Online Health Chat with David Vexler, MD
July 19, 2013
As an expectant parent, you take special steps to create the best possible environment for your newborn, which may include attending childbirth education courses, touring the hospital, packing a bag for the big day, choosing the right pediatrician and even decorating the nursery.
Expectant mothers are encouraged to create a birthing plan that includes various delivery options and information to ensure the delivery is a special moment for mother, father and baby. Some expectant mothers may favor the services of a doula or midwife rather than a physician. Some women choose to move about, sit or lie down as labor progresses, and may opt to progress labor by use of Pitocin® (oxytocin) or stripping of membranes. While delivering, some mothers may elect pain medication while others may want to have a natural childbirth.
Options for childbirth can include cesarean, birth in bed, a birthing stool or water delivery. These options are dependent on what your hospital is able to accommodate. Other requests, such as music, dimming of the lights and photography or videos, also may be considered. Post-delivery requests include whether you plan to bank the umbilical cord blood and if you intend to breastfeed.
Whatever the birth plan includes, it is important for the expectant mother to remember that not every aspect of child delivery can be accounted for. The delivery may be early or complicated by other factors, which require the intervention of a physician to ensure the health of both mother and baby. Other times a mother in delivery may change her mind about an option, such as pain medication, and the delivery team needs to be flexible to accommodate her changing needs. Whether everything goes as planned or something unexpected arises, the birth of your baby is a special event that will not be forgotten.
About the Speaker
David Vexler, MD, is a member of the Cleveland Clinic Regional Obstetrics and Gynecology department. Board certified in obstetrics and gynecology, Dr. Vexler has been practicing at Hillcrest Hospital for 16 years. Dr. Vexler completed his obstetrics and gynecology residency at SUNY Health Science Center-University Hospital of Brooklyn, NY. He earned his medical degree from Mount Sinai School of Medicine, in New York, and the University of Cincinnati College Of Medicine, in Cincinnati.
Let’s Chat About My Not So Planned Birthing Plan
Bed Rest During Pregnancy
Susan: What are the reasons someone would need to be put on bed rest? How does it help?
David_Vexler,_MD,_Ob/Gyn: Many patients are put on bed rest when they are at risk for premature delivery and for high blood pressure. Patients who have an incompetent cervix with a stitch placed may also be put on bed rest. Bed rest has become more controversial recently. Many obstetricians question the efficacy of bed rest in preventing premature births since most studies show that it doesn't improve outcomes. Also, potential complications from bed rest include an increase in blood clots in the lower extremities.
Blood pressure may improve with more limited activity. Many obstetricians are now placing patients on reduced activity regimens instead. However, since there are still limited options to prevent preterm births, many obstetricians still advise bed rest.
Pruritic Urticarial Papules and Plaques of Pregnancy (PUPPP)
Colli: A friend of mine recently had something called PUPPP rash. What is it and can I prevent it in my pregnancy? How is it treated?
David_Vexler,_MD,_Ob/Gyn: Pruritic urticarial papules and plaques of pregnancy (PUPPP), also known as polymorphic eruption of pregnancy. This is a benign condition to both mother and baby. However, it can be extremely annoying. This condition is usually treated with topical ointments and baths and usually resolves with delivery. There is no way to prevent this—it is random.
It is important to distinguish this rash from that caused by acute cholestasis (sludging in the liver). This condition will increase the risk to the fetus, and a high-risk obstetrician may recommend early delivery.
Worrier: What is preterm labor? What does it feel like? How is it treated?
David_Vexler,_MD,_Ob/Gyn: Preterm labor is labor that begins prior to 37 weeks of pregnancy. For most patients it feels the same as labor feels when the baby is at term, but labor varies from patient to patient. Most studies show that once preterm labor becomes advanced, the labor will be stopped and the baby will be delivered early.
mom2two: At what point is it safe to start forms of induction, i.e. stripping membranes or stretching the cervix to get labor moving?
David_Vexler,_MD,_Ob/Gyn: Usually, these techniques can be applied at 38 to 40 weeks.
Dream94: It’s my first pregnancy, and I’m not sure what to expect. What are the benefits of a water birth versus a bed birth? How long do you have to be actually pregnant before the pregnancy is induced?
David_Vexler,_MD,_Ob/Gyn: Water births have recently become popular—but there are benefits and risks. This is something to discuss with your OB/GYN (obstetrician-gynecologist). Typically, obstetricians do not allow a pregnancy to go beyond 42 weeks, but there may be small increased risks with going on 41 weeks of pregnancy that should be discussed with your physician.
Forceps and Vacuum Use
Lin: Are forceps or vacuum methods commonly used during delivery? I hear a lot of scary things about forceps. Are they safe?
David_Vexler,_MD,_Ob/Gyn: It depends on the hospital where you deliver. Forceps and vacuum deliveries are safe when used by experienced obstetricians. I mostly use a vacuum, but some physicians feel more comfortable with forceps.
There are two main reasons we use forceps and vacuums today. One is to shorten the second stage of labor (pushing) when the baby is in distress. We also use it when a mother is exhausted after pushing for a long period of time, and we feel it is still safe to have a vaginal delivery.
AKVmv: What happens to cause a baby to be breech (feet first presentation)? Can a breech baby be safely delivered vaginally?
David_Vexler,_MD,_Ob/Gyn: No one knows for sure what causes a baby to be breech. However, one theory is that many breech babies have a head that is likely too large for the woman's pelvis, and nature is attempting to put something smaller in position for delivery.
