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Prenatal Appointments, Interventions and Tests

Q1: What are your thoughts on giving RhoGam at 28 weeks pregnancy?
Q2: Do I really have to take blood tests at my first prenatal visit?
Q3: Insulin therapy for a positive gestational diabetes test at 14 weeks?
Q4: Do you have information regarding treatment for a positive GBS test?
Q5: Can you comment on natural induction techniques?
Q6: Is there research on the pros and cons of steroid use and its effects on the baby at any stage between 31 and 40 weeks?
Q7: Research on Amniotic Fluid Index (AFI)
Q8: Tips for ‘mature moms’ and the medical system.
Q9: Can you point me to any research or literature about the accuracy of estimating due dates during mid-pregnancy?


 

Q1: What are your thoughts on giving RhoGam at 28 weeks pregnancy?

Q: What are your thoughts on giving RhoGam at 28 weeks pregnancy?

A:  My go-to website for reliable health information is MedLine Plus, the consumer health website run by the U.S. government. When I searched it using the terms "Rh incompatibility" it came up with this. I didn't check out the links, but I would predict there is no information on adverse effects. The standard for making an informed decision is to have both benefits and adverse effects. Still, I have never heard or read anywhere that Rhogam has had adverse effects, and I think it would have stuck in my mind if I had.  

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Q2: Do I really have to take blood tests at my first prenatal visit?

Q: I am 31 years old, and expecting my 4th child.  One of the things I am least looking forward to is the blood tests that are done at the first prenatal visit.  They make me feel nauseous and faint, and I feel bad for the rest of the day.  I am healthy, low risk, and all of my former pregnancies were healthy.  My children were all delivered by midwives, the first 2 at a hospital, the 3rd one at home, because the hospital closed.  My midwife did not push many tests, but she did insist on the initial blood tests.  It seems to me that this should not be necessary.  My blood type is already established, I have no risk of stds, and I have never had any negative results from my blood tests.  If they are worried about anemia, couldn't this be tested with a simple pinprick?  I think that baby and I need those 4 vials of blood more than the lab does!

A: I think the best way to handle this is to use the acronym BRAIN in a discussion with your midwife. (I would credit the source, but I don't know it.) It is generic, so you can use it for making any decision you may need to make about your care.

Benefits: Why are you recommending this? In the case of a test, what do you hope to learn?
Risks: What are the potential problems? This would be the time to bring up your unpleasant symptoms.
Alternatives, including doing nothing: In this case, it could be not doing the blood test at all or perhaps doing more limited testing. You also want to know the pros and cons of the alternatives.
Intuition/instinct: Once you have the information and have digested it, what is your heart or gut telling you?
No or not now: You have the right to refuse any medical procedure. If you do decide to refuse, I recommend having a discussion about the circumstances under which you would reconsider or change your mind.

I hope this will help you and your midwife to come to an agreement that is satisfactory for both of you. 

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Q3: Insulin therapy for a positive gestational diabetes test at 14 weeks?

Q: I am 20 weeks into my 7th pregnancy and finding myself incredibly discouraged with my care providers approach to gestational diabetes. In my first 5 pregnancies, I passed the one-hour glucose test, but failed it by one-point in my sixth pregnancy. So, being the compliant patient I was at the time, I took the 3-hour test and failed miserably (course, I also just sat in the waiting room from one draw to the next not knowing it would be smart to be active instead). There is diabetes on both sides of my family, I was 38 at the time and I have a history of larger babies (8 pounds 6 ounces, 8 pounds 15 ounces and 9 pounds 1 ounce were my three largest). So, I continued to be a compliant patient and I followed all of their directions regarding diet, exercise and eventually, insulin. My son was born weighing 8 pounds 4 ounces. His initial blood sugar level was 40 and they climbed up from there. He was considered jaundiced and they sent us home with a biliblanket.

Because of the gestational diabetes in his pregnancy, I was told I had to take the one-hour glucose test at 14 weeks. Unfortunately it never occurred to me to refuse it. I drank the glucola, went to my pre-natal appointment and returned to the lab one-hour later for my draw. It took the tech three pokes and 30 minutes to get blood out of me (finally succeeded in my hand). I failed the test by several points, but refused to take the 3-hour so they turned me over to the Diabetes and Pregnancy Care team whom I have been working with for the past 5 weeks (it took a week before I had test results and an appointment). Before meeting with them, I started keeping a food log and testing my glucose levels 4 times a day. For the past 3 weeks, they have been pressuring me to start insulin because my fasting levels are above 90. My fasting levels range from 85 to 111 with the majority of them falling between 90 and 100. So far, they are not concerned with my post-prandial numbers.

I am incredibly hesitant to start on insulin at this point. I have been told the point of insulin is to reduce the risk of having a big baby and because I have a history of big babies to begin with, there is more reason for me to start on the insulin. I am not concerned about baby's size so much as baby's blood sugar levels at birth. I have been told the only side effect to insulin is the potential -- albeit quite rare -- for me to get hypoglycemic. I'm struggling with the guidelines they have established for fasting numbers (60-90) as they seem low and rigid. I'm quite concerned -- based on previous experience as well as those of friends and acquaintances -- about the amount of intervention that will be "recommended" as I progress through the pregnancy.

Can you direct me to anything in particular regarding insulin therapy in pregnancy that would support not starting it at this point? Would you agree with my care providers that it is in my and baby's best interests to begin?
A: Unfortunately, my focus has always been on what the research has to say on what best promotes healthy birth in women who are not experiencing pregnancy complications, and while I think that running mildly higher than normal blood sugar levels after eating--what has come to be called "gestational diabetes," but should more properly be called "carbohydrate intolerance of pregnancy"--falls in that category, your situation does not. The fact that your blood sugar is still high after an overnight fast and that this was the case as early in pregnancy as 14 wks indicates a more serious problem.

If I understand your concern correctly, you feel that using insulin during the last pregnancy turned out to be problematic for the baby. He was smaller than your other children have tended to be, which suggests that he may not have been getting all the fuel he needed for growth, and his blood sugar was low at birth, which tends to support that theory. I think the way to go here is to work with your care team in making shared decisions. I would raise these concerns and point out that, in fact, it looks like you may well have been hypoglycemic and that it is important for you and your team to come up with a nutrition, exercise, and insulin regimen that keeps your blood sugar in the higher end of normal range. If there isn't a doctor who specializes in diabetes on the Diabetes and Pregnancy Care team, I would insist on a referral. I say this because my brother is an endocrinologist, and Type 1 diabetes runs in my family, so I am very aware that insulin regimens can be tricky, especially so in pregnancy when metabolism is more volatile, and needs change as pregnancy progresses. I have heard him rant more than once about the problems that can arise from having nonspecialists such as internists or obs manage diabetes. As for other interventions, you have the right to make informed decisions, which of necessity must encompass informed refusal as well as informed consent. "Informed Decision-Making" on the Childbirth Connection website can help you with this.

