Erythroblastosis Fetalis (EBF)

EBF is the result of blood incompatibility between the mother and her fetus. Understanding how the negative and positive blood incompatibility occurs can be confusing, but here goes.

When the mom’s blood type is negative and the baby’s father’s type is positive, the baby has a 50/ 50 chance of being positive too. Being positive is what causes the problem between mom and baby. The mother’s body normally views the baby as a friendly, harmless parasite. In the Rh negative mom whose baby is Rh positive, the mother’s body views the fetal blood cells as dangerous intruders and takes action. Mom becomes sensitized and develops antibodies (weapons) to destroy the red blood cells in the baby. As the red blood cells are being destroyed, the baby becomes anemic. More problems develop as the baby tries compensating for the anemia. In severe cases, the fetal heart and liver can fail from trying to keep up, although with current treatment 70 percent of even severely affected babies survive.

A Stitch in Time

Prevention is always the best approach to any problem. This is no exception. Once the mother is sensitized, the sensitivity is lifelong and irreversible. It doesn’t help to lock the barn door after the horse has escaped.

Blood typing, Rh determination, and antibody screening are routinely done at the first prenatal visit. All Rh negative mothers have the antibody screen repeated a t 28 weeks of pregnancy. If there are no antibodies to indicate she’s sensitized, a prophylactic injection of Rh Immune Globulin (RhIG) should be given. After delivery, if the baby’s blood type is positive, another injection of RhIG is given within 72 hours, locking the barn door to sensitization. Even if you’re having a tubal ligation, you need RhIG because occasionally tubal ligation fails, or at a later time you might want your tubes reconnected.

Other Indications for RhIG

• Spontaneous abortion (miscarriage) occurring more than 6 weeks after the last menstrual period.

• Induced abortion

• Ectopic pregnancy

• After amniocentesis

There’s always great optimism that EBF will be wiped out in our lifetimes. Do your part; there are always inadvertent slipups. If any of the above situations occur, remind your doctor to order the RhIG injection. Don’t assume you don’t need it – you do.

ABO Incompatibility

Occasionally, blood incompatibility can result when mom has type O and baby has either AB, A, or B type blood. Only 2 percent of births are affected by ABO incompatibility. This type of EBF is different from the Rh-problem. ABO isn’t as serious and doesn’t become more severe with each pregnancy. The baby doesn’t die before birth, and the sophisticated technology, such as amniocentesis and ultrasound, isn’t necessary. Preterm delivery isn’t necessary. ABO incompatibility is more a pediatric disease than an obstetrical one and can usually be treated with little difficulty after the baby is born.

The Overdue Blues-Postdates Pregnancy

You’re now 2 weeks past your due date and officially considered postdates by your doctor. You’re afraid to be seen in public because you’re tired of people asking “Haven’t you had that baby yet?” You stop answering the phone because your mother calls every 3 hours to ask “Is anything happening?” You’ve stopped speaking to your husband, your doctor, and the rest of the world. You don’t want to be pregnant anymore. You want your doctor to do something! You may be miserable, but your doctor isn’t having any fun either. She has to worry about your “aging” placenta providing enough oxygen and nutrients to your baby. Your doctor has to weigh many factors in order to make the appropriate decision in your particular case. If your actual due date is really uncertain, add more gray hairs.

The state of your cervix is usually the critical factor in whether or not labor can be induced. With an unripe cervix, some doctors prefer to leave Mother Nature alone if the fetal well-being tests are reassuring, the baby is growing appropriately, and there’s an adequate amount of amniotic fluid. Some obstetricians start fetal testing at 41 weeks.

The more unripe the cervix, the less chance of a successful induction of labor. There are no guarantees the oxytocin will work. In some cases with an unripe cervix, doctors try the serial induction technique: The first day is spent just trying to ripen the cervix, another day is spent “priming” the uterus, and on the third day efforts are made to establish true labor sometimes it works, sometimes not.

If your cervix is ripe and ready to go, most doctors feel comfortable inducing labor. Everybody can breathe a sigh of relief. If you and your doctor opt for inducing labor, skip to the induction section-your prayers have been answered.

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Pass The Smelling Salts!

The possibility of more than one baby lurks somewhere in the dark recesses of every pregnant woman’s mind. Twins occur once in every 100 pregnancies. The thought may delight some and provoke horror in others.

Head Start

Before ultrasound, as many as 30 percent of twin pregnancies were surprises. The smelling salts weren’t needed until delivery. Early diagnosis of the twin pregnancy is critically important; plans must be made. In the first or early second trimester, an ultrasound exam can eliminate surprises. You can see two babies in there-no guessing. For the duration of your pregnancy and definitely after, you’ll need to make adjustments in your life-style.

Double Trouble

Twins may double your fun after birth, but there are potential problems during pregnancy that your doctor will want to anticipate and avoid. The twin pregnancy is high-risk. Careful attention to detail and planning help ensure a happy landing for your double duo. Listing some of the potential problems for you isn’t done to scare you but to give you a good idea why you need skilled care during your pregnancy.

Potential Problems for Twin Pregnancy

• Significantly higher infant mortality rates than single pregnancies.

• Low birth weights.

• Preterm labor. Twins deliver on the average about 3 weeks early.

• Discordant growth-intrauterine sibling rivalry. One twin receives more nourishment from the placenta, and the other one is “underfed.” “The placenta always liked you better” kind of thing.

• Preeclampsia.

• Maternal anemia.

• Placental problems such as premature separation and placenta previa.

• Complicated labor. If one twin is breech, a cesarean birth is often done.

Now you know why many obstetricians have gray hair. Guiding your twin pregnancy to a successful, uneventful completion is a real challenge for both you and your doctor. There are five important things you can do for yourself:

• At about 28 to 32 weeks, your doctor may ask you to quit work and spend a fair amount of time lying on your side to increase placental blood flow. T his also helps the babies gain weight.

• Learn the signs of pre term labor. Pay attention to what your body is telling you.

• Don’t hesitate to call the doctor or the office nurse if you think you’re having contractions.

• Eat a well-balanced diet with adequate calories.

• Take your vitamins, the ones with the iron and folic acid.

Your doctor will perform several ultrasound exams during pregnancy to follow the growth patterns of both babies-remember the sibling rivalry. Nonstress testing might be added weekly at 32 weeks, if it’s indicated, to evaluate how well the babies are doing.

