FROM THE BACK COVER: Praise for The Anxious Parent's Guide to Pregnancy
An outstanding blend of practical information and humor. Dr. DiLeo provides a wealth of useful information in a style that ensures a productive relationship between patient and physician. Dr. DiLeo's insight on pregnancy is so valuable that I plan to recommend this superb contribution to the literature to all of my patients.
—Douglas M. Montgomery, M.D., F.A.C.O.G., Chairman of the Department of Obstetrics and Gynecology, Ochsner Clinic Foundation, New Orleans, and specialist in maternal-fetal medicine
Dr. DiLeo possesses an extremely rare combination of medical expertise, along with the ability to write in an informative and entertaining style, adding strong doses of compassion and wit. I've read just about every pregnancy book available, and many make great bedtime reading (as the medical jargon and dry writing styles often put you right to sleep). This book will not only keep you awake, you will be compelled to read it from cover to cover while you celebrate the miracle of your pregnancy with your favorite book and doctor.
—Jeanine Cox, Publisher and Co-founder, BabyZone.com
As both a surgeon and first time pregnant woman, I had the privilege of reading this book from both perspectives. The unique thing about The Anxious Parent's Guide to Pregnancy is that Dr. DiLeo finally provides a guide that interweaves the parent with the obstetrician, the philosophy with the physiology, and the practical with the miraculous. This book is nothing less than a complete celebration of pregnancy and childbirth, but with all the facts. An entertaining read!
True to its title, my anxiety as a prospective mother has been successfully tamed by the perspective Dr. DiLeo instills into even the serious complications that are a part of any thorough discussion of pregnancy. The surgeon in me applauds an important, informative book. The mother in me finds great comfort in the perspective provided, and the woman in me had great fun reading such a charming and funny book about such a serious subject.
-Elizabeth Kinsley, M.D., F.A.C.S.
My professional interests are many, but Dr. DiLeo's take on nutrition in pregnancy is right on. Finally, someone has decided to stop over-complicating the diet for normal pregnancy with ridiculous chapters on calorie counting that no one will follow. And finally, someone has decided to champion the role of nutrition and diet in complications unique to high risk pregnancy. This is the pregnancy book dietitians and nutritionists have been waiting for. And it's fun, too. It's a book that is both delicious and nutritious.
—Diana Davis, L.D.N., R.D., licensed nutritionist, holistic Registered Dietitian, certified American Dietetic Association, national lecturer on nutrition and neuro-linguistics.
PUBLISHED EDITION NOTES
Library of Congress Cataloging-in-Publication Data
DiLeo, Gerard M.
The anxious parent's guide to pregnancy / Gerard M. DiLeo.
p. cm. ISBN 0-07-138307-7
1. Pregnancy. 2. Childbirth. 3. Parenting. I. Title.
RG525 .D535 2002
1234567890 AGM/AGM 1098765432
ISBN (Print) 0-07-138307-7
ISBN (Electronic) 978-1-4524-5754-3
618.2—dc212002022401
This book was originally printed on acid-free paper. Subsequently, it was printed into the Internet aether. The font used is pregnanediol-3-glucuronide.
COPYRIGHT NOTES
© 2002, 2012 Gerard M. DiLeo. All rights reserved. Except as permitted under the United States Copyright Act of 1976, no part of this publication may be reproduced or distributed in any form or by any means, or stored in a database or retrieval system, without the prior written permission of the publisher. Imprimatur applied for; Nihil Obstat pending.
SMASHWORDS EDITION LICENSE NOTES
This ebook is licensed for your personal enjoyment only. This ebook may not be re-sold or given away to other people. If you would like to share this book with another person, please purchase an additional copy for each person. If you’re reading this book and did not purchase it, or it was not purchased for your use only, then please return to Smashwords.com and purchase your own copy. Thank you for respecting the hard work of this author.
MANDATORY BLAMELESS LEGALESE
In reading this book, you acknowledge that I am NOT your doctor. No advice is to be assumed to be a doctor-patient relationship. You also acknowledge that all publications, even e-books such as this one, are dated to some extent, and that there may be more up-to-date information that may make material in this e-book inaccurate. This e-book is not medical advice, but a resource you can use only in consultation with your established physician, so any information should be verified with you own doctor. Your doctor is the only source of information for you to rely upon or base decisions upon. So there.
To Linda, the mother of our children
To Rosalie, the mother of me
Other books by Gerard M. DiLeo
Eddie H. Christ, a Sibling Rivalry Story of Biblical Proportions
Gender Correctness and Picking the Right Person to Deliver Your Baby
Two Sides of the Same Coin: Gynecologists and Obstetricians
Groups, Solo Doctors, and Midwives
If You Choose to Forgo an Obstetrician
The Best Prenatal Care Begins Before Conception
The Ten Commandments of Pregnancy
Relationship with Your Obstetrician • Prenatal Vitamins • Previous Surgery on the Cervix • Keeping a Previous Abortion a Secret from Your Doctor
I: So You Went and Got Pregnant
The Womb of the Unknown Pregnancy: The Art of Classical Obstetrics
Your Due Date: Fun with Arithmetic
2: Normal Pregnancy in the First Trimester
Prenatal Care in the First Trimester
Medical History • The Initial Physical Exam • Measuring Your Pelvis • Blood Work and Other Lab Tests
Battle of the Bulge: Changes in Your Body
Estrogen • Progesterone • Human Placental Lactogen (hPL) • Human Gonadotropic Hormone (hCG) • Prolactin
Nutrition: Eating Right for the Mother-Child
What Are the Extra Nutritional Requirements of Pregnancy?
3: The Initial Trials of Pregnancy
Spider Veins (Telangiectasias)
Change in Response to Exercise
Cravings: "I Can't Believe I Ate the Whole Thing"
Morning Sickness: The Nausea and Vomiting
Prescription Medicines for Treating Nausea • FDA Drug Risk Categorization • Drug Risks in the Real World • Other Causes of Nausea • Management of Nausea (in Chronological Order) • Fetal Development in the First Trimester
Timing of First OB Appointment • Running, Exercise, and Low Progesterone • Safety of Ultrasound • Horror Stories Relatives Tell You
Part Two: Miscarriage and Other Pregnancy Loss
Babies and Daytime Emmys: Stress, Exercise, Sex, and the Risk of Miscarriage
Threatened Miscarriage: Bleeding in Early Pregnancy
But What If It Really Is Miscarriage?
