Second and Third Trimester Concerns

Podcast Transcript

Erica Newlin, MD:

Welcome to Ob/Gyn Time, a Cleveland Clinic podcast covering all things obstetrics and gynecology. These podcast episodes are intended to help you better understand your health, leaving you feeling empowered to live your best. We hope you enjoy today's episode.

Hi everyone. I'm your host, Dr. Erica Newlin. Welcome to Ob/Gyn Time. During this season, we are focusing on topics related to pregnancy and obstetric concerns. On this episode, I'd like to welcome Dr. Goebel and Dr. Parker, who will be talking to us about the second and third trimester. Dr. Goebel, Dr. Parker, thanks so much for joining me on the podcast.

Kathryn Goebel, MD:

Thanks for having us.

Erica Newlin, MD:

Can you tell us about your role in the Cleveland Clinic and a little bit about your background, Dr. Goebel, you can go first.

Kathryn Goebel, MD:

Well, I have been at Cleveland Clinic now for 14 years. I do general obstetrics and gynecology with a focus on pelvic ultrasound. I've been taking care of pregnant patients for a lot of years now and you know, I think it's really helpful to understand what are common concerns and you know, what can be expected as normal and when is it time to be concerned.

Tammy Parker, MD:

I have been at Cleveland Clinic now for 16 years. I'm a general OB/GYN, and I specialize in both, so I take care of a lot of pregnant women. I also do a lot of gynecologic surgery as well. I think it's really, really important for people to understand how the progression of the pregnancies go and what's normal and what's not.

Erica Newlin, MD:

Let’s start by, we have an initial episode that talks about pregnancy, and we've talked about this a little bit in prior episodes, but Dr. Goebel, can you remind the audience what we mean by trimesters and how we delineate the second and third trimesters?

Kathryn Goebel, MD:

Sure. So as I'm sure you've talked about before, our pregnancy math is a little bit squirrely. We actually start counting the weeks based on when your last period was. So with that then a pregnancy is 40 weeks long.

The second trimester starts at the beginning of week 13. The third trimester starts at the beginning of 28 weeks. If you didn't know your period, or you had IVF, your dating may be a little bit off, but again, a pregnancy is 40 weeks long, even though you're actually only pregnant for 38 weeks of that.

Erica Newlin, MD:

Great. And I tell patients I get really confused if they tell me months in pregnancy, like seven months pregnant.

Kathryn Goebel, MD:

Yes, I agree as well.

Tammy Parker, MD:

Hundred percent.

Kathryn Goebel, MD:

Yeah. Your, your OB/GYN is always going to go by weeks, not months.

Erica Newlin, MD:

Yeah. Dr. Parker, what are the most common physical changes in the second trimester and which ones surprise people the most?

Tammy Parker, MD:

For one, their pants are going to start to get a little tighter because their belly's going to start to sort of show a little bit, and that's different for every person, depending on their body type. Also, it depends on the pregnancy. The first pregnancy, they may not show for a very long time into their week twenties.

But for someone who it's their second, third, fourth pregnancy, they may start showing as early as 12, 13, 14 weeks. So for many, when they are on their second pregnancy, that's quite a surprise for them because they didn't realize it's going to show so much earlier.

Other things that are going to change. If they had a lot of positive things that are changes, as if they had a lot of nausea, vomiting in the first trimester, generally that will go away in the second trimester. For most, there are some women that hang onto it a little bit longer. For the majority of women into the second trimester, they're going to start to feel a little better as well as usually a little bit of a energy boost as well.

However, if they have several children at home, they don't always get that energy boost in the second trimester. Other physical changes, they may see a little as they get later into the second trimester, they may see some feet swelling. They may have some joint pain, they may have some pelvic pressure or discomfort as well.

Kathryn Goebel, MD:

We also tend to see heartburn start showing up in the second trimester as well. Some people can have some rib pain as their, you know, rib starts to stretch out to accommodate the size of the baby. And then a lot of people will notice the hip and lower back pain that maybe they weren't expecting that that would happen until the end.

But just because all of those ligaments are relaxing to make room for the growing uterus, a lot of just those general discomforts for some women will start in the second trimester.

Tammy Parker, MD:

Yeah. One of the things that I've warned my patients about when it's not their first pregnancy is that they generally are going to start to feel pelvic pressure much, much earlier than they did in their first pregnancy, which can be quite alarming for some, because that pressure can be significantly different.