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Q4: Do you have information regarding treatment for a positive GBS test?

Q: I am 37+ weeks and have just received the news that I tested positive for GBS.  I have heard of some natural treatments, but I wondered what advice you might have.

A: I have just reviewed the last 5 years of GBS research on PubMed and didn't find a single study of natural treatments. All I could find was a review of trials of a chlorhexidine vaginal wash in labor, which had some effect in reducing skin colonization in the newborn but even in the aggregate, didn't have enough people enrolled in the component trials to determine if it would reduce early-onset neonatal infection. In any case, that would hardly count as "natural" treatment.

I can tell you that use of antibiotics in labor works. If you want the nitty gritty, here is where you can read the CDC's current guidelines and the reasons behind them. I think your best bet is to agree to antibiotic treatment and use natural remedies to try to counteract its downside, which is killing off the friendly bacteria as well, by using probiotics. Midwives and lactation consultants can often advise you on this.

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Q5: Can you comment on natural induction techniques?

Q: My midwife and I plan to do some natural induction techniques starting at 36 weeks due to some health concerns. Any thoughts on that?

A: As for "natural induction" techniques, I would be cautious. If it involves herbs, they are drugs too. Breast stimulation is effective at shortening pregnancy, and if you are otherwise healthy, appears safe. Here is a website with instructions.  Moxibustion, a Chinese medicine technique, should also be safe. It consists of using heat from a burning herb to stimulate certain acupressure points. Still, I'd wait for 39 completed weeks (the beginning of the week that ends with your due date) before trying anything.

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Q6: Is there research on the pros and cons of steroid use and its effects on the baby at any stage between 31 and 40 weeks?

Q: I am currently 31 weeks into a so-far normal uncomplicated 2nd pregnancy. I am in the "high-risk" category at my ob/gyn clinic due to our first pregnancy ending at 40 weeks and a few days in a stillbirth due to unknown cord accident. That pregnancy was also completely normal and uncomplicated.

My ob/gyn has given us the option to take a steroid just in case the baby runs into any trouble and is born prematurely either on her own or thru an induction or emergency c-section in case of fetal distress. Our doctor knows we want to avoid an induction if at all possible.

I've tried to find more information on this and found the Childbirth connection website which makes a decent case for using corticosteroids and the drugs.com website which was a little more nerve-wracking along with one or two other sites that were less helpful. Our doc wants us to decide before we get to 34 weeks since after that she didn't see the benefit of using steroids.

My question is: have you seen any other research into the pros and cons of steroid use and its effects on the baby at any stage between 31 and 40 weeks?

A: Let me start by saying how sorry I am for your loss. If I understand what you are saying, though, the cause of the stillbirth was a cord accident at term, a "struck by lightning" event that is neither predictable nor preventable, is extremely unlikely to happen again, and has nothing to do with preterm birth. Yet your doctor wants to give you steroids, a treatment whose purpose is to mature the baby's lungs in cases of threatened preterm birth, a problem you are not experiencing. I may be missing something here, but this does not seem rational to me. Steroids are powerful drugs. I would be concerned about taking them unless I had the problem they are meant to treat. It reminds me of an anecdote I read that was used to illustrate the effects of belief systems on maternity care in which an obstetrician talked a woman who had lost her first baby to a nonsurvivable congenital anomaly into an elective cesarean for the next baby to make sure that wouldn't happen again.

I can only imagine how anxious you must be and how nerve wracking it will be as you approach the same point in pregnancy, but if fear, not logic, drives your decisions--or your doctor's recommendations, for that matter--it may lead to intervening in ways that do more harm than good. Lamaze International has materials here on what best promotes safe, healthy birth. And barring an emergency, I recommend using the acronym BRAIN to help you make informed decisions about your and your baby's care:

B enefits
R isks (there always are some)
A lternatives, including doing nothing
I ntuition/ instinct
N o or not now

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Q7: Research on Amniotic Fluid Index (AFI)

Q: I have come up against quite a block of information regarding amniotic fluid index (AFI). I love what you have written regarding shifts in "pockets" as the baby moves and addressing the reason a doctor might be looking at AFI in the first place and the comment regarding risk of induction vs supposed risks of possibly low amniotic fluid. I have found two studies. One only evaluating 8 women with a variance of .65! The other study had 40 women and not much better accuracy. Are we really using 48 women with such variance to dictate public health? Can you comment on the validity and reliability of the research?

A: The clinically important question with any test is does it accurately discriminate between affected and healthy individuals so that affected individuals can be treated without doing undue harm to healthy ones? The answer with all forms of tests of fetal wellbeing, including amniotic fluid volume measurements, is "no." Here's what I found when doing the research for the induction chapter for the forthcoming new edition of Obstetric Myths Versus Research Realities:

  • I could find only one study in 1600 women in which results of amniotic fluid measurements were concealed. (Concealment is important because knowing the results leads to inductions, and inducing labor leads to more fetal distress and cesareans independent of fetal condition.) Low amniotic fluid volume was associated with increased likelihood of low blood pH at birth, but the authors concluded that the sensitivity (test accurately identifies affected individuals) was too low at 29% to make the test useful for identifying at-risk fetuses. We also, of course, don't know if even in compromised fetuses, induction overstressed a fetus who would have been able to tolerate a spontaneous labor.Morris JM, Thompson K, Smithey J, et al. The usefulness of ultrasound assessment of amniotic fluid in predicting adverse outcome in prolonged pregnancy: a prospective blinded observational study. BJOG 2003;110(11):989-94.
  • We have a trial assigning 900 women to routine AFI evaluation at hospital admission in early labor or not. Investigators found that women having AFI doubled their odds of cesarean for fetal distress (6.5% vs. 3.2%) with no difference in neonatal outcomes.Chauhan SP, Washburne JF, Magann EF, et al. A randomized study to assess the efficacy of the amniotic fluid index as a fetal admission test. Obstet Gynecol 1995;86(1):9-13.
  • We have a systematic review of trials comparing two techniques of amniotic fluid volume estimation. More women with AFI were diagnosed with having low amniotic fluid volume than with single deepest pocket (22% vs. 9%), which resulted in more inductions (14% vs. 7.5%) but no differences in neonatal outcomes. Nabhan AF, Abdelmoula YA. Amniotic fluid index versus single deepest vertical pocket as a screening test for preventing adverse pregnancy outcome. Cochrane Database Syst Rev 2008(3):CD006593.
  • Finally, we have a study showing that low amniotic fluid volume in the absence of other symptoms is not concerning. Investigators compared 200 women induced for isolated low amniotic fluid volume with 400 similar women with normal fluid volume and spontaneous labor onset. Women induced for low fluid volume were more likely to have cesareans (16% vs. 6%) and cesareans for nonreassuring fetal status (8% vs. 2%) without improving neonatal outcomes.Manzanares S, Carrillo MP, Gonzalez-Peran E, et al. Isolated oligohydramnios in term pregnancy as an indication for induction of labor. J Matern Fetal Neonatal Med 2007;20(3):221-4.

