Common Pregnancy Questions, Part 2

What’s pregnancy acne about?

 Acne in pregnancy is extremely common and it is often more difficult to treat.  “Pregnancy acne” is not a special form of acne.  Pregnancy acne occurs due to the overproduction of sebum oil which happens from all the hormonal changes.  Unfortunately, some women are more susceptible than others. Some studies show that as many as a third of cases actually improve in pregnancy but most women will report some worsening.  

 What are some general things to keep in mind when choosing acne products for pregnancy?

First things first when it comes to taking care of your face during pregnancy to minimize pregnancy acne.

The various forms of treatment include the following:

1. Wash your face twice a day.  You can use a mild cleanser with warm water and gently wash your entire face.
2. If you have oily hair, shampoo daily.  Be careful to keep your hair off your face.
3. Avoid picking, scratching, popping or squeezing acne sores.  These types of habits can spread infection and potentially cause scarring.
4. If you use cosmetics, stick to oil-free products.  Descriptions such as water-based, noncomedogenic or nonacnegenic. 
5. Avoid resting your face in your hands.  This can trap skin oils and sweat, which can irritate acne.

What medication is safe to use to treat pregnancy acne?

Medication is the second line of treatment for pregnancy acne.  Erthromycin (Erygel) or clindamycin (Clindagel) is often the drug of choice of pregnancy acne.  Azelaic acid (Azelex, Finacea) is another option.  Both of these medications are applied to the skin as a lotion or gel and are available by prescription.

Other more controversial and less studied products include benzoyl peroxide and other over-the-counter or prescription strength benzoyl peroxide during pregnancy.  

Medications to avoid during pregnancy include isotretinoin and other retinoids, minocycline, doxycycline and other tetracycline’s.

Initially you should consult with your obstetrician or health care provider for first line treatments.  If those prove to be unsuccessful consult with your dermatologist.  Together you can weigh the benefits and risks of various treatment options.

 When does the third trimester start and end?

The third trimester is from week 27 to 40 week.

By 40 weeks, your baby will be about 19.6 inches (50cm), and weigh approximately 7.5 lbs (3.4kg)

What are the most common symptoms during your third trimester?

The most common symptoms during the third trimester include more frequent Braxton Hicks contractions, heartburn, backaches, shortness of breath, varicose veins, hemorrhoids, frequent urination, insomnia and anxiety in anticipation of delivery.

What are the most important changes that happen to the fetus?

During the third trimester the fetus is preparing for delivery. Hair growth, weight gain, practiced breathing, finger and toenails grow, testes descend into the scrotum for a male fetus and the skin becomes smooth.

When do most women give birth?

The majority of women give birth between 37 and 42 weeks.

What are some signs that something is wrong?

Concerning third trimester symptoms include vagina spotting or bleeding, uterine cramping, lower abdominal pain, persistent headaches, nausea and vomiting and decreased fetal movement.  

 During the third trimester, what are the most important things to do or keep track of?

The most important things to keep track of during the third trimester is keeping track of daily fetal movement, getting adequate rest, eating a healthy well-balanced diet and preparing you and your partner for labor, delivery and preparing for a new born.

What causes feet to swell in pregnancy? 

Swelling in pregnancy is completely normal and expected. If you think about it, your body produces 50% more blood volume and other body fluids that help in the growth and development of the baby.  All the additional fluids will be evenly distributed throughout the body and be most obvious in the hands, legs, feet and face. It’s most noticeable after 28 weeks as you enter your third trimester of pregnancy.  During the third trimester, the growing uterus puts additional pressure on the lower extremities making the swelling even more pronounced in the legs, feet and ankles.  

When does swelling in pregnancy usually begin?

During the late second and third trimester the growing uterus puts additional pressure on the lower extremities making the swelling even more pronounced in the legs, feet and ankles.  “Cankles “are affectionately used to describe swelling of where the leg meets the ankle.  Swelling is more noticeable during the day and goes down at night. Pain, heaviness and tingling are common symptoms.  Prolonged standing and being on your feet for long periods of time will also make the swelling worse.  The last couple weeks of pregnancy are the most challenging. Your feet will increase by one shoe size during pregnancy.

Are swollen feet during pregnancy ever cause for concern? 

When swelling of the feet seems excessive and with a more rapid onset that could be a subtle sign of preeclampsia or high blood pressure of pregnancy. If one leg or calf appears to swell disproportionately to the other leg this could be a sign of a deep vein thrombosis.  Both of these conditions and swelling with pain or a rash should also be addressed by your obstetrician. 

