeak to it, on occasion.  It was only every now and then that this happened - and of course, NEVER when a HCP was there.  I also associated it with baby moving.

Baby turned out to be breech with a low lying placenta (partial previa, I believe - not right over the cervix, but in the way).  The clicks seemed to me to come from the lower part of my abdomen - I wondered if it was her legs?  Or maybe it was a noise from the placenta?  Baby doesn't squeak or click anywhere now, by the way - and she didn't at

It was weird.

Oh - should also mention that the clicks started quite late on - I think after 28 weeks, though I can't be sure.  Of my 4 pregnancies, I only had clicks in that pregnancy.

I've heard quite a few women talk about this, so it can't be *so* desperately unusual.

Maybe congenital dislocation of the hip. Not experienced it but have heard other midwives speak of it!

One of my clients reported this with all of her babies . . . maybe joint and disc pops could be a normal part of development as the muscles strengthen?

Condyloma Issues

New Treatment for Genital Warts

[from ob-gyn-l]

Condylomas Lawsuit

I had Dr. Shah for our lectures on HPV (it pays to go to school in the same city as the guys "across town"). Quoting from our handout, which is a chapter in press...about respiratory papillomatosis:

"RRP of juvenile onset is acquired most often by transmission of HPV-6 or HPV-11 at the time of birth, during fetal passage through an infected birth canal.

Children with RRP rarely give a history of birth by cesarean delivery, an indication that most of the infection occurs by intrapartum transmission. The possibility of transmission in utero is raised by occasional reports that RRP was present at birth or in the first weeks of life. The risk factors for RRP of juvenile onset are vaginal delivery, being first-born and having a teenage mother."

Does this mean we should section all teenage nulliparas ????

The information I am lacking is the prevalence of HPV6 and 11 in pregnant women, and the probability of transmission. Shah's paper did imply that almost all childhood cases were delivered vaginally, but if, as has been suggested here, the prevalence in mothers is high and the prevalence of respiratory papillomas in neonates is low, then no action is probably warranted.

Since most children are delivered vaginally, this is an expected finding. Consider looking at the proportional data for VD and CS.

I'll still go with the vaginal route. Thanks again.


In the U.S. there have been lawsuits where patients won huge awards because their doctor "did not perform a c/section to prevent papillomatosis" but I try not to let juries get in the way of science :)

The current (1993) STD treatment guidelines from the CDC also recommend AGAINST c/s for neonatal indications. I would only consider c/s for large condyloma which may bleed or obstruct delivery...

Prenatal Massage

As a doula, MT, and a trainer for MT & pregnancy, I would not recommend that you find a table with a cut out.  Those tables are extremely bad on the pregnant body ­ they put a tremendous amount of strain on the low back, the round ligaments.

Prenatal Opening of Infibulation

In the unit where I work, we deinfibulate women antenatally.  There is a specialist midwife who does it, usually at about 26 weeks.  If the woman prefers, we can do it in labour.

The woman sits with her legs in a stirrupy position (we have a special bed which is like a cross between a dentists chair & a birthing bed).  The midwife uses lignocaine to anaesthetise the laabit and then carefully cuts through the infibulation.  We find that most women have complete genitalia underneath the infibulation.  She continues cutting upwards until the urethra is visible.  Then she blanket stitches the cut sides to  prevent them fusing.  The woman is given topical lignocaine gel to apply to the wounds to stop the area stinging.  Apparently the main discomfort is because the sensitive tissues underneath are exposed for the first time in many years, and it can take a few weeks to get used to the sensations.

Travel in Pregnancy

TSA Travel Tips for Pregnant Passengers - The TSA is  confident that their electromagnetic screening technology is harmless to mothers and babies.  However, "If you are pregnant and still concerned, you can opt out of going through screening technology altogether and requesting a pat down. "

Five ways to avoid germs while traveling (and the rest of the time, too!  REMINDER - Even mild viruses can cause blindness, deafness and cerebral palsy in your baby.)