Delivery may add a few more gray hairs to your obstetrician’s head. He’ll want you to deliver in a hospital with equipment and personnel trained to care for you during labor and your babies at birth. Talk to your doctor about your options. If preterm labor strikes, a perinatal center is usually your best bet. It’s less anxiety-provoking if you plan ahead for all possible situations. Have a game plan. You’ve had enough surprises.

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Six to eight percent of all babies born arrive before 37 weeks’ gestation. These small numbers, however, account for 75 percent of all the neonatal deaths – a significant statistic. It costs as much to care for 5 preterm babies as it does 150 pregnant women. Everyone agrees that prevention is the best approach since Mother Nature provides the best incubator. But this is easier said than done.

An Obstetrical Stew

It’s extremely difficult to prevent something when you aren’t sure of the exact cause, as in 50 to 60 percent of preterm labors. The current strategy is to identify – in advance those women most at risk for preterm labor. A look at a risk-assessment guide reveals an obstetrical stew of social, physical, and pregnancy factors that contribute to preterm labor. The following is a sample list.

Major factors for preterm labor:
Previous preterm labor
Multiple pregnancy (twins or more)
Abdominal surgery during pregnancy
Two second-trimester abortions
Cervix less than 1 cm long
Cervix dilated more than 1 cm
DES daughter
Cone biopsy of cervix
Incompetent cervix
Irritable uterus
Polyhydramnios (excessive amniotic fluid)
Uterine anomaly (double uterus)

Minor factors for preterm labor:
Bleeding after 12 weeks
One abortion in the second trimester
Three or more first-trimester elective abortions
Febrile (fever) illness
Pyelonephritis (kidney infection)
More than 10 cigarettes per day

Prevention

The earlier preterm labor is diagnosed, the sooner treatment can begin. Once the cervix has started to dilate, it’s difficult to stop the progress of labor for very long. Intensive education of women in the high-risk group is one method being used to prevent preterm labor. The women are shown how to assess themselves for signs of preterm labor. The education is reinforced by frequent telephone contact with nurses who provide support and information.

Ambulatory home monitoring is an investigational technique that may help identify pre term labor. The woman wears a uterine contraction monitor several times a day. The recorded contractions are transmitted by phone to a central unit where doctors or nurses evaluate the strip. Some feel that the home monitoring system is effective, but others feel that education and self-assessment by the pregnant woman combined with frequent nurse contact work as well and are also less expensive. Time will tell.

What’s Cooking: Symptoms

Symptoms of preterm labor are often very subtle; they may go unrecognized until the cervix has dilated. You can suspect preterm labor if you have:

• An increase in your usual clear, mucous, vaginal discharge

• Noticeable tightening of your uterus, every 10 minutes or less

• Backache different from the type you usually have

• Feeling of pressure in your pelvis

Urinary tract infections are a common cause of pre term labor symptoms. Call your doctor if you have one or “more symptoms (frequency and burning on urination). It’s easier to check it out than to deal with a preterm baby in the neonatal intensive care unit (NICU) for a month or two.

Treatment-Your Interventions

If you experience uterine contractions before 37 weeks of your pregnancy, lie on your left side and drink a quart of water. The combination of rest and fluids often quiets the irritable uterus. Call your doctor and tell her how often your contractions are occurring and what you’re doing to quiet your uterus.

Treatment- Your Doctor’s

If contractions continue in spite of your interventions, hospitalization is required to observe and treat preterm labor. Half the women treated will respond to bedrest on the left side and an IV to increase their fluid level (hydration). The fetal monitor documents the uterine activity and ensures that the baby is doing well. If after an hour or two the contractions are getting closer and/or the cervix is changing, the decision to try to stop labor has to be made. Labor usually won’t be stopped if:

• You’re 35 weeks or more pregnant

• The baby’s lungs are mature

• You’re 4 or more centimeters dilated

• Your bag of water has ruptured

Contraindications to suppressing labor include fetal distress, poorly controlled diabetes, severe preeclampsia, intrauterine infection, and bleeding.

Several drugs are used to stop labor if you’re between 26 and 35 weeks pregnant. They buy time to allow the baby’s lungs to mature. The more your cervix is dilated, the less time you can buy. The decision to use the drugs rests with you and your doctor.

If you’re less than 34 weeks pregnant and your hospital doesn’t have an NICU, you’ll probably be transferred to a hospital that can provide the expert care your baby needs. This is in the best interests of your baby. If the receiving hospital has a highly trained transport team, you may be allowed to deliver in your hospital. After delivery, your baby is then transferred.

The Crisis

The delivery of a preterm baby precipitates a major emotional and financial crisis. Important developmental tasks have been interrupted. You’re plunged into motherhood before you’re emotionally ready-you have no time to savor the anticipation. You have to work through the formidable emotions of disappointment and guilt. Disappointment is painful and acute-you didn’t have your fantasy-perfect birth experience. Instead of a picture-perfect, full term baby, your preemie is skinny, red, wrinkled, and frighteningly fragile looking.

Disappointment is minor compared to the guilt you feel. You’re convinced somehow that you’re responsible for your baby being born early. Emotionally, you have a lot of grieving to complete. You find yourself stumbling through the grieving process with stops along the way. Anger follows shock and can be directed outwardly to those around you or inwardly expressed as depression. Anger comes from fear. Communicate your feelings and fears to each other, your doctor, and the nurses caring for you and your baby.

Then, there’s your baby. Instead of euphoria, there’s fear for the fate of your very little new one. You’re expected to begin the attaching, loving process when there may be no guarantees she’ll survive. You may try to protect yourself, after all you’ve been through, by delaying the attachment process. You wonder if you’ll have to say goodbye before you really have the chance to say hello. The situation can seem overwhelming. What do you do now?

Coping

You and your husband need as much love and support as your new baby does. This isn’t a time to tough it out alone. Gather around you all the emotional support you can. Use the hospital social worker, chaplain, or other professional to help you work through that difficult but necessary grieving and adjustment process.

The development of the NICU has had a tremendous impact on the survival rates for the very pre term baby. Babies as young as 28 weeks, in the hands of a neonatologist and highly trained nurses, have very good survival rates.

The personnel in the NICU know the value of having you touch, spend time with, and nurture your baby right from the start. Liberal visiting hours provide the opportunity to hold and cuddle your baby. You can still develop that important attachment. It won’t take long before you no longer notice the tubes and machines. You only have eyes for your “little one” as he grows into that regular-sized baby you expected.