Ultrasound • Blood Work • Time
When the Verdict Is In: Treatment for Miscarriage
Complications of D&C (Dilation and Curettage)
Infection • Synechiae • Perforation • Psychological Complications • Incomplete Removal of the Products of Conception • Recurrent Miscarriage
5: Other Types of Pregnancy Loss
Ectopic Pregnancy: Being in the Wrong Place at the Wrong Time
Molar Pregnancy: Abnormal Fertilization
Q & A—Miscarriage and Other Types of Pregnancy Loss
hCG Values • Exaggerated Grief in Miscarriage • Absorbed Twin •Safety of Intercourse with First Trimester Bleeding • When to Attempt to Conceive Again After a Miscarriage • Miscarriage and Pregnancy Between Two Sisters
Part Three: The Second Trimester
Prenatal Care in the Second Trimester
Special Testing for the Second Trimester
Alphafetoprotein • Ultrasound • Amniocentesis
The Psychological Toll of False Positives
7: High Risk in the Second Trimester
IUGR (Intrauterine Growth Restriction)
Pregnancy-Induced Hypertension
Premature Rupture (or Leaking) of Membranes—PROM
Abdominal Tenderness of the Uterus
The Middle Trials of Pregnancy: Other Second Trimester Considerations
Urinary Problems—Too Much or Too Little • Ligament Pain • Other Pains and Trials
Not There Yet, But Getting Close
Flying in Pregnancy • Breast Masses in Pregnancy • New Eyeglasses
Part Four: The Third Trimester
Prenatal Care in the Third Trimester
The Lagniappe Period of Pregnancy—Laissez les bon temps roulez
9: High Risk in the Third Trimester
Abnormal Amount of Amniotic Fluid
Decreased "Reactivity" on Nonstress Test
Unconventional Positions of Baby
Contractions Coming More Than Four an Hour
Any Sudden, Sharp Pain That Doesn't Go Away
Right Upper Quadrant Pain or Right-Sided Back Pain
10: Fetal Surveillance in High- Risk Pregnancies
Biophysical Profile (Peek-a-Boo, We See You!)
Trial of Labor (Prolonged Stress Test)
Artificial Rupture of Membranes (AROM)
Other Considerations Near Your Due Date
Elective Induction • Repeat C-Section Versus VBAC • Maternal Choice
C-Section • C-Section-Hysterectomy
II: The Terminal Trials of Pregnancy
The Victor Hugo Index: Who Was Victor Hugo and What Does He Have to Do with Pregnancy?
False Labor: The Frequent Flyer Club
Puerperal Urticaria of Pregnancy (PUP)
The Wait: Expecting the Expected Date of Delivery
Questions You Forgot to Ask Before the Eleventh Hour
Does Your Doctor Deliver All of His Own Patients? • Who Are the Doctors Who Cover for Your Doctor? • Prenatal Classes: Lamaze or Bradley? • When Should You Go to the Hospital? • What Are Your Doctor's Quirks When It Comes to Labor and Delivery? • Should You Get a Birthing Contract? • How About a Birthing Understanding?
Postdates • Diabetes • Pregnancy Complications • When You Shouldn't Have an Induction • Criteria for Induction
Pro and Cons of Elective Induction
Convenience • Comfort • Safety for Your Baby • Increased Risk of C-Section • Excommunication from the Church of Natural Processes
Stripping the Membranes • Normal Cervical Changes Near Term Prior to Delivery
"Front" Pain • Leg Cramps and Leg Pain • Lactation Before Delivery • Induction Versus Labor at Thirty-Seven Weeks • Mucus Plug
Pregnancy Retreat • Uretonin Theory
Growing Pains • Braxton-Hicks Contractions • False Labor • True Labor • Latent Phase of Labor
Why Don't Contractions Other Than True Labor Change the Cervix? • The Nuisance of Other Types of Labor Before the Real Thing
No Labor (What's It Going to Take?) • Not Enough Labor (Half-Fast Labor) • Too Much Labor (As If Just Enough Labor Weren't Enough)—Tetanic Contractions • Precipitous Labor
Labor—What It Means for You in the Real World
What Will Make the Difference Between Your Having a Vaginal Delivery or a C-Section?
Your Power • Your Passenger • Your Passageway
Living with It or Through It: The Philosophy of Pain Relief and Labor
Sedation • Epidural Anesthetics • Spinal Anesthetic (Saddle Block) • New Concoctions • Pudendal Block • Local Anesthetic
Choosing the Way to Give Birth
Natural Delivery • Natural Delivery with Local Sedation or Pudendal Block • Delivery with Sedation • Delivery with Regional Anesthesia • Where You Deliver Is Part of How You Deliver
Some Thoughts That Come to Mind When You've Seen a Zillion of These
The Moment We've All Been Waiting For
The Position of the Unknown Baby—What Is It and How Does It Get
I'll Answer The Rest of Your Delivery Questions Now
What's the Deal on Episiotomy? When an Irresistible Force Meets an Immovable Object • What's the Deal on Vaginal Tears? • What's the Deal on the "Husband Stitch"? • What's the Deal on Forceps? • What's the Deal on the Vacuum Extractor? • What's the Deal on Fetal Distress?
Shoulder Dystocia—When a Baby Throws a Shoulder Block • Uterine Atony • Uterine Inversion • Cord Breakage When Trying to Remove the Placenta • Retained Products of Conception; Retained Placenta • Failure to Progress • Fetal Distress • Meconium • Amnionitis • Bleeding
What's the Deal on C-Sections?
What's the Deal on C-Section Rates?
What's the Deal on VBAC (Vaginal Birth After Cesarean)?
What's the Deal on Saving and Storing Cord Blood?
Each Labor Gets Faster • Umbilical Cord and Stillbirth • Traveling Late in Pregnancy • Bad Tears with a Previous Pregnancy, the Likelihood of a Repeat Bad Experience, and Types of Episiotomies
The Placenta Has Left the Building
Your Own Parade—Who Are These People?
