True Birth

Preterm labor is one of the most evasive disease processes we know about in pregnancy and is one of the leading reasons a pregnant woman seeks treatment in a hospital setting. Until now, we have had very little understanding about why preterm labor (PTL) happens.

Most of the therapeutic interventions surrounding PTL involve identifying who is in true preterm labor and appropriating care to delay delivery not stopping preterm labor. Traditional treatments for preterm labor focus on supporting the fetus for extrauterine life including antenatal corticosteroid therapy to support the lungs, group B strep prophylaxis to prevent infection, magnesium sulfate for neuroprotection and assembling the appropriate team for delivery.

Why is there no treatment to stop or better yet prevent preterm labor? Is there something that can be done? Dr. Yaakov Abdelhak believes so and explains his method for the prevention of preterm labor in this podcast.

Dr. Abdelhak posits that the enigmatic and often unpredictable realm of preterm labor might be less about the unknown triggers of early labor and more a matter of cervical insufficiency—a condition traditionally underemphasized in prenatal care. He champions the idea that diligent monitoring of the cervix, particularly its length, during pregnancy isn't just a sidelined metric but a potentially pivotal indicator. This perspective opens a new avenue in understanding and possibly predicting not only preterm labor but also second-trimester miscarriages, conditions that have long puzzled and challenged obstetricians.

Dr. Abdelhak's argument isn't merely a call for heightened awareness; it's an appeal for a reevaluation of our clinical priorities. By refocusing our attention on the often-overlooked cervix via ultrasound, he suggests, we might unlock new strategies to safeguard pregnancies. It's a compelling reminder that sometimes, in medicine as in policy, the answers lie not in the broad unknown but in the nuances we've yet to fully grasp or appreciate.

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We want to hear from you. What is your biggest fear in childbirth?

Listen is as our two hosts explain what they think a woman's biggest fear is. Also take our instagram poll and let us know what your biggest fear is.

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What's the cause of fetal growth restriction? How can you prevent it? In this episode of True Birth, we will talk about fetal growth restriction/FGR previously termed IUGR or Inner Uterine Growth Restriction.

What is FGR?

[1:36]

It is when the baby falls below the 10th percentile for weight. 10% of babies will be below the 10th percentile, by definition. Hence, 10% of babies will be classified as fetal growth restricted. It's important for you to know that because 10% of babies are not in a pathological situation. They're not in a bad situation. They're not in a situation where they're not growing.

[2:35]

It's important to consider each woman and her partner uniquely in pregnancy. A women that is 5'9 with women and a woman that is 5 feet tall will have different size expectations and patterns when it comes to pregnancy.

Possible reasons that the baby is small

[4:17]

The number one reason that a baby could be on the smaller side is that the mother is small and the father of the baby is maybe not the tallest guy. We use the term FGR/Fetal Growth Restriction when they're in utero, but once they're delivered, we call them SGA/Small for Gestational Age.

[5:06]

When you find the baby's not growing well, this will generally be after 20 weeks Babies are generally the same size until 20 weeks.

[6:08]

Another reason the baby is small is that it's supposed to be small and there's nothing wrong. The number two reason is placental perfusion. It has a problem with the baby getting enough blood flow and nutrients. It is just not getting enough of what it needs to grow well. And there are many reasons why the placenta won't function. So when you see a small baby, especially in the third trimester after 27 weeks, 30 weeks, start thinking, "Oh, how are her blood pressures? She's spilling protein. Is there something going on with this patient that's pointing me towards preeclampsia?"

[8:07]

TORCH is an acronym that stands for toxoplasmosis, rubella cytomegalovirus, herpes simplex, and HIV. Cytomegalovirus is a virus that's very common in the population. Most people have been exposed to cytomegalovirus. T

Ultrasound tools

[12:09]

To understand Dopplers without getting into the physics of what the Doppler effect is, you can take your transducer, you could put it over the cord, and you can turn on the Doppler and you could see the blood flow through the cord.

[13:48]

When you look at a Doppler, and you see the blood flowing the way it should, before the next heartbeat, you measure how fast it's going right before the next heartbeat.

[15:14]

When you talk about fetal growth restriction, you can't just talk about the baby's size because there's only one piece of it. The other piece is what is the placenta telling you? What are the Dopplers telling you?