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Facts and Fallacies

Preeclampsia has probably been around for as long as women have been getting pregnant. It’s also known as toxemia, pregnancy -induced hypertension, or EPH gestosis. Preeclampsia is the most misunderstood and myth-ridden disease in pregnancy. Let’s clear up some of the more common myths with some facts.

• Preeclampsia isn’t related to obesity or excessive weight gain during pregnancy.

• It isn’t caused by salt (sodium chloride). Women with preeclampsia actually have normal sodium levels. Salt restriction isn’t recommended.

• The condition isn’t cured or alleviated by taking water pills (diuretics) for the swelling.

• Preeclampsia isn’t caused by a diseased placenta, poisons, or toxins in the body. The term “toxemia” is still used, but it isn’t an accurate one to describe the disease.

• It isn’t prevented by vitamin therapy or high-protein or other special diets. There’s no known prevention.

Preeclampsia is one of the most studied diseases in pregnancy. In spite of all the research, we still don’t know what causes the disease or how to prevent it T he only cure at this time is to deliver the baby.

The Computer Goes Kaput

Preeclampsia usually occurs during a first pregnancy. Five percent of pregnancies develop preeclampsia. In addition to the first-time mother, women with diabetes, chronic hypertension, and multiple pregnancies are at risk for developing the disease. Preeclampsia seems to result from a number of interacting factors that affect the response of the mother’s immune system. Her immunological system may short-circuit because of poor nutrition plus exposure to placental hormones for the first time. Genetic factors may play a part… some unknown incompatibility between mom and dad. Who knows for sure? The body’s immunological computer, because of some unknown variable, doesn’t “program” the body’s response to the pregnancy in a normal way and preeclampsia results.

Software Snafu-What Goes Wrong

Preeclampsia has important effects on you and your baby. Your vascular system, which holds and carries blood throughout your body, changes in shape with this disease. Instead of being straight hollow tubes with unrestricted blood flow, your vessels look more like sausages. Some areas are very narrow and others very wide. The increased pressure inside the blood vessels forces fluid out into the tissues, to relieve the pressure. Your blood becomes thicker without the fluid. Your blood pressure (BP) rises because of the areas of constriction in the vessels. The changes in the vessels produce the three symptoms used to diagnose preeclampsia: edema (swelling), hypertension (increased blood pressure), and protein in the urine.

The blood flow to the baby is decreased due to the decrease in fluid volume inside your vessels and the increase in blood pressure. These “short rations” produce a small baby whose physical growth potential isn’t reached. Intrauterine growth retardation (IUGR) is the term used to describe the condition.

Signs and Symptoms

Preeclampsia is similar to a computer virus. It’s present long before you realize something is wrong. The disease makes its appearance some time after the twentieth week of pregnancy. The first sign is usually a weight gain of more than 2 pounds in I week. Generalized swelling (edema) appears next. It’s normal to have swelling of the feet and ankles, but it isn’t normal for the face and hands to swell. Pay attention if you can’t get your rings off and your face seems fuller than usual.

After the swelling, your blood pressure starts rising. A BP of 140/ 90 is abnormal in pregnancy. You can still have preeclampsia even if your blood pressure doesn’t reach that level. If the top number of your BP rises 30 points above your early or prepregnancy BP and the bottom number rises 15 points, it’s still possible to have preeclampsia. For example, if your first trimester pressure was 90/60 and now you consistently register 120/75, you need to be evaluated, particularly if you have swelling also. With mild preeclampsia, you may not have protein in your urine.

Downtime-Treatment

Since delivery is the only cure for preeclampsia, your doctor tries to slow the progress of the disease until your baby’s lungs are mature enough for safe delivery. There are no advantages to waiting if it isn’t necessary – the disease doesn’t get better with time.

Preeclampsia is classified as mild or severe. Each category is managed differently. With mild preeclampsia, you may have generalized swelling and your BP is elevated but under 160/ 110. You probably have no protein in your urine. You feel fine, which is misleading. With this disease, you can rapidly progress from the mild to the severe form in a matter of hours. It’s very unpredictable. Listen to what your doctor tells you and cooperate fully. Your doctor may let you stay at home instead of hospitalizing you if you have mild preeclampsia. Your doctor’s instructions usually include lots of rest while lying on your side. This position helps the edema fluid be reabsorbed back into your vessels. Your blood pressure usually decreases, and your baby benefits from the extra blood flow. You can enjoy catching up on your favorite soap or reading a romantic novel for the third time. Strict bed rest usually isn’t necessary, but cooking, cleaning, shopping, and bouncing babies around are off limits. If you try to continue your normal activities, your preeclampsia will only get worse and you’ll end up in the hospital.

Besides rest, your doctor will have you take your BP several times a day. Check your BP in the same arm in the same position each time for consistency in the readings. She may also have you check your urine for protein with a dipstick.

Your trips out of the house will be short. You can go to the doctor’s office or hospital to have stress or nonstress testing to monitor how the baby is handling the effects of the preeclampsia. You may have blood tests done weekly to monitor the progress of the disease. Ultrasound exams may be done to reassure everyone your baby is growing on schedule. If you aren’t getting better despite the decreased activity, hospitalization may be necessary.

With severe preeclampsia, your BP will be 160/ 110 or higher on two or more checks 5 minutes apart after resting. Your urine will show 2+ or more protein. You probably won’t feel well. You may have what you think is heartburn and a headache. The treatment is hospitalization. The decision to deliver your baby will depend on what your doctor decides is the best course of action for both you and your baby.

With severe preeclampsia, your doctor is worried about convulsions. She’ll give you magnesium sulfate, the drug used to prevent seizures, usually administered intravenously. When the drug is first administered, you may develop a stuffy nose, headache, and feel very flushed. These common side effects subside within a short period of time.

Your doctor will discuss the available options and help you understand the best course of action for both you and your baby. Remember, with delivery comes the cure. Preeclampsia has no long-term effects, you get well, and everything returns to normal. You’re soon feeling better and getting acquainted with your newborn baby.

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Not So Simplex

Herpes simplex used to be just a plain old “cold sore.” In the 1980s it became the dread virus that threw a wet blanket on the fires of the sexual revolution. The herpes hysteria grew because medicine had neither prevention nor cure. Even the admonition “Hey, let’s be careful out there!” didn’t help. The herpes hysteria has diminished because of the more serious threat of AIDS.