From a Vaginal Delivery • From a C-Section
Lochia—How Much Bleeding Is Normal After Having a Baby?
Puerperal Fever • Subinvolution • Blood Loss • Infection • Urinary Tract Infections • Postpartum Depression • Thrombophlebitis
19: Breast- Feeding and Other Postpartum Concerns
The Mammalian Art of Breast-Feeding
Minimenopause • Care of Your Breasts
The Evasive Art of Not Breast-Feeding
What's a Good Excuse Not to Breast-Feed?
Disadvantages of Breast-Feeding
Mastitis • Prolonged Galactorrhea • Social Anxiety • Being Tied Down • Delay in Mammogram • Pregnancy • Contraception While Breast-Feeding • Cosmetic Concerns
When Can Sex Resume? • What About Birth Control? • What About Circumcision? • What About Tub Baths? • What About Driving? • What About Stairs? • What About Scissors? • The Cosmetic Aspects of Childbirth (by Elizabeth Kinsley, M.D., plastic surgeon)
Conehead Babies • How Many C-Sections? • Breast-Feeding with a History of Hepatitis B • Rubella Vaccine • Postpartum Tubal Ligation • Spacing Babies
20: Complications Unique to Pregnancy
Medication Used in Preterm Labor • When Is Labor Preterm? Does Gender Influence How Babies Do in Preterm Deliveries? • Modern Developments to Fight Complications of Prematurity • How Should Your Preterm Baby Be Delivered? • Picking the Right Dentist • Incompetent Cervix and the Mechanical Aspects of Premature Delivery
Premature Rupture of Membranes (PROM)
Chronic Hypertension • Pregnancy Complicated by Chronic Hypertension • Pregnancy-Induced Hypertension—The Plot Thickens • Telling the Difference Between Chronic Hypertension and Pregnancy-Induced Hypertension • There Is No Cure for Pregnancy-Induced Hypertension, but the Treatment Is Delivery • Eclampsia • Testing You and Evaluating the Health of Your Baby with Pregnancy-Induced Hypertension • Management of Pregnancy-Induced Hypertension • S/D Ratio • A Bad Disease Gets Worse— HELLP Syndrome • Pregnancy-Induced Hypertension—In Summary
Gestational Diabetes Mellitus (GDM) • Diabetes Mellitus
Complications Due to Advanced Maternal Age
Down Syndrome • Twins at This Point in Your Childbearing Career • Other Risks
Genetic Testing: Invasive Prenatal Diagnosis
Medically Recommended Procedures Versus Medically Necessary Procedures
Rh-Negative Blood, Rh Sensitization—Sesame Street Hematology
Babies Too Small and Babies Too Big
IUGR—Intrauterine Growth Restriction (SGA—Small for Gestational Age) • Macrosomia (LGA—Large for Gestational Age)
Infections Impacting Pregnancy
Sexually Transmitted Diseases (STDs) • Nonsexually Acquired Infections
21: Pregnancy Complicated by Preexisting Conditions
Bladder Infection • Kidney Infection • Hydroureters • Hydronephrosis • Kidney Stones
Hypothyroidism • Hyperthyroidism
Feeling Depressed • Clinical Depression Complications Remembered
Gas in Pregnancy • Excessive Vaginal Discharge • Changing Blood Type?
Part Eight: Special Conditions in Pregnancy
22: When Life Becomes Complicated
Multiple Gestation—the Romance of Twins
Drugs in Pregnancy and During Breast-Feeding
Having Another Baby After Having a Special Child
Pregnancy After You've Been the Victim of Sexual Abuse
VBAC—Vaginal Birth After Cesarean • Herpes—When Is an Obstetrician Not a Gynecologist? • PROM—Premature Rupture of Membranes • Home Delivery— Beauty and the Beast • HUAM—Home Monitoring for Preterm Labor • Evidence-Based Medicine • The Business of Medicine—Modern Warm and Fuzzy Deliveries • Maternal Choice C-Section • Lawyers Versus Doctors • Post-Tubal Syndrome—Maybe It Does, Maybe It Doesn't, Exist • Circumcision—Usually a Personal Preference
Preface
This is more than just a book about pregnancy. It's about life and family too. I've noticed that in most pregnancy books today there's a huge gulf between the actual physiology and the philosophy of reproduction. But both of these things are so beautifully intertwined during pregnancy that I wanted each to help explain the other. In The Anxious Parent's Guide to Pregnancy, I feel I've been able to accomplish this. This isn't a book written by a doctor who writes like a doctor; or written by someone who had the quintessential experience and who is trying to write like a doctor. Instead, it is a pregnancy book written by a doctor who writes like a parent. Raising children is a lot more than merely having children, and having them is a lot more fulfilling when you can appreciate the joy in raising them.
As an obstetrician who has taken every single delivery one at a time in a twenty-year career (sometimes two at a time), I have a perspective that goes beyond the sterile collection of lists of other pregnancy books. I do this by using periodic asides, called PANICKILLERS, to allay anxiety. These are bottom-line appraisals of how much concern you should put into a particular subject covered. (Hence the name of this book.) I have also included what I call FASTFORWARD capsules that summarize explanations, providing quick scans of the most important points of a discussion. When there has been a major shift in information between the first edition of 2002 and this one (2012), I have included a distinction as an aside I call SEACHANGE. And every now and then, there’s a PAUSE.
No, I've never had a baby myself. I don't think I could find anything on me that would accommodate ten centimeters dilation. But I have lived with the mother of my children throughout all of our pregnancies, slept in the bed with her, appreciated every symptom and complaint, and shared with her some interesting episodes. My love for her, what she has experienced, and the great things she has done have added considerably to my observations of life in pregnancy beyond mere obstetrics. You can't learn the real meaning of family by reading just a pregnancy book written by a doctor; you can't appreciate what's at stake by reading a birthing enthusiast's manual written in politically correct agenda-ese. It's got to come from the heart of a parent. And this parent just happens to know what's important and what's not; what's likely and what's unlikely; and what's prudent and what's nonsense.