If you develop “cankles” during the 3rd trimester, the best treatment is to elevate your legs above the level of your heart periodically throughout the day, wear support hose, comfy shoes and stay hydrated with plenty of water.

Every pregnancy is different.  Depending on the amount of weight you gain, frequency of exercising, foods (and salt!) you consume and what season you are during your third trimester will all affect the swelling in your body and feet! 

Avoid prolong standing and wearing too-tight of elastic stockings or socks.

What is the doctor doing when checking my cervix at 38 weeks?

The cervix can be checked in a couple of different ways.  

An internal pelvic exam uses two fingers by the doctor, nurse or midwife to check and feel how many centimeters the cervix is opened or dilated.  Zero centimeters means the cervix has not dilated at all and 10 centimeters means the cervix is completely open and the baby is ready to deliver. During a pelvic exam, the cervical softening or effacement can be checked as well. The more effaced the cervix is the more likely the cervix will dilate.

Alternatively, a pelvic ultrasound can also be used to measure the length and dilation of the cervix during any stage of pregnancy.

Is a Hospital Tour necessary?

Taking a tour of the hospital before you go into labor gives you and your partner helpful information about the layout of labor-land.  You can either sign up for a hospital tour physically or often do them virtually. A tour allows you to be familiar with the hospital, showing you where to park, which elevators to take you to labor and delivery and understanding the roadmap on the “big day!”

Taking a tour will make you feel more relaxed, more prepared and less stressed. 

Do I need a birth plan?

A birth plan allows the couple to do a deep dive into all aspects of the labor and delivery process and what happens with the baby during the first few days of life. But creating a birth plan is not for everyone and most couples do not make one.

A typical birth plans makes sure you and your partner cover every aspect of the delivery and postpartum process, from allowing the nurses to place an IV into your arm when you first arrive to whether or not the baby is placed directly on your chest immediately after delivering versus going to the baby warmer.  It’s your personalized road map through the entire process.

Other common highlights of a birth plan include acceptable baby monitoring, pain medication options during labor, preferences for who should be in the delivery room, cutting an episiotomy versus letting the vagina tear naturally, delayed umbilical cord cutting, maternal-baby bonding guidelines, acceptable baby vaccines and other postpartum wishes.

The most important thing to remember about a detailed birth plan is they may not go exactly as planned.  Even with your personalized road map there can be unexpected detours and obstacles that you did not anticipate. You have to be open minded and not feel defeated or a failure if it doesn’t go exactly as planned.  During the labor and delivery process, even as a practicing OBGYN, you have to expect the unexpected.

Remember, “man plans and God laughs” is a perfect metaphor for the labor and delivery experience.

What should be included in my hospital bag?

Pack your bag ahead of time! Slippers, robe, comfortable PJ’s, camera (charged!), back-up batteries for all electronics, cell phone, video camera, memory sticks, camera and cell phone chargers, your favorite playlists, special object (photograph, stuffed animal) to focus on during labor, cord blood kit for storage, toiletries including your personal shampoo, soap, toothbrush, hairbrush, “belly bandit” to wear postpartum, Baby memory book , favorite outfit you received from your baby shower to dress the baby in, favorite pillow and blanket, comfy sweats and nursing bra to wear postpartum.

What to know about labor?

It can be confusing knowing when true contractions are occurring versus Braxton Hicks contractions.  Simply put, Braxton Hicks contractions are painless contractions where real contractions are painful.  When you experience a Braxton Hicks contraction you will see your uterus tighten and become hard, like a rock, but it is not associated with pain. Real uterine contractions start as a menstrual cramp and continue getting more intense and painful unlike Braxton Hicks contractions.

Timing your contractions helps you differentiate between false and early labor.  Uterine contractions that have a pattern of every 3 to5 minutes for 2 hours help you become more aware labor is starting.  Measuring contractions from the beginning of one contraction to the beginning of another contraction is one way of tracking the frequency.  As long as you are consistent in how you time the contractions you will see a pattern that suggests labor is happening.

As labor progresses, the intensity and frequency of the contractions will become stronger and more painful.

What are the first signs that you’re in early labor? 

As you get closer to term (38 to 42 weeks) your uterus, which is one large muscle, will start to contract.  If the uterine contractions are irregular, occurring sporadically, and the pain in minimal, you are not in early labor.  Once the uterine contractions become regular, appear closer together with an increase in intensity this is a sign that labor has started. Regular and painful uterine contractions, occurring every 3 to 5 minutes for 2 hours, are a sign early labor has begun.

Another sign that early labor has started is if your bag of water breaks.  It may be a subtle “leak” or a “big gush” when your “water breaks” and you may or may not have uterine contractions.  But one thing is definite, early labor will begin within hours of your water breaking.