But those ligaments that kind of stretched in that first pregnancy never really go back to a hundred percent. And so they start to feel that pressure very, very early, even in the, you know, 15, 16, 17 weeks, which they absolutely did not feel in their first pregnancy. So it can be alarming to them, but I tell them that's very normal.

Erica Newlin, MD:

For sure. And you mentioned when you were talking that people carry very differently. And I think that's important to note because a lot of patients tell me that people stop them on the street and they're like, you look like you're about to pop. And they're like, I'm only 28 weeks.

Kathryn Goebel, MD:

Absolutely like it is. It is incredibly rude how many strangers feel free to comment on pregnant women's bodies. And you know, we get patients coming in saying, you know, everyone's telling me I'm too big already, or maybe my dates are off. Or alternatively people are saying, oh you, you must be too small. My personal favorite is when they say, you know, my mom wanted me to double check to make sure it's not twins because I'm so big. I find that one a little bit insulting.

Erica Newlin, MD:

Do you think there's any truth to boys carrying differently than girls?

Kathryn Goebel, MD:

No. I think it's based on your shape of your pelvis, the length of your torso. Lots of different factors. Absolutely.

Erica Newlin, MD:

Yeah, I carried straight out in the front and people would stop me on the street and be like, that's a boy. Be like, uh, hello.

Tammy Parker, MD:

Well, I had twins and I had a boy and a girl, so I just was big.

Erica Newlin, MD:

What about when do people start feeling their baby move, and what should those first movements feel like?

Kathryn Goebel, MD:

So it kind of depends. I typically tell patients that most people will start feeling regular movement somewhere between 18 and 22 weeks. If it's your second, third pregnancy, you're, you know, baby sitting right low and kicking you right in the bladder you may feel movement before then. But for most women it's between 18 and 22 weeks.

And a lot of that will depend on where your placenta is. So if your placenta is in the front, we call that an anterior placenta. Basically, it's like a pillow between your abdominal muscles that can sense the movement and the baby kicking. So in that case, when the placenta is in the front, you're typically only going to feel it if the baby is kicking very low, like towards the bladder. And then, you know, once that uterus starts stretching and baby can kick you all around, then you're going to feel a lot more movement.

Tammy Parker, MD:

I also tell my patients that it's very inconsistent when it first starts. So they may think they have something and then there's nothing. But then when they get to the point where like maybe they've gone a couple days and they're pretty sure that's what it is, and it goes away, not to, you know, be alarmed right off the bat. Because the baby could have just moved in the uterus. It could have been kind of facing the front and really kicking and pushing and pulling and whatnot, and then maybe flipped over and is now facing towards the back, and they're not going to feel it quite as much. So at the beginning just to kind of take it with a grain of salt. But then as they get to the point where they're feeling it daily, then they should start feeling it daily, and then it will progress more and more as they get larger.

Erica Newlin, MD:

What do you tell people about kick counts as you get further into the late second trimester, third trimester?

Kathryn Goebel, MD:

So as we get, you know, really past 30 weeks, babies will typically get into a normal pattern of movement. A lot of women will say, oh, I notice my baby's really active after I eat. Or in the evening when I'm resting, but kind of quiet when I'm busy running around doing all the things I need to do. But if that's your baby's normal pattern of movement, that's totally fine.

Really the concern to me is if you have a drop off from that or a significant change for that, and that's really when you need to do kick counts.

So Kick Counts is basically you eat something, drink something cold, lay on your left side and count the movements. If you get 10 movements in that hour after you eat your baby is likely fine. Now, there are some high-risk conditions where you may be asked to do kick counts every day, but for most women it's just kind of figuring out what is your baby's normal pattern of movement and is today different.

Erica Newlin, MD:

And I always tell people it's never a silly thing to call about. I think a lot of patients feel embarrassed to call, but it's really, I would prefer someone call and then have a triage visit where everything is fine and baby started moving, then for something to be wrong.

Tammy Parker, MD:

Absolutely. I say the same thing, we'll never turn you away if you tell us the baby isn't moving well.

Kathryn Goebel, MD:

Right. It better to have 10 false alarm visits than you stay home and something be wrong.

Tammy Parker, MD:

Absolutely. And 99% of the time people are going to go home when they're decreased fetal movement. They even feel it on the way to the hospital or to the office. Still tell them to come regardless and have the, you know, testing done to make sure that everything looks okay. But majority of them will be fine, but we still, you don't want to be that low percentage that it's not.