Pregnancy, Breast-Feeding, and Travel from the CDC

Pregnancy and Flying from the Health Physics Society

[InfoBeat News, 12/12/01] - Most pregnant women who want to travel this holiday season should not fear that flying will cause complications or bring on motherhood a little sooner than expected. According to new recommendations from the American College of Obstetrics and Gynecology, healthy women with low-risk pregnancies can safely fly up until their 36th week, or one month prior to their due date.Women who should not fly at any time during their pregnancy are those at risk for complications or pre-term delivery, including women with poorly controlled diabetes, pregnancy-induced high blood pressure, or sickle cell disease - which can be worsened by high altitude.

The Pregnant Traveller from the British Columbia Ministry of Health

Effects of Altitude

Effect of altitude on the amniotic fluid index.
Yancey MK, Richards DS
J Reprod Med 1994 Feb;39(2):101-4

Should a pregnant flight nurse be allowed to fly?
Drew KG
J Air Med Transp 1991 Jul;10(7):11-2, 15, 19-21

Physical activity at altitude in pregnancy.
Huch R
Semin Perinatol 1996 Aug;20(4):303-14

[Altitude exposure and staying at high altitude in pregnancy: effects on the mother and fetus]. [Article in German]
Baumann H, Huch R
Zentralbl Gynakol 1986;108(15):889-99

Esoteric Concerns about the Ocean

Calicivirus Emergence From Ocean Reservoirs: Zoonotic and Interspecies Movements

Engagement in Nullips at Term

A summary of what the research actually shows about primips and 'engagement' at term OR even in early labor

When I see a nullip not engaged at term, I'm concerned about CPD, polyhydramnios, malpresentation  but might also consider placenta previa or fibroids as obstructing the head from  entering the inlet of the pelvis.  I'd bet on CPD or malpresentation.

Questionable dates? Fibroid or mass in the pelvis? BPD very large? Cord in front of head? Face presentation? Placenta low lying?

Fundal Height in Grand Multips

What is normal for a grand multip (G10 P6) as far as fundal heights in the first trimester??   Do you even bother with them?

This mom was feeling her uterus above the pubic bone at supposedly 4.5 weeks, which stimulated her to buy a pregnancy test (which was positive).  Solid menstrual dates by NFP charting.

She is now 10 w 4 days.  In the AM before emptying her bladder, she can feel the fundus at the umbilicus, but it is "resting" in the abdominal cavity, and her abdomen barely bulges up when she is laying flat.  At this point, the fundus measures 18.  After using the bathroom, it goes back down to around 16.  No fetal movement has been felt.

With her last baby, at 11 weeks, she had an ultrasound due to feeling the fundus halfway between the umbilicus and the pubis.  There was only one baby in there, and her dates were exactly correct, the baby even being born on her due date.  By 20 weeks the measurements had normalized.

So, how normal is it for the uterus to be floating around even as high as the umbilicus at 10.5 weeks?  Should she be thinking twins?  Last time the uterus seemed large for dates in the beginning as well.  Is it just that the ligaments are so stretched out that the uterus can seem to come "loose from it's moorings?"

I just have not had my hands on a grand-multip uterus before, especially in the first trimester.

Anything is normal for grandmultips.  No, I don't measure them before 20 weeks; I'm just looking for a consistent increase but don't worry about the correlation between centimeters and weeks of pregnancy.

I've known of moms having to go into maternity clothes at 8 weeks, but I do expect them to "normalize" by 20 weeks, when I start measuring.

Flu Shot and Other Vaccinations During Pregnancy

See also: H1N1 Novel Pandemic Flu (Swine Flu)

Miscarriages linked to flu vaccine being administered during pregnancy in new study [9/13/17] - Experts stress research at preliminary stage but warn possibility of association cannot be ignored

Breastfeeding After Immunization of Moot Immunological Benefit to Newborn
[3/4/14 - Medline registration is free.]

This paper was confusing to me, but maybe you'll have better luck with it.  I couldn't tell if it was trying to argue for vaccination of pregnant women during pregnancy rather than shortly postpartum?  Or whether it was saying that breastfeeding doesn't transmit disease-specific antibodies?  If the latter is true, then it might be more beneficial to the baby for the mom to be vaccinated during pregnancy, since the big download of immune factors occurs in the last month of pregnancy.  However, I don't love the idea of stressing a mom's immune system too close to the birth in case it interferes with labor and birth.  I don't want to confuse a reaction to an immunization with something related to labor.  And I don't love the idea of stressing the mom's immune system too close to the last month of pregnancy, in case this interferes with the download of immune factors to the baby in the last month of pregnancy?  And I don't love the idea of injecting the mom with weird stuff too early in pregnancy either!  Maybe around 34 weeks is the best time if a mom wants to be vaccinated?  I'd love to see more research about this!