What are all of the reasons women might need to be induced and WHY is it imperative that they are? 

The majority of labor inductions occur as a result of medical complication that can negatively affect the health of the mother or baby such as maternal high blood pressure, diabetes or poor growth of the baby. Medically indicated inductions should occur after 34 weeks ideally unless it’s a matter of life and death for mom or baby. “Elective” inductions can also be considered for a nonmedical reason at 39 weeks if the cervix is favorable for induction.  An example of elective induction is if a previous delivery happened quickly and there are concerns the woman would not make it to the hospital when she goes into labor.   When deciding to have an elective induction it has to be after 39 weeks with the accurate dating of the pregnancy and an inducible or “favorable” cervix. A cervix is favorable when it’s thinned out and dilated before the induction begins.  Labor tends to go more quickly and is more likely to be a vaginal birth with a favorable cervix.  If the cervix is “unfavorable” the process of an induction may take a couple of days or end up in a cesarean section. 

What are the health hazards if they are not induced? 

If a medically indicated induction does not occur there can be potential health dangers to both the mother and baby.  The most concerning health hazard could be death to the mother and baby.  Other complications include infection, maternal seizures, stroke, emergency hysterectomy and significant blood loss. 

What is not a reason to be induced? 

If you have being induced electively you must have a cervix that is favorable for delivery.  If you don’t have a favorable cervix, you should not be induced unless there is a medical indication.  

Can Castro Oil induce my labor? 

The most common myth is using castor oil to put you into labor.  The problem with Castro oil is that it has side effects including diarrhea, dehydration and uterine irritability.  Unfortunately, all these recommendations are also known as old wives’ tales. If any of these suggestions put a woman into labor it’s just a wonderful coincidence.

What are some myths of what will put a woman into labor?

There are many suggestions given by friends, mothers, grandmothers and next-door neighbors about activities that will “definitely” put you into labor.  They include eating spicy foods, drinking special teas, having mind blowing sex, explosive (and multiple!) orgasms, intense exercise workouts and, of course, labor inducing-acupuncture.  

FUN MYTHS ABOUT LABOR AND DELIVERY

Here is a list of memorable myths of labor and delivery from my patients over the last 3 decades.

1. Once your water breaks your baby will pop out!  All women wish this was the case but it’s not.
2. When labor begins is obvious—not always!
3. Labor is always painful.  For a handful of lucky women, they don’t experience horrible and painful contractions.
4. Your obstetrician is present during most of your labor.  Unfortunately, the doctor comes and goes and then returns when the baby is just about to delivery.  The nurses are the ones who are with you during the entire process.
5. You rarely poop when you push out the baby’s head—sorry ladies most women do!  I will never say no to an enema!
6. Doctors don’t care if you wax or shave your vagina before giving birth—we may say we don’t care but it is easier to repair a vagina if there is less hair around the opening.
7. You can receive a “light” walking epidural if you want to walk around with mild labor pains.  In theory we tell patients that this is available but in practice it never happens.
8. Most women will delivery around their due date—rarely does a women delivery on her due date.
9. Episiotomies will reduce the amount of tearing that happens in the vagina—not true, if you can avoid one you should ask your doctor to do so.
10. Losing your mucus plug or having your cervix dilated means you will immediately going into labor—pregnant women wish this was the case!
11. Tall women have the perfect pelvis for a vaginal delivery—unfortunately even tall women have small pelvis.  You may look “wide” from behind but you may not have a large pelvis.
12. More babies are born during a full moon—studies don’t support this myth!
13. A well thought out “birthing plan” is key to a successful vaginal birth—if you ask the nurses on labor and delivery, most couples that create a 7 page birth plan for a vaginal birth are more likely to end up with a c/section.  Controlling new moms’ and dads are even more high risk to have a csection!  
14. Your labor will be just like your mom’s-there may be similarities in your pelvis but there are many other factors that make your labor go one way or the other.  Truth be told your labor will not be like your moms.
15. If I drink castro oil, take laxatives, eat Mexican food or go for acupuncture I can induce labor.  These are myths that are not reliable plus for some you will get major diarrhea as a result.

Here is my list of Labor-do’s and don’ts 

”Do” pay attention to you symptoms and “don’t” minimize what you are experiencing or feeling.

“Do” prepare yourself and your partner for the big day so you are aware of what labor will look like.  

“Don’t” wait to the last minute to prepare your birth plan and discuss it in detail with your healthcare provider.

“Don’t” be afraid to call your doctor is you are not sure what symptoms you are experiencing.

“Don’t” wait too long to pack your hospital bag.