And, of course, we also know that amniotic fluid volume is not fixed but varies according to maternal hydration.

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Q8: Tips for ‘mature moms’ and the medical system.

Q: I am 36 weeks pregnant and 40 years old (first time mom).  I went into my pregnancy healthy and continue to experience a healthy pregnancy with minimal issues. Any thoughts/tips/suggestions on "mature moms" and the medical system?

A: Many obstetricians regard older mothers, especially 1st-time older mothers, as "X marks the spot where something could go wrong at any moment." They then recommend extra tests and procedures such as induction of labor or cesarean surgery in the belief that this will avert the dangers. It won't. The truth is just the opposite. The safest, healthiest birth is the one with the least use of medical intervention given the individual woman's case, which in the case of a healthy woman who isn't experiencing obstetric complications, is zero. Testing isn't harmless either. Fetal surveillance testing such as the biophysical profile has an extremely high false-positive rate (the test says there is a problem, but it is wrong). In fact, in the case of a healthy woman, a positive bio-physical profile is much more likely to be wrong than right, but once you have a test that says the baby might be having a problem, no ob is going to shrug his shoulders and dismiss it and neither are you. Giving you repeated messages that instill doubt and fear take their toll as well. They lay you open to agreeing to tests and interventions without questioning them and undercut your confidence in your ability to birth this baby. You say you are a runner: how well would you do in a race if you went into it thinking you weren't really strong or capable enough to complete it and you were likely to seriously injure yourself at any moment?

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Q9: Can you point me to any research or literature about the accuracy of estimating due dates during mid-pregnancy?

Q: I got pregnant at the beginning of January, and know within 7-10 days when I conceived. Because I am still nursing my two-year-old, and hadn't had a period to base my pregnancy off of, I agreed to an early dating ultrasound. I estimated I was around 6 weeks, 2-3 days when I had the u/s, and the actual machine dated me at 5 weeks, 5 days. The tech then went to a different computer and told me it would compute my "official" date, which was 5 weeks even. I was happy with the date (though I knew it was at least a week later than I really was), because I didn't go into labor with my son until 41 weeks 1 day, and am planning a VBAC for this birth.

I had my routine anatomy scan last week, and the tech/attending OB moved my due date from October 6 to September 22/24. I want to either keep my original due date, or only move it up a few days at most, as I want be able to go into labor on my own, and not be battling against a repeat c-section at the end of this pregnancy. I have an appointment with my midwife next week, so I don't know how hard and fast she plays by the rules regarding a changed due date, if at all, yet.

Can you point me to any research or literature about the accuracy of estimating due dates during mid-pregnancy? Any other advice about this situation is greatly appreciated, especially in regards to what I can do as a client in keeping or advocating for my original due date. Thanks so much!
A: Definitely insist on sticking with the 1st trimester ultrasound due date. First-trimester ultrasounds are more accurate: "The earlier the ultrasound assessment the more accurate the prediction of date of delivery," and, if that weren't enough, the date agrees with your own estimates, which is strong confirming evidence.


Q: I am turning 40 in two weeks and I am due to deliver in six. I am healthy, active, and have an excellent diet. I have had two previous, non assisted, non medicated vaginal deliveries. Because I am above the magic age of 35, however, I have been told that I am "high risk." For the last four weeks of my pregnancy my doctor has advised me to go to a perinatal specialist twice a week, once for a non-stress-test, and once for a biophysical profile. This is in addition to a weekly visit to my OBs office. Based on an early ultrasound they have also placed my due date at April 25th. I don't think it is possible, without divine intervention, to have a due date before the 28th. I have asked the doctor, midwife, and perinatologist if there are studies showing how all this monitoring would increase the positive outcomes for the mother and child or whether it just increases the rate of interventions. All I get are scary statistics such as "risk of stillbirth in advanced maternal age is at least as high, if not higher than, the risk of stillbirth in a pregnancy complicated by medical problems like diabetes or hypertension." I have several friends who have experienced this level of testing and it left them totally stressed out for the last four weeks of their pregnancy. One felt she was pushed to induction with Pitocin because the doctor didn't want her to go a day over her due date since she was over 40. She, and I, have both been told that the risk of the placenta disintegrating quickly is too great. Is this level of perinatal monitoring standard practice? Are there alternatives? Is there any reason to induce just because of someone's age? I have already had two ultrasounds with this pregnancy and refused a third. Eight additional ultrasounds seems really excessive. Here are some citations that the perinatologist sent to me. I would appreciate your feedback on them.

Frank A. Manning. Antepartum fetal testing: a critical appraisal Current Opinion in Obstetrics and Gynecology 2009, 21:348–352

Ruth C. Fretts, and Ugonna A. Duru, New Indications for Antepartum Testing: Making the Case for Antepartum Surveillance or Timed Delivery for Women of Advanced Maternal Age Seminars in Perinatology Volume 32, Issue 4, August 2008, Pages 312-317.

A: Well, the good news is that the perinatologist actually gave you some papers on the issue. The bad news is that he gave you "narrative reviews," meaning the author or authors collected studies and chose data from them that supports their opinion. This is quite different than a systematic review, although even systematic reviews are subject to the biases of their authors and sometimes to the problem of "garbage in, garbage out" if their component studies are flawed. At any rate, I have the papers and will read them along with some systematic reviews that I just happen to have on me because I'm working on the chapter on induction of labor for the new Obstetric Myths Vs. Research Realities. The questions that need to be answered are:

  • Does routine fetal surveillance testing prevent clinically important adverse outcomes?
  • Does it introduce risks such as increased risk of cesarean surgery or labor induction? One of the problems with all fetal surveillance tests is they have a high false-positive rate, meaning that the test indicates that there is a problem but there really isn't. Of course, once you have a test that says something might be wrong, you can't shrug it off, although ironically, a compromised baby who might have tolerated normal, spontaneous contractions might not be able to tolerate an induced labor.
  • Would study results apply in your case? The thought occurs that prior cesarean is associated with late fetal death of unknown cause in subsequent pregnancies. Women of your age are much more likely than younger women to have had children before and therefore would be more likely to have had prior c/secs--especially in this country where 1 in 3 first-time mothers delivered by c/sec in 2005. Was that taken into account in determining excess rate of fetal death?
    Let’s start with fetal surveillance testing. The theory behind it is that fetuses that are in trouble display symptoms of that trouble by deviating from normal physiology such as how much amniotic fluid they make or physiologic responses such as how their heart rate responds to stimuli such as Braxton-Hicks contractions. By identifying those fetuses and either inducing labor or delivering by cesarean surgery, stillbirths can be prevented. Unfortunately, like electronic fetal monitoring, the best information we have, a systematic review (see my prior post with link to definition) (Lalor 2008), tell us that it hasn’t worked out that way. Biophysical profile testing in high-risk women (hypertension, intrauterine growth restriction, pregnancy longer than 42 completed wks, uterine infection, preterm rupture of membranes, diabetes, etc.) did not reduce adverse outcomes, and the two better-done studies reported an increase in cesareans. Nonstress testing likewise has not been found to decrease adverse outcomes, a fact acknowledged in Manning 2009, the narrative review (which amounts to an opinion piece) whose citation you sent me. Manning, BTW, cites Lalor 2008 and then does a tap dance around the issues that testing fails to improve outcomes and concludes that “The concept of multispectral combined fetal testing including acute biophysical variables, amniotic fluid volume and arterial and venous Doppler flow velocity waveforms is established.” Establishing the concept is not, please note, at all the same thing as establishing effectiveness of testing. Manning’s conclusion is not surprising since the Lalor systematic review names him as the originator of biophysical profiling, citing a 1980 paper of his. Thus you see demonstrated live and in color why narrative reviews do not constitute evidence in the sense of practicing evidence-based medicine.