Erica Newlin, MD:

And then Dr. Parker, you mentioned the increase in pelvic pressure that might be normal, kind of some other aches and pains that might be normal. How do you recommend that patients differentiate between the normal pelvic pressure feeling and when something might be wrong?

Tammy Parker, MD:

So generally, if you rest, it's going to get a little better. So if you're up on your feet all day and you feel a lot of pressure, you feel you know what we call round ligament pain. So round ligament pain is very common and it basically is pain that kind of goes down from the bottom of the belly, kind of down towards the vaginal area.

It's very sharp, it's very quick, and it's with change of movements generally. So you flip over in bed or you go from laying to sitting or sitting to standing, or you turn fast or make of quick movements, that's generally where it's going to be, and it's quick and it's gone.

Sometimes people will get other pains that are lasting a little bit longer, but if they're resting and it goes away, then it's not anything that's going to be bad. But if your pain is significant, if you're in a fetal position in a ball and can't move, or your pain is not going away with rest, then it's recommended to contact your physician. And you know, generally we'd want to evaluate you in triage or at the office.

Kathryn Goebel, MD:

Yeah. And other signs that it might be something more serious would be if you have a fever with your abdominal pain or if you're noticing any vaginal bleeding.

Kathryn Goebel, MD:

Those would be things that it could be a serious complication and you should come in and be evaluated.

Erica Newlin, MD:

And then Dr. Goebel, you mentioned that people may have increased heartburn during pregnancy. How do you recommend people manage those symptoms maybe before they try over the counter medications?

Kathryn Goebel, MD:

Sure. So heartburn, you know, like we said, people think about it as, oh, that's an end of pregnancy thing, really can happen at any time, but often shows up in the second trimester. Common sense, things like avoiding spicy foods, you know, some dietary changes, not eating too late at night.

A lot of people find that their heartburn is worst when they're laying in bed. Adding an extra pillow so you're a little bit more upright can just help you know, physiologically that there's not going to be as much reflux from the stomach.

Another thing that sometimes we see in the second trimester, nasal congestion and post nasal drip, which sometimes can contribute to discomfort in the back of the throat as well, so that often will feel better after a steamy shower. The nasal saline sprays are fine to use as well, a humidifier or you know, in the summer just sleeping with the windows open. Some people find those nasal strips really, really helpful if they're struggling to breathe when they're laying down as well.

Erica Newlin, MD:

What do you usually tell patients about weight gain and expectations for weight gain?

Tammy Parker, MD:

So for the majority of patients, the recommendations are if you have a normal BMI, 25 to 35 pounds is even up to 45 is normal. But if you're underweight, then you'd even want to gain more than that. If you're overweight, then it's really only, you know, somewhere between 10 and 20. Probably closer to 10 to 15.

Patients I tell them, don't weigh yourself at home. Eat healthy, stay active. And most patients I feel like are the healthiest that they ever been when they're pregnant because they have a reason to be outside of, you know, when they're not pregnant. So I usually tell them, I don't want you to weigh yourself. We weigh them at every visit.

Most women are not going to gain a whole lot until you get into the later second trimester. So the second half of the pregnancy, more so. So a lot of times people are concerned that, oh, I only gained one pound and I'm 18 weeks. Well, the baby doesn't weigh hardly anything at that point, so I'm not overly worried. But I'll tell them, I'll keep an eye on them, ask them what they're eating, make sure they're eating enough, but not to, you know, overeat because now you haven't gained anything, because generally you're going to gain later in the pregnancy. So second trimester, it's just more of a matter of kind of keeping an eye on things, if I see they're gaining too much.

If someone comes in from between their eight and their 12 week appointment and they've gained 10 pounds, I'm certainly going to discuss their diet because generally they shouldn't gain that much at the very beginning. However, once they get into the third trimester, then we generally tell them about a half a pound to a pound a week.

Erica Newlin, MD:

And I often tell patients that I care more about their behaviors often than the weight on the scale.

Tammy Parker, MD:

Absolutely.

Erica Newlin, MD:

So I certainly talk with them about nutrition choices and things like that. Yes. But so much of the weight gain is genetic.

Tammy Parker, MD:

Yeah, absolutely. Yeah. because you can have someone who's tiny that's eating super well and exercising and they gain, you know, 50 to 60 pounds and you're like, don't have a good reason for it. But that's uncommon.