This is a revision of the original “Anxious Parent’s Guide to Pregnancy,” from 2002, still available, believe it or not. During the 10 years since its publication, I spent many years on the Labor and Delivery Unit at Tampa General Hospital with a teaching institution, working with medical students, residents, fellow attendants, and—frankly—senior staff who humble me in my knowledge of obstetrics. A lot of what has been revised comes from my experience there and in the academic challenges a medical school and residency program presents.
Enjoy this book. It's an easy read, filled with all of the essential information, and tempered by the perspective of someone who has lived childbirth from many angles.
Acknowledgments
This book has been a long time coming. I'd like to thank my patients who have provided me the human perspective of the science of obstetrics that would otherwise be a mere catalog. I'd also like to thank my agent, Peter Miller, who has stood by me longer than he should have. My editor, Matthew Carnicelli, and the production team at Contemporary Books have turned me from a Saturday Night Live wannabe into an (almost) serious medical author, and the good people of BabyZone.com have graciously let me contribute to what I think is the best pregnancy and parenting site there is. I'd like to express my gratitude to my office staff, Ann Dalton, Ida Albin, and Marlena Angeletti, who actually bought this pie-in-the-sky story that I was going to be a published author, while helping me keep my office running so well. Thanks to Dr. Nick Landry for taking care of my patients while I was away writing. And one more special thank-you goes to Dr. Elizabeth Kinsley for being a friend, a plastic surgeon, a contributor, and pregnant—all at the same time.
For their support, I'd like to thank my children, Evan, Luke, Blaise, Phoebe, and Cara, but doubly Luke for showing me the blessings in having a handicapped child. I'm forever indebted to my parents, the late Dr. John DiLeo, for always saying, "Education first," no matter what, and Rosalie DiLeo, for naming me after the patron saint of expectant mothers—who woulda thought?
And most of all, I'd like to thank my wife, Linda, the beautiful woman who gave me such wonderful children and stood behind me throughout the writing of this book, when she had every right to say, "With all of this work, you better frickin' end up on Oprah."
First Things First
Planning for Your Pregnancy
Cloned sheep and postmenopausal conceptions may steal all the media attention, but most pregnancies are still the result of good oF natural sex. IVF, GIFT, ZIFT, AI, and ICSI are all acronyms entering the vocabulary of the mainstream Infertility Nation, the population of which increases as the patience for natural processes wears thin from cycle to unfulfilled cycle. But even though the numbers of children born with the help of technologically begotten conceptions are going up, most children still come from parents who have successfully achieved not IVF (in vitro fertilization), but IBF (in bed fertilization). These Posturepedic parents generally fall into three distinct groups: the Mathematicians, the Merry Wanderers, and the Shocked.
The Mathematicians are the couples who are so serious about planning their life together that they try to plan their pregnancies as well—as if any formula involving children could ever be valid. They call it family planning. I call it chaos theory. Nevertheless, many couples do scheme and plot the perfect time to have the perfect baby for their perfect lives. They consider the optimal financial timing, philosophize about the most successful spacing of siblings, and design the intertwining of family careers. They make coital calendars with X-rated hieroglyphics and coordinate romantic trysts based on urine and little machines. They are devastated when all of the tumblers don't line up the right way in that one month on their calendar circled with the red glitter paint. When their deadlines pass, these couples make it possible for infertility doctors to make a good living.
The Merry Wanderers don't plan to that exact a degree, but instead tread teasingly through an acceptable mind-set in which conception is neither aggressively sought nor avoided—the seductively risky living dangerously approach.
The Shocked are those others who get their snug and warm hedonisti- cally woven rugs pulled out from under them when, in spite of their best efforts, fate steps in with an amazing feat of untimely fertility and ruins their childless carnival and seasonal runs to Club Med.
FASTFORWARD
Planning the exact timing of a pregnancy is very difficult, even for the most methodical of us. In spite of our best scheming to seek or avoid pregnancy, the timing of pregnancy is often a fatalistic phenomenon.
Except for Immaculate Conceptions, no one can predict exactly when conception will occur, but it probably will occur for most sexually engaged couples. There are infertile couples, but they're the minority that fall through the procreation cracks. When the pregnancy test reads positive (formerly called "The Silence of the Rabbits"), all three groups take out their pencils to calculate their lives around that most profound Holy Day of Obligation, the due date. At this point they are all mathematicians, and it's time to pick out a doctor.
Gender Correctness and Picking the Right Person to Deliver Your Baby
There is no gender-specific advantage in knowledge or skill when it comes to obstetrics. In providing medical care for women, a consensus has been emerging that women do it best. The truth is that it's a great irony that the gender- focused specialty of OB-GYN is gender neutral when it comes to the best doctors. Being of the male persuasion (I was persuaded at my conception), I've had to suffer from the competitive edge female physicians hold over me in the marketplace. It's a great conspiracy against us male doctors in that smart female physicians don't downplay it, and male physicians themselves tap into it when interviewing a prospective associate who has been screened for the "right" marketable gender. The media propagate this thinking: "I went to my gynecologist and she told me that...." For all things gynecological, politically correct commercials assume that your gynecologist is a woman. But on the ads for gastritis, diarrhea, and constipation, "... my doctor—he said to take...."
FASTFORWARD
The gender advantage of an obstetrician is mainly a marketing consideration. The best obstetrician for you is the doctor who has proven to be the best gynecologist for you.
I've known women who have actually gone out of town to see a woman doctor who was not as good as the male doctors in her hometown. (Of course, tell a man to see a woman urologist and the bells of chauvinism ring even louder.) Once I had a patient whose husband made her switch to another male doctor because he had five children. Since I had only four, the husband assumed he was more of a family man and therefore less likely to look upon his wife in that way. Men! What can one do?
On the other hand, I've had women come to me, refusing to see a female associate because they felt that women physicians are rougher than men, that the same gender doctor is less understanding. On the doctor end of this are the complaints of superb female gynecologists who have lost patients because they treated them no more special than a male doctor would, but because the expectations were higher, the comparable care was an unforgivable letdown for these disgruntled patients, resulting in anger and flight to—of all things— a male doctor.