[15:34]

Biometry is when you measure the femur and the abdomen and measure the head to get the size and weight of the baby and estimated fetal weight.

Guidelines about how to approach Fetal Growth Restriction

[18:12]

If you're below the third percentile, even if everything else is okay, that's the baby you got to deliver at 37 weeks. You can't just sit around and look at that baby for 37 weeks get the baby out. If your baby is above the third percentile and the Dopplers are elevated but not absent, get the baby up. And if there's no flow, the blood stops, that's even more concerning. If you see the reverse flow, you're dealing with a much more ominous situation and you don't want to go past 32 weeks. If you don't think the baby's doing well, you might have to come out even earlier.

Biophysical profile

[22:09]

One of the things that some patients might have to consider in other practices is that they would need to start having biophysical profiles done. A biophysical profile is when you're checking for a series of four different things and looking to ensure that the baby is reassuring overall. What is the baby's movement? What is fetal breathing, which is an exercise the baby does to inhale and exhale fluid? What is his tone? Is the baby flex or the floppy? Or if you feel the baby's not moving, these are things that you have to consider.

[23:51]

One of the things you're looking for when talking about growth restriction is you want to see how the baby is handling the uterine environment? How's the baby doing on the inside? These tests will wish to you to identify a baby that's not doing well or not getting enough blood flow. You need to know if you can wait on it and let the baby stay inside, or is it time to get the baby out? Because then the baby will do better outside of the womb.

Recommendations

[24:20]

The recommendation is that if you recognize growth restriction, you should at least be monitoring weekly, that might be nonstress tests, or that might be a biophysical every week. And if you have a severe growth that restricts a baby under the third percentile or abnormal Dopplers or accident, then twice a week. If you have reversed outside flow, put those patients in the hospital because they need to be monitored around the clock and you got to pull the baby out before it's too late.

[29:08]

The most reliable and consistent way to assess blood flow to the baby is the umbilical artery. Look at the ductus phimosis. When the umbilical cord hits the baby's belly button, a big part of the vein goes up into the heart carrying the birth at heart, and you can see if there's resistance, or even at the umbilical vein.

Here is the photo that we have permission to share.

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One of the most asked questions during an office visit is: "Doc, how do I prevent tearing?" In this episode, we discuss how to prevent perineal tearing during delivery.

Tearing and Contractions

[1:56]

When Kristin was pregnant, her biggest fear wasn't the tearing but the contractions. Seeing other women with contractions made her feel that it was painful. She says that tearing is more of having an injury that you overlook until it happens.

Infections in Tearing

[2:29]

The body is designed to tear. If a woman has a baby and tears, they should keep their legs together, and it will heal. With thousands of adult women living with tearing, there hasn't been one infection. Though there are vaginal infections postoperatively, there hasn't been a repaired tear that got infected.

[3:35]

The Human body is designed for tearing. A human design where a specific area would not be infected, but other areas would be contaminated.

The Fear of Women about Tearing

[4:52]

There are all these things that women make themselves crazy about how to prevent tearing. They make themselves crazy about things like perineal massage. They're looking it up on the internet and massaging their perineum.

Massaging to Prevent Tears

[5:30]

The skin stretches better when you use mineral oil as a lubricant instead of a surgery loop. Dr. Yaakov is constantly massaging and stretching the skin as much as possible because if the head of a baby comes out slowly, the skin has more time to accommodate and stretch. Those quick deliveries are more common to have a tear.

Using Mineral Oils

[6:36]

Mineral oil is very good. But when the head is coming out, Dr. Yaakov milks the skin on the sides and just pushes it back on the head. With the head coming out and the skin bulging with it, he is trying to milk it back while putting a lot of pressure right on the perineal skin because he is spreading that pressure out across the whole perineal body.

[7:27]

Even with all of Dr. Yaakov's strategies, 80% of first-time mothers tear. So he thinks that mineral oils and milking the skin over the head are beneficial.

Controlling Tears

[8:07]

The more you control the tear of the bottom, the more likely she's going to have a tear on the anterior perineum, which is near the urethra, clitoris, and labia. The more you prevent it on the bottom, the more likely it is to go up. The worst thing that can happen is uncontrolled delivery, where the baby's head just pushes and pops out. They head back, and the baby will headbutt you right into the most sensitive part of the body. That will easily cause real trauma. So you have to control that. You have to control the head and not let it extend too quickly control the extension while you're trying to prevent a tear.