As to why these testing schemes do not work, there are three reasons for this: first, screening tests will necessarily have high false-positive rates, that is, the test will indicate a problem, but most babies with intermediate scores are actually fine and most of those who are not fine are not so compromised that they cannot withstand the continuation of the pregnancy or tolerate normal labor. Testing schemes also do not account for such normal variation as sleeping babies not being as responsive to stimuli and amniotic fluid volume varying with maternal hydration. Ironically, inducing labor in these cases not only exposes mother, current baby, and future babies to the excess risks of an unnecessary cesarean, but given that inducing labor almost always involves rupturing membranes and stronger contractions often over a longer time period, it is possible that a baby who might have withstood a normal labor can’t manage these additional stressors and labor ends with an urgent cesarean. This scenario will, of course, be taken as validation that testing and induction work, as in, “Thank God we got there in time.” The second reason is false negatives, that is, the test indicates that all is well, but there is a sudden fetal demise. This can occur inexplicably, an accident with the umbilical cord, perhaps, or with explanation such as the placental abruption (the placenta detaches partially or completely before delivery). The third reason is the test result is a true positive that cannot be prevented by delivery, for example, a heart defect, or some subtle problem in which delivery only defers death, so, for example, the baby becomes a SIDS statistic.

Turning to excess risk of stillbirth associated with maternal age and pregnancy duration, Fretts 2008, the other narrative review you sent me, referred to Reddy et al. (2006), a study that analyzed this relationship in 5.5 million U.S. women. The investigators found an increased risk of stillbirth in women 40 or older with increasing gestational age at term (37 wks or more) in singleton pregnancies with no congenital anomalies compared with similar women younger than 35. Quantifying that risk using the data from that paper so that you or other healthy women aged 40 or more who might be interested can determine what your risks might be is another matter. For starters, the study reported stillbirth rates in the subset of women free of medical complications (diabetes, hypertension, kidney or heart disease), and reported rates separately in women with prior births and in women who were first-time mothers, but prior c/sec was left off the list of exclusions, and investigators did not report the two factors in combination, i.e. first-time mothers free of medical complications and women with prior births free of medical complications.

Prior c/sec increases both the risk of unexplained stillbirth and explained stillbirth (stillbirth subsequent to placental attachment problems) in subsequent pregnancies, so this will affect rates in the population of women with prior births. The investigators also note that maternal medical complications are likely to be underreported in birth certificate records, the data source for this study, so some percentage of women in the “no medical risk” subpopulation probably had medical risks. Making my own calculations from data in the analysis, here is the best I can do:

  • In the whole population of women with no medical conditions, 0.6 more babies per 1000 were stillborn in women 40 or older in weeks 39-40, and 1.5 more babies per 1000 were stillborn in women 40 or older in week 41 compared with women less than 35. No data are given for week 42.
  • Among women having a first baby with no medical conditions, 4.2 more babies per 1000 were stillborn in pregnancies continuing beyond 37 wks (the demarcation of full-term) in women 40 or older compared with women younger than 35.
  • Among women with prior births with no medical conditions, 1.7 more babies per 1000 were stillborn in pregnancies continuing beyond 37 weeks compared with women less than 35.

In summary, the excess risk in older mothers is real, but for the reasons I listed above it is probably smaller in healthy women, and especially in healthy multiparous women with no prior cesareans than the numbers I calculated from their data. We also have no idea whether routine testing with delivery for nonreassuring results or routine induction at 40 wks. will improve outcomes or what the tradeoffs would be with excess complications as a result, but based on what we know, it isn't likely to favor either policy.

Looking at induction, you should know that elective induction before 39 completed weeks, that is, the beginning of the week that ends with your due date, is not recommended because of increased risk of serious respiratory problems in the baby. In women with prior vaginal births only, there is no increased risk of cesarean, provided the cervix is ready or almost ready for labor (Bishop score 6 or more on a scale of 10). If the Bishop score is less than 6, there is an increased risk of cesarean (roughly 5% more c/sec than spontaneous labor) that is not eliminated by cervical ripening agents or techniques. In women having a first baby, the risk of excess cesarean is doubled compared with a first-time mother starting labor spontaneously, and, again, that risk is not eliminated by cervical ripening.

Q: I just had an interview with a prospective client and she mentioned that she had a low reading on the PAPP-A test. None of her providers seemed to have any idea what that really meant and are proposing a late 3rd trimester ultrasound. She is hoping to avoid the u/s, especially since she has a good understanding of the slippery slope that could ensue as a result.

I feel comfortable with discussing the pros and cons of testing, informed consent, etc., but this test specifically, I have no knowledge of. Would you please share your thoughts and any info you may have? How specific is it? What does a low reading really mean? What would an ultrasound tell them?

A: I ran a search on Yahoo and turned up this article and on Medline Plus, Pub Med's site for the public, and turned up this one. The gist is that the test screens for Down's syndrome, and a low reading means a higher risk of having it. Keep in mind that screening tests are NOT diagnostic. Most positive screening tests turn out to be false positives. Screening tests are only intended to separate out a segment of the population for further testing. If your client wants to pursue this--and I say "if" because if she would take no action if she found out that the fetus had Down's syndrome, she may not wish to pursue further testing --she will want to find out what her testing options are, how accurate their results are in ruling in or ruling out Downs syndrome, and what their risks are.

I'm still scratching my head over your saying that her care providers ordered a test without knowing how to interpret its results, not to mention that they could have obtained this information from the internet with a few clicks of a mouse or, if they wanted to do it the old fashioned way, a phone call to more expert colleagues. If I were her, I would seek out a genetic counselor or some expert of this type to discuss the test's implications and her options because if what you say is true, she is unlikely to get what she needs to make an informed choice from them.

Q: My current pregnancy is considered "high risk" because I was diagnosed with pulmonary embolism at 13 weeks - therefor I'm on blood thinner injections.