The herpes virus is the Greta Garbo of sexually transmitted diseases elusive and mysterious. The true incidence of herpes isn’t known since it’s not reported to public health agencies. Even trying to confirm whether or not you have herpes can be maddening. Let me count the ways.

Blood Test

A blood test only proves exposure to the virus, not whether you’ve had herpes. Most adults will have a positive test that only shows a universal exposure to the virus.

Cultures

The only way to prove the diagnosis of herpes is to use a swab and dab the suspected area and have the specimen tested to see what grows (culture). Problems arise with false positives (the test says you have it but you don’t) because of other viral infections. False negative culture (virus present but doesn’t grow) occurs even if you have lesions but they aren’t “shedding” at the time. It’s also possible to contract the virus and not have it show up as an infection for years. No one knows for sure what triggers the infection. Some marriages have met an untimely and unnecessary end over who gave what to whom. Remember, a clinical diagnosis, where the doctor just looks at the lesion and says “Yep, you’ve got it,” is subject to error. Cultures must be done to be certain.

Contracting herpes creates havoc with both your body and psyche. Common feelings are shame and guilt. You may feel like a sexual leper. Your pregnancy will probably dredge up those old feelings you thought you had worked through, especially the guilt. Now you have your baby and the possible consequences to consider. The facts should reassure you and allow you to enjoy your pregnancy without the gloom and doom.

Just the Facts

One percent of pregnancies are complicated by herpes. The risks to pregnancy differ between the primary infection (your first) and any recurrence. In early pregnancy with a primary infection, there’s a greater risk for miscarriage but not birth deformities. Herpes generally isn’t an indication for terminating pregnancy. In the last 6 weeks of pregnancy, there’s an increased risk for preterm labor and infecting the baby after birth. Recurrences of herpes during pregnancy don’t offer any risk to the baby; very rarely does the virus cross the placenta to the baby. The number of babies who actually become infected with herpes after birth is very small, 1 in 4000 or 5000. Unfortunately, those babies who acquire herpes have a mortality rate of 40 percent. Two-thirds of those who survive have serious neurological problems or eye damage. To help ensure your peace of mind, here are a few simple guidelines to follow:

• If you’ve already been proven as having herpes, no cultures are needed during pregnancy.

• If you haven’t previously had herpes and you discover lesions (sores), you need to be cultured while the virus is still “shedding.” The best time to do a culture is when you feel the tingling or burning right before the outbreak and the first or second day after the outbreak. Make an appointment with your doctor and show him exactly where your suspected lesion is.

• During outbreaks, be sure not to spread the lesions to other parts of your body. Soap and water are good disinfectants. Corn starch on the sores and drying them with your hair dryer work as well as anything.

• There’s but one cardinal rule: The baby and the virus shouldn’t meet. If lesions are present when you go into labor, you’ll most likely have a cesarean.

• If no lesions are detected at the time of labor, you’ll have a vaginal birth.

Delivery Management

When lesions are present at delivery, a cesarean birth is done to try to prevent transmission of the virus to the baby, but there are no guarantees. When there are active lesions and the membranes are ruptured, the role of cesarean is unclear. Some doctors won’t do a cesarean if the water has been broken for more than 4 hours because they feel that the infection has had ample time to travel upward into the uterus. Other doctors prefer to do a cesarean regardless of the length of time the membranes have been ruptured. It’s a tough decision because no one knows for sure which is the best approach.

The Good News

Even if you deliver with active lesions, remember that more than 90 percent of babies don’t become infected. Most babies appear to be protected from infection by the mother’s antibodies.

After delivery, even if you have lesions, the only precaution you need to observe is good hand-washing. Isolation procedures or a private room aren’t necessary. The nursery may insist you room with your baby, depending on their policy. You can breast-feed if you wish.

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Rain on Your Parade

For the majority of women, pregnancy is a normal and physiologically uneventful process. You count on breezing through pregnancy with no problems, looking and feeling great. When complications arise, you’re forced to make adjustments in your idyllic pregnancy plan. It is not an easy adjustment for most women. Your self-esteem suffers. Disappointment and anger are common emotions as you struggle to deal with the unexpected events. You add anxiety and fear for you and your baby to the witch’s brew of unknowns facing you. You need expert care, added emotional support, and accurate information to cope effectively with the changes.

When you understand the basics, your anxiety decreases. When you’re calm, you’re better able to hear and understand what your doctor communicates to you. You’ll find that you can cope and maintain some control over the unanticipated events which altered your pregnancy plans. You don’t have to junk your original blueprint for your pregnancy; you just have to do some remodeling. For example, you can still enjoy and revel in the normal aspects of your pregnancy. You can feel the baby move, take childbirth classes, and shop for baby furniture. You’ll still experience those “normal” aches and pains of pregnancy along with every other pregnant woman. Only part of your pregnancy is complicated, not all of it!

Gestational Diabetes

Approximately 1 to 4 percent of pregnant women develop the condition known as gestational diabetes. What happens?

Pooped Pancreas

During the second trimester, the hormones of pregnancy are in full force. These hormones inhibit the effectiveness of insulin in the body. The pancreas, which produces insulin, has to work harder to produce more insulin to keep up with the increased demand. Most women are able to meet the increased demand; for those who can’t, a temporary state of diabetes results when the demand is greater than the supply of insulin.

Banking on Your Body

In the diabetic state, your body can’t effectively transact the business of converting the food you eat into energy. The food you eat can be considered energy checks that you deposit in your body bank. Insulin acts as the bank teller who converts your checks into available energy. Simple sugar is like cash for immediate energy; fat is stored as savings for emergencies; other sugar is stored as an easy access checking account. Insulin is the key to the system running efficiently and keeping you in funds. Without insulin, your assets are frozen. Your deposits don’t make it into your accounts, and you don’t have access to what’s already there. Your blood develops high levels of sugar but isn’t able to use it. It’s similar to having $1 million in a safety deposit box but not having the key to open it.

Good News

Unlike the type of diabetes that requires insulin; gestational diabetes is a temporary condition. After delivery, when the pregnancy hormones are gone, your body returns to its regular metabolism. Also, your baby doesn’t run the increased risk of developing congenital anomalies since gestational diabetes doesn’t develop until the second trimester. Let’s discuss some potential problems that do need to be anticipated.