This is all asinine, of course. A woman doctor doesn't want to be known as a great gal, but as a great doctor; a male physician doesn't want a patient to go to him just because he's a man any more than he wants a patient to rule him out because of his maleness. No matter what the patients seek in a doctor, no matter what the media assume to be the best gynecologist-patient gender match, no matter how the women's magazines politic in the way of gender correctness, all doctors—male and female—want to be best at being doctors. Male doctors are defensive and huff that you don't have to go to an oncologist who's dying of cancer; female doctors point out that their sex doesn't make them more knowledgeable although less sympathetic. A gynecologist doesn't have to be a man or a woman to do this important work—although a gynecologist is usually a man or a woman because most people, including professionals, are. I'll go out on a limb here and say that men are probably better than women at taking the credit for populating the Earth and that women are probably better at doing the actual populating. But the knowledge, skill, dexterity, sensitivity, and reasoning of obstetrics are not better administered by one sex over the other.
Now that I've quashed any assumed gender superiority in OB-GYN, who is the best obstetrician to go to?
You're probably already going to him—or her. (Observing gender neutrality while writing a book about obstetrics is a major distraction, so forgive my using the male and female genders in a polite rotational way. To escape the wrath of the Ellen Jamesians, I will toss his, hers, him, her, he, and she around with responsibly correct reckless abandon.)
Where was I?
You're already going to her—or him. The point is that if you trust your doctor—male or female—as a gynecologist, you should be able to trust your doctor as an obstetrician. They're the same people.
Admittedly, if you're choosing a doctor for the first time, this difficult decision is all the harder when it means selecting an obstetrician because this special kind of doctor must treat two patients simultaneously: you and the child you're carrying. But the sum of the expectant mother and the expected is more than the mere addition of the parts because there is a third entity, the pregnancy itself, which is that symbiotic relationship between mother and child. This third entity has it's own type of respiratory system, circulatory system, and nutritional exchange. For that brief time of gestation there is a different anatomy altogether: the combined mother-child.
To relate properly to an expectant mother (and father), an obstetrician must be able to relate to all kinds of entities—the mother and father individually, the married couple, the developing child, the pregnancy relationship between the mother and child, and the pregnancy relationship among the mother, father, marriage, and child. It can get fairly crowded in this psycho- dynamic exchange. But the most important relationship is that of the mother and child, because there are diseases of just the mother, diseases of just the fetus, and very strange medical complications that are the result of mother and fetus together.
A lot of this is book knowledge for sure, but there has to be insight as well because as the mother-to-be your thinking is altered as well. Ovarian, pitu
itary, thyroid, and adrenal hormones jive together with your fervent hopes and dreams to create another thinking and emotional species altogether—the mother-and-child—the pregnancy—a dynamic metabolism honed over the span of evolution to produce a miracle nine months later. Emotional and behavioral aspects of your personality underscore a maternal instinct that comes from deep inside the primitive human brain.
So how does that affect the selection of the doctor who will mastermind your prenatal care? Whether male or female, this doctor better be perfect. At least in your eyes.
Everyone realizes that perfection is an unattainable ideal. But different couples have different priorities as to what constitutes an acceptable level of perfection. You may want the hand-holding type of doctor who will do all the worrying for you, taking both of you through the prenatal course in a mystic cloud of vague pronouncements of well-being. You may want the opposite, a Carl Sagan who will explain the billions and billions of details, pointing out all of the risks and benefits of every option pregnancy has to entertain. You may even want a pal, somewhere in between the first two types, but with enough empathy to struggle with you over a particular decision.
All of these types have successful practices because they attract adequate numbers of patients who seek them out because of their specific approaches. But all obstetricians hope to blend the three types perfectly so that their care is knowledgeable, caring, trustworthy, and endearing.
It is sometimes unfortunate that choosing an obstetrician can be not so much a search for one doctor but an escape from another. Being both an obstetrician and a father, I've had ample opportunity to consider the intricacies of what's important in an obstetrician-patient relationship. A lot of my training in this insight comes from the mistakes of other obstetricians. If you leave one doctor, you no doubt will be switching to another. Your new doctor will be smart to listen to the reasons you switched to her and she will incorporate safeguards into her own practice based on what she can learn from you:
•"I called my doctor for three days and he never returned my call."
•"There are several doctors in the practice, and they all tell me different things."
•"I asked my doctor about this and she just blew me off."
FASTFORWARD
When choosing an obstetrician, you should be able to take as much time as you need to feel comfortable that your questions have been answered. Ask about the type of practice-solo, group, etc; on call arrangements; and refer to the list of other important questions found in the 'Birthing Understanding' in Chapter 12.
Strangely enough, the medical world and patients' reasons for selecting doctors have changed in a very short time. I no longer see people switching doctors because they feel some are knife-happy or too greedy. They seem to switch for failures in the doctor-patient relationship; such a relationship should be professional, but always personable as well. This isn't taught in medical school. A lot of it is innate, but a doctor learns a lot about human nature in the first years of unsupervised private practice too.
As a pregnant woman, you want the best for your unborn child, and you'll usually know after a first visit whether a certain obstetrician's for you. Besides our board exams, we OB doctors must also pass the maternal instinct test.
Two Sides of the Same Coin: Gynecologists and Obstetricians
Your doctor's metamorphosis from gynecologist to obstetrician can be a fuzzy transformation indeed. One positive pregnancy test and he crawls out of his gynecology cocoon as a beautiful obstetrics butterfly. One delivery later and your doctor renews her life cycle by becoming your gynecologist again. The real definition of an OB-GYN doctor, therefore, is based upon what you are— pregnant or not. Your transition from nonpregnant to pregnant walks hand in hand with your doctor's transition from a doctor caring for the nonpregnant woman (gynecologist) to the doctor attending the pregnancy of the child- carrying woman (obstetrician). Because of the fickleness of infertility and the uncertainties of very early pregnancy, an OB-GYN doctor also has to shimmy as both, thinking on two different levels until your particular condition settles toward one of them.