I've had two previous, uncomplicated home births. My plan is to STILL have a home birth with baby #3. I have a home birth midwife whom I trust, and a maternal fetal medicine doctor so my blood thinner levels can be monitored and adjusted as needed during the pregnancy. I give the background mainly because of my question. My MFH doctor wants to do a lot of NST and fetal heart monitoring (20 minute strips in office). By a lot, I mean every visit. Personally, I'm uncomfortable with this. I know that NST can be inaccurate, is there any information you can relay to me about 20 minute strips? I'm just afraid that due to the machine they'll find "something". I know I have the right to refuse, but having some background research would be great! I can't find anything about the risk/benefits of such monitoring. Add to that notion, that when my mother asked if they were worried about the baby during this pregnancy, they said "No, our main concern is mom. Baby should be fine and unaffected by the blood thinners" then I wonder why they want to do all this amount of testing anyway. Any research you've found would be great!!

A: I think you are right to be anxious about the possibility of a false-positive (the test says there is a problem when there isn't). The NST has a high false-positive rate in general and, according to this systematic review (a structured study of studies on a particular topic), the NST has not been shown to be beneficial in high- or intermediate-risk pregnancies. Moreover, the NST looks for fetal heart rate response to such things as Braxton-Hicks contractions and fetal movement, and somewhere rattling around in my brain, I recall that until the fetus reaches maturity, the fetal heart rate doesn't respond to these sorts of stimuli. Don't quote me on that, though, because I might be remembering wrong. I suggest you ask your dr to show you research confirming the benefits of weekly NSTs because they certainly aren't harmless. A test result saying the baby may have a problem can't be ignored, which is likely to lead to an unnecessary induction, cesarean, and possibly a preterm delivery. If your dr can, then you will have to weigh the benefits against the risks of a false positive, but if your dr can't, then you may wish to decline.

Q: This was her first pregnancy and she had expected a natural birth until her membranes ruptured about three weeks before her due date. Regular contractions started about an hour later and we went to the hospital. A few hours later and she was on pitocin. Then about six hours later the nurse discovered that the baby was breech. We were told that there was no choice but to do a c-section.

Naturally, we were overjoyed to see our new son, but as the days went on we began to wonder what caused her membranes to rupture prematurely. We had put so much effort into this (our first) pregnancy only to get less than satisfactory results. Sadly, our doctor informed us that it would be next to impossible to uncover a cause for her premature rupture of the membranes (PROM).

So without a definite cause we turned to statistics for answers. And we didn't like what we found.

Some studies claimed that internal exams, done during the 9th month, can increase the risk of PROM, and some studies found this to not be the case. But I couldn't find a study that demonstrated the usefulness of internal exams.

So why did our OBGYN conduct an internal exam?

Here are the details. During the 36th or 37th week we went in to see the doctor and were told that it was time to "check the cervix". This sounded benign enough so my wife got into her gown and let the doctor peek inside. But the doctor did more than peek. She swabbed her cervix and then (with a glove) felt around for about thirty seconds. My wife was in pain the whole time. Then the doctor informed us that bleeding and discharge would be normal within the next five or six days. We were shocked! Dumbfounded, we left the building but the reality hit us a few hours later. The natural pregnancy was over. We felt violated, angry, and sad.

Six days later, her waters broke prematurely. Admittedly, there's no way to know if the internal exam played a role in this, but it's unsettling to think that our doctor may have increased the risk of PROM without our consent. In fact, our doctor didn't tell us anything more than, "now I'm going to check the cervix".

I've come across various risk factors for PROM and the only three that we had were: Baby found breech, Group B Strep found on the cervix, and the Internal Exam.
Note: the internal exam found her cervix to be at zero

I'm not even sure if the above-mentioned are actually risk factors or not. Did our doctor break the law by not getting informed consent? Why did it take thirty seconds to "check the cervix"? Why was there pain? Why is bleeding and discharge considered normal? Why is there such a high rate of PROM? Why did we constantly feel on the defensive in our doctor’s office?

Any information that you could share would be great.

A: It has become routine to check the cervix every week once a pregnant woman reaches full term (37-42 weeks pregnancy duration). As you have found, some research suggests that the examination may increase the risk of prelabor rupture of membranes. More importantly, NO research has found that the practice has any benefits. The information gained from this exam has little predictive value. A woman can have a soft cervix that is completely effaced (gathered up into the uterus--think of pulling your pursed lips flat) and starting to open, and the baby's head can be low in the pelvis, and she can go for another couple of weeks before labor starts. She can also be "none of the above" and go into labor the next day. On occasion, it is useful to evaluate readiness for labor when an induction is under consideration, but the general rule is "don't have a test unless the information will be used to make a decision."

Unfortunately, as you have begun to discover, virtually all obstetric tests, procedures, and restrictions have been shown to be harmful, ineffective, and usually both when used routinely or frequently and sometimes with any use at all. This is because any intervention in the normal process has the potential to cause harm, so when it is imposed in situations where there is no problem or a problem that could be solved by lesser means or just by having patience, there is no counterbalancing benefit.

Your doctor did not break the law because your wife accepted the exam, which is implied consent. I don't think it would occur to any doctor to ask specific permission in that a vaginal exam would seem to their minds to be as trivial and innocuous as taking your wife's blood pressure or listening to her heart. Of course, for a woman with sexual abuse or assault in her past, this might be far from the case, apart from any possible adverse effects or discomforts of the exam, but that is an argument for another day. I don't know why the exam took such a long time or why it was so uncomfortable. You could ask your wife's ob this, although it is likely the ob won't remember.

I don't know if the rupture of membranes a week later is connected. In any case, with so few doctors doing vaginal breeches, your wife would almost certainly have had a cesarean anyway. The only way that might have been averted was if your ob had told you the baby was breech, which can often be discerned by feeling the baby's position from the outside (Leopold's maneuvers), although it is not foolproof. Now's there's a test with real value! It has no downside, and if you had known in time, there are things that can be done to try and get a breech turned before labor.

If your wife finds she is experiencing emotional distress over this birth, I recommend Solace for Mothers, a website that offers peer support for women who have had challenging childbirths. You may also find peer support and information on cesareans and vaginal birth after cesarean (VBAC) on the International Cesarean Awareness Network website. And you can give feedback on your care provider and hospital on the Birth Survey website, which will help other women make informed choices of care providers and place of birth.

Q: I am having my first baby in China and they do things very differently here. Their medical training is very out dated and they don't seem to be able to comprehend informed consent, and definitely not informed refusal.
Today my doctor wanted to do a Non-stress Test on the baby. I'm 27 weeks. I don't really feel that it is necessary as the baby is very healthy and active. She insisted that after 36 weeks I needed a non-stress test every week till the baby was born. When I refused today she said I was a bad patient and that I had to do it next time. I'm wondering if I should let them do just one so they leave me alone. I don't intend to let them do 3 or 4 that's for sure.