[10:35]

Experienced providers have a better ability to prevent a tear. The more deliveries you've done, the more little tricks you have up your sleeve.

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A woman's weight and BMI during and after pregnancy is often discussed and debated. This is especially true in the case of high-weight women, who, as research shows, have a higher risk of complications like cesarean birth.

Today's episode is to discuss high weight women in pregnancy and when we need to concerned and when we don't PLUS, we also discuss some very questionable myths and treatments followed for high-weight women that you need to be aware of. But these in no way imply that people with very low body weight have uncomplicated pregnancies. To prove that, we compare pregnancy risks, body weight gain, and recovery in low-weight, normal weight and high-weight pregnant women and see clearly why a lower than ideal body weight could also pose significant birth complications.

PS. Excessive weight is sometimes associated with ovulation issues. That, in turn, could be caused due to PCOS (PolyCystic Ovarian Syndrome), which is associated with a hormonal imbalance that messes up your ability to metabolize.

Here are a few known complications faced by high-weight women during pregnancy:

>> Preeclampsia -- Condition associated with high blood pressure and other complications, including retaining fluid and end-organ dysfunction. In extreme cases, it can lead to eclampsia or seizures, a severe form of preeclampsia.

>> Diabetes (pregestational and gestational) -- Diabetes that's detected during the first trimester or the beginning of the second trimester is called pregestational diabetes. These can lead to abnormalities of development and more chances of miscarriages. Gestational diabetes is a form of diabetes that's developed in women during pregnancy. Women who have this condition wouldn't have had diabetes previously.

>> Preterm delivery -- A condition that might cause pregnant women to go into labor early.

>> Macrosomia -- High weight of the baby

>> Higher weight loss -- High-weight women tend to lose more weight during pregnancy, which is unhealthy. It's healthy to end a pregnancy with a greater weight than what they started with.

>> High risk of C section -- High-weight women are at a 70 % risk of a C-section -- even after complications like hypertension and diabetes have been neutralized.

>> Less sensitivity to oxytocin -- Hence an increased need for oxytocin augmentation.

>> The need to use IPCs (Intrauterine Pressure Catheter) -- a device placed inside the pregnant woman's uterus to monitor uterine contractions during labor.

>> Pelvic outlet is narrower -- This is alleviated by making positional changes. >> Uterine tilt if a woman previously had high weight and lost it abruptly -- This

is alleviated by making positional changes.

>> Remodelling of bones -- As the bones become more narrow, changes are caused in getting the baby.

>> Shoulder dystocia and postpartum hemorrhage -- Massage from postpartum hemorrhage is also harder.

>> Difficult labor -- Caused due to positional issues of internal organs and the baby

A common pregnancy complication seen (especially) in low-weight women: >> Hyphemeresis -- A condition that causes severe metabolic disturbances,

including abnormal amounts of nausea and vomiting.

There's a ton of other valuable insight offered in this episode. Do not forget to tune in!

RESOURCES MENTIONED:

• Episode 042: True Birth Podcast: Uterine Tilt
• Episode 029 True Birth Podcast: Preeclampsia
• Episode 020 True Birth Podcast: Shoulder Dystocia
• Episode 060 True Birth Podcast: Hyperemesis Gravidarium

To connect with us, Find us on: www.truebirthpodcast.com

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Face presentation is when the baby's face is presenting through the cervix first. Normally, the baby's head is flexed so that the chin tucked. Non-head down positions (including breech, transverse lie, face, brow, and compound presentations) do happen too are account for less than 4% babys at term.

When the baby is coming out face first, the baby's head and neck are hyperextended creating a more difficult and sometimes impossible birth.

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Going to the dentist in pregnancy is not only allowed but its recommended. Regular dental check ups and good dental hygiene are advisable in pregnancy. This episode also contains a bit about: The Count.

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There are two main types Types of Twins twins when it comes to pregnancy, dizygotic twins and monozygotic twins. In this episode, we review these different types.

Types of Twins

[0:45]

There are two types of twins: Monozygotic and Dizygotic. Each has its own subcategories. (Di) means two; (Mono) means one; Zygote is a fertilized egg. Dizygotic means two fertilized eggs, and Monozygotic means one fertilized egg that split into two. Dizygotic is commonly known as fraternal twins, which means non-identical twins. With Monozygotic, it would be identical twins that split into two.