Groups. Solo Doctors, and Midwives
Whether you seek a large group practice or a solo practitioner, there are trade-offs no matter what the flavor. Large groups tend to have a wide variety of personalities to choose from while maintaining a consistent quality of medicine. The many doctors keep each other sharp, and these are the ones most likely to keep up with the medical literature in a timely manner. A large group is also more likely to have subspecialists easily available because the volume of patients can justify the expense of a consultant on the payroll. But this volume also tends to depersonalize your experience. You may not see the same doctor twice in a row, which can be disturbing when you are being followed for a problem that may span several visits. Also, this is exactly the type of situation that might result in two doctors advising two different things. On the other hand, coverage for emergencies is usually better in a large group, the shared on-call schedule so infrequent for a particular doctor that she is well rested, fresh, cheerful, and keen. The flip side of this is that you probably won't be delivered by your chosen doctor. Perhaps not even by a doctor at all.
Midwives have been successfully attending deliveries for thousands of years. Today's certified nurse midwives work in hospitals and are backed up by obstetricians in case of complications. I myself like midwives. A midwife walked me through my very first delivery, and demonstrated a technique I have maintained all of these years. (She later went on to become an obstetrician, mainly out of political frustration.) Midwifery is not to be confused with home delivery, which I address with no small amount of commotion in "Controversies in Obstetrics" in Chapter 22. In my opinion, a normal vaginal delivery in a hospital or birthing center, attended by a certified nurse midwife, backed up by an obstetrician, is as good as a delivery by an obstetrician. It may even be better since midwifery entails more of a total psychodynamic approach. Large groups are usually the ones that routinely employ midwives.
The small group or solo practitioner won't be as swank as the large group, but you're likely to spend much more one-on-one quality time with the same doctor throughout your pregnancy. Also, since there's usually a financial penalty to her when another doctor covers for her and delivers your baby, you're more likely to have her at your delivery. But she'll be running late for many of your appointments, at the mercy of her other patients who may be laboring or delivering during the office hours you were scheduled for.
FASTFORWARD
Group practices are swankier than solo practices and the individual doctors are exposed to influences that keep them sharp, but they're more impersonal and you won't see the same doctor for each visit throughout the pregnancy.
A solo doctor will be dedicated to you and can better assure you of being there for your delivery, but he must be there for all of his other deliveries, meaning that you should bring a lot of reading material to each appointment.
Nurse midwives offer all of the advantages of an obstetrician when backed up by an obstetrician, and promise their patients more of a total experience.
Doctors who are employees of a hospital or HMO will be forced to practice along fiscally sound guidelines. Although this may be medically sound, you may notice a difference.
Hospitalists are usually excellent.
Employee doctors are a strange breed. On one level they don't care how much time they spend on each patient because they're on a salary; but on another level they may get fired for not being productive enough. This is particularly true if they're employees of an HMO. When the turnover is high for employee doctors, there can be many reasons, but the fact that the turnover is high says it all.
“Hospitalists” are the newest breed of Obstetrician. These are hospital-based physicians, hired by a hospital, to maintain a presence on the Labor and Delivery area in case a patient’s own Obstetrician cannot make it to the hospital in time, or to manage Emergency Room “drop-ins” who have no regularly assigned Obstetrician. They are usually excellent, for they have to answer to the private physicians relying on them to manage sudden situations correctly.
If You Choose to Forgo an Obstetrician
The safety of your pregnancy depends on the quality of person to whom you're entrusting your baby, his eighty years or so of life, your own life, and . . . you get the point. I deal with home deliveries in detail in "Controversies in Obstetrics" (Chapter 22), but here are the questions you need answers to:
Is there some sort of certification your midwife has passed, or is she some sort of grandfathered (grandmothered?) provider? What amount of continuing medical education has she taken in the last two years? Does she have the official backup of an obstetrician ready to take you on as a surprise obstetrical complication? And if so, does that doctor have an arrangement with other doctors to deal with this sort of thing should he be off? Or are you on your own if you need transport to a hospital nearby, taking potluck with whatever doctor is on the indigent "life-and-limb" unassigned patient list for that day?
How heroic is she when it comes to pulling off that difficult vaginal delivery she sees as a victory, and does this victory conflict with what's best for your baby? What is her protocol with fetal assessment during labor and how well does she respect signs of fetal distress, like meconium?
FASTFORWARD
Since your baby is so important, investigate a home delivery advocate before allowing this type of delivery. Don't assume expertise without checking her out. Many are self-appointed experts. Be assured of proper backup.
If you're not comfortable with any of her answers, that's your maternal instinct flaring its nostrils. If her answers are well-thought-out and give reasonable explanations, then the only peril left to deal with is the controversy over home delivery.
Choosing the Right Hospital
The greatest doctor or midwife in the world will be inadequate if the facilities are. The ideal hospital for pregnancy, labor, and delivery is one that has in-house anesthesia; a Level III neonatal nursery (that designation means they can handle anything); neonatologists to run the Level III nursery; nursing personnel whose numbers aren't continually adjusted based on the hospital census; private rooms that transform themselves for labor, delivery, and recovery (LDR rooms); pediatric cardiovascular and neurosurgeons; and protocols intuitively sensitive to your needs. There are only a couple of hospitals that meet all of these criteria. One is in Shangri-la, the other is in Oz.
All of this stuff costs money. With the diminishing reimbursements to hospitals by third-party providers, cost containment has made this type of hospital very unlikely. Some endowed large city centers come close, but gilded edges tarnish very easily.
We're talking trade-offs here, aren't we? Not when your baby is concerned, we're not! Well... maybe.
So what are the deal breakers? If you can't have it all, what should you have? Twenty-four-hour in-house anesthesia is an assurance for safety that can't be replaced. If you have anesthesia available to you anytime, even at three in the morning, that means that there's C-section readiness should your baby take a bad turn during your labor. It also means that you can have your epidural immediately if you decide that Lamaze is for the birds, that you hate your husband (the callous brute), and that jumping out of the window might seem reasonable.
FASTFORWARD
Twenty-four-hour in-house anesthesia and a decent nursery should be the deal breakers when it comes to choosing a hospital.
There should be at least a Level II nursery, which has a neonatologist who can take action when surprises happen. A good Level II nursery can handle a lot of difficult situations or at least stabilize a baby for transport to a Level III nursery should the need arise.