ALSO, she wants to take another blood test. I asked what for and she said to check my blood type and my liver and kidney function. I reminded her that we have already taking two blood tests and tested those things. she said that they (the liver and kidney function) can change towards the end of the pregnancy and if I don't take the tests now I have to take them when I come in for the birthing.
I haven't even read anything about ANOTHER blood test. Is this standard (or maybe it was in the past?) is it true that these things can change? I'm not against the needles to having a blood test, but I am against needless tests that just rack up the medical bills.

Again I am contemplating just letting them do it to avoid drama at the birthing but I'm so tired of them bossing me around and telling me nothing as if they own my body and I have no say.

A: You are in a difficult situation because, as you already know, your care providers are not practicing care that is based on the research evidence, and their reaction to your resisting them doing what you know to be incorrect is to accuse you of being a "bad patient." I think I know why they think this way: they believe that all this testing and technology is the best way to ensure a healthy baby in a population where almost all women are only going to have one child. Unfortunately, they are wrong, and if you go along with their plans, you are likely to end up with a cesarean surgery or other medical intervention that you did not truly need. Any intervention can do harm as well as good and having it when you don't need it exposes you and your baby to those harms with no counterbalancing benefit, and, in the case of cesarean surgery, any future children. You may also end up psychologically distressed about the birth, which will seriously harm you and make it more difficult to cope with the challenges of becoming a mother.

It doesn't sound as if your care providers are open to working with you. That being the case, only thing I can do is advise you is to search the internet to see if you have any alternatives to the treatment you are now getting. Are there any midwives or doctors who specialize in natural birth? Are there home birth practitioners? If you were not in China, I would have some ideas on where to suggest that you look, but I don't know anything about China. I apologize for that. This probably confirms what you already know but here are the practices that promote safe, healthy birth.

Q: I am pregnant for the first time at age 38. Of course, I'm considered of "advanced maternal age" and high risk. My doctor has referred me to a genetic counselor, in conjunction with my regular ob/gyn. I have an initial consultation set up but I'm really not sure if I need this or not - I'm not convinced that the screening/tests conducted are going to do anything but worry me. I guess my question is, are these tests really necessary, given my age? No one in my family or my husband's has a history of genetic problems. The only risk factor I have is my age. Any suggestions?

A: Regardless of your genetic background, age is an issue, at least for Down's syndrome. However, the rule is that you should only have a test if the information will help you make a decision. If there are no circumstances under which you would end a pregnancy, you may wish to refuse genetic testing. In such a case, getting a positive result will, as the Dutch term it, "spoil the pregnancy." If there are conditions that would lead you to end the pregnancy, then you have to consider how likely one of those conditions is and weigh that against the accuracy of the test you are considering, the potential harms of the test and how likely they are to occur, what further tests or procedures would be recommended if the one you are considering is positive, and the accuracy and potential harms of those.

Q: My OB told me today that the research shows that patients diagnosed with GD benefit from stress tests 2 time a week because it has been shown that if you have a normal stress test your baby's chance of living thru the next 4 days is 98-99%. Do you know the research she is citing and do you know of any other that promote or not the effectiveness of the non-stress tests?

A: I don't. Ask your ob for the research, and I will be happy to go over it for you.I can say this, though: the problem with all tests of fetal well-being is their high false-positive rates, that is, the test says there is a problem, but there really isn't. In a healthy woman, which you are if your GD is under control--or even in a woman with moderate problems--the test is much more likely to be wrong than right if it says there is a problem. But no one is going to sit on their hands with a test result that says the baby is in trouble, so women who have tests of fetal well-being are not infrequently going to end up with labor inductions, cesarean surgeries, or both that they didn't need. Add on to that the false-negative rate: the test says everything is fine when it isn't. It is also possible to have a true positive where delivering the baby won't solve the problem. In fact, it is also possible for a compromised baby to be able to tolerate normal labor but not induced labor where contractions can be longer, stronger, and closer together. Even a healthy baby can be distressed who wouldn't have been with natural contractions. (This, of course, just reinforces the medical model approach. "Thank goodness we intervened," everyone says, it never occurring to them that intervening was what caused the baby to go into distress.) In short, the odds are 99.9% that your baby will live through the next four days whether you have the stress test or not, and you could end up with a cesarean that you didn't really need and, ironically, that puts you, your baby, and future babies at greater risk of death and serious harm.

Q: I was recently reading your Lamaze Pregnancy publication (2007), and came across several good articles. I found the articles "Due Date Dilemma" and "Daddy's Side" to contain helpful information. However, I was disappointed by the article "Too Many Tests"(pg. 13). In it Glucose Screening was discussed with the response "so the only downside to this condition (gestational diabetes) is that the baby may get large..." This is inaccurate information that could be damaging to the public. According to Gabbe, Niebyl, & Simpson, pregnant women with uncontrolled GDM put their infants at risk for congential malformations, fetal macrosomia, hypoglycemia, jaundice, and even fetal death (2002). Also in Current Diagnosis & Treatmen Ob & GYN (2007) it is stated "there is an increase in miscarriages, congenital malformations, preterm birth, pyelonephritis, preeclampsia, in utero meconium, fetal heart rate abnormalities, cesarean deliveries, and stillbirths" in women with gestational diabetes. Rakel (2002) states in reference to gestational diabetes, "Early impairment in glucose metabolism may not be associated with any maternal signs or symptoms, but it can have fetal effects that include macrosomia, fetal distress, and fetal demise." In my own experience as an OB/Gyn nurse these infants have a more difficult delivery (shoulder dystocia), difficulty feeding, difficulty keeping their blood glucose within normal limits and difficulty staying warm. I ask that you re-educate the public about gestational diabetes and the need for testing. Women whose blood sugar is elevated need further education regarding diet, exercise, and the possibility of insulin use during pregnancy. If you need more supporting sources I would be happy to provide them to you. Thank you for your time.

Decherney, A. & Nathan, L. (2007) Current Diagnosis & Treatment Obstetrics & Gynecology (10th ed.). McGraw-Hill Company
Rakel, R. (2002). Textbook of Family Practice (6th ed).

WB Saunders Company: Philadelphia
Gabbe, S., & Niebyl, J., & Simpson, J., (2002).