Fit or Fat

The higher blood sugar levels you experience with gestational diabetes present some problems (or you and your baby. Your baby’s prime fuel is sugar. By 12 weeks she’s making her own insulin to handle the sugar you give her. Your blood sugar crosses the placenta very easily. When you have excess amounts in your bloodstream, it gravitates to the baby. Uncontrolled blood sugar levels that are chronically elevated pose big risks for your baby.

The chronically elevated blood sugar levels force-feed the baby; excessive weight and size result. The more your baby weighs the more potential problems for both of you during labor and delivery. For example, you may have no problem delivering an 8­pound baby, but at 9 to 10 pounds there isn’t enough room. Birth injury to you and the baby is a possibility. Your chances for a cesarean birth increase. Jaundice and low blood sugar (hypoglycemia) are also common complications for the baby when blood sugar is uncontrolled during pregnancy. Detection and management of the condition are crucial for a successful pregnancy.

Detection and Treatment

The American College of Obstetrics and Gynecology (ACOG) recommends screening all pregnant women 30 and over and those who have risk factors for diabetes. Many experts believe that all pregnant women need screening at 24 to 28 weeks of pregnancy. Screening includes either ingesting a 50­gram sugar drink or eating a meal high in carbohydrates. A blood sample is taken 1 to 2 hours later. Some doctors have sugar meters in their office and offer this test to their patients; it’s worth doing. These days, with early detection and appropriate management, many potential problems can be avoided.

Treatment of gestational diabetes is fairly simple. Your doctor will prescribe a diet from the American Diabetic Association (ADA). The diet controls your blood sugar, keeping it within safe levels. Most pregnant women are able to maintain their blood sugar with just the diet. It’s important to follow the diet if you want to avoid the problems discussed earlier. A reasonable exercise program also helps control blood sugar. If your blood sugar can’t be controlled with diet and exercise alone, insulin will be prescribed also. Remember, this metabolic condition is only a temporary one; with just a little extra effort on your part, you can assure that your baby will be healthy.

After Delivery

Half the women who develop gestational diabetes during pregnancy are at increased risk for diabetes in later life. So even if your metabolism returns to normal after delivery, you need follow-up. Developing diabetes in later life is associated with a family history of the disease, obesity, lack of exercise, and inappropriate diet. After pregnancy, resolve to continue the good eating habits you learned from your ADA diet, and continue exercising to lose unhealthy pounds. It will pay off in the future.

Insulin-Required Diabetes

For those of you who are diabetics and regularly use insulin, there’s also good news. The outcomes for women with diabetes and their babies is the best it has ever been. With well-controlled sugar levels during pregnancy, you can expect and have a healthy baby!

Management of insulin-required diabetes in pregnancy has become more efficient, less costly, and less disrupting to your life-style than it used to be. Monitoring sugar levels at home gives you more control and the consistent feedback you need to keep your blood sugar levels consistently within safe limits.

To assure the best outcome possible for your planned baby, see your internist, obstetrician, or perinatologist before you get pregnant. Achieving the best control possible before conception lowers the risks for congenital anomalies. By the time you realize you’re pregnant, it may be too late since the anomalies occur in the first trimester. Get an early start on prevention.

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Two kinds of women drive doctors crazy: those who call for every little twinge and those who wouldn’t call if they were staked to an ant hill because “I didn’t want to bother you.” Here are some hints to help you avoid falling into these two categories.

Any Vaginal Bleeding

Vaginal bleeding doesn’t automatically mean disaster, but the source of the bleeding needs to be investigated. Panic usually follows if you’re on the toilet when you discover the bleeding because even a few drops will look like gallons as soon as they hit the water. Wipe with toilet paper and make note of the color-bright red or more reddish-brown? Did the bleeding start after some activity, such as intercourse or moving furniture? Is it associated with cramping or localized pain anywhere? Your doctor will ask you these questions and how much blood you think you lost. Just remember the difference between bleeding and hemorrhaging: If blood isn’t running down your leg and filling up your shoe, you’re not hemorrhaging. Keep calm and call your doctor.

Swelling of Face and Fingers-Generalized Swelling

Swelling of feet and ankles is common in pregnancy, so it’s no cause for alarm. Swelling of face and fingers along with feet and ankles may be a sign of preeclampsia (toxemia) and needs some follow-up with your doctor.

Severe or Continuous Headache

Headache that is severe or continuous is another possible sign of preeclampsia. Dimness or blurring of vision may accompany this type of headache. Migraine headaches also have these symptoms.

Abdominal Pain

Aches and pains are so common in pregnancy that you sometimes need help in deciding if your abdominal pain is something to be concerned about. Before calling your doctor, think about what kind of pain you’re having. Where is it? What does it feel like? Do you have any other symptoms besides abdominal pain, such as bleeding? Have you noticed an increase in your vaginal discharge? Does the pain come and go, or is it constant? It may just be the old round ligament pain again, but call your doctor and check it out.

Persistent Vomiting

You need help with this one so you won’t become too dehydrated and upset your body’s chemical balance. Don’t wait until you’re dried out that your tongue looks like the sands of the Sahara. Call your doctor.

Chills or Fever

This could be old garden variety f1u that no one can do much about, BUT, it could also be a kidney infection, which is serious. If your temperature is over 101 degrees, call your doctor. If you have a fever lower than 101 degrees but pain in the area of your kidneys and/ or frequency and burning on urination, call your doctor; you may have a kidney infection.

The garden variety flu with temperatures below 101 degrees with no other symptoms usually resolves itself within 24 hours. Try Tylenol and fluids. If your symptoms don’t resolve within 24 hours or you’re concerned, call your doctor.

Painful Urination

Most women don’t have to be encouraged to call the doctor for this one. You feel like your bladder is going to burst, but all you can manage are a few drops that feel like razor blades. A bladder infection, besides being painful, is a common cause of preterm labor symptoms and needs to be treated because you can’ t cure it yourself.

Accidental Injury

Generally, the baby is well protected from blunt trauma to the abdomen in early and middle pregnancy by the cushioning effect of the amniotic fluid. In late pregnancy, injury to the baby is more likely to occur when the head is fixed in the pelvis and amniotic fluid is normally decreased.