Kathryn Goebel, MD:

But it's also, you know, you have to think about what are the attitudes around food and pregnancy, because I think there are some women who run into trouble with weight gain because they've always been very careful with their diet. And now, you know, society is telling them you can eat all the things you want.

And then women end up with, you know, excessive weight gain, which is really not good for mom or baby. So really my advice is always eat a healthy, well-balanced diet. Eat plenty of fruits and veggies, lean protein sources, whole grains, minimize you know, the simple carbs, minimize the processed foods. Make sure you're feeding, you know, your pregnancy, real food, you know, instead of just eating a bunch of garbage because you feel like that you can.

Tammy Parker, MD:

Absolutely. And I always tell them, my patients that come in in October, I'll have a conversation like, listen, we've got Halloween where we have candy everywhere. We've got Thanksgiving to follow that, that what do we do? We eat because that's what Thanksgiving is. And then we get into Christmas where there's cookies and there's pies and there's all the things. And what do we do at Christmas? We eat.

So I always tell my patients usually in October, like, listen over the next three months, it doesn't mean you just get to eat. Have a piece of pie, you can have a cookie, but you can't have seven. And just really tell them to watch because it's difficult because that stuff is everywhere no matter where you go at work, at, you know, at home, wherever. And so I might just tell them to really watch out during those months for sure.

Kathryn Goebel, MD:

Right. And don't forget about the social pressure of, you know, grandma at, you know, Thanksgiving. Like, oh, you're pregnant, you should have extra dessert.

Erica Newlin, MD:

Are there specific recommendations as far as caloric needs? Should you be doubling your caloric intake?

Kathryn Goebel, MD:

Absolutely not. So if you look at, you know, in the first trimester, you really should be eating a normal diet. And again, for women who have significant nausea and vomiting, you may actually lose weight in the first trimester, and that's fine. You'll gain it back again later. But if you look at the actual caloric needs for the pregnancy, it's about 350 extra calories per day in the second trimester, and about 450 extra calories per day in the third trimester, which is really not that much.

You're not eating for two. It's really just thinking about, okay, so I need to get in, you know, these extra calories. You know, am I going to add that in with a snack that has healthy fats, protein in it. You know, am I going to treat myself to dessert? Fine. But we want to make sure that those extra calories primarily are nutrient dense, healthy calories, and not just simple carbs.

Tammy Parker, MD:

Yeah, and sometimes you even find in the third trimester that patients say, I am so full, I can't eat anything. And so you have to kind of worry about that as well. But I always tell patients, you know, small frequent meals throughout the day, just kind of grazing, but make sure your grazing is healthy grazing. Not, well, I'm going to eat a candy bar, I'm going to eat a bowl of ice cream. But you know, eating healthy protein rich foods that you're still getting enough protein in, but you're also making sure you're getting enough calories as well.

Erica Newlin, MD:

What kind of testing can someone expect during the second and third trimester? Let's start with what is the anatomy scan?

Tammy Parker, MD:

The anatomy scan is generally done second trimester. It is an ultrasound that's done on the baby, basically to look at all the parts of the baby and to identify if they see any significant anomalies in anything or if anything's missing.

Basically, I tell my patients they're looking at everything from the top of their head down to their, the bottom of their big toe. They're going to count the fingers, they're going to count the toes, they're going to look at the heart. I always tell them the heart takes a little while because there's a bunch of valves and different things within the heart that they're looking at.

So don't be alarmed if they feel like they're looking at the heart for a long time. Or if you know the tech is doing it and the doctor comes in and redoes the heart or redoes a certain body part. That doesn't necessarily mean anything's wrong, it just means that they maybe wanted to see better views, but there's many, many things that they look at to see what's going on. If the patient hasn't identified the gender of the baby, the gender of the baby can also be seen at the anatomy scan as well.

Erica Newlin, MD:

It's amazing to me the resolution of ultrasounds now and how detailed they are. I have a 6-year-old and now a 1-year-old, and even in that five years, how much more detailed and how many different views that they got in those two different pregnancies. It's pretty incredible.

Kathryn Goebel, MD:

Yeah, yeah, absolutely. Everything, you know, compared to even 15 years ago that just the quality of the ultrasound images and the use for 3D ultrasound as well has really increased the number of conditions that can be diagnosed. You know, on that anatomy ultrasound.

Often I tell patients though, that because of the position of the baby is important for seeing certain views, particularly brain views and heart views. Sometimes they won't be able to see everything at one anatomy scan because if the baby isn't being cooperative with position or just depending on how you know their body habitus is, if things can be more challenging.