Most importantly, “DO” go into labor with an open mind, trusting your doctor and knowing whatever happens is beyond your control.  “Don’t” have a planned labor agenda, it’s rarely followed!

How common are breech (butt or feet first) babies?

3-4% of term pregnancies are breech pregnancies.   97% of all deliveries are head first, also known as vertex. Vertex presentation can delivery vaginally, whereas breech baby’s need to be delivered by CSection.

What happens if the baby is in the breech position at term?

Most pregnant women want to avoid a C-section at all cost and are willing to try old wife tales and Eastern methods to change this mode of delivery.  The good news is that homeopathic, Chinese and other Eastern approaches to turning a breech to a vertex presentation pose no real danger to the baby. Since the Tilt, Webster technique, Pulsatilla and Moxibustion are relatively safe techniques they are certainly worth a try.

External cephalic version (ECV) is an option for turning a baby who is in the breech position to a vertex. ECV is not for the faint of heart since it can be very painful and uncomfortable for the mom.  It’s performed in a hospital setting and the baby is continuously monitored.  The success of flipping a breech baby to the head down position is around 50%.  Preterm labor, premature rupture of membranes, fetal distress and placental abruption (damage) can occur from all the external pressure placed on the uterus with this procedure.  Fortunately, complications are rare.  If the ECV fails, a breech baby has to be delivered by Csection to ensure a healthy birth.

Are women ever induced when they really don’t need to be? 

The obstetrician is the doctor in charge in determining if a woman needs to be induced and what is the indication for delivery.  At times a high-risk obstetrician called a Maternal-Fetal Specialist is consulted to be involved in the discussion making process.  The field of obstetrics is not always black and white when it comes to major pregnancy decisions.  As a long time, practicing obstetrician, you sometimes have to go with a gut decision always having the woman and baby’s health at the top of the priority list.  As long as the doctor is not inducing you so he won’t miss his annual golf tournament I image most obstetricians have the mom and baby’s best interest in mind.  

How many weeks do inductions usually occur? What is the earliest/latest?

Inductions for medical complications putting the mother or baby at risk can be done at any time during pregnancy.  Ideally, it’s best to get to 39 weeks when it’s known that the lungs of the baby are completely developed.

The latest to induce a low-risk woman is at 42 weeks pregnancy.

What are some techniques for handling early labor pains? 

Early labor pains can be easily handled with a few classical techniques.

• Breathing in a calm and controlled manner where you take a breath slowly, in through your nose and out through your mouth.
• Relaxing your body, lower back and pelvis, keeping your body flexible-making circles with your hips.  Bouncing on a birthing ball and sitting in a rocking chair helps shifts pain during early labor.
• Messaging the lower back by your partner helps release extra tension builds up.
• Taking a warm bath or shower.
• Visualizing or focusing on a relaxing place such as a beautiful sunset or your favorite vacation spot.  This is referred to as going to your “happy place”.

When is it time to go to the hospital or birthing center? 

When to make the drive to the hospital varies for every pregnant woman.  If you are having painful and regular contractions every 5 minutes for 2 hours or break your bag of water it’s time to call your healthcare provider.  Depending on the amount of pain you are experiencing will determine when it’s time to go the hospital.  If you can tolerate the pain and are able to easily breathe through the contractions you may be able to stay home a bit longer. Once the pain becomes more intense and increasingly painful then it’s time to gather your hospital bag and head over to the hospital.

How long does a “typical” labor last?

For first time moms who go into labor spontaneously, labor lasts 12-18 hours. If you have already had a vaginal delivery, labor lasts an average of 6 to 8 hours.  

Is it better to rest up or stay active (like walking) to keep things progressing?

It’s best to keep active during early labor.  Walking can help promote uterine contractions.  If you are in false labor walking may cause the uterine contractions to stop.

What should you eat or drink during labor?

Eating in labor is not recommended since many women become nauseous and have vomiting, especially during the active stage of labor and pushing.  The other concern about eating in labor is if there is fetal distress and an emergency cesarean section is necessary having food in your stomach can increase your risk of getting food in your airways (aspiration) during surgery.

Stick to ice chips and sips of water!

What are the pros and cons of ripping naturally during childbirth versus having an episiotomy? 

I always reassure my patients the decision of cutting the vagina or letting the tissue tear naturally is determined at the time of the delivery.  Some factors include how long the woman has been pushing, how large is the baby’s head, how swollen is the vagina and is there any reason to deliver the baby quickly due to fetal distress.  As long as you reassure a pregnant woman you have their best interest and the interest of the baby first and foremost, the conversation ends comfortably.