Seven percent of women experience some type of injury during pregnancy. The vast majority of these accidents don’t harm the baby. Occasionally, injury to the abdomen can seriously decrease oxygen to the baby. Premature separation of the placenta from the uterine wall and high stress levels associated with an auto accident or other trauma are thought to be contributing factors.

If you have an accident, and your abdomen receives a blow, call your doctor. Some reassuring tests can be done in the hospital. In addition to examining you, the medical staff can evaluate the baby. A contraction stress test and fetal monitor can detect signs of fetal distress. The Kleihauer-Betke blood test is done to detect fetal bleeding. The tests may take 2 or 3 hours to complete, but you’ll have some peace of mind to go with your bruises.

An ounce of prevention: Wear your three point seat belt restraint. The lap belt should be positioned on your thighs. Seat belts significantly decrease injury to both mom and baby.

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• Prenatal Workup
• Prenatal Care

Your official relationship with your doctor begins with the three-part prenatal workup. First, a medical history reveals any past or current health problems for you or in your immediate family that may affect your pregnancy. The questions are very standard, so don’t get excited when you’re asked if you mainline heroin or have syphilis. If you have any unusual (or what the “moral majority” might consider) unspeakable diseases or habits, don’t be embarrassed or withhold information. With few exceptions, health care providers are nonjudgmental or at least desensitized. The goal is to give you the best care possible and work with whatever problems exist, no matter what they are.

Next is a physical exam. Besides the usual poking, prodding, and stick out your tongue routine, your pelvis is evaluated for its potential as a gateway for your baby’s journey into the new world. Adequate and borderline are two terms commonly used. “Adequate” means that the baby should slip through without problems; “borderline” means wait and see: It might be a tight squeeze. If your doctor describes your pelvis as big as the Grand Canyon, consider it a compliment. But don’t get ugly and hateful if your doctor says “She has a pelvis I could deliver through” and you end up with a cesarean birth. It happens. Nothing is 100 percent guaranteed.

During the pelvic exam, your uterus is palpated (felt) to determine if the date of your last menstrual period (LMP) is consistent with the size of your uterus. The exam provides reference points to be sure that things are proceeding normally during the pregnancy and the baby is growing on schedule. If you’re unsure of your LMP, or have risk factors, an ultrasound may be done at or before 20 weeks’ gestation to more accurately pinpoint your due date. The distance from your pubic bone to the tip of the uterus (fundus) is measured in centimeters. The number of weeks you’re pregnant will approximate the size of your uterus; 20 weeks will equal 20 centimeters, give or take a centimeter. This is another way to follow your baby’s growth.

The last part of the workup includes lab tests done for the following various reasons.

Routine Tests

Blood Count (Hemoglobin and Hematocrit)
This test detects anemia. It is repeated around 28 weeks to monitor if blood volume has expanded adequately. Your hematocrit normally decreases during the second trimester from increased plasma volume and the slower increase in red cell production. The normal decrease is not synonymous with anemia. Since the decrease is a healthy sign, some practitioners argue against routinely giving iron supplements.

Urinalysis and Culture
This test screens for infection and other kidney disease since symptoms may not be present.

Blood Type and Rh Factor
This test establishes if there’s a risk for potential incompatibility and Rh disease.

Antibody Screen
Your body produces substances (antibodies) in response to exposure to other substances that are foreign to your body (antigens). Blood screening detects antibodies that may be harmful to your baby.

Rubella (Measles) Antibody Titer
This test determines if you’re immune to measles. Nonimmune rates in women are about 10 percent. Measles produce serious congenital deformities if the mother is infected during pregnancy. Immunization for nonimmune women is done after delivery.

Serology (VDRL)
This is the test for syphilis. The positive rate is very low, but testing is required by state law.

Blood Sugar
This test screens for potential gestational diabetes (pregnancy-induced glucose intolerance). Pregnancy is the perfect time to screen all women for diabetic tendency. The hormones of pregnancy inhibit insulin production, and a temporary diabetic condition can result. A meal high in carbohydrates or 50-gram glucose drink is taken and the blood sugar level tested in 1 or 2 hours.

Subsequent Visits

Office visits are monthly until 32 weeks, every 2 weeks until 36 weeks, and usually weekly during the last month. Your visits may be fairly brief, but they’re very important. Besides answering your questions, your doctor will evaluate and record several things, including:

1. Blood pressure (BP). Normally your BP decreases by the second trimester. If your BP increases during the second trimester, it may be one of the signs of preeclampsia, a dangerous disease for both you and the baby.
2. Weight. Your pattern of weight gain is important to your baby’s growth. Unusual weight gain, more than 2 pounds in 1 week, may be the first sign of preeclampsia.
3. Uterine size. Your doctor measures the distance from your pubic bone to the top of your uterus. The measurement indicates if the baby is growing appropriately and helps detect the small for gestational age (SGA) and intrauterine growth retardation (IUGR).
4. Fetal heart rate. Your doctor does this test routinely to reassure you and entertain the siblings. It’s a nice touch, but it doesn’t provide reliable information regarding the baby’s well-being. There’s no validity to predicting sex according to heart rate, which tends to be faster in early pregnancy and slows as the central nervous system matures. Usual heart rates are between 120 to160 beats per minute.
5. Fetal movement. An active baby is usually a healthy baby. Try to become acquainted with your baby’s wake and sleep cycles (activity patterns). Your doctor will routinely ask if the baby moves a lot.
6. Urine testing. Your urine is traditionally tested every visit for protein and sugar. Many normal pregnant women spill sugar into their urine. A blood sugar test is the preferred way to screen for diabetes. Protein is checked to detect preeclampsia, but weight gain and BP are earlier indicators of the presence of the disease.

Other Tests

Chlamydia
Chlamydia is a common sexually transmitted disease, with 3 million new infections occurring annually in the United States. There are no known adverse effects on pregnancy. Occasionally, the mother contracts a postpartum pelvic infection from chlamydia. The newborn baby whose mother has the chlamydia virus in her cervix can contract eye infections or pneumonitis after birth. Chlamydia, detected during pregnancy, can be treated effectively before delivery to eliminate the risk to the baby and mother.

Chicken Pox
Five percent of the adult population escaped contracting chicken pox as a child. Only one-fourth of adults with no history of having the virus are susceptible. A lab test will detect immunity if you’re uncertain whether you’ve had it. Chicken pox can be very serious in pregnancy. If you aren’t immuneand you’re exposed to the virus, you can be treated with zoster Immune globulin (ZIG) while pregnant. Talk to your doctor.