Or especially with twins when they're trying to look at two babies, sometimes they may have you come back for a follow-up anatomy scan a couple weeks later, and that doesn't necessarily mean anything is wrong, but sometimes they just don't get those ideal views and waiting until the baby is a little bit bigger can make that more reassuring.

Tammy Parker, MD:

Yeah, and if anything is identified at the anatomy scan that looks abnormal, generally that's going to be addressed at that time and kind of go forward with, okay, what do we see? What does this mean? What further testing do we need to do? Is there any further testing? Do we need to follow up just with another ultrasound? So if there's something that's abnormal, there's going to be more ultrasounds than they know to set those up and stuff like that.

Erica Newlin, MD:

Should patients expect an ultrasound in the third trimester?

Kathryn Goebel, MD:

So it kind of depends. Not everyone will get a third trimester ultrasound. Certainly women who have conditions that we're more concerned, there may be an issue with baby's growth, so diabetes, hypertension, things like that.

But also we are, you know, measuring the uterus at those in-person prenatal visits after 20 weeks. So if we notice a trend that the uterus is not growing as we would expect between visits, and again, the absolute number matters less than you know, the trend across several visits. And so if we notice that, you know, based on the concern is the uterus measuring larger or smaller than we would anticipate, that would be another reason to get a third trimester ultrasound.

And then also in that last month, if it can't be determined from physical exam if the baby's head down or not, that might be a reason to get an ultrasound towards the end of pregnancy as well.

Erica Newlin, MD:

Can you talk about how maybe helpful or not helpful to have an estimated fetal weight at the end of pregnancy using ultrasound?

Kathryn Goebel, MD:

Sure. As we get really closer to delivery, our estimates become a little bit less accurate by ultrasound, especially if the baby is sitting really low in the pelvis. Some of those ultrasound views of the head are distorted, so we can make an estimate, but there's a margin of error there. So the question is always people saying, oh, is my baby too big to have a vaginal delivery?

And that's really fairly uncommon, but sometimes, particularly when we are worried about the size of the uterus, or again, somebody who has diabetes, when we know those babies tend to be larger, we will get an ultrasound about four weeks before the due date to try to get an idea of how big baby is going to be for delivery to see does that need to change the plan of, you know, when we would recommend delivery or how we would recommend delivery go.

Tammy Parker, MD:

And I generally tell my patients who are getting third trimester ultrasounds that because of the margin of error, it basically tells us, do we have a really big baby or a really little baby? But anything in between just doesn't matter. And so just take it with a grain of salt. So we just are looking to make sure it's not growth restricted or if it is something that's really, really large that we just need to figure out what's going to be our best plan going forward.

Erica Newlin, MD:

For sure and I often tell patients that in order to recommend a C-section straightaway without a trial of vaginal delivery are, it actually needs to be a pretty high, yeah, estimated fetal weight

Tammy Parker, MD:

quite high.

Erica Newlin, MD:

Let's talk about routine blood test and screening. What should people be prepared for in the late second, early third trimester?

Kathryn Goebel, MD:

So typically between 25 and 28 weeks we'll do screening for diabetes of pregnancy, so that's called the glucose tolerance test. Basically, they have you go to the lab, or it may be done in your doctor's office, depending if they have blood draw there, but you basically drink a sugary drink and then they draw your blood an hour later to see how your body is responding to a known amount of glucose.

And so that is sort of the screening test for diabetes of pregnancy. Because some women, even if they have totally normal blood sugars outside of pregnancy, may act like a diabetic in pregnancy. And that's important to know just because, not only for mom's health, making sure that her blood sugars are controlled, increased risk for high blood pressure, things like that. But also for baby, because it's not good for baby's development to be exposed to continuously high blood sugars. So that's a test that we do.

Typically along with that, we would recheck what's called a CBC or a blood count, and that's screening for anemia in pregnancy. Typically that would be done with your first trimester labs, but it's checking to see basically how are your iron stores holding up and do you need to be taking any extra iron. And then the third routine blood test that is done usually towards the end of the second trimester is a repeat syphilis testing.

Erica Newlin, MD:

Yeah, we happen to test for syphilis a lot during pregnancy, and I just tell people that that is due to our guidelines, not because of any suspicion that I have for them.