A: To give a little background, I asked if the author of the question above could provide citations for the sources she cited so that I could evaluate them. Unfortunately, the cited sources are textbooks, which means I don’t have access to them. Textbooks, though, present the conventional wisdom on any particular medical issue. Conventional wisdom is that GDM is a serious condition with potentially severe adverse effects if left undiagnosed and untreated. The question is whether conventional wisdom is correct. I wrote an article a few years ago on what was then iVillage’s ParentsPlace.com. In it, using the research evidence and pointing out the logical inconsistencies, I make the argument that the conventional wisdom is not correct. The article goes into much greater detail, but let me address the issues raised in the question above:

  • GD diagnosis and treatment could not possibly prevent congenital malformations or miscarriage since these are 1st trimester events and GD testing does not occur until the 3rd trimester. Lost in the noise of the later studies is that, in any case, blood sugar metabolism is normal in the 1st trimester. If it isn’t, it isn’t GD. As I wrote in my article, the hormones of pregnancy suppress the mother’s insulin, preventing her from metabolizing glucose in her own cells and making more circulating glucose available to the growing baby. GD is a matter of the woman’s pancreas not being able to keep up with demand, a problem that doesn’t arise until late in pregnancy.
  • A great deal of confusion arises by using the term “diabetes,” which mixes together pre-pregnant diabetes with what should properly be called “glucose (or carbohydrate) intolerance of pregnancy.” This terminology was used in Europe and is more accurate since with GDM, sugar levels do not reach the diagnostic threshold of true diabetes. The research physicians who have built their careers on gestational diabetes—this disease was invented in the 1970s and 1980s and did not exist before that time—chose the term deliberately at one of the early international workshops so that everyone would take the problem seriously, especially insurance companies, who would be expected to pay for all of this. The result is that two fundamentally different conditions are lumped together, and some complications, such as kidney problems, which only result from long-standing severe aberrations of glucose metabolism, are attributed to GD.
  • Some complications attributed to GD are because hyperglycemia is much more common in high-weight women. High-weight women are more likely to have high-weight babies—in fact, the baby’s birth weight is much more strongly correlated with the mother’s prepregnant weight than it is with her blood sugar level. Big babies are more likely to experience hypoglycemia after delivery and shoulder dystocia. High-weight women are also more likely to have hypertension or other health problems and therefore the consequent adverse effects of those medical conditions on the baby, including increased risk of death. Identifying and treating GD won’t make those problems go away, and they can be diagnosed and treated without reference to the mother’s blood sugar status.
  • Excess cesarean surgery rates, fetal distress, preterm birth, difficulty feeding could well be caused by the obstetric management that follows the diagnosis of GD. Among untreated gestational diabetic women, 20-30% will have a baby above the 90% range in birth weight instead of the statistically expected 10%, but the belief that most GD women are destined to have a large baby or that going to term poses risks leads to early term inductions and scheduled cesareans and to a too quick diagnosis of "failure to progress." Babies delivered before they are ready are more likely to have respiratory and breastfeeding difficulties. Cesarean sections interfere with establishing breastfeeding. Continuous, ongoing stress is strongly associated with preterm delivery, and the regimens of tests and procedures and the anxiety generated by the “diabetic” label is nothing if not stressful. Calorie-restricted diets and insulin to tolerance, which some protocols call for, can cause episodes of low blood sugar. Etc., etc.
  • Neonatal hypoglycemia is associated with high-weight babies, stressful deliveries, and preterm delivery. You don’t need to know that the mother is diabetic to identify babies at risk for hypoglycemia or to treat babies with symptomatic hypoglycemia.
  • Finally, pretty much everywhere women are routinely tested and treated for GD. If the author of the question is still seeing the problems she is seeing anyway, it’s because testing and treatment aren’t working.

I would be all for testing and treatment if all that happened was that women identified as having glucose intolerance of pregnancy were given good nutritional counseling and encouraged to exercise regularly and told these things, while important for every pregnant woman, were especially important for them. The GD diet—whole grains, fruits and veggies, avoid simple carbs, moderate in fat—is a good diet for any pregnant woman. Regular exercise is also beneficial. The possibility of identifying the rare case (about 1 in 1000) of a woman who has real diabetes would also be valuable. But that’s not what happens. The GD label means that the woman and her baby are subjected to a regimen of tests and medical interventions with considerable potential for harm and no convincing evidence of effectiveness. I’m with the authors of Guide to Effective Care in Pregnancy and Childbirth who classified GD testing and dietary and insulin treatment under “Forms of care unlikely to be beneficial.”

Q: As a doula, I would like to provide research to my clients about 40 week ultrasounds. You hear over and over women being induced b/c the ultrasound said the baby was too big, baby is too small, too little fluid, aging placenta, etc. Is there a study that shows the outcomes for baby do not change but the interventions increase? How can I reassure moms that these scans can be avoided and they can go into labor and have a healthy baby without fear that these things need to be checked?

A: Here is a copy of a research summary by Amy Romano:
Prenatal Diagnosis of Suspected Fetal Macrosomia Increases Risks of Cesarean Section and Maternal Morbidity without Improving Newborn Outcomes Sadeh-Mestechkin, D., Walfisch, A., Shachar, R., Shoham-Vardi, I., Vardi, H., & Hallak, M. (2008). Suspected macrosomia? Better not tell. Archives of Gynecology and Obstetrics, doi: 10.1007/s00404-008-0566-y. [Abstract]

Summary: In this prospective observational trial, researchers followed 145 women thought to be carrying babies weighing more than 4000g (about 8lb, 13oz) to evaluate the reliability of sonographic and clinical estimates of fetal weight and to determine whether a diagnosis of "suspected macrosomia" affects pregnancy management or outcomes. To answer these questions, they first divided the "suspected macrosomia" into two subgroups depending on whether the babies in fact weighed more or less than 4000g. This resulted in a "false-positive" subgroup of 82 babies thought to be macrosomic but actually weighing less than 4000g and a "true-positive" group of 63 babies thought to be macrosomic and indeed weighing more than 4000g.

The researchers compared outcomes between these two groups, then compared the "true-positive" group to all other births of macrosomic infants to women admitted to the same hospital in the study period (i.e., women giving birth to infants weighing over 4000g but who did not have a prenatal diagnosis of suspected macrosomia).

The study confirms an existing body of literature that tells us that prenatal methods for detecting macrosomia are not reliable—only 44% of babies suspected to weigh over 4000g actually did. Clinical estimates (those performed by a care provider using palpation) were more reliable than ultrasound estimates, but were still off by more than 10% in one out of every six cases.

The 145 women with suspected macrosomia were assigned by the admitting doctor to elective cesarean surgery (16%) induction of labor (39%) or observation awaiting labor (46%). Thirty-five of the 56 women who underwent induction and 47 of the 66 women who were admitted in spontaneous labor gave birth vaginally, for an overall vaginal birth rate of 57% (including 2% who had instrumental vaginal births). The remaining women gave birth by cesarean surgery either before (21%) or during (22%) labor.

When researchers compared outcomes of the "true-positives" with the "false-positives" within the "suspected macrosomia" group, there were no differences in maternal or infant complications.

When the researchers compared the true-positive macrosomic infants in the study group (those suspected to weigh and actually weighing >4000g) to the macrosomic infants in the comparison group (those not suspected to be macrosomic prior to birth), they found much higher rates of intervention and related morbidity in the study group. The cesarean surgery rate for macrosomic infants in the suspected macrosomia group was 57%, compared with only 17% for macrosomic infants in the comparison group (absolute difference 40%). Likewise, 25% of macrosomic infants in the study group were induced compared with 14% in the comparison group (absolute difference = 11%). There was no difference in shoulder dystocia between the two groups. However, maternal morbidity (including hemorrhage, wound infection, wound dehiscence, fever, and use of antibiotics) was significantly higher in study group, most likely because of the much higher rate of cesarean surgery in this group.