Cytomegalovirus (CMV) and Parvovirus
CMV exposure may occur in health care workers, school teachers, and day care providers. Parvovirus causes “Fifth disease,” which is a ‘fairly common viral illness in schoolchildren. If the mother contracts the infection during pregnancy, the risk to the baby is very small. If you’re exposed to either virus, tell your doctor who’ll advise you.

Human Immunodeficiency Virus (HIV)
HIV is a sexually transmitted disease that causes AIDS (acquired immunodeficiency syndrome). The virus attacks the body’s immune system, resulting in a loss of resistance to various infections. T he virus may be present in the blood many years before symptoms of AIDS develop. Ninety percent of AIDS cases have occurred in homosexual or bisexual men, intravenous drug users, and those who’ve received HIV-contaminated blood or blood products. In cities with a high rate of IV drug users, HIV in pregnant women is becoming more prevalent.

Obstetricians are concerned about HIV because the pregnant woman can unknowingly transmit the virus to her unborn child. If you’ve had sexual contact at some time with someone in the high-risk groups for carrying the AIDS virus, discuss your concerns with your physician.

Hepatitis B (serum hepatitis)
It’s possible to carry the hepatitis B virus and not have symptoms. The virus can be transmitted to the pregnant woman’s baby during delivery. When a pregnant woman is identified as a virus carrier, treatment can be given to the baby at delivery to prevent infection. Health care workers and Southeast Asians are considered at higher risk for being carriers of the virus. In some areas, hepatitis B testing is routine for all pregnant women. If you’re in the high-risk category, talk to your doctor.

Toxoplasmosis
If you’re a cat owner or work in the veterinary field, this one’s for you. Toxoplasmosis is an infection resulting from contact with airborne protozoa from cat feces or from eating contaminated raw or rare meat. The infection isn’t serious unless it’s the first occurrence and you’re pregnant. If you’re in the at-risk category, tell your doctor so she can test to see if you’ve had a previous infection. It’s nice to have reassurance that there’s no risk to your baby. Ideally, you should be tested before you become pregnant.

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Good Vibrations

Choosing a doctor or birth attendant without careful thought has all the pitfalls of an arranged marriage: You don’t know what you’ve committed to until it’s too late. Save yourself and the doctor wasted time and emotional trauma by doing your homework now.

Think about what kinds of personality traits make you the most comfortable. If your doctor is the autocratic type and you want to share in the decision-making process, you’ll be at each other’s throats in no time. If you don’t like to worry about details, a take-charge type may be just your style. Decide what is your style and find someone who’ll “wear well” over the months of your pregnancy. Breaking up after you’re several months into the relationship can be inconvenient, if not painful, for both of you.

If you have insurance with maternity benefits, your first step is to know exactly what is and is not covered. It’s a waste of valuable time to investigate hospitals and doctors if they don’t accept your particular insurance plan. Many plans now contract with certain hospitals and doctors to provide services for their subscribers. You need to know what, if any, limitations apply. You may want to ask your insurance representative the following questions.

Questions for the Insurance Company

• Which hospitals in my area accept my insurance?

• Do you have a list of physician providers from which to choose?

• What’s the total reimbursement you provide for my doctor?

• What’s the total reimbursement allowance for hospital costs?

• How many hospital days do you allow for a vaginal birth and a cesarean birth?

• What type of hospital room does my plan provide for? Private? Semiprivate or ward?

• How is payment handled for services? Direct payment to physician? Reimbursement to me after delivery?

• What obstetrical costs do you cover? Ultrasound? Blood tests? Amniocentesis? Fetal well-being tests (stress and non stress testing)? Medications?

• Is there coverage for neonatal or pediatric care?

• What coverage is there should complications occur?

Before you plunge ahead to find your doctor, give some thought to your birth preferences. If you have some very specific plans for your birth, such as epidural or single-room maternity care, keep in mind that most doctors limit their practice to one or two hospitals. If you find that your chosen doctor doesn’t practice at the hospital which offers these options, you’ll have to decide between your doctor and your preferences and what your insurance allows.

Call the hospitals in your area and ask to speak to a nurse in the labor and delivery department. Explain that you’re pregnant and interested in what the hospital has to offer for birth options. Here are some sample questions:

Questions for the Hospital

• What types of birthing rooms do you offer? Traditional? Single room, labor/ delivery/recovery/postpartum (LDRP), or a combination?

• Who do you allow for support persons? How many? Do you let children attend births? If you do, are sibling preparation classes offered at the hospital?

• Do you allow video cameras during delivery?

• If a cesarean has to be done, do you allow support persons in the operating room?

• Do you offer vaginal birth after cesarean?

• What types of anesthesia for delivery do you provide? Is epidural anesthesia available?

• Do you have 24-hour coverage for anesthesia in the hospital, or do you use on-call people after hours?

• After delivery, how soon can I nurse my baby?

• Does the baby have to stay in the nursery, or can I have unlimited access to him?

• How soon after delivery do you usually discharge patients?

You can add or delete questions to the list depending on what’s important to you. Don’t ask nurses about hospital fees; they usually don’t know about those things. Labor nurses are also great resources for matching you with a suitable doctor based on your preferences. Give the nurse a sample of your high-priority preferences. For instance, if you don’t want an enema or perineal shave and you want to stay out of bed as long as possible, who would go along with your wishes? If you want someone who is flexible or fatherly, ask for the names of doctors who fit your bill. Ask your friends and family for some recommendations. Call a few childbirth educators and get their input. Many resources of information are out there.

When you sit down with your prospective doctor, ask diplomatic questions; no one likes to be interrogated. It’s counterproductive and usually futile to ask such questions as the doctor’s personal cesarean birthrate because most doctors don’t keep track. Hospitals have that information but are unlikely to share it with you. In reality, cesarean birth statistics don’t always give valid insight into the quality of obstetrics being practiced because too many variables enter into the decision to perform a cesarean.

Be friendly and relaxed. You aren’t negotiating a Middle East crisis, you’re just looking for a doctor. If you ask open-ended questions you’re more likely to get the candid answers you need to make your decision. Keep in mind that your mission isn’t to make judgments, you just want to find a doctor whose philosophy and personality are compatible with yours. Here are some sample questions.

Questions for the Doctor

• What do you like best about the hospital where you primarily practice?