Kathryn Goebel, MD:

You know, unfortunately syphilis rates have increased in the United States, and because it can be so devastating to a baby if it's untreated, and because it is so easily treatable, the guidelines have become, you know, universal that we screen everybody at least twice, sometimes three times during pregnancy. And it, it does not at all indicate what I think your personal risk for getting syphilis is. But again, because it is treatable and devastating if not treated, we are very proactive with screening for that.

Erica Newlin, MD:

Can you comment on blood type and how that's important at certain stages in the pregnancy?

Kathryn Goebel, MD:

Sure. So blood typing, knowing if your blood type is positive or negative is typically done at the first prenatal visit or the first prenatal blood work. If your blood type is negative, you will get an injection at about the 28-week mark. So usually you will get blood work drawn within a couple of days of that visit just to confirm that you have not developed any antibodies for that blood type protein.

Erica Newlin, MD:

And then Dr. Parker, can you comment on group B strep and what it is and what the testing is like?

Tammy Parker, MD:

So group B strep is a normal bacteria that we can carry in the vagina and it comes from the colon and we carry it some of the time, but not all the time. And so outside of pregnancy we don't test for it, it doesn't matter because it's just bacteria that we can have. It's not necessarily an infection. However, in the pregnant person, we test it at 36 weeks and we test it with a swab that's a vaginal rectal swab in the office. And the reason we're looking for it is to know if we need to treat it for the baby, not for mom.

And if it's negative, then it's negative, but if it's positive, then when they're having a vaginal delivery and they're in labor, we treat them with generally penicillin unless they have a penicillin allergy. And then we run some sensitivities to use other antibiotics. However, the reason that we do it is that as the baby comes through the vagina, if there is group B strep in the vagina, the baby has a chance of having contact with the group B strep, and they can get sick with it.

It's a very, very low risk. However, if they do get sick, it's very significant. Some babies can get pneumonia, sepsis, meningitis, things that you don't want to see your baby ever having. So therefore, we treat them during their labor. Generally, if it's the penicillin, it's penicillin every four hours during their labor and through their end of their delivery. And that gives the baby protection so that we eradicate the group B strep out of the vagina itself.

Erica Newlin, MD:

Let's shift a little bit and talk about Braxton Hicks contractions. What are they? How can you tell them from real labor?

Kathryn Goebel, MD:

So, Braxton Hicks contractions, really by definition, are contractions that don't put you into labor. And so women may never feel a Braxton Hicks contraction and just go into labor. But most pregnant people, you know, will start having them sometimes as early as the second trimester, but pretty routinely in the third trimester.

They're described differently. Some people will experience it as sort of a band or a tightening lifting sensation around the top of their uterus. Some will feel it more low down, kind of like period cramping.

Often if you're dehydrated, if you're out running around, you may notice several of them in a row. But if you sit down and drink water, they'll go away. And that's how you can know the difference between, you know, how will I know if I'm going into labor is a very common question, especially someone who's been getting Braxton Hicks contractions.

And really the answer is if you rest and hydrate and they space out and go away, it's not labor. If you're really in labor, those contractions will start being in more of a timeable pattern. They'll continue to get closer together, more intense, really no matter what you're doing.

Erica Newlin, MD:

And if someone's experiencing contractions that are getting stronger, what's the line usually for when they should go to the hospital?

Kathryn Goebel, MD:

Depends on how far along they are. If they're full term, typically, if they don't have other risk factors, they're planning for a vaginal delivery. We know the baby is head down. They can wait at home until those contractions are consistently every five minutes apart.

Now, if somebody is, you know, preterm, you know, maybe are 24, 28 weeks at a point where really we would try to stop, you know, labor if they're having consistent contractions, less than 10 minutes, that are not getting better with rest and hydration that are painful. We recommend to come in for evaluation.

Erica Newlin, MD:

When should people consider making a birth plan?

Tammy Parker, MD:

So birth plans are individual, obviously, and no one has to make a birth plan, but anybody can.

And what I always tell patients with birth plan is if you have specific things that you want to happen during your labor and your delivery, then you know, think about what you would desire, and that's your plan. However, I always tell them the best plan is to come with an open mind. We will always try to adhere to people's birth plan as well as we can.

We're never out to sabotage them, no matter how long they are, how many things that are on there. And we a hundred percent want to respect what you desire. But our main goal is to have a healthy mom and a healthy baby always.

So if we come in while something's going on with your labor and we suggest doing something that is outside your birth plan we have definitely considered that your birth plan is what you desire, but we also really want to make sure that you and baby are both safe. And so if we suggest something, we're suggesting only to keep you on track and to keep you and baby safe. And that's our only reason that we're, you know, coming in to intervene.