The episiotomy used to be the most common surgical procedure performed on women.  But now the episiotomy is on the decline and less recommended as the first choice of helping delivery a baby vaginally.  It used to be this procedure made enough room for the baby’s head to be delivered with the least amount of damage to the vagina.  Now it’s thought to be more damaging then helpful.

The “pros” have been it helps make the pushing phase led to a faster delivery, prevents tearing into the rectum or urethra, an heals faster than tearing. 

The “cons” or complications include infection, longer healing time, increased extension of vagina affected, bleeding, pain at the site of the episiotomy and future pain with intercourse.

Vaginal tearing is now a more common practice and recommended by Obstetricians. 

Why might a women’s vagina tear?

Women who are more likely to tear include the following:

• If it’s your first baby
• Having a larger than normal size baby
• Vacuum or forcep assisted delivery
• If the baby is being born face-up (occiput posterior)
• Uncontrollable pushing
• Needing to expedite delivery due to fetal distress

Severe vaginal swelling due to prolong pushing. There are times where an episiotomy allows for an easier vaginal delivery.  Unfortunately, the decision to do an elective episiotomy is not known until the moment the baby’s head is crowning.  Hopefully you have had the conversation with your Obstetrician to allow her to make that judgement call at the time of that unpredictable moment!

What problems can severe tearing or extensive episiotomies cause?

Severe tears or extensive episiotomies into the vagina or rectum can cause pelvic floor dysfunction and prolapse, urinary incontinence, fecal incontinence, sexual dysfunction including pain with intercourse.

What are risk factors that increase your risk of needing a C-section before a woman goes into labor?

Women who may be at higher risk to need a C-section while in labor include:

• Maternal Obesity
• Low Amniotic Fluid
• Postdates
• Unfavorable cervix 
• Twin pregnancy
• Maternal medical complications including High blood pressure of pregnancy (Pre-eclampsia), Gestational Diabetes, Heart disease
• Baby complications including smaller or larger than average, birth defects
• If the baby has an unusually large head.
• Previous Cesarean Section
• Breech or Transverse presentation
• History of a herpes infection

 

What are the complications during labor that a C-section would be medically necessary?

The most emergent reason to need a C-Section during labor would be fetal distress, placental abruption (placenta separates from the uterine wall), breech or transverse presentation and an active herpes outbreak.

Are epidurals safe for pain management during labor?

If they want pain medication I personally advice my patients to choose an epidural as the form of anesthesia since it is a nerve block and therefore does not affect the fetus during labor.  With the epidural the patient losses the pain sensation to the area of the uterus so pain from the strong force of uterine contractions is not felt. Lighter dosed epidurals are called “walking epidurals” and are used for those women that prefer less sedation.  With an epidural you do not have any problems feeling drugged or foggy as you would with intravenous sedating medications.  With an epidural, when the time comes to push the baby out you still can feel the rectal pressure that assists you in pushing effectively.  Ultimately your choice of pain relief will be determined by you and your partner’s preferences along with your health care provider.

What about using laughing gas in labor?

Laughing gas or happy gas is not a new fad to help take the edge off the agony experienced from the painful contractions during labor. It’s been used since the 1800’s for pain relief especially for use while in the dentist’s chair.  In the 1950’s, nitrous oxide which is the active ingredient to laughing gas, was used for women during labor. The pain of labor is truly no laughing matter. ☺  Once epidural anesthesia was introduced in the 70’s and found to be a more reliable and effective pain option, laughing gas lost its popularity. In Europe, nitrous oxide is regularly used for women in labor. 

The idea behind laughing gas is to use a cocktail of 50% nitrous oxide with 50% oxygen delivered through a breathing mask which gives you a feeling of euphoria and relaxation. Basically, you become less focused and aware of the intensity of the pain experienced during labor.  Midwives are especially excited to be able to use nitrous oxide for their laboring patients.  A recent study in Anesthesiology 2016 showed nitrous oxide may take the edge off but won’t be effective for extreme pain and these women will ultimately need an epidural for true relief. In other words, nitrous oxide will never replace an epidural as the ideal way to manage labor pain. 

Benefits include:

• Allows patient to move around in labor
• Short acting
• Self-administrated by inhalation
• Effective for mild pain of labor
• Safe alternative option of pain relief
• Easy to use
• Has a euphoric, anti-anxiety and relaxing effect
• Leaves the body in minutes
• Less expensive than current pain relief options
• Midwives and other trained medical staff can administer nitrous oxide
• Colorless and nonflammable gas with a slightly sweet odor

The side effects of nausea, vomiting and feeling lightheaded are no laughing matter, and often are a reason not to use method of pain relief.