Even if you're planning natural childbirth, anesthesia capability is crucial to assure you adequate care in an unforeseen emergency. A Level II nursery is a close second. The candlelight dinner—that marketing perk that whispers, "We care"—should be a distant consideration. If they care, they'll pay for in- house anesthesia and a good neonatologist.
The Best Prenatal Care Begins Before Conception
Maybe you're too late for this section, but if you're not yet pregnant, then heed this call: obstetrically speaking, the best prenatal care begins before you conceive. And if you can't exactly determine when that will happen, the safest way is to stay prepared, to modify your lifestyle as if pregnancy could happen at any time.
FASTFORWARD
Your baby is what you were! Conditions during conception may reflect what was happening three months earlier, when your egg began its journey to the surface of the ovary for ovulation.
Recent studies have shown that the extra ingredients in prenatal vitamins, especially Folie Acid, started a few cycles before conception, can lower your risk of genetic problems and miscarriage. Many researchers feel that when a woman ovulates, the egg's journey to the ovary's surface actually began three cycles earlier. Knowing this, beginning the specially formulated prenatal vitamins three months before your conception makes a lot of sense. And this certainly makes one stop and think about what may have been eaten, consumed, or inhaled over the previous quarter year. Men too have to understand that prior exposure to dangerous substances can affect the ultimate sperm produced. Party on, Garth? Having a baby is an adult decision, and nothing underscores this more than realizing that adult decisions require thinking about the future, even if it's only three months at a time.
The Ten Commandments of Pregnancy
The number ten has always meant something special to human beings. For example, our entire counting system is set on base ten. There were Ten Commandments for goodness' sake. Now scientists feel, as difficult as this is to imagine, that there are actually ten dimensions. So when I cite the important considerations in pregnancy, I don't have to wonder how many to list. I choose ten of course, and I do this for an extremely relevant and scientifically significant reason: That's the number of fingers and toes parents count at their very first perusal of their newborn child.
There are, however, countless considerations, not just ten, when it comes to pregnancy. No matter how many books you read, documentaries you watch, or support groups you attend, there's nothing like actually having a baby to demonstrate how little we all know about this baby business. There could just as easily be a hundred or a thousand points to make about pregnancy. Since space is limited, I'll present ten really good pointers:
I. Get pregnant for the right reasons. There are a lot of wrong reasons to get pregnant. A child is too important to create for frivolous, careless, or selfish reasons. Your decision to have a baby should be based on wanting a child, wanting to raise a child, wanting to make the world better because of how you raise your child.
II. Be a good mother and father before conception. This means being a good husband and wife before exposing children to the complex psychody- namics that constitute a marriage. It's best for all future children if both of you are secure in your relationship before making the next leap toward a family.
III. Be good parents during the conception process. This involves being sensitive to what you expose yourself to during this time. Smoking, alcohol, and drugs are implicated in abnormal pregnancies and pregnancy complications, as well as in miscarriage. Even the guy's exposure to such substances can have an impact so it's best if a safe lifestyle is equally espoused by both of you. Since the very egg you conceive with begins its maturation a few months before actually being released, waiting three months will allow conception with an unpolluted egg, so to speak.
IV. Be a good mother in early pregnancy. Ditto on the smoking, alcohol, and drugs. Your obstetrician can give you a list of medications acceptable in pregnancy. Weeks six through nine (four through seven after conception) are crucial to your infant's organ development, so this is the time of highest risk. It is therefore prudent for you and your unborn baby to be evaluated as soon as pregnancy is suspected.
V. Know the warning signals that should prompt a call to your doctor during your pregnancy. Bleeding, leakage of fluid, and decreased fetal movement are the big three, but ask your doctor. (All of the red flags will be discussed in chapters that follow.)
VI. Stay active and fit. Your exercise regimen before conception need only be modified slightly to avoid undue stress on your ligaments and joints, which will tend to loosen somewhat during pregnancy. You must take care not to get overheated, however, because an increase in your core body temperature may affect your baby's development or heart rate (hot tubs included), although this has never been proven. But don't be sedentary. Cardiovascular fitness helps labor and delivery substantially. Statistics for healthy labor and delivery outcomes weigh heavily on the side of physical fitness. And speaking of weighing heavily...
VII. Concentrate on good nutrition. High-protein, low-fat, low-sugar diets are the best way to go, but fanaticism is to be avoided. After all, you should enjoy life too. Potato chips in your fourteenth week aren't the best choice, but they won't give your child Attention Deficit Disorder.
VIII. Attend childbirth preparation classes. At least for your first baby. Really. In spite of what I'm about to say. True, your first impression of the instructors may be that these are geeky people who for some strange reason chose this to be their holy mission; but these classes fill in a lot of the blanks that regular OB visits may leave. Although it is best if the Ob-Gyn you choose helps clarify and explain the varied aspects of your pregnancy, there's nothing like the detailed education of childbirth classes—for husband and wife. You should be aware that many of these instructors sometimes have a political agenda, downplaying epidurals and other pain management as unsatisfactory alternatives to more natural approaches. This sort of thinking won't bother you if you're planning on a natural childbirth, but if you're an admitted coward, the denunciations of modern pain relief will give you anxiety. If you ignore the tirades, you can otherwise rely on the medical information as accurate. You'll know when self-appointed birthing guru hooey interweaves with legitimate medical information when you look over at your spouse and see that one raised eyebrow. If you can't swing the time to do the classes, I suppose you had better read the rest of this book.
IX. Trust your doctor. Many pregnancy books encourage you to challenge any aspect of your prenatal care. Unfortunately, some of these authors unilaterally decree what issues are apparently unethical, be it indications for C-section, usage of labor inducers, or other judgment considerations. But when it comes right down to it, you either trust your doctor or you don't. If you do, you'll feel comfortable with the rationale for any decisions that need to be made. If you don't, you're going to the wrong doctor.
X. Appreciate the important things in your life. Realize that you're going to have to put yourself second for a while. Realize that although children are hard work, they give back more than they take. Know that if you're anguishing over birth contracts and fashionable delivery methods, it's not how you have the baby but how you raise the baby. Let me repeat that because it's a theme that is the basis of all that's important in life: It's not how you have the baby, it's how you raise the baby.