Otherwise, our plan for you is to come in and labor on your own, have your baby with, you know, very little intervention. We would love that, but we know that that's not always the case. It's not always how things go. If they do make a birth plan and they have specific things, definitely let the team know when you come in for sure. You can review with your own doctor, but in many places your own doctor doesn't deliver you. So if your doctor's not going to be the one that's there, that may not be something that, not that it doesn't matter to that doctor, but they're not going to be the ones that are actually going to be there.

If there's something that you feel is very different than the norm, then I definitely would bring that up with your doctor before you come into labor, because then your doctor can explain that if it is something that's very different, like, okay, well if that's the case, but would you be willing to maybe do this or that, or whatnot, and if there was an emergency of any sort.

So if it's something that you know is very, very kind of, you know, not super mainstream, then I think it's important to kind of discuss that with your prenatal provider prior to showing up in labor.

Kathryn Goebel, MD:

I think it is important to think about how you would want this experience to go, but I also don't like to see people disappointed with their birth experience. I think particularly for first time moms, especially online culture, there's such this emphasis on a natural delivery, and I really, I hate that term.

At the end of the day if you walk out of the hospital with a healthy mom and a healthy baby to me, we have done our job and we will try to be respectful of exactly how you want that process to go. But I always tell patients, sometimes babies are not playing according to your plan. And so I think it's important to have thought about all of those things.

But also if you know your plan is to have an unmedicated childbirth and you end up being in labor for two days and getting an epidural, I don't want you to be disappointed in yourself. So I think it's important to know this is how I would like it to go ideally, but like Dr. Parker said, come in with an open mind. It may not be the ideal scenario, but it may end up being what is the safest way to get your baby to come home with you two days after you deliver. And I think at the end of the day, like she said, we are not out to sabotage anyone's birth plan. We love a normal low intervention physiologic birth.

Erica Newlin, MD:

For sure. And we have another episode where we talk about the labor and delivery experience, and we talked about things very similarly, really focusing on communication and collaboration and including the patient as part of the team.

Tammy Parker, MD:

Yeah. I found that most people's birth plans are what we do already, right?

You know, I, I want my husband to cut the cord. We ask every husband, right? So most of the things that are on the birth plan are normal things, but it just lets them think about things and go from there, you know? And then we can discuss it if it's something that, like I said, really off the mainstream.

Kathryn Goebel, MD:

Yeah, and I think one of the most important things on a birth plan is who you want there with you. Make sure that you know, depending on your hospital's policy, how many people are allowed in the room to begin with, but also make sure those are people who are really going to be supporting you in your labor and not second guessing you or making you feel that they're, you know, critical of your choices or what's going on. So I think the most important birth plan is who's there to support you.

Erica Newlin, MD:

And then switching gears a little bit, what's a membrane sweep?

Tammy Parker, MD:

So a membrane sweep is when you're term and you come in and your doctor starts to check your cervix, is what we call it. And that's basically, we place two fingers in the vagina and we find the cervix and we measure with our fingers how dilated you are. So a membrane sweep can only be done if you're dilated some.

But basically it's, we take our finger and we kind of put it between the membranes themselves and the cervix edge and we sort of sweep our finger around in a circle and kind of detach that little area there. And what it does is it releases prostaglandins and what I explain to patients is prostaglandins are the hormones that cause you to cramp when you have your period. So if we get prostaglandins to release, you are going to start to cramp a little bit. So it may start the process. So basically it may facilitate the process of getting you starting to cramp in the prostaglandin release.

Kathryn Goebel, MD:

Yeah, and it doesn't always work. No. But for women who have, you know, are again, are full term and are ready to have this baby and are hoping to avoid having to have an induction in the hospital, it can be a really nice method to kind of get things going.

Erica Newlin, MD:

Do you have any strong feelings on membrane sweep in patients who are GBS positive?

Kathryn Goebel, MD:

There's really no clear guidelines on that. Theoretically, you know, there could be introduction of bacteria higher up, but the membranes are still intact. So some providers will offer it and some providers won't.

But I think it's an extra conversation to have because again, there's no recommendation against doing it in patients who are group B strep positive. But I think there is some theoretical risk. So I think you have to take into account that, and it needs to be a conversation between a patient and their provider of what their risk, comfort level is with that.

Erica Newlin, MD:

What are other natural things people can do to induce labor?