[1:50]

You can have twins one of two ways. With Dizygotic, you can have a woman ovulate two eggs at the same time, which is uncommon. That means each ovary ovulates an egg, and they both find their way into the uterus and get fertilized, so you have two pregnancies going at the same time. Basically, they're siblings, but instead of carrying two years apart, your body decided that you're just going to carry two at the same time, getting a two for one. The other type of twins, which is less common for every two or three cases, is Monozygotic. This is where one egg gets fertilized for whatever reason.

[5:48]

With Monozygotic, there's one egg that splits itself and turns into "Monozygotic Twins" or identical twins. If that egg splits very early, then each piece of the egg develops a completely separate pregnancy with a completely separate placenta.

Early Conception of Twins

[6:55]

If the egg splits within the first three days, you have two separate placentas and two separate pregnancies. With twins, there are two separate layers called the Chorion and Amnion. These are the two layers of the placenta. The one that is further inside is the Amnion, and the one that is on the outside is the Chorion. With normal pregnancies, both act as a single layer. But with twins that are completely separate, they will have two of both layers.

[8:34]

If the egg separates after the first three days, but not after the first seven days, then each baby will develop its own Amnion even though they will share a placenta. That means each baby has a cord running to the same placenta on different sides of the amniotic separation, which is that wall between them. That wall is a membrane that prevents the twins from entangling their cords. If the baby separates after that seven-day zone, then they not only do share a Chorion, but also an Amnion. This means that both Chorion and Amnion are shared by the twins.

Monochorionic and Dyamniotic Twins

[10:15]

Monochorionic and Diamniotic twins have special considerations and special risks. If it was actually two eggs, and they both get fertilized, then it's Dizygotic. But if it happens to be a Monozygotic twin that developed early, it will act like a Dichorionic. So how do you know what you are dealing with? You got to look early because early on, it's very clear on ultrasound if you got two eggs in there that got fertilized or one egg that split in half.

[11:16]

Even if you have one egg and one sperm that got fertilized that split into two, if they split early enough, they are going to have their own two pregnancies. It's going to be their separate pregnancies. If there had been two eggs that get fertilized, it would act the same way. They will be genetically identical.

[12:12]

7% of Monozygotic twins are Monochorionic or Diamniotic. But the majority of twins are Dizygotic, which means they come from two separate eggs that are fertilized early in pregnancy. With ultrasound, it's very easy to see early on the two separate sacks that are almost not touching your or very little touching. There's a sack, and there's a baby on this side. Those sacks are going to grow, and they're going to merge. If one placenta isn't attached to each other or they are within two separate locations, then you are dealing with Diamnitoic twins.

Managing and Identifying Twin Pregnancies

[14:57]

To figure out what type of twin pregnancy a woman has, their placenta is looked at using ultrasound. The points that are looked at are if the twins are sharing a placenta or if the placenta is in the same place. Currently, you cannot tell on ultrasound if it's one placenta or two that are just against each other. Sometimes, placentas grow to each other, and there won't be any separation between them. At this point, it's very important to know if it is Dichorionic or Monochorionic because each is managed differently.

[16:04]

Another way to identify a twin pregnancy is to look at the twin membrane. You then magnify that, and then you measure it. If it's above point two millimeters, then it's a sign that it's a Dichorionic. But if it's less than .12, then it's a sign that it is a Mono.

[17:12]

Once you have techniques, you don't get rid of them. Even if a better technology comes along, you will learn to accept it. But sometimes you can't see it that well. If the patient's hard to scan or the memory is not in line well, the best way is to scan the membrane, and you zoom in on it. You count the layers, and if you see two layers, that means that the baby has one outer sac and two inter sac. But if the baby has two outer sacs and two inter sacs.

Twin Transfusion Syndrome

[18:08]

When you have a Monozygotic twin, there is a possibility that one twin can thrive more in the uterine environment than the other twin. With Monochorionic twins, there is a 15% chance of something called Twin Transfusion Syndrome. This is where one baby is getting too much blood back from the placenta, and the other baby is getting too little. The continuous pump where one baby continuously gets more and the other one gets less makes the other baby struggle. One baby cannot keep up with the volume and is overloaded, while the other one is struggling because it's not getting enough blood.