In any case, it's absolutely important that women receive single-dose vials so that they're not exposed to the extra preservatives in a multi-dose vial.  And it's absolutely important that they receive killed virus only.

How to Protect Pregnant Women From the Flu [Medscape 9/9/14] -

They say that getting an influenza vaccination is the best way to prevent influenza infection. Hmmmmmmmmmm . . . Is this really better than meticulous hand washing?

Flu Vaccine in Pregnancy: What’s a Girl to Do? (Ask Dr. Aviva!)

Vaccinating pregnant women “halves the risk of pertussis in infants’ first four months” ~ A critique by Dr Suzanne Humphries - See more at: http://www.vaccinationcouncil.org/2013/03/21/vaccinating-pregnant-women-halves-the-risk-of-pertussis-in-infants-first-four-months-a-critique-by-dr-suzanne-humphries/#sthash.iMeTH2S2.dpuf
Vaccinating pregnant women [allegedly] “halves the risk of pertussis in infants’ first four months” ~ A critique by Dr Suzanne Humphries

The paper states..."Since a vaccine creates different immunologic response pathways than natural immunity, the body will act according to how it was programmed by the vaccine. The body still sees the invader, but immunity doesn’t work against that invader the same way it would naturally, if it was first vaccinated⎯and that is what is meant by “original antigenic sin (OAS).” When it comes to B. pertussis, OAS is very important and well described. B. pertussis secretes several toxins, one of which only emerges after the infection takes place. That is called adenylatecyclase toxin (ACT). Here’s how ACT works: Once whooping cough bacteria attaches to cells in the bronchi, a gene in the bacteria switches on and as a result, ACT toxin which acts like a force-field against the immune system, is produced. ACT stops the immune system from recognizing the bacteria and gives the bacteria about a two week advantage until the immune system wakes up to the fact it has been duped. In the case of natural whooping cough immunity, ACT or adenylatecyclase toxin forms the basis of the initial immune response. That front-line immune response is not only critical for eliminating the first round of pertussis bacteria, but also crucial for removing the bacteria upon later reinfection. And remember that whether or not one is vaccinated, they still become colonized when the bacteria is circulating. The difference will be that the vaccinated person will stay colonized longer and be more likely to develop some degree of cough, which is how pertussis is spread.

I wonder what effect these vaccinations have on the mother's normal immune function in late pregnancy.  Her body is supposed to be busy creating extra antibodies to download to the baby in the last month so that the baby is born with her immunity to EVERYTHING she's immune to.  It seems logical that vaccination in late pregnancy could disrupt this process.  Could it increase GBS colonization also?

Pertussis really is becoming so common. I know two families who have had whooping cough in the past month, and being vaccinated didn’t help either one. There is new research showing both that the vaccine may NOT stop you from being contagious and also that there is also a vaccine-resistant version of pertussis going around.

Whooping cough vaccine may not halt spread of illness [11/25/13] - nbcnews.com

Whooping cough may be becoming resistant to vaccines [2/8/13] - usatoday.com

Vaccine-resistant pertussis strains found in Philadelphia [5/16/13] - familypracticenews.com

Researchers find first US evidence of vaccine-resistant pertussis [2/7/13] - cidrap.umn.edu

When pertussis went around my daughter's school, it was the vaccinated kids who got sick.  The un-vaccinated kids (who were also likely breastfed as that's what the norm is up here in our community), were fine, including my daughter!

Novel Influenza A (H1N1), previously called Swine Flu

This has been moved to: H1N1 Novel Pandemic Flu (Swine Flu)


Why do pregnant women get so hot, as if there's "a bun in the oven", and they're the oven?

Engine and radiator: fetal and placental interactions for heat dissipation.
Schroder HJ, Power GG.
Exp Physiol. 1997 Mar;82(2):403-14.