Kathryn Goebel, MD:

There are a lot of old wives’ tales out there, and a lot of that stuff doesn't work. I always tell right off the bat, whatever your grandma says, please do not drink castor oil. It will give, it will give you horrible diarrhea. It will most likely not put you into labor.

But even if it does, you're coming in in labor with horrible diarrhea. Nobody wants that. You don't want that. We certainly don't want that. Your nurse certainly doesn't want that. So castor oil, please don't do it. Spicy food will probably just give you heartburn and make you uncomfortable.

There is some weak evidence for dates, but you need to eat a lot of dates and you need to be doing it for several weeks. Dates have a ton of sugar in them, so particularly for patients who are gestational diabetics not probably the best choice. Raspberry tea and pineapple, really, there's no evidence to support them. So if you like raspberry leaf tea and you want to have a cup of it a day, that's totally fine. It's probably not going to help with your labor process.

As far as things that actually work, sex and nipple stimulation are really, what's it. So the semen contains prostaglandins like Dr. Parker already said, with the membrane sweeping prostaglandins can start that early cramping that can start labor. And then nipple stimulation causes release of oxytocin, which is biochemically the same as the Pitocin that we give to induce labor. So those are things that, you know, certainly women can try. Generally, I say sex and nipple stimulation are your options. You decide if you're desperate enough yet to do that.

Tammy Parker, MD:

And I also tell them that like, obviously it doesn't work for everybody right away, or everybody would have sex at 38 weeks and have their babies because everybody's done at that point, right?

So I said, your body has to be kind of ready to do it, but it's not going to be harmful because if there are physiologic changes with that, with the prostaglandin release and the oxytocin release, but it may help soften the cervix up, it may you know, not necessarily put you into labor, but it might help dilate some.

It may just do the beginning stuff of what the cervix needs to do as opposed to, you are 41 weeks with a cervix that's, you know, long closed and high. So you might, at 38, 39 weeks, if you're having sex and you're doing nipple stim, you might be three centimeters dilated. And if for some reason you do need to be induced for whatever reason, it would be an easier induction because you've, your cervix has already started to make some changes.

Erica Newlin, MD:

You mentioned nipple stimulation. A lot of patients are asking me about collecting colostrum or kind of trying to collect breast milk prior to delivery. What do you tell people who ask?

Kathryn Goebel, MD:

Absolutely not. Your full milk supply typically doesn't come in until the second or third day after you deliver.

You know, and your body is designed to produce colostrum after you deliver. Some women will leak before delivery, especially if it's, you know, they've had multiple pregnancies before, but there's really no benefit in collecting that. Your body will make enough for your baby after you deliver.

So if they do, do nipple stimulation and they do get some colostrum come out, there's no benefit in keeping it. You're going to want to give your baby the fresh right from the nipple stuff after you deliver.

Tammy Parker, MD:

Agree.

Erica Newlin, MD:

Well, thank you both so much. Is there anything you would like to add?

Kathryn Goebel, MD:

Yeah, I, I really think it's important for women to, you know, feel that they can ask all of these questions. And, you know, women always joke about, oh, you know, I have pregnancy brain.

I like to call it placenta brain because I don't like to blame it on the baby. But you may, you know, think of all of these questions after you leave your doctor's office. So I always say, you know, for non-urgent questions, keep a running list on your phone of things like, is this normal? Is this not normal?

Because the problem, of course, is that there's so much garbage information online. And just making sure that when you are checking to see is something normal. Checking with a reputable source or you know, or asking your own provider.

Tammy Parker, MD:

Yeah, I, I tell them the same thing, like, don't Google stuff because you can find any answer you want on Google. So if you have a question, just ask. We're always happy to answer the questions. Communication is, you know, the key to having a healthy pregnancy, I think, and making sure that you're talking with your providers and not just your friends or your grandma that's giving you, you know.

Erica Newlin, MD:

Or chat GPT.

Tammy Parker, MD:

Or chat. Yeah, absolutely. Absolutely.

Erica Newlin, MD:

Well, perfect. Well, again, thank you both so much.

Tammy Parker, MD:

Thank you.

Kathryn Goebel, MD:

Thanks for having us.

Erica Newlin, MD:

Thank you for listening to this episode of Ob/Gyn Time. We hope you enjoyed the podcast. To make sure you never miss an episode, subscribe wherever you get your podcast or visit clevelandclinic.org/obgyntime.