Significance for Normal Birth: The concern that a baby is growing "too big" is one of the most common reasons cited for induction of labor and also prompts decisions to perform cesarean surgery both before and during labor (Declercq, Sakala, Corry, & Applebaum, 2006). However, there is strong and consistent evidence that elective induction or cesarean surgery for "suspected macrosomia" does not improve outcomes and expert bodies including the American College of Obstetricians and Gynecologists oppose routinely interfering when a baby is suspected to be large (American College of Obstetricians & Gynecologists, 2004).

This study, summed up by its title, "Suspected macrosomia? Better not tell" provides damning evidence that shows clearly that the provider's belief that the baby is "too big" is itself a strong risk factor for injudicious intervention and poor health outcomes.

An initial suspicion that the baby is large may instill fear in the pregnant woman which may impede both her confidence in her body and her labor progress. Slow labor progress reinforces the suspicion that the baby is big and more aggressive management ensues. This management often hinders the woman's ability to move freely and assume the positions that may help her baby negotiate through her pelvis, further slowing progress and reinforcing the perceived need for surgical intervention. Based on this study and previous evidence, women should strongly consider refusing tests late in pregnancy intended to estimate fetal weight.

The estimate itself may be bad for her health because the care provider's expectation that the baby will be macrosomic appears to increase both unnecessary medical intervention and the morbidity that may accompany it.

References:
American College of Obstetricians and Gynecologists. (2004). Ultrasonography in pregnancy. ACOG Practice Bulletin No. 58. Obstetrics and Gynecology, 104, 1449–58.

Declercq, E., Sakala, C., Corry, M. P., & Applebaum, S. (2006). Listening to mothers II: Report of the second national U.S. Survey of women's childbearing experiences. New York: Childbirth Connection.), 116-122.

As for amniotic fluid volume estimates, here is a study that, as I recall, was summarized in last year's Lamaze research summaries, but since I can't get at those, I give you the citation and the study abstract:

Manzanares S, Carrillo MP, Gonzalez-Peran E, et al. Isolated oligohydramnios [low amniotic fluid volume] in term pregnancy as an indication for induction of labor. J Matern Fetal Neonatal Med 2007;20(3):221-4.

OBJECTIVE: To evaluate the outcome of active induction of labor for isolated oligohydramnios in low-risk term gestation. METHODS: This retrospective study analyzed the obstetric and perinatal outcome of 412 singleton term pregnancies with cephalic presentation and no maternal risk factors or fetal abnormalities. Two groups were compared: 206 deliveries after induced labor for isolated oligohydramnios, and 206 deliveries matched for gestational age following spontaneous labor with normal amniotic fluid index. RESULTS: The overall rate of cesarean deliveries and cesarean deliveries for nonreassuring fetal status, and operative vaginal delivery rates and those for nonreassuring fetal status were higher in the oligohydramnios group than in the control group. There were no differences between groups in neonatal outcome or perinatal morbidity or mortality. CONCLUSION: Active induction of labor in term low risk gestations with isolated oligohydramnios translated into higher labor induction, operative vaginal delivery and cesarean section rates. This led to increased maternal risk and an increase in costs with no differences in neonatal outcome.

Unfortunately, though, since conventional obstetric prenatal care consists of instilling fear from the very first visit, by the end of the pregnancy, most pregnant women are probably not convince-able.

Q: I’m currently trying to weigh up the benefits and risks of the 19-week ultrasound. I chose against any first trimester screening, but am finding this decision more difficult. I'm partly concerned about the unknown effects of ultrasound and partly just don't "feel like it". I mean, I'm enjoying getting to know my baby myself and am worried relying on ultrasound to "see" my baby might stain the beauty of using my intuition. However, I realize the scan might be beneficial in picking up e.g. spina bifida, which then would influence me to choose a different birthing plan. So I'm just putting the word out there to ask others about their thoughts and feelings on the benefits and risks of this scan?

A: I'll weigh in for starters. When having any test, one must consider its potential harms vs potential benefits, and its accuracy. One must also consider whether one intends to take any action based on test results. If the answer to the last question is "no," then stop right there. The rule is: Don't have the test.

One benefit that you have listed is that the discovery of a neural tube defect would change your plans for the birth. I'm not sure what that change of plans might be, but if that is your only concern, why not just take a quick peek in the 3rd trimester? That's plenty of time to decide that you will have your baby in the hospital instead of at home or in a free-standing birth center and whether the condition is serious enough to warrant planning a c/sec. (Neural tube defects, you should know, are not a black & white issue. They can range from extremely minor to severe, as can, no doubt, other congenital anomalies.)

On the minus side, you have articulated a concern that is on the money: "getting to know the baby." If you would not end the pregnancy based on what is shown on the ultrasound, you will have, as the Dutch call it, "spoiled the pregnancy." You will almost certainly spend the rest of the pregnancy in anxiety, distress, and grieving for something that cannot be treated until the baby is born. But there is worse: Ultrasound scans not infrequently give ambiguous news or even an erroneous diagnosis. Then you will not only worry your way through the rest of the pregnancy for nothing, but studies have shown that even after the baby is born and shown to be healthy, women may continue to worry that all is not well with their child. A mother who is unduly anxious and hypervigilant about her baby is going to be a different sort of mother from one who is not, and that could have subtle, yet powerful, consequences for their relationship.

As for potential harms of exposing the unborn baby to ultrasound in the 2nd trimester, I haven't researched this recently, but I would think that the odds are that risk of harm would be minimal with a single abdominal scan after the 1st trimester. It's hard to prove a negative, though. There is always the possibility that if the study measured something else or used a bigger population, it might detect an association. What I would do in your shoes if I were going ahead with the scan is:

-- To ensure greatest accuracy and reliability of diagnosis, have the scan done by a certified sonographer in a facility that specializes in imaging or a hospital imaging department. Don't just have your ob do it in the office. Ask for the qualifications of the person doing the scan and the person reading it. Don't assume; unless things have changed fairly recently, unlike, say, your hairdresser, there are no regulations regarding training and experience for ultrasonographers. Obstetricians can be "trained" as part of a weekend cruise junket.

-- Discuss what you want to know because knowing it could influence your plans. Then find out how to get the briefest possible exposure that will find those things out. In other words, don't agree to a fishing expedition of whatever length and exposure is the usual protocol.

-- Discuss whether an abdominal scan is ordered, where the probe is moved across your belly, or a vaginal scan, where the probe is inserted vaginally. For one thing, there may be a difference in risk since the probe is inches from the baby with very little in between. Also, some women have bluntly described a vaginal scan as "rape with a foreign object." Certainly, if you have sexual assault or abuse in your past, I would leery of agreeing to a vaginal scan. At the very least, you don't want any surprises on this point.

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The questions and answers offered in this section are from evidence-based information, and archived from the Lamaze Ask Henci forum that was available through 2014. For medical advice, please see your care provider.