[20:32]

If the twins are identified as Monozygotic and Monochorionic, then one of them is going to be given more blood. When blood goes to the placenta, it is shared equally between the twins. But if the arterial supply of the placenta is a bit different than the return, then both babies don't get the same amount of blood. Instead of each baby having the same amount of return channels, both get different supplies of blood. One is automatically going to get less and the other one a little more. Then the sequence of Twin Transfusion begins. One baby's getting overloaded, the other one's not getting enough.

[24:05]

The earlier Twin Transfusion happens, the bigger the problem. If it happens late in the game, then you deliver the babies. But if it happens early in the game, you can't deliver because they're too premature, and they can't survive. So if it happens early, you have to stop this vicious cycle from continuing. Most of the time, people will lose a baby because of the twin transfusion sequence if it's left untreated because the fluid is so great. The excessive fluid will cause pre-term labor, and the patient will just lose the pregnancy because they go into labor early. Even if they carry long enough to get into viability, one baby will get heart failure because it can't handle all the fluid.

[25:00]

**of note The correct term is reverse in this episode. The correct information is as follows: The fetus with more blood flow is called the recipient twin, and the fetus with less is called the donor twin

Velamentous Cord Insertion

[29:06]

Velamentous Cord Insertion is when the umbilical cord hits the placenta and branches into a spiderweb-like structure, and they drop into the placenta at different points. And that's how all the blood is getting everywhere. But if that separation happens, then it can become a major problem. It's a common complication in any pregnancy because you don't want those vessels exposed, especially if they're in front of the cervix. With twin pregnancies, Velamentous Cord Insertion is a more common phenomenon where you have that cord insertion. Often, it is tied to a twin transfusion sequence.

Treating Velamentous Cord Insertion

[30:33]

You can go in with a scope, and you can identify the vessels. It mainly involves a lot of ultrasound and targeting. Then you either ablate with a laser or radio waves. Oblate means you are sealing or coagulating them off. You are taking the vessels that run from A to B or B to A, and you are dividing the placenta, so it's going to function like two separate placentas instead of one. If you overdo it, then you end up with the reverse where the other baby is getting too much. This is because you go in with instruments, and therefore there's a risk of pre-term labor or amniotic fluid membrane rupture.

Monoamnionic Twins

[35:04

Twin Transfusion doesn't happen with Mono twins because there's only one membrane on one side. The problem is that the cords are tangled, which happens early on. As soon as locomotion happens within 12 weeks, babies start swimming. This is the rarest and highest risk type of twin. What happens with those twins is you don't do anything until 24 weeks because you can't do anything. You just hope for the best. Once you get viable, you basically put them in a hospital and watch them, and you monitor them several times a day. Once you start seeing fetal heart rate decelerations, you get everything ready and get them delivered. If nothing bad happens, depending on how conservative you are in 34 weeks, just go in by C-Section and deliver them.

Conjoined Twins

[37:21]

The egg doesn't split until day 11 or 12. If it doesn't split within that period, you will get conjoined twins. That is a really big deal because now you have a team of surgeons figuring out if you could separate them and depending on where they're separated. Sometimes they share vital organs, and you can't separate them. But these conjoined twins happen very rarely.

Managing Risks for Twin Pregnancies

[39:02]

If you have monozygotic twins, but they're Monochorionic and Diamniotic, then they have two separate rooms. In this case, you just have to monitor them every week. You monitor them every other week because even the simplest, least complicated twins are high risk because there's growth discordance where one baby grows better than the other. There is a risk of pre-term labor, which is much more common with twins. There's also the risk of placenta abnormality, where the placenta is in the wrong place. There are all kinds of risks that go up, so you need to get ready for double risks.

Twins with Different Birthdays

[42:23]

Every once in a while, you might find twins that have different birthdays. These types of twin pregnancies are always C-Section. So whenever you encounter twins with different birthdays, it is assured that they were delivered through C-Section.

Least Popular Calendar days to deliver at Hackensack

[46:06]

The first date is September 11, the second is October 31, and the last one is a leap year, which is February 29.

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Placental abruption (aka abruptio placentae) is where there is a partial or complete detachment of the placenta from the uterine wall prior to delivery of the baby. In this episode we discuss how the terminology changes by trimester. A placental abruption is an obstetrical emergency and can cause injury to both the mom and baby.

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