Single Umbilical Artery - Two-Vessel Cord

The Relationship Between Placental Location and Fetal Gender (Ramzi’s Method):
Can Placental / Chorionic villi Location be used as Indicator for Fetal Gender at Six Weeks Gestation using 2-D and Color Flow Sonography?
December 2007

Dramatic differences were detected in chorionic villi / placental location according to gender. 97.2% of the male fetuses had a chorionic villi/placenta location on the right side of the uterus whereas, 2.4% had a chorionic villi/placenta location to the left of the uterus. On the other hand 97.5% of female fetuses had a chorionic villi/placenta location to the left of the uterus whereas, 2.7% had their chorionic villi/placenta location to the right side of the uterus.127 cases were found to involve bicornuate uteri with single foetuses, most male fetuses were located in the right horn of the uterus and showed right placental laterality (70%). Most female fetuses 59% on the other hand, were located in the left horn and showed left laterality (59%).Moreover, most of the males located in the left horn exhibited right laterality (89%). Also most females located in right horn exhibited left laterality (976.4%). In addition this research indicated that there was a possible link between renal pyelectasis and placental location, and it might be used as a genetic soft marker.

Ramzi’s method is using placenta /chorionic villi location as a marker for fetal gender detection at 6 weeks gestation was found to be highly reliable. This method correctly predicts the fetus gender in 97.2% of males and 97.5% of females early in the first trimester. And it might be helpful to use as a genetic soft marker in relation with fetal pyelectasis.

[Editor: I find this absolutely fascinating.  It's hard to imagine a mechanism behind this difference since the placental location is determined at implantation, which is well before there is any difference in the fetus other than the DNA.  However, folklore has sometimes associated a left/right dichotomy with a feminine/masculine dichotomy.  The best mechanism I can imagine is that the implantation site is random, but that placentas that implant on the "wrong side" are much less likely to continue the pregnancy.  This would be a strong contributing factor to the very high percentage (70%?) of fertilized eggs that do not make it past the first trimester.]

Increased risk of miscarriage and ectopic pregnancy among women with irritable bowel syndrome.
Khashan AS, Quigley EM, McNamee R, McCarthy FP, Shanahan F, Kenny LC.
Clin Gastroenterol Hepatol. 2012 Aug;10(8):902-9. Epub 2012 Feb 25.

CONCLUSIONS: IBS, a common disorder in women of reproductive age, appears to increase the risk of miscarriage and ectopic pregnancy. These findings indicate the importance of prenatal care for women with IBS.

Possibility of Male Pregnancy

Sex During Pregnancy

Guidelines for Vaccinating Pregnant Women  - from the CDC.

Stone Baby - 32-week intra-abdominal pregnancy which had died and calcified.

APLA is a an abnormal clotting condition. The blood is more coagulatable than usual. People are at higher risk of stroke and thromboembolism. There are many many degrees of the condition though -- and some people are at low risk and some are very high risk. There are some blood tests which can show a person's individual risk....but family history is a good guide.

some people benefit from taking blood thinners like low-dose aspirin. Some need medications. Some simply need to avoid things which increase their risk (like smoking or birth control pills).

During pregnancy the hyper-coagulable state may be increased further, putting women at risk for embolism and (maybe) at higher risk for early miscarriage. Anyone with APLA should be evaluated to see if they need treatment during pregnancy and postpartum.

Sexual Violence and Pregnancy-related Physical Symptoms
Mirjam Lukasse, Lena Henriksen, Siri Vangen, Berit Schei
BMC Pregnancy Childbirth. 2012;12(83)

Conclusions: We found that women who reported sexual violence suffered longer and from more pregnancy-related physical symptoms compared to women not reporting sexual violence. The symptoms may seem like minor complaints to those who provide health care during pregnancy. However, they may cause women major discomfort and severely affect their well-being during pregnancy. Few women spontaneously disclose their history of violence to health professionals.[10,28] Clinicians should consider the possible role of a history of sexual violence or other abuse when treating women who suffer to a great extent from pregnancy-related physical symptoms.

Emergency Preparedness and Response: Information for Pregnant Women - Specific Emergencies


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