• Do the doctors in your call group share your birthing philosophy? How do they differ?

• What is your policy regarding ultrasound exams during pregnancy? How many do you routinely do? If you do an ultrasound, can my husband and children be present?

• If I develop a complication, will you still care for me, or transfer my care elsewhere? If you’d transfer me, where would I go?

• What birth options are you comfortable providing?

• What procedures do you routinely require during labor?

• What is your policy regarding preps, enemas, fetal monitoring, and IVs?

• How do you feel about support persons? Do you limit the number of people?

• What is your approach to episiotomy and positions during delivery?

• What are your preferences regarding medications and anesthesia for labor and delivery?

• How do you feel about vaginal birth after cesarean? Do you offer that option?

Once you’ve made your choice, communicate your desires and preferences clearly to your doctor; mind reading wasn’t a part of his medical training program. Effective communication is the key to establishing the important trust and rapport vital to any successful relationship, and it’s no different with your doctor.

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The ’70s homestyle room with the dying fern and rocking chair is now dated. Many obstetrical units are adopting the newer and more practical concept of single-room maternity care. This concept is the wave of the 90s in obstetrics as more women choose this option. With single-room maternity care, Mom stays in an LDRP (labor/ delivery/ recovery/ postpartum) room, eliminating the inconvenience and discomfort of moving from a labor bed to the delivery room and then moving again to the recovery room and still again to the postpartum floor. The ideal room design usually accommodates 8 people. The labor bed converts into a birthing bed. The delivery equipment, such as oxygen and resuscitation is efficiently and conveniently located behind pictures and in drawers so as to not detract from the homelike setting. Some hospitals offer romantic, candlelight, gourmet dinners for the new parents.

Although the single-room maternity concept is ideal, many older hospitals are unable to provide this service in its purest form. What you may find is a compromise such as the labor and birthing room, combined with recovery and postpartum provided on the postpartum maternity floor. It’s still a great improvement over the traditional method of a separate room for each aspect of the birthing process. The days of having to move to a gurney when you’re fully dilated while the nurses frantically tell you not to push are mercifully becoming obsolete.

Hospitals are more flexible in offering the option of keeping the baby and mother together. Mom can keep baby in her room or send her to the nursery if she desires some time off. In some hospitals, one nurse cares for both mom and baby until discharge, assuring a nice continuity of care. If you find this concept appealing, call your local hospitals and ask if they offer this option.

Home Birth

Home birth continues to account for only 1 percent of the obstetrical population in this country. The highest numbers of home births are concentrated in upper New England, Texas, and the Pacific Coast. Midwives are licensed in 11 states and in Arizona doctors do their share of home deliveries. Most deliveries (90 percent) are uneventful, while 2 percent involve serious, unanticipated threats to mother and baby. Previous screening helps identify some but not all problems in advance. In 1975, the stillbirth rate in California for home deliveries was twice as high as for in-hospital births. Based on this information, there is little doubt hospital births are safer. The decision for a home birth usually transcends economic and safety considerations. There is often a deep emotional commitment to a home birth experience, and a previous negative experience in the hospital can reinforce the commitment. If you are one of those people who have such a commitment, you need to plan carefully. Have your prenatal workup performed by an obstetrician, and determine if you have any medical or health problems, your pelvis is more than adequate, and your blood work is normal. A very important consideration is the time it would take you to get the hospital in case of an emergency. Ask your doctor what is considered a reasonable time limit and if he/ she would agree to provide back-up if you have to go to the hospital because of complications.

If you pass the first step, you can start shopping for a birth attendant. If your area allows certified nurse midwives or doctors to do home deliveries, you are in luck. If not, you have to interview lay midwives very carefully. Some lay midwives have no experience beyond having their own babies at home; they have decided that delivering babies would be an interesting hobby. You wouldn’t dream of trusting your next door neighbor to repair your expensive stereo as a hobby. Don’t let her deliver your baby either! If your area has no licensing and standards, be an informed consumer. Screen your prospective birth attendant well. What training has she had? How many babies has she delivered? (Fifty is an appropriate number.) Does she have resuscitation ski1ls? Is there a plan for complications such as bleeding, breech, or prolapsed cord? Be sure she has a well-defined disaster plan. If she is willing to care for you even if you develop a high-risk complication such as preeclampsia, look for another birth attendant.

Sibling Participation

The attendance of siblings at birth is slowly increasing but still not universally accepted. The more disdainful see it as an effective method of population control: They predict that little boys will grow up impotent and little girls will avoid pregnancy like the plague. No one has confirmed that such dire consequences have occurred. In fact, some parents have reported a wonderful experience and less sibling rivalry which they attribute to participation in the birth experience. The prospect doesn’t appeal to everyone; you have to decide what suits your family and if the perceived benefits outweigh the potential disadvantages. Discuss the possibilities with your husband and your children.

Incorporating your kids into the birth experience requires common sense, preparation, flexibility, and a willingness to have them see you unnatural. Children need some preparation: They need to know where babies come from, how they get here and an introduction to the panting, blowing, and funny faces you may be making so they won’t be frightened. Give them a preview of the hard work you will be doing, so the real experience won’t scare them. Read the excellent book Birth-Through Children’s Eyes listed in the Recommended Resource section for more comprehensive ideas. Many hospitals offer sibling preparation classes-sign the kids up. Your children also need a designated support person of their own in case they find the experience too intense or boring. Give each child something to do such as taking pictures, bringing ice chips, or stimulating acupressure points on your feet to send you energy so they will feel needed.

If you find you’re spending more time worrying about your children and their reactions during labor, give yourself permission to alter your plan and have them leave for a while. Some women prefer to labor without the children and have them come in immediately after the baby is born for the family togetherness.

Epidural Anesthesia – Painless Pursuits

The trend in obstetrics is toward more painless childbirth. While there are those women who still wish to labor without medication, many are opting to experience as little pain as possible. Epidural anesthesia is gamll1g in popularity after a decade or so of the cold turkey method.

Epidural anesthesia, given during the active phase of labor, numbs you from the waist down. You can use your breathing exercises until epidural time and then relax until it is time to push. Hospitals are vying for the consumer dollars by offering this anesthesia option. If “No pain, no gain” isn’t your cup of tea, ask your doctor if this option is available to you. Now you can really have it all ways. This is a nice time to have a baby!

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