In the U.S., most breech presentations are delivered by cesarean (C-section). Studies show that there is a 10 percent complication rate with vaginal breech delivery (brain damage or death). In certain patients it may be possible to perform an external cephalic version, in which we manually turn the baby through the patient’s abdomen. It is rarely successful in a woman having her first pregnancy, but can be more successful when a patient is having subsequent deliveries. A prior C-section is a contraindication to external manipulation (a mother with a prior C-section should not have this).
Vaginal to Cesarean Delivery
3553abe: I am scheduled for a vaginal delivery, but what are the circumstances that could occur that would change it to a C-section (Cesarean)?
David_Vexler,_MD,_Ob/Gyn: There are numerous conditions that may warrant a change prior to labor—too many different things to go into here. The most common is a breech or transverse presentation of the baby. However, most primary, or first, C-sections are performed during labor. The most common reasons are failure to progress, which can be failure to get to full cervical dilatation, an inability to push the baby out and fetal distress prior to the end of labor (when the mom is not fully dilated).
Vaginal Birth After Cesarian
mom2two: With my first baby 14 months ago, I was brought in for induction with complications, including eclampsia and/or HELLP (hemolysis, elevated liver enzymes and low platelet count) syndrome, three days before my due date. It was caught with blood work the day before delivery. Prior to induction, my doctor realized the baby flipped to breech overnight, so I had a C-section as to not further injure my liver. I am now two weeks from my due date with my second baby. Any insight about whether these ‘flukes’ could happen again? Also, am I a good candidate for vaginal birth after cesarian (VBAC)? So far, there are no signs of complications and the baby’s head is facing down. How safe are VBACs? When I mention to people that I am planning to have one, they become very concerned and ask if it's safe. What are the success rates?
David_Vexler,_MD,_Ob/Gyn: You likely had preeclampsia with HELLP syndrome. Eclampsia is preeclampsia with a seizure. I'm assuming you would have remembered if you had a seizure! Preeclampsia is a condition that includes elevated blood pressure, increased urine protein and edema (body swelling). HELLP syndrome is a complication of preeclampsia that includes hemolysis (breakdown of red blood cells), elevated liver enzymes and low platelets. You likely had a cesarean for the breech as there is a high rate of complications associated with a vaginal breech delivery. This is the best scenario for attempting a VBAC. Our overall success with VBAC is about 60 percent, but with a previous c-section for a breech baby the rate is much higher. The only caveat is that you need to make sure that your c-section was performed as a low-transverse incision It doesn't matter what the skin incision looks like—only the uterine incision counts. Any other type of incision increases the risk of a uterine rupture in labor to an unsafe level. A low transverse incision has a risk of 1 percent of uterine rupture during labor after c-section. You should discuss this with your obstetrician prior to making an attempt at vaginal delivery.
mom2two: A friend recently had a rough delivery--she wound up with a uterine infection and the full-term baby was in the NICU for a few days on antibiotics. What is a uterine infection, what are the risk factors, and how common are they? How does a uterine infection affect the mom and baby?
David_Vexler,_MD,_Ob/Gyn: Most likely your friend experienced a prolonged labor which increased her risk for a infection. Uterine infection is typically an infection of the lining of the uterus that may also lead to an infection in the newborn.
Risk factors include prolonged rupture of membranes, prolonged labor and Group B strep colonization. Uterine infection can affect the mother and baby in a similar fashion, with a fever, etc. The treatment is intravenous antibiotic therapy.
Moderator: I'm sorry to say that our time is now over. Thank you again Dr. Vexler for taking the time to answer our questions today about planning for childbirth.
David_Vexler,_MD,_Ob/Gyn: Thank you for your questions. Best of luck with your upcoming delivery.
To make an appointment with David Vexler, MD or any of the specialists in our Ob/Gyn & Women’s Health Institute at Cleveland Clinic, please call 216.444.6601 or call toll-free at 800.223.2273, ext. 46601. You can also visit us online at clevelandclinic.org/obgyn.
For More Information
On Cleveland Clinic
Cleveland Clinic’s Obstetrics & Family Maternity Center at Cleveland Clinic birthing hospitals offers a supportive environment and the latest technology provided by a world-class medical staff. Women and babies benefit from three tiers of obstetrical services, including midwife services for low-risk obstetrical services, Ob/Gyn physicians for low- and medium-risk obstetrical services and maternal-fetal medicine specialists for management of high-risk pregnancies. Cleveland Clinic birthing hospitals offer world-class care in labor and delivery for women and/or their babies with serious health conditions. Expectant mothers and babies receive personal attention and emotional support before, during and after delivery.
Our birthing hospitals support mothers who opt for a natural birthing experience. Water births and hypnobirthing are available options. Birthing balls, experienced labor coaches and a tranquil environment cater to your birth plan needs.
Cleveland Clinic’s gynecology program is top ranked in Ohio and ranked third in the nation by U.S.News & World Report.
At Cleveland Clinic’s Children’s, the Special Delivery Unit offers women who are carrying babies with known birth defects a compassionate, family-centered setting for labor and delivery, with access to world-class adult and pediatric specialists. The unit also treats pregnant women with serious medical conditions, such as congenital heart disease, cancer or autoimmune diseases. As part of the Fetal Care Center, the Special Delivery unit provides mothers, unborn babies and newborns advanced diagnostic and treatment options.
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