Besides reading a book on pregnancy, you might also pick up a book on parenting because after you have your baby, your obstetrician's job is over. Yours is just beginning.
Q&A
The "Q & A" section is a great way to shed light on finer points that tend to get lost in categorizations in the text. At the end of each part, I include actual questions that have been sent to me, along with the answers I have given. They're typical of the actual conversational tone in the doctor-patient relationship. This gives more of a "press the flesh" treatment on described problems, individualizing issues that come up but are generally ignored in the clear but otherwise incomplete chapter explanations.
Relationship with Your Obstetrician
Question: I chose my obstetrician carefully, but I find that she uses a nurse for the routine visits so I have yet to even meet her. How should I approach this uncomfortable situation?
Answer: Welcome to managed care. Enter the physician extender. With reimbursements going down and overhead going up, the only way doctors can maintain their income is to deal with more volume. But a doctor can only see so many people. If a doctor properly supervises her practice, the use of a physician extender like a nurse practitioner is safe, ethical, and financially necessary in these troubled times of managed care. If the doctor is responsible, so will be her supervision.
Prenatal Vitamins
Question: I can't swallow those big vitamin pills—they make me gag. What if I don't take them at all?
Answer: Some women cannot swallow the big horse pills that most prenatal vitamins are without gagging. If there is any degree of morning sickness, prenatal vitamins can make this worse. The iron in them generates burps and aggravates the esophageal reflux that pregnancy is famous for, seriously challenging the self-esteem of any lady who fancies herself demure. If it's the sheer size of the pill, and you can't break them into halves or thirds (which is OK) your doctor may have to prescribe chewable or liquid vitamins to overcome these difficulties. Sometimes it's wise to just wait a few weeks, then restart a vitamin because vitamins are more than just a good idea. They are an important component of modern prenatal care. But they have to be tolerated to do any good.
Previous Surgery on the Cervix
Question: I've had my cervix frozen twice for dysplasia (precancerous cells). Will this affect my fertility or pregnancies?
Answer: The cervix is that structurally strong opening that holds a pregnancy in until labor causes enough force to push a baby against it, allowing dilation. One would think that any destructive procedure, like freezing the cervix to cause a "freezer burn" of precancerous tissue (called cryosurgery), could weaken the strength of the cervix and make premature delivery more likely. In my experience I haven't found that to be so, even with multiple episodes of cyrosurgery (and laser too). Of course, some women have a congenital weakness of the cervix already, so it's hard to say whether preterm delivery is really a complication of cryosurgery or laser treatment, instead of just a bad cervix to begin with. Theoretically, cryo might cause scarring, interfering with the passage of sperm or with dilation during labor. A gentle probing can solve the first problem, and if necessary, a C-section will tackle the latter.
FASTFORWARD
Conservative treatment for cervical dysplasia usually doesn't interfere with pregnancy or delivery.
In spite of theoretical dangers, freezing and other techniques to destroy precancerous cells (dysplasia) are for all practical purposes fairly harmless out in the real world. This is because the real functioning portion is the internal cervix, which lies well up the cervical canal, well out of the way of the more superficial zone of destruction. Seldom do destructive procedures go that deeply. Except for cone biopsies.
A cone biopsy is the most aggressive way to remove abnormal uterine tissue. This technique is usually reserved for particularly severe cases (borderline cancer) or when it's not known how far up the cervix the abnormal tissue extends. A scalpel is used to remove a cone-shaped chunk of the cervix, and this excision, along with the added tissue damage caused by suturing and by cauterizing to control bleeding, might get close to the internal opening of the cervix (the "internal os").
But cryo and laser are not even in the same ballpark. The only problem that could remain is that the sampling area for Pap smears could get scarred up the canal, making it more difficult to get an adequate Pap, which of course is very important when a woman has had dysplasia already.
Keeping a Previous Abortion a Secret from Your Doctor
Question: I've had an abortion, and now that I'm pregnant again Vm wondering if keeping this information from my doctor will affect the care. Does he really have to know?
Answer: Not really. If you didn't have any serious complications related to the abortion, like a postoperative infection that might have scarred the inside of your uterus or another medical condition that became evident only after the challenge of an operative procedure (the actual termination), then I can't see how this information would be crucial.
However, do you really want this type of relationship with your doctor? You certainly depend on honesty from him; shouldn't he expect the same from you? Yours is a lie of exclusion. A doctor-patient relationship goes both ways. If he's professional, regardless of his views on abortion (and I'm sure this is why you ask), he should treat you no differently because of that information. If you can't fess up, then there's a serious problem with the doctor-patient relationship.
The Big Question
And I'd like to end this with a ringer question:
Question: Is it how you have the baby?
Answer: No, it's how you raise the baby.
PART ONE
THE FIRST TRIMESTER
1.
So You Went and Got Pregnant
The Womb of the Unknown Pregnancy: The Art of Classical Obstetrics
With the advent of ultrasound and near-perfect urine and blood tests, the diagnosis of pregnancy is pretty much a no-brainer for today's lab-connected physician. But there is a certain romance of sorts in the history of pregnancy diagnosis before these modern aids were in common use. Doctors used to be trained differently—to use judgment and diagnostic skills that today seem obsolete.
Yesteryear's medical books, incorporating the intrigue and romance of physiologic processes, were so beautifully written that it's hard for me to ever throw any of them away. Looking through them is a journey back into the wonders of the art of diagnosis. Today you're handed ultrasound pictures of your baby on a silver platter and your doctor is spoon-fed rising values of hCG, the pregnancy hormone, almost before your period is late. In earlier nonsophisticated times, many women couldn't get the diagnosis of their "delicate condition" until midpregnancy. We should never pine for a return to those days, but it is fun to see the diagnosis through the eyes of old-time medicine, like watching a child's wonder at the simplest of things we take for granted every day. Pregnancy is and has always been a beautiful experience; and although the science of obstetrics has made for a better pregnancy, the beauty of the art of medicine has been somewhat lost. But as a Rembrandt in an attic remains beautiful even if there's no one there to appreciate it, so it goes with the signs and symptoms that were noted in years past.
Back in the "olden times," circa i960 (last century, remember?), the "old time" diagnostics were grouped into three classifications: