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For women over the age of 40 looking to get pregnant, it is important to start working with a fertility specialist sooner than later. The treatment options available become more limited as we age, so…
October 14, 2021
Dr. Jones: So you've just done everything you can to get ready to start a family, and now you can hear your biological clock ticking loudly. When should you get help?
You're a 43-year-old woman, and you've heard your baby biological clock ticking. You want to have a baby, and you stopped your birth control, and it didn't just happen. When should you get help?
Well, it depends. Of course, it depends on a lot of things, your health history, and the male part, but actually, we start with your age. And when it comes to this age, sooner is better than later.
We're going to do this in three parts. So if this isn't your age or the age of the person you're worried about, check out our other podcasts because we have done this in three different age groups.
Here in The Scope virtual studio with us is Dr. Erica Johnstone. She's a specialist in reproductive endocrinology and infertility and an associate professor at the University of Utah. Her special techniques for fertility include advanced reproductive technology, some amazing technology that can help people have a family of their dreams who otherwise might not be able to have a family.
She has enormous experience with in vitro fertilization in her clinic and with egg and sperm donations and other advanced technologies. So you're over 40 but not close to 50 quite yet, and you know your biological clock is ticking and you want to have a child. Should you just try for a while or should you try to see someone before you try?
Dr. Johnstone: So I would recommend scheduling an appointment as soon as you start trying. And part of the reason for that is it may take a little time to get that appointment, but we know that for women who are 40 and above, time is absolutely of the essence. And so we wouldn't want women to miss an opportunity to become pregnant because they're unaware of something that may be affecting their chances. So really, the sooner, the better.
Dr. Jones: Right. They might need a little tune-up.
Dr. Johnstone: Exactly.
Dr. Jones: Sooner than later. So who should you try and see, and what will they do?
Dr. Johnstone: So for women over 40, I do recommend seeing a reproductive endocrinologist or an infertility specialist. Now, it is true that sometimes it can take some time to get an appointment, and so it's also a good idea if you have an OB-GYN or can see one quickly, to start with an OB-GYN who can get started in talking to you about your fertility and doing initial fertility tests.
Dr. Jones: Things like sperm count? Or what kind of testing do you think?
Dr. Johnstone: Exactly. So for the male partner, we would do a semen analysis and look at the number of sperm, how many of those sperm are swimming forward, and how many of those sperm have normal head shapes.
For the female partner, we would look at some general health labs. We always want to look at general health and make sure there aren't any important things about your overall health condition, maybe things like diabetes or high blood pressure that can be optimized before you become pregnant.
But then we also look at your menstrual cycles. Are they regular? Are you ovulating every month? We look at your uterus and ovaries for factors that may be making it hard to become pregnant, like certain types of ovarian cysts or fibroids. We make sure the fallopian tubes are open. And then we also look at ovarian reserve, which is looking at whether the number of eggs remaining in your ovaries is normal for your age. Is it higher than average? Or is it lower than average?
Dr. Jones: Most women . . . or I shouldn't say this. Many women have male partners who are about their age. And, of course, some women in their 40s might have partners that are . . . their male partner in their 20s. But it's not uncommon for women in their 40s to have male partners that are in their 60s. Are there any data about men as they get older and their fertility?
Dr. Johnstone: Sure. So men's fertility does decline with age, but at a much slower rate than for women. When women go through menopause, it is extraordinarily unlikely that they would become pregnant naturally again, whereas we know it is possible for men to conceive pregnancies really all the way into their 70s and 80s, but they're more likely to have abnormalities of their sperm.
And then there are certain risks for children born to older fathers, which include neurodevelopmental type diseases. Things like autism and bipolar disorder can be more common in children born to older fathers.
Dr. Jones: So how likely is it that women will be successful having a baby the ordinary way, just trying to get pregnant on their own, when they're, let's say, between 40 and 45 compared to 45 and 50?
Dr. Johnstone: Sure. So for women between 40 and 45, it's actually changing quite rapidly with each passing year. So on average, when we look at large groups of women, of women who want to conceive at age 40, about half will get pregnant naturally. But that decreases quickly to perhaps 20% to 25% by age 42 to 43. And by age 45, it's quite rare to become pregnant naturally.
Dr. Jones: Let's say you're 48. Are there options you should be thinking about from the beginning?
Dr. Johnstone: Absolutely.
Dr. Jones: And the miscarriage rates are higher too. So actually getting pregnant is part of the problem, but staying pregnant is even a bigger problem sometimes.
Dr. Johnstone: Yeah. So as women get into these ages where natural conception is unlikely even with assisted reproduction, the option that's most likely to be successful is using donor eggs. So eggs from a woman in her 20s that will give you a very high chance of being able to become pregnant.
Dr. Jones: Is there any age that's too old?
Dr. Johnstone: This is a really difficult question, and it's one that we're seeing as women in our country and throughout the world continue to become pregnant at older ages.
The risks during pregnancy go up kind of slowly as women get through their early and mid-40s. But by the late 40s and 50s, pregnancy becomes a very high-risk endeavor. As women get into their 50s, if they do become pregnant, a very high chance of having problems with high blood pressure during pregnancy, issues with growth for the baby, potentially serious complications.
And so women who are in their late 40s and 50s and are thinking about pregnancy, we recommend they sit down with a maternal-fetal medicine specialist to really understand these risks for them and what other health conditions they may have that may further increase those risks.
Dr. Jones: Right. There's a famous story from the Bible about Sarah who was 80, I guess. And so I guess I don't . . . When I read that I went, "Yeah, right. That's not going to happen." I mean, I know miracles happen in the Bible, but 80 is really . . . that's not going to be okay.
Dr. Johnstone: No. And I think it's important for people to know when we see women in the media giving birth at very old ages . . . I think the latest I've seen recently was 72. Again, these pregnancies were usually conceived with donated eggs, and sometimes they don't portray just how risky these pregnancies can be.
Dr. Jones: Oh, absolutely. I mean, you see many older movie stars even in their early 60s or their mid-50s who are giving birth and they never tell the specifics because it's a private issue as to where these pregnancies happened, what kind of eggs they were. But whenever I see somebody who's in their early 50s giving birth who's a movie star, I went, "Yeah, right."
Dr. Johnstone: Absolutely.
Dr. Jones: I don't want people to think that that's just an ordinary, common occurrence because then they'll be hopeful, and you don't, unfortunately, know that the person availed themselves of technology right away.
So anyway, as women get closer to the end of their reproductive life, closer to 50, the chances of a successful pregnancy becomes smaller and smaller, and the chances of miscarriage get larger. But there are options that can help you to have the children of your hopes, and we can help.
I really want to thank Dr. Johnstone and all the technologies that she's so good at accessing to help people have their families. And thanks to you for joining us on The Scope.
For women over the age of 40 looking to get pregnant, it is important to start working with a fertility specialist sooner than later. The treatment options available become more limited as we age, so finding the right doctor to help with conception can be a crucial step in your fertility plan. Learn what can be done to help women over 40 become pregnant.
What You Need to Know About Fertility Treatments: Between Age 35 to 40 If you and your partner have been tying to get pregnant between 35 and 40, you may want to speak with a fertility specialist.…
October 07, 2021
Dr. Jones: So you've done everything you can to get ready to start a family, and now it didn't just happen. When should you get help?
You are a 38-year-old woman and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help? Well, it depends. Of course, it depends, and it depends on a lot of things -- your health and history and the male part of getting pregnant part of the business. But we usually start with age.
And we're doing this in three parts. So if this isn't your age or the age of the person you're worried about, check out our other podcasts.
Here in The Scope virtual studio with us is Dr. Erica Johnstone. She's a specialist in reproductive endocrinology and infertility and an associate professor at the University of Utah.
So let's say you're between 35 and 40, maybe you're 38, and you've been trying to get pregnant for a couple of months and you're a little worried. You've been reading ladies' journals and you know the clock's been ticking. When should you get help? And does the age or health of your partner make any difference?
Dr. Johnstone: Absolutely. So for sort of the typical woman between the ages of 35 and 40, we usually recommend trying for about six months before you seek help. Now, who's the typical woman? This is a healthy woman who generally has regular periods coming about every 25 to 35 days, and a woman who doesn't have serious underlying health conditions.
We would think about seeking help earlier in the case of serious underlying health conditions, irregular periods, or a woman who has previously been treated for cancer with chemotherapy or radiation.
Then when we think about the partner. Some of it, we think about some of the same key things. Generally, six months, but reasons to seek help sooner would be if he has been treated for cancer with chemotherapy, radiation, if he's had testicular cancer even that was treated surgically, if he has other serious health problems, particularly if he has other serious health problems that may be affecting his erectile or ejaculatory function. Again, these would all be reasons to seek help sooner than six months.
Dr. Jones: Who should you see to get help and what will they do?
Dr. Johnstone: In this age group, some women may choose to start with their general OB-GYN for their evaluation, but many women will choose to start with a reproductive endocrinologist. And one of the main reasons for this is that . . . It's important to know for most women between 35 and 40, they will be able to successfully get pregnant, but time is more of the essence for women between 35 and 40.
It could hurt to lose time if you spend several months with your OB-GYN, then get a referral to a reproductive endocrinologist, and potentially it takes another couple of months to be seen. So again, many women in this age group will start with a reproductive endocrinologist.
Those early visits will involve a very thorough evaluation. Key pieces of this evaluation will be asking you a lot of questions about your menstrual history. If you keep menstrual journals, it's wonderful if you have them available for your visit. A very detailed look at your medical history, medications you're taking, surgeries you've had, lifestyle habits, things like alcohol, tobacco use, exercise, etc.
For a male partner, we would look at the same things, medical history, surgical history, key lifestyle factors, and factors affecting sexual function. Then as we go into evaluation, we would start for the male partner, typically, with a semen analysis where we would ask him to give a sperm sample. And then we would look at the number of sperm, how many of those sperm are swimming forward, and how many of those sperm have normal head shapes.
Dr. Jones: So reproductive endocrinologists aren't completely common. There are many people who might be listening to our podcast who live in towns that are not big metropolitan areas.
And so sometimes a reproductive endocrinologist is a long ways away, and that sometimes going to be difficult for people to pack up and drive three or four hours to see somebody. And that could be stressful.
So does stress increase difficulties getting pregnant? I just thought I'd throw that in there because some of us are really stressed out.
Dr. Johnstone: Absolutely. So there've been a lot of studies on this subject and they've been mixed in their findings. So I wish I could say stress has no effect at all. I couldn't say that, but I can absolutely say that stress is not a complete block to pregnancy.
And so I recommend to anyone who's trying to conceive to look for ways to reduce and manage their stress. But the number one reason to do that is because it can take time to get pregnant and we never know how long it's going to take.
And so, for your overall health and for the health of a relationship, it makes sense to try to find ways to manage and reduce that stress. But know that it's okay that there's stress. And the fact that you're worried about this, and the fact that it's hard to try to conceive doesn't mean that you won't get pregnant.
Dr. Jones: I remember a study years ago that just getting an appointment to a reproductive endocrinologist, to a referral fertility center, increased the chances of getting pregnant in the next six months. So that was just people who got an appointment and it was four or five months away compared to people who just tried on their own.
So sometimes doing things that will help alleviate your stress, even though you might have to travel for it, getting an appointment means that you've taken a step to move forward, and sometimes that itself makes you feel a little bit better.
Dr. Johnstone: Absolutely. And I should mention we currently are doing a lot of telehealth visits, and that means you may have the opportunity to gain a lot of information and get a lot of questions answered while sitting comfortably in your home, even if that's several hours away.
And I think that's one of the few bright lights that have come out of the COVID pandemic, is that there is greater availability for telehealth. And again, I think this is something that can really be helpful to couples in making access much better and also in giving you the opportunity to talk about these things from the comfort of your home as opposed to being in the doctor's office.
Dr. Jones: We also know that women as they get into their late 30s are a little more likely, unfortunately, to miscarry if they do get pregnant. And we know that sometimes by the time you've lived on the planet long enough, you've accumulated some illnesses, diabetes, hypertension, other conditions that might make pregnancy riskier.
And of course, just being over 35, some people think makes you a riskier pregnancy. But if you have any kind of medical conditions that you take medicines for, it's important to kind of think about how you get yourself in the best shape to be the pregnant person that you want to be for this baby you want to grow.
Dr. Johnstone: Absolutely. I think one thing I would add to that . . . So, one, if you have health conditions, check in with your doctor, but we also might refer you to a maternal-fetal medicine specialist to prepare for addressing those health conditions. How will your pregnancy affect your diabetes, your high blood pressure? How will your high blood pressure or diabetes affect your pregnancy?
Another thing to think about is some couples begin their fertility journey when they haven't had any medical care for a number of years. And so, if you are starting to try to conceive and you have not seen a health care provider in several years where it's possible that you may have high blood pressure or pre-diabetes that isn't diagnosed, it's a good idea to just get a general checkup at some point within that year before you try to conceive so that we can find these things rather than finding them once you're pregnant. We can do a better job of treating them and preparing you for pregnancy if we know about them first.
Dr. Jones: Exactly. So we aren't so fertile as a species to start with on a month-by-month basis, and we aren't so fertile as we get older. Peak human fertility starts to decline in the late 20s. So if you're in your late 30s, don't wait too long to get help if you aren't getting pregnant right away because we can help.
Thanks to Dr. Johnstone and thank you for listening on The Scope.
If you and your partner have been tying to get pregnant between 35 and 40, you may want to speak with a fertility specialist. The fertility treatments available to you greatly rely on the age of the woman trying to have a child. In this episode, Dr. Kirtly Jones speaks with fertility expert Dr. Erica Johnstone about helping women in their late 30's to become pregnant.
If you and your partner have been struggling to get pregnant, it may be time to consider speaking with your doctor about fertility treatments. It’s important to realize that the conception…
September 30, 2021
Dr. Jones: You've done everything you can to get ready to start a family, and now it just didn't happen. So when should you get help?
So you're a 28-year-old woman, and you've been trying for a while to get pregnant. You stopped your birth control, and it didn't just happen. When should you get help?
Well, it depends. Of course, it depends. It depends on a lot of things, your health and history, and the male part of getting pregnant part of the business. But we usually start with your age. We're going to do this in three parts. So if this isn't your age, or the age of the person you're worried about, check out our other podcasts about when to get help getting pregnant.
Here in The Scope studio virtually with us is Dr. Erica Johnstone. She is a specialist in reproductive endocrinology and infertility, and an associate professor at the University of Utah. Welcome, Dr. Johnstone.
Dr. Johnstone: Thank you.
Dr. Jones: Well, we're so glad you're here. So let's just say that you, the listener, are between 25 and 35. Of course, you could include 20 to 25. So let's just say you're under 35 years old, and you've decided to try to get pregnant, and you're so excited, but it didn't happen in the first three months. When should you consider getting some help?
Dr. Johnstone: So generally, for women who are under 35, we recommend trying for a full year before you seek help. And that's because it often happens. Close to half of women will conceive within those first three months. There are plenty of women and plenty of couples with perfectly normal fertility for whom it will just take a little bit longer.
Now, there are a few exceptions to that, situations when it might make sense to seek help sooner. One of those is if either the woman or her partner has previously been treated for cancer with chemotherapy or radiation.
Another of those situations is if a woman is having very irregular periods, going 45 days or more without a period, or potentially having no periods at all. Those would be times when you'd want to seek help sooner.
Dr. Jones: I know that people who want to have a baby, when they're finally ready, they want to do it right now. "I just want to have a Christmas baby," or, "I want to have a spring baby. I don't want to be pregnant in the summer." But what should you be doing while you're going to try on your own for a while? What do you tell people when you say . . . It's hard to tell someone to go away and come back in six months. What can you tell people to be doing while they're trying to get their 12 or 13 cycles of trying in?
Dr. Johnstone: Sure. So, first of all, things we think about are just being ready to be pregnant. So some key parts of this. One, take a prenatal vitamin every day. Two, if you're a smoker, I recommend that you quit smoking. The same is true for vaping, any sort of illicit drugs. You want to really limit your use of alcohol and caffeine. I recommend that every woman who's trying to conceive, make sure that she's up to date on her vaccines, including the COVID vaccine.
Then when it comes to actually trying to get pregnant, we think that probably, over time, one of the most effective strategies is just to have frequent sexual intercourse throughout the menstrual cycle, ideally about every other day, three times a week. This should work well. And with this approach, then you don't need to strictly worry about timing intercourse, just frequent intercourse throughout the cycle.
Dr. Jones: Right. Some people really struggle because they want to buy a kit that will tell them when they're ovulating, or they want to use their symptoms. But it turns out that just doing it is the way people get pregnant.
Dr. Johnstone: Absolutely. As it turns out, as many kits and products as there are now, the human race existed for many, many, many generations before the existence of those products.
Dr. Jones: And so who should you see to get help? If you're still a relatively young woman and a relatively young couple, and it's been nine months and you're picking up the phone to make an appointment, because you might not get the appointment next week, who should you be calling?
Dr. Johnstone: So I think for women under 35, it's reasonable to start with your OB-GYN, particularly if you already have an OB-GYN who you've established care with, who you might be able to get in to see sooner. It's also always an option to see a reproductive endocrinologist. And so, for women in this age group, either is a good option.
Dr. Jones: And so what would they do? Let's say you've been trying and it's got to be 10 months or something like that, and you got your appointment and you want to kind of be ready for what kinds of things they might do when you go to visit them. So what would they be doing in this first part of your visits with them and your evaluation?
Dr. Johnstone: One of the first things will be a very detailed history. We'll look at a woman's menstrual history. We'll look at her medical history, any surgeries that she might have had, any symptoms she might have related to her periods, pain with intercourse, things like this. We'll look at a general health history, health habits.
And we'll do the same for the male partner in terms of his general health history, any issues with things like erectile dysfunction, or difficulty with the ejaculation, etc.
And then we'll start with some tests, typically for both partners. So, for the male partner, we will usually do a semen analysis. And so this is collecting a sperm sample after about two to five days of abstinence, so that we can look at the number of sperm, we can look at how many of those are swimming and swimming in a progressive fashion, and how many of the sperm have normal head shapes. And this helps us to say, "Do we think there's a male factor making it harder to conceive?"
For the woman, we will often do some general health labs. Essentially, women in early pregnancy get a lot of blood tests done that are screening tests, looking at blood counts, maybe looking at their thyroid, their blood type, checking their immunity to different diseases, infectious disease testing. We know that every single one of these tests, it would be optimal if there's a problem to find it before pregnancy.
We'll also look at ovarian reserve. And what that means is does a woman have a normal number of eggs for a woman her age? Is it higher than most women her age, or is it lower than most women her age? And one of the important things to know about that is while it's really useful as we talk about treatment, it is not a predictor of who will and who won't get pregnant.
Dr. Jones: It just may help direct what kind of treatment is most likely to be helpful and which might not be?
Dr. Johnstone: Yes, exactly. We'll also typically do an ultrasound to look at a woman's uterus and ovaries, look to see if we see abnormal ovarian cysts, fibroids, polyps, any sort of structural or anatomic findings that might be contributing to the difficulty.
And finally, we would do a test like a hysterosalpingogram or a saline infusion sonohysterogram to assess whether a woman's fallopian tubes are open.
Dr. Jones: Right. So those are the beginning tests, and it helps guide a future therapy, I think. There are circumstances that would make it important to at least get information or get help sooner. You already mentioned that if women's cycles are really irregular, or if either the partners have had treatment for cancer when they were younger, it might mean that they don't have as many eggs and sperm.
But if a woman or her partner has a pretty serious medical condition, we want to make sure that that medical condition is in really tip-top shape before they get pregnant. So sometimes do you recommend people see a specialist, like an OB specialist, before they get pregnant?
Dr. Johnstone: Absolutely. So for women who have significant underlying health conditions or something in their history that might make their pregnancy higher risk than for other women, we'll recommend that they see a specialist in maternal fetal medicine before conceiving to talk about, "Are you on the best medications for your condition? How is that health condition going to affect your pregnancy? And how is your pregnancy going to affect that health condition and the treatment options?"
Dr. Jones: Right. Well, remember, it takes normal eggs and normal sperm, and fallopian tubes, and a uterus to get pregnant and grow a baby. And in humans, it often takes a little time. But don't wait forever. We can help. And thanks to Dr. Johnstone and thanks to you for joining us on The Scope.
If you and your partner have been struggling to get pregnant, it may be time to consider speaking with your doctor about fertility treatments. It’s important to realize that the conception strategies and medical options available to you greatly rely on the age of the woman trying to have a child. Learn the methods to help young women under 35 become pregnant.
During pregnancy, your top priority is to keep your child safe and healthy. We know the dangers of COVID-19, the disease caused by SARS-CoV-2. But is the vaccine safe for you and your developing…
September 09, 2021
You are pregnant and trying to do the right thing to keep yourself healthy and provide a safe place for your growing pregnancy. Is it time to get a COVID vaccine?
I have tragic memory of being part of a team that cared for a wonderful young woman who was pregnant and got influenza. Influenza isn't usually lethal to healthy young people, but it's dangerous in pregnancy. We knew this young woman. She worked in our unit, and she and her baby died of influenza. This was before my hospital required all employees to be vaccinated for the flu each year. Now we have over a decade of information about the influenza vaccine in pregnancy and safety, and we encourage every one of our patients to get the flu vaccine. It saves lives.
Now we have this other virus, COVID-19. COVID isn't new to us as humans. We've seen several other COVID viruses that were quite deadly in the past 20 years, but they didn't go that far and we see coronaviruses, the COVID family, make up some of the virus that caused the common cold. But COVID-19 is very contagious and causes severe illnesses and death all too frequently and lingering illnesses in many of those who weren't even really sick.
So when we first offered the COVID-19 vaccine, we had little information about COVID vaccine in pregnancy, but we had almost nine months of data on the COVID-19 virus infection and how it affected pregnant women. Here at the University of Utah, Dr. Torri Metz, a specialist in high-risk pregnancy, helped lead a national team to collect information about pregnant women who were infected with COVID-19. We talked with her, and she said it was sobering to see that young, healthy women who were pregnant had much more serious courses of the infection than women of the same age who weren't pregnant. They were more likely to get hospitalized, they were more likely to be admitted to the intensive care unit, they were more likely to be put on a ventilator, and if their oxygen levels became too low, they were more likely to lose their babies and sometimes they lost their lives.
But it took us another nine months to collect information about women who were pregnant and were vaccinated and compare outcomes to women who were pregnant and were not vaccinated. And the news is good and compelling about the safety of the COVID-19 vaccine in pregnancy.
So what is true? One, the Moderna and Pfizer vaccines had no adverse effects on fertility, pregnancy, and offspring in lab animals. Two, in 35,000 women who were pregnant and received the COVID-19 vaccine, headache, muscle aches, chills, and fever were less frequent in pregnant women than in non-pregnant patients. Three, injection site pain, where you got the shot, was more frequent in pregnant women, but it wasn't really all that bad. Four, the safety data following 4,000 pregnancies in women who were vaccinated showed no higher rates of miscarriage, no higher rates of preterm birth, no higher rate of newborn birth defects, or deaths compared to what we normally experience in pregnancy. I'm going to say that again. There were no higher rates of miscarriage, preterm births, or birth defects in women who were vaccinated compared to women who aren't vaccinated. Number five, women who are infected with COVID-19 have an increased risk of harmful abnormalities in the placenta. Women who are vaccinated don't have these harmful changes. Six, women who are vaccinated are five times less likely to get COVID-19 compared to pregnant women who are not vaccinated, one-fifth the rate of getting COVID compared to non-vaccinated pregnant women. Seven, women who are vaccinated give good antibodies to COVID-19 to their newborn babies. So there are seven true things.
What's not true? One, the COVID-19 vaccine causes infertility. It doesn't. Two, the Moderna and Pfizer vaccines have DNA in them and will alter the DNA of the fetus. Nope. These vaccines have mRNA in them, and these molecules are very short-lived and act mostly in the muscle around the shot. They don't change the DNA of the fetus or the mom. Three, the COVID vaccine has a microchip in it to track you. Really? I don't know where that ever came from, but it's one of the silliest of the vaccine myths.
Women who are pregnant are at high risk if they become infected with COVID-19. Pregnancy may lower women's immune responses, but the vaccine is still very protective against women developing complications from COVID-19.
With the information about the risks of COVID-19 infection to the pregnant mother and now the efficacy data from the vaccine outcome data collection and the safety information from more than thousands of women who were vaccinated while pregnant, the Centers for Disease Control and Prevention, the American College of Obstetrics and Gynecology, and the Society of Maternal-Fetal Medicine have strongly recommended that women who are considering pregnancy, trying to get pregnant, who are pregnant, or who are breastfeeding get vaccinated with the COVID-19 vaccine.
I think back to the day when I saw a young woman die of influenza and how much the flu vaccine is part of our counseling to pregnant women during flu season. So if it's flu season and you're pregnant or breastfeeding, don't forget to get your flu vaccine. And no matter what season it is, if you are pregnant, trying to get pregnant, or breastfeeding, please talk to your clinician and get vaccinated against COVID-19. And because no vaccine is perfect, please wear a mask that covers your nose and mouth when you're indoors in groups of people and practice social distancing if you're with people who aren't vaccinated.
And thanks for doing what you can to protect yourself, your baby, and those around you. And thanks for joining us on The Scope.
During pregnancy, your top priority is to keep your child safe and healthy. We know the dangers of COVID-19, the disease caused by SARS-CoV-2. But is the vaccine safe for you and your developing child? Learn latest research about the safety of COVID-19 vaccines in pregnant women—and women trying to become pregnant—and takes a hard look at the most common misconceptions surrounding the topic.
You’ve taken steps in your family planning, and now you’re ready for a baby. How long after stopping birth control are you fertile again? Well, it depends on the contraceptive.
August 05, 2021
You have done all the right things in planning your family and now you're ready to have a baby. How long after stopping birth control before you try to get pregnant? How long does it take to be fertile again? And how long is too long?
Start from the top. How do you stop your method of contraception? Well, that seems like an easy question, but sometimes it isn't. You can stop using your condom or diaphragm or contraceptive foam right now and you can take off your patch, take out your ring or stop your pills today.
Taking out your implant or your IUD takes a medical appointment with your clinician or your family planning clinic. Really now, we don't recommend that you or a friend try to take out these medical devices on your own, so getting an appointment may take a few weeks.
Now, how long does it take after stopping birth control before you're fertile? Well, it sort of depends. If you're using barrier methods, such as condoms or diaphragms or foams or jellies, you could get pregnant the next time you have sex without your protection. Of course, you have to ovulate, and that will be on your regular schedule, but barrier methods don't change that.
If you're on birth control pills or patches or rings, the hormones in these methods are gone from your body within a week. And in the case of the progestin-only mini-pill, it may just be a couple of days then your body will get back to ovulating, so it may be a month or two before you ovulate.
Now, if you don't have regular periods or have a period on your own in three to four months, you should see your doctor. Maybe you weren't regular before you started hormonal contraception or maybe something in your body has changed, but it's not due to your method that you were using.
If you use an implant, the hormones from the implant will be gone in a couple of days, and then your body will get back to ovulation in a month or so, or sometimes in a week. If you're using a copper IUD, you'll be fertile the first time you have sex after it's removed if you're ovulating that day, but you probably won't be fertile on exactly the day that you have it removed, but maybe the next day.
If you're using a hormonal IUD, the hormones will be gone from your body in the week after it's removed, and you should be back to ovulating either next day or next week with a normal uterine lining within a month or so. Of course, there are very rare cases in which the IUD or the implant didn't come out all the way or you thought it was out and it wasn't. And in those situations, there may be a delay in fertility until the implant or the IUD is completely removed, but this is very rare.
If you're using the Depo-Provera shot, the hormone in the shot is in your muscle for months, and it may take as many as 10 months from the last shot before you ovulate again. Of course, as the shot is designed to be given every three months, you may be fertile in as little as four months after the last shot. Because return to fertility is delayed and a little compared to other methods, we usually counsel women who are hoping to get pregnant in the next year but don't want to get pregnant right now to use a method other than Depo-Provera.
Now, when can you try to get pregnant? Do you have to wait a while? We used to think that women were less fertile or more likely to have a miscarriage if they got pregnant immediately after discontinuing a hormonal contraceptive method. We have clinical data that says now it's not so. So you can start to try to get pregnant right away, even though it might be a couple of weeks before you ovulate.
Now, how long is too long? If it's been a year since you stopped your birth control and you aren't pregnant, you should see your OB-GYN. For women over 35 who have lower fertility related to getting older, maybe you should seek some help in evaluation if it's been six months. Is it your birth control that's contributing to not getting pregnant? The answer is no. Using birth control in the past doesn't contribute to fertility problems, but you did get older while you were using birth control so you naturally would be less fertile when you stopped.
How can we be so sure that birth control doesn't cause fertility problems? We don't have a randomized controlled trial of women using different kinds of birth control compared to women who are abstaining from sex, and then seeing which group of women got pregnant first, but that would be an amazing study to do. However, 22 studies that enrolled a total of 15,000 women who discontinued contraception were looked at, and the rate of pregnancy was 83% within the first 12 months of contraceptive discontinuation.
Now that's not significantly different for hormonal methods and IUD users, and it's not significantly different than women who weren't using birth control before they started to try to get pregnant. The study also showed that how long a woman used contraception did not significantly affect the time to fertility when you take into account the age of the woman.
The amount of time it takes to get pregnant is a function of a lot of things. It's your age, your weight, conditions in your pelvis, such as infections or endometriosis, how regularly you ovulate, how often you have sex, and of course the fertility of your partner.
So make decisions about when to start your family or increase your family based on conditions that matter to you and your family, and not because you're afraid that your longer use of birth control will make a difference. Longer use of hormonal contraception may actually decrease the risk of your having problems because it lowers your risk of conditions in the pelvis, such as endometriosis, and some types of ovarian cysts. And here's hopes for the family of your dreams and thanks for joining us on The Scope.
You’ve taken steps in your family planning, and now you’re ready for a baby. How long after stopping birth control are you fertile again? Well, it depends on the contraceptive. Learn how long it typically takes to conceive after ending common contraception methods and when to involve a specialist if you’re having trouble getting pregnant.
High-risk pregnancies require a team of experts to address both child and mother's needs before, during, and after delivery. Dr. Stephen Fenton is the founder and director of the Utah Fetal…
January 29, 2021
Interviewer: We're with Dr. Stephen Fenton. He is the founder and director of the Utah Fetal Center at Primary Children's Hospital. And it is for women who have high-risk pregnancies due to a congenital anomaly with the child. There is kind of a way things used to be done. And now there's a way things are done at the Utah Fetal Center, Primary Children's Hospital, which is a much better way. Dr. Fenton, first of all, you're the founder and the director. You came in and you said, "I want to start this center."Why did you say that?
Dr. Fenton: I don't want anyone to ever think or believe that what was happening before wasn't being done to the best of its ability because it certainly was. All of these conditions were being cared for before. But the reality is it was kind of done in what I would term a physician-centered approach. So oftentimes that would require multiple clinic visits because they were separate clinics in each of the physician's clinics. And you can imagine how frustrating and how hard that must have been for that mom to kind of shoulder that burden all on her own.
Interviewer: It was a very stressful time.
Dr. Fenton: Very stressful time.
Interviewer: Just to coordinate her care kind of.
Dr. Fenton: I mean, and during all that time, of course, worried about her unborn child. And so what we've done is we've kind of shifted it from this physician-centered care to what I term patient-centered care with a multidisciplinary approach. So we, over the last five years, have put together a multidisciplinary team of all of these specialists that care for the child and for the anomaly. In addition, we've added adult specialists, so maternal fetal medicine or high-risk OBs that care for the mom, all in one place. We didn't have adult providers at the Children's Hospital. Now we have these adult MFM providers who help care for these moms. We also added a coordinator. We've added nurse coordinators that actually help the mom wade through all of this, and ancillary staff, such as a social worker, who can also help with the non-clinical aspects. We are now all in the same place. Instead of being in our individual silos, if you will, we're all located together where we can look at the images together, where we can talk about it, and where we can come up with a care plan not only for the mom until baby is delivered, but also for the child after delivery.
Interviewer: What is the objective of the center?
Dr. Fenton: We want to make sure mom and baby first have the right diagnosis. It's much easier to help the parent learn what the condition is and start understanding what the treatment, if any, will entail before the child is born. Now that's one aspect. The other aspect is some of these kids need intervention before they're born. And in order to do that, it's very specialized. It requires a team and it requires being able to take the mom to proper diagnosis and from diagnosis to intervention, and then from intervention to delivery safely. And you can't do that without proper infrastructure, and the Utah Fetal Center is that infrastructure.
Interviewer: Can you give me an example of a couple of the common conditions that you would require that would require this multidisciplinary team?
Dr. Fenton: Congenital diaphragmatic hernia is one that comes to mind, myelomeningocele, that's another word for spinal bifida, CPAM or congenital pulmonary airway malformation also known as congenital lung lesion, atresias, intestinal atresias, omphalocele, gastroschisis. These are all things that are surgical too. We oftentimes see kids that don't necessarily require surgery. So some of the genetic disorders like trisomy 21. We also see kids that have neurologic issues, so brain malformations that won't necessarily require intervention, but will require a coordinated care with multiple providers.
Interviewer: What does that initial consultation entail when they come to you? What does that look like?
Dr. Fenton: In the morning, they oftentimes will undergo an ultrasound and consultation with one of the maternal-fetal medicine physicians that work at the Utah Fetal Center. Dependent on what the original diagnosis is, and oftentimes we have already received outside imaging from the referring providers and reviewed it, they might also undergo a fetal MRI, and that fetal MRI will give us even more detail, especially when we can compare it to the ultrasound that happens on that same day. It's read by the fetal radiologists that work in the center. And then usually we give them a little bit of a break. They go to lunch, etc., and then come back in the afternoon or early afternoon, and there, they will see the specialist, the sub-specialist that will ultimately care for their child.
Interviewer: If a patient wasn't referred and they believe that the Utah Fetal Center is the place that they would like to go, are they able to call?
Dr. Fenton: Absolutely. They can go to our website, utahfetalcenter.org and self-refer. We really want to help these parents get through this very, very difficult time. We understand that there are a lot of providers out there that are doing a portion of this, and we certainly appreciate all that they are doing. We are not looking to just assume all care of these moms because we know that a lot of their care can be delivered close to home, but we do feel like it's very, very beneficial to start that coordination of care early so that we can help the parents understand what is happening, obtain expectations on the treatment plan, as well as understand the treatments involved and then initiate that plan early, and in the long run we know that doing so with the help of the many providers, not only here at the University of Utah and Primary Children's Hospital, but across the state will allow us to do that.
High-risk pregnancies require a team of experts to address both child and mother's needs before, during, and after delivery.
Will eating spicy food during pregnancy make your child go blind? Can cocoa butter prevent stretch marks? Does a chronic stomach ache mean your baby will be a boy? OB/GYN Dr. Kirtly Parker Jones…
March 07, 2019
Dr. Jones: If you have heartburn when you're pregnant, it means that your baby will have a lot of hair when it's born. Really? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope of Some Myths About Pregnancy, on The Scope.
Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.
Dr. Jones: Pregnancy is mysterious, and what is going on in there is mostly unseen and to my biologic eye, magical. There are outcomes that are good and some less than good, and we cannot explain all of them based on scientifically proven cause and effect. So we turn to myths and old wives' tales. Some of these exist back to before there were well-defined scientific methods, and some are new. Let's look at a few.
One, the shape of your pregnant belly can tell you whether you're carrying a boy or a girl. If you carry your baby bulge low, it's a boy. If you carry it high, it's a girl. There is no fact to that. What is a fact that the first pregnancy, before the abdominal wall is stretched out, tend to be visually higher. As the abdominal wall gets stretched out with each new pregnancy, the uterus appears to be carried lower, but it's not the sex of the baby.
Number two, your baby's heart rate can determine the sex of your baby. Higher heart rates are a boy, lower is a girl. That's a no. There is no evidence that the heart rate is determined by the baby's sex.
Number three, spicy foods can cause your baby to be born blind. That's a no. However, because pregnancy hormones and the pushing of the uterus as it gets higher can cause reflux, spicy foods can be less well tolerated, but they won't make your baby blind.
Four, cocoa butter prevents stretch marks. That one is a no. But it does smell good and it makes your skin feel soft, so go for it if you like it. But it makes your sheets greasy.
Number five, looking at the sun during an eclipse will give your baby a cleft palate. That one would be hard to prove because there are few pregnant women who would be so careless as to look at the sun when they're pregnant during an eclipse, and there are a few eclipses and I don't really recommend a randomized controlled trial to test that one out.
Number six, you should eat for two when you're pregnant. I don't know where that one came from except that it's usually a rationalization about how much you might want to eat. You can get enough energy to make a baby in about 300 calories extra a day, about 3 little cookies with no redeeming nutritional value, 3 tablespoons of peanut butter, notice that's not a rounded tablespoon but a flat one, ladies, or 3 glasses of reduced-fat milk, a good nutritional source of calcium and protein. So you should eat for about 1.16 persons or about 1 and a 6th.
Number seven, you cannot color your hair when you're pregnant because it will harm the baby. That's a no. If it were true, there would be some serious fashion problems. It probably isn't good to introduce any new chemicals that you aren't sure about in your first trimester, but after that the amount that might be absorbed by your skin, if you do it a couple of times during your pregnancy, is unlikely to be a problem.
Number eight, drinking dark beer will help your milk come in. That's a no. Really? That's my family's favorite myth. It was given to my mother in Germany by the nuns at the hospital when she delivered me. It was given to my sister and to me, and it sure seemed to bring it on. Well, actually, it doesn't make the milk be produced. However, relaxing a new mom just out of the hospital, who's worried about everything, can help the milk come down. The let-down reflex of releasing the milk stored in the ducts so the baby can nurse can be inhibited by anxiety and stress and maybe the alcohol and dark beer can work for that.
Number nine, if you have heartburn, you'll have a baby with lots of hair. No. Well, a study from Johns Hopkins, published in 2006 in the journal "Birth," asked 64 pregnant women about their degree of heartburn during pregnancy, and an independent observer graded the amount of hair in the newborns, and there was a simple linear association between the degree of heartburn and the amount of hair. The more heartburn, the more hair, and the association was highly statistically significant. Now, I can see that there might be some racial differences in how hormones affect pregnancy and then affect the sphincter or the tight place between the stomach and the esophagus that prevents reflux and heartburn, and some racial groups have babies with more hair and some with less. However, 90% of the women in this study identified as Caucasian. So there isn't really a good reason for this amazing statistical outcome. The author said, "Much to our surprise and somewhat to our chagrin, our application of straightforward but standard scientific methods to investigate the validity of this ubiquitous pregnancy 'myth'" -- they put quotations around the word "myth" -- "resulted in its partial confirmation." Who knew? Pregnancy is still mystifying.
If you have questions about what you've been told by your mom or your auntie, talk to your clinician and make them do their homework and look it up, and thanks for joining us on The Scope.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.
Common pregnancy myths and old wives’ tales.
Early miscarriage, or spontaneous abortion, is common—the most common complication in pregnancy. Approximately one million American women experience a loss of pregnancy in the first twelve…
September 20, 2018
Dr. Jones: Early miscarriage is common, the most common complication in pregnancy. How do we think about our options to manage this?
Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.
Dr. Jones: About one million American women experience early pregnancy failure each year. This is the loss of a pregnancy in the first 12 weeks. Before the common use of early pregnancy tests and ultrasounds, women often didn't even know they were pregnant for several months. Now, women know that they're pregnant if they want to within two weeks after fertilization, and an ultrasound of five to six weeks from the last menstrual period, four weeks after fertilization can show early fetal development and whether the pregnancy is developing as it should.
As many as 60% of eggs that are fertilized don't lead to live births. Most of those aren't even recognized as a pregnancy. But for women who've had a positive pregnancy test, 15% to 25% of those pregnancies will not proceed past the first trimester, the first 12 weeks. Early pregnancy loss is common, and it may be that recognized as cramping and bleeding early in pregnancy, signs of the pregnancy is probably going to end in a spontaneous abortion without any medical intervention.
All over the world women miscarry early, and most do not get or need medical intervention. However, with the use of early ultrasound at six weeks from the last menstrual period, we can see if the pregnancy is going to fail. If there's a sac without a heartbeat or a fetus, or if there's a tiny area that might have been an early fetus that doesn't have a heartbeat, that pregnancy will probably miscarry. However, it may take weeks to months for that to happen on its own.
Some women are willing to wait for nature to take its course -- have their miscarriage, pass their tissue, or may just be heavy bleeding. They won't really see a fetus because one hasn't developed. But some women want to get on with their reproductive lives, end this pregnancy so they can start again if they want to.
In the U.S. in past years, women who had access to early pregnancy care and found that they didn't have a heartbeat were recommended to have a D&C. This is a procedure in the operating room with anesthesia. The cervix is stretched open with a dilator, and a tube is passed into the uterus to aspirate the sac and the early placenta. This is expensive -- it can cost thousands of dollars -- and time consuming.
Techniques that have evolved over the last 20 years include using a syringe with a suction device and a little tube to remove the failed pregnancy, and this can be done in about five minutes in the office under local anesthesia. Many physicians are familiar and comfortable with this option, and they counsel this option for the patient. But many are not and are most likely to counsel going to the operating room.
Over the past 15 years, medications have been studied that can cause the uterus to cramp and push out the pregnancy. One of these medications, Misoprostol is widely available and has been used especially in women who've already started to cramp and bleed as they begin to miscarry early. One large study found that this oral medication is as successful in women experiencing early pregnancy failure as a surgical procedure if they've already started cramping and bleeding. The risk of heavy bleeding and infection were not any different in the surgical procedure than the medical one.
If women have an early pregnancy that isn't growing, doesn't have a heartbeat or an ultrasound, but they haven't started cramping and bleeding yet, taking this medication is less successful than if women have already started the process. A recent study published in "The New England Journal of Medicine" compared women who took the cramping medicine called a uterotonic Misoprostol with women who were given the same combination of drugs as women use when they are choosing a medical abortion. This combination has been used safely by millions of women around the world for the past 20 years, and it combines a medication called Mifepristone followed by Misoprostol.
This randomized trial showed that women who were given just the cramping medicine when they had a failed early pregnancy demonstrated by ultrasound, they were successful in completing a miscarriage at home within 4 days and about 67% of the time. Women who were given the two medications were successful in ending the failed pregnancy, but in 4 days 84% at the time. Women who hadn't completed a miscarriage in four days were offered another dose of medication. Some women who didn't complete their miscarriage had a suction procedure to finish the miscarriage.
Most women were satisfied with the process and said that they would recommend it to a friend and they would choose this way of ending an early pregnancy loss if it happened to them again. Now, not all physicians are familiar with these medications and not all pharmacies carry them. But these options can become an important choice for some women.
So how do you use this information? Early pregnancy failure can be devastating to women who've been hoping for a baby. Once the ultrasound findings that there's no growing fetus are explained, a woman may choose to wait until nature takes its course, knowing that this might take days to weeks. Some women want it all over with as soon as possible and are comfortable with the surgical procedure and are not comfortable with what can be significant cramping and bleeding that can come with a spontaneous abortion or with the medication.
Some women want the timeliness of taking the medication rather than waiting, but want the privacy of being at home, knowing that they can call their physician if they're having any difficulties. However you and your clinician come to manage this problem, it's often an emotional roller coaster, a big loss, as well as a physical loss. Make the choices that work the best for you and get the information that will help you move forward. And thanks for joining us on The Scope.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.
Research shows caffeine is a stressor in pregnancy, and babies with stress in the uterus are more likely to have health problems as children and adults, one of those problems being overweight. Dr.…
May 31, 2018
Dr. Jones: Will caffeine consumption during pregnancy make it more likely that your infant and child will be fat? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Seven Domains of Women's Health on The Scope.
Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones, on The Scope.
Dr. Jones: Recently, a report from the Norwegian Mother and Child Study on caffeine intake and infant body weight made all the news. Let's take a little minute to review caffeine in pregnancy and this study before the caffeine drinkers get too worked up.
We've talked before on The Scope about the recommendation that women limit their caffeine intake to less than 200 milligrams per day. Now that would be about two small cups like the cups that your mother used to put coffee in, or one 12-ounce cup. Not the extra grande or supersized cups of coffee, or cans, or Coke cans of caffeinated soda. The reasons for this recommendation comes from the Scandinavian studies that are very large and can follow moms, and babies, and dads of babies.
There's a suggestion that consuming more than 200 milligrams of caffeine per day slightly increases the risk of miscarriage, and consuming large amounts of caffeine or caffeinated beverages, that's usually coffee in Sweden and Norway, can restrict growth of fetuses in development. This suggests that large amounts of caffeine may be a stressor in pregnancy. And we have evidence that babies that are stressed in the uterus are more likely to have health problems as children and adults. One of those problems is being overweight.
The study looked at 50,000 pregnancies and followed the kids' weights at their well child check-ups. Compared to women who took no caffeine or very little caffeine in pregnancy, less than a cup of coffee a day, the kids were a little smaller at birth but then put on weight faster throughout childhood. The kids of women who consumed a lot of caffeine, four cups or more equivalent in tea or caffeinated sodas a day, were on average 2.5 ounces heavier at 3 to 12 months, 4 ounces heavier at toddlerhood and 12 ounces heavier at 8 years of age.
Now, that isn't a lot, significantly less than one pound, but it shifts the curve of weight so that slightly more kids were overweight in the high-exposure to caffeine group. To say that another way, for any one child the differences would be small, but it would be significant for a population of children.
Now, this is a very complicated issue. This is not a randomized trial where 1,000 pregnant women get a boatload of coffee and 1,000 women don't get any caffeine. These outcomes from the caffeine and pregnancy study come from large observational studies where data were collected during the pregnancy and the kids' early growth and analyzed later. So women who drank a lot of coffee in pregnancy are different in other ways than women who don't drink caffeinated beverages.
In this study on caffeine intake in pregnancy from Norwegian moms, the higher the caffeine intake, the higher the likelihood of a mother being older than 30 years of age and having had more than one baby. Women who took a lot of caffeine ate more calories and were more likely to smoke in pregnancy. Moreover, women with very high caffeine intake were more likely to have low education, have been obese before pregnancy, and have partners who were obese and smokers compared with those consuming less caffeine per day.
All of these factors can be stressors in pregnancy and can change the baby's response to stress after birth. All of these factors may also play into a child becoming overweight. In this study, they had so many pregnancies that they could exclude women who smoked and whose babies were underweight at birth. And that's a risk for extra weight gain.
However, growing up in families where moms and dads may be overweight, smoke, and drink a lot of caffeinated beverages, may mean that there are other dietary differences.
So what's the takeaway from this study? Well, it's another reason to limit caffeine intake in pregnancy. You know your caffeine sources. Yep, chocolate, caffeinated teas, and coffee, and it would be best to avoid caffeinated sodas altogether because the sugar or the sugar substitute probably aren't so great for you or your baby. And the can is lined with stuff that's been associated with excess baby weight gain. That's baby weight of the baby, not the mom.
Limit to one 12-ounce cup of coffee or two 6-ounce cups of coffee a day or equivalent in tea or chocolate or less. The amount of caffeine in coffee, sodas, and teas may vary, but you can check it out on the internet. Be calm, be wise, be moderate, and thanks for joining us on The Scope.
Announcer: Have a question about a medical procedure? Want to learn more about a health condition? With over 2,000 interviews with our physicians and specialists, there's a pretty good chance you'll find what you want to know. Check it out at thescoperadio.com.
Will caffeine consumption during pregnancy affect your child? We find out on The Scope
States with the least access to family planning have the highest rates of unplanned pregnancies and maternal deaths. Starting May 18th, Utah will become one of a few states that allow women the…
May 03, 2018
Dr. Jones: What if you didn't have to go to the doctor's office to get your birth control prescription renewed? What if low-income women, that includes moms and students, had access to the most effective means of contraception? This is Dr. Kirtly Jones from Obstetrics and Gynecology at the University of Utah Health, and this is The Seven Domains of Women's Health on The Scope.
Announcer: Covering all aspects of women's health. This is The Seven Domains of Women Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: What would the world look like if every child was wanted and planned for with a mother in her very best physical, emotional, and financial health? We know that the health status of the mom and the early environment for the infant have long-lasting positive and negative effects on children and the adults that they will become. So planning your children to support their success is a good idea, huh?
It turns out that governments, state and federal, have a heavy hand in determining who gets birth control, what kind they get, and where they get it, and how much they pay for it. The states with the least access to family planning have the highest rates of unplanned pregnancies and the highest rates of maternal deaths. On the other hand, the states that offer women and families the greatest access to family planning do better.
This year, the state of Utah took a step in the direction of making contraception easier to get and more affordable for some women. Firstly, Utah now joins a few other states, including California, Oregon, and Colorado, in allowing women to get their birth control prescription renewed and refilled by a pharmacist. One factor in women having gaps in their contraceptive coverage is when their prescription runs out. They may have to go back and see the doctor or the nurse practitioner. This can be time-consuming, taking time off work or child care, and can be expensive.
Now, for women who've had a prescription by a licensed provider and the prescriptions can be renewed and refilled by a pharmacist, this makes it more convenient for women to continue on their birth control pills, patches, or rings. Just a few years ago, this idea would not have found favor in the Utah legislature, but the reality that unwanted and unplanned pregnancies are expensive for the state in the case of Medicare, covering the pregnancies and deliveries, and that the knowledge that women who get pregnant who aren't healthy have more expensive pregnancies, as well as more complications for their babies that are born, this got the legislators' attention this time.
The new law, which unanimously, I will say that again, unanimously passed the Utah legislature takes effect May 8th, 2018. Women will need to fill out a form at the pharmacy to assess their risks, and they'll need to check with a clinician every two years instead of every year.
At the same time, the governor also signed a bill to increase coverage for the most effective and expensive forms of reversible contraception. The most effective forms of contraception are long-lasting IUDs and implants. They may last for 3 to 12 years depending on the type, but can be removed at any time and fertility resumes very quickly.
The methods aren't so expensive on a month-to-month basis, but because all of the costs have to be paid upfront, many low-income women can't access these methods. Utah now joins many states and by including a Medicaid waiver to allow low-income women to have access to these methods on their Medicaid. Utah was only one of seven states that didn't have this waiver, and now it joins most of the states in the U.S. Of course, these methods require a trained health professional to place them, and many doctors don't know how. So the next job is to make sure that the many clinicians around the state have the knowledge to counsel women and the skills to provide them.
So Utah is in the forefront with the few, mostly blue states in the first bill that allows pharmacists to renew, for a year, a birth control prescription, and that is great. The state is catching up with most states with the second bill about Medicaid waiver. A great part of this news is that the legislators who wrote these bills that were passed were informed by young professionals at the University of Utah. The first bill was suggested by a pharmacy grad student at the University of Utah, and the second bill was proposed by a legislator who spent a lot of time listening to the rationale and ideas of a group of young clinicians and educators at the U. How great is that?
Wouldn't it be great if every baby born in our pretty, great state could be wanted and planned for by a mother in her best physical, psychological, and financial health at the top of her game in all of her seven domains of health? Did I say that already? It would be really great. And I've said great at least seven times in this broadcast, so I'm really excited.
Ladies, at the end of the day, it's really up to you. But now, it just got a little easier. And thanks for joining us on The Scope.
Having high blood pressure can contribute to miscarriages. Women's expert Dr. Kirtly Paker Jones discusses some important things women should consider about their health before trying to get…
April 26, 2018
Dr. Jones: Most women who were trying to become pregnant and had a miscarriage are eager to try to get pregnant again. What have we learned about how women might prepare for the next try? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is "The Seven Domains of Women's Health" on The Scope.
Announcer: Covering all aspects of women's health, this is "The Seven Domains of Women's Health" with Dr. Kirtly Jones on The Scope.
Dr. Jones: Early pregnancy loss, miscarriage, is pretty common. Rates vary from 15% to 30% depending on the age of the woman and how early a pregnancy is detected. Certainly, we know that some things are associated with higher rates of early miscarriage, such as age of the mom, especially after 40, and poorly controlled diabetes, for example. However, for young women who had one or two miscarriages, are there any new clues about causes or things women can do to increase the chance that the next pregnancy would be healthy and go to term?
Now, early miscarriage has been the focus of a lot of research in the past 15 years as well as the focus of a lot of cultural myths for thousands of years. We hear from our mothers, sisters, and aunties that we should eat this, don't eat that, do this, don't do that. One recommendation that had been around for about 15 years is that low-dose aspirin, a baby aspirin of 81 milligrams, would increase the chances of pregnancy and decrease the risk of miscarriage.
Several years ago, a large randomized trial done here at the University of Utah and in three other centers around the country looked at over 1,000 young women under 40 who are healthy and had a history of 1 or 2 early miscarriages. These women are randomized with baby aspirin and folic acid, or just folic acid, and their next pregnancies were studied very carefully. Overall, they found that the majority of women had successful pregnancies, about 58%, with the next try whether they took the aspirin or not, and aspirin didn't decrease the chance of miscarriage.
Now, this work was reported in 2014, but there have been some other interesting findings from this study and one that was reported recently. Women in this study were mostly white, often overweight, and the average was 29. The average blood pressure was 111/72. Now, that's a nice average blood pressure for young women. But here's what's new.
For every 10 points increase in the diastolic blood pressure, that's the lower number, there was an increase of 18% in the risk of miscarriage. This means that young women with slightly elevated blood pressure but not a diagnosis of hypertension were increased risk of miscarriage. The study in the journal "Hypertension" found no association of blood pressure with the ability to get pregnant or the rate to get pregnant. They controlled for smoking, body mass index, marital status, education, and other factors that are known to be independently related to miscarriage. And that means that the blood pressure alone or with other factors that they couldn't measure is associated with an increased risk of miscarriage.
Now, we know that hypertension before pregnancy is associated with a number of various very serious problems in pregnancy including still birth, pre-eclampsia, pre-term birth, and placental abruption where the placenta prematurely separates from the uterus before the birth of the baby. This finding that even what we might call pre-hypertension, just a medium elevation of blood pressure in young women, is associated with miscarriage is important. So what's the takeaway from this?
First of all, all pregnancy should be started with women in their best emotional, physical, social, and financial health. If you're thinking about getting pregnant, stopping smoking and maintaining a healthy weight are important because both of these conditions are associated with miscarriage, smoking, and being overweight. And if you can get your blood pressure checked before you get pregnant and if the lower number is between 70 and 80, you might consider increasing your exercise, being mindful to manage your stress, and consider a diet lower in salt and higher in vegetables and healthy fats, kind of that Mediterranean diet thing that we've talked a lot on The Scope a lot.
No matter what happens in your pregnancy, these changes are good for your current and long-term health. Of course, if you are hypertensive, with the lower number over 80, you should get your blood pressure under control before pregnancy with diet and exercise, or with medication. This is really important not just for you, but for the new person you hope to grow. And thanks for joining us on The Scope.
A recent British study suggests women who sleep on their back during the third trimester are at higher risk of stillbirth. But, collectively as a department, specialists in high-risk obstetrics at…
March 08, 2018
Dr. Jones: Finding a comfortable position in bed when you're pregnant can be hard. There's just so much of you. But can some sleeping positions be harmful for you and your baby? This is Dr. Kirtly Jones, from Obstetrics and Gynecology at the University of Utah Health, and this is The Scope.
Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: A recent British study suggested that women who sleep on their back in their third trimester of pregnancy are at increased risk of stillbirth. This shouldn't be complicated, but it is. And here in the studio to help us understand the strengths and weaknesses of this study are not one, but three specialists in high-risk pregnancy from the University of Utah, Dr. Martha Monson, Dr. Lauren Theilen, and Dr. Karen Gibbins are here in the studio. Thanks for coming, all three of you. Does that mean you disagree?
Dr. Monson: No, actually.
Dr. Theilen: No. Absolutely not.
Dr. Gibbins: This is a rare circumstance.
Dr. Jones: Well, this is good news. So you all agree that there's some problems here about either sleeping on your back or this study. So let's talk a little bit about that. I actually understand that the entire division, some 15 specialists in high-risk obstetrics have said, "Wait a minute, there's a problem with this study." Let's talk about it. What is stillbirth?
Dr. Theilen: This is Lauren Theilen, and we define stillbirth as the death of a fetus within the womb that happens at or after 20 weeks of pregnancy.
Dr. Jones: Okay. And how often does it happen?
Dr. Gibbins: In the United States, we currently estimate that stillbirth happens in about 1 of every 160 pregnancies. So that comes out to about 26,000 stillbirths in a year.
Dr. Jones: Well, then, what are the causes? I mean, are they all the same cause, or what's going on here?
Dr. Monson: This is Martha Monson here, and there are multiple causes. We can go over that. So problems such as preterm labor and multiple gestations, so this would be like twins or a triplet pregnancy, and placental abruption, so that's when the placenta starts to separate from the uterus prematurely, are thought to cause about one in three stillbirths, especially those that occur before 24 weeks.
Other causes such as placental insufficiency, and this is when there's placental failure that leads to poor baby growth, is thought to be the cause in about one in four stillbirths, especially those that occur after 24 weeks. Of course, there are birth defects or are genetic syndromes, and these are thought to cause about 1 in 10 stillbirths. Infections of the baby, the placenta, or a mother are thought to cause about 1 in 10 stillbirths.
Dr. Jones: So that means about . . . for the unexplained, because if we're talking about the position you're in, it maybe in the unexplained group, that's maybe one in four, one, about a quarter?
Dr. Monson: Yeah, about that, about a quarter of stillbirths.
Dr. Gibbins: One in four or fewer.
Dr. Jones: Or fewer. Okay, so well, then, but the problem if any, if pregnant women sleeping on their back, how many people are we talking about who are sleeping on their back and how did they get this number?
Dr. Gibbins: So that's one of the problems with the way the study was conducted. The best way to find out what is happening during a pregnancy is to collect it when it is happening. However, that's very difficult. So stillbirth is a very rare occurrence, thankfully. And so the way that these researchers collected this data is they asked women to recall how they were sleeping during their pregnancies. And sometimes they asked women to recall this multiple weeks after the stillbirth and the delivery had occurred. So that would be like asking you a month and a half ago, "How did you go to bed that night?"
And so at this point and time, women who've experienced stillbirth, A, they've forgotten, B, they've been searching the internet and any resource they can find for why this horrible thing happened to them, and they have may have seen that some people have a suspicion that sleeping on your back may have caused their stillbirth. Because of being exposed to those ideas out there, they're more likely to report when a researcher asks them, "You know what? I bet I did sleep on my back. I am blaming myself, I'm feeling guilty, I'm wishing I had done something differently, and so I'm going to say I slept on my back."
Dr. Jones: So it's the way the study is conducted and maybe the way the questions that are answered that might affect this statistic of this twice the increased risk. But even if the chance is 1 in 1000 of people who might have been on their back, that's still a tiny number.
Dr. Gibbins: It is still a very tiny number. And when we're talking about making a broad recommendation for all pregnant women, and we're talking about more than 4 million women a year in this country. And just like you are saying, if we're talking about a small percentage of the 26,000 stillbirths in this country, you get down into a few thousand overall that even could be affected by this.
Dr. Jones: Well, I would have to say, if you'd ask me now, now if this was 100 years ago when I was pregnant, I couldn't have told you where I was sleeping. And in the third trimester, you're all over the bed as best your big belly can do. When I made noises, I'm not using the word snoring because it's so unladylike, but if I did make noises when I was pregnant my husband, who's the sleep doctor, would nudge me and then I'd roll into another position. So you're all kind of over the bed. In any given night I might have spent . . . I don't know. So women have heard about the back to sleep business and with their babies . . .
Dr. Gibbins: Correct.
Dr. Jones: . . . and they might be sensitized to their own sleep.
Dr. Monson: And I think that's . . . The Back to Sleep campaign, you know, what Dr. Jones is referring to is the idea that sudden infant death syndrome could be prevented by putting your newborn on their back when they're sleeping as opposed to putting them on their side or their front. And that has been a public health measure with great success. It is very clear that putting your baby to sleep on their back is the right thing to do and will prevent suffocation deaths for these babies. And I think that is exactly why this concept is so appealing. If we had something . . .
Dr. Theilen: Modifiable.
Dr. Monson: . . . modifiable, as "simple" as that sort of behavioral change, that would be wonderful.
Dr. Jones: Right.
Dr. Monson: However, I think it's a reach in this situation.
Dr. Jones: I want to talk a little bit about the biological plausibility. Meaning, somebody did this big study because somebody thought it there might be some biology. And we know that women in their third trimester tend to snore or make noises. And snoring might lead to obstructive sleep, apnea, meaning they're not getting as much oxygen to the baby or themselves. Or, you know, they're sleeping on their big blood supply. So there is a little biological plausibility.
Dr. Theilen: Yeah, absolutely.
Dr. Jones: So we need a study that will actually do a better job. Are we doing that study?
Dr. Gibbins: So yes and no. There is a large multicenter trial that has been completed in the United States looking at approximately 10,000 women during their first pregnancies. And in that study, a subset of those women had very intensive sleep assessments during their pregnancy. And that data has not been fully analyzed and released yet. I'm hopeful that that will shed some light on this issue. Because that data was collected during the pregnancy when women didn't know what outcome they were going to have. So it's more likely to be accurate and predictive.
Dr. Jones: Right. Well, and I'm going to give a shout out to our very own department which helped really lead this sleep assessment with these many, many women. So what's the takeaway for our listeners, pregnant or not pregnant, and bed partners of pregnant women? What should we be telling them?
Dr. Gibbins: I want women to not feel guilty. That's my biggest takeaway. We do not have enough data to say that sleeping on your back leads to stillbirth. At best, I think it may be linked to sleep apnea. And then the sleep apnea, exactly like you were saying, is the cause, not the sleeping on your back. It is hard enough to get pregnant and to sleep well. The stress caused by trying to sleep in a position that is unnatural to you is more likely detrimental in my mind than the act of sleeping on your back.
Dr. Jones: And we all, we've talked about stress in pregnancy and how that's not good for your baby.
Dr. Gibbins: That's not good for your baby.
Dr. Jones: So get a good night's sleep and grow your baby as best you can. And good luck and thank you for joining us on The Scope.
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debunking old wive's tales about sleeping on your back and the health of you baby today on The Scope
Recently, frozen embryos have been in the news with a woman giving birth to an embryo that had been frozen for over 24 years. Not only did the birth break a medical record, it brings up a lot of…
December 28, 2017
Dr. Jones: What do you call a human egg five days after fertilization that's in the freezer? This is Dr. Kirtly Jones from Obstetrics and Gynecology at University of Utah Health, and this is The Scope.
Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: This week in the news was a report of a live birth, of a baby resulting from an embryo, a zygote, preimplantation embryo that has maybe from 8 to 100 cells that was frozen 24 years ago. Reportedly, this is the longest time between freezing and live birth, at least that we know of, at least in the U.S. In reality, this record is going to be broken regularly as the technology which allowed us to freeze early preimplantation embryos became regularly used over 20 years ago. So more and more babies from embryos in long-term storage will be used. We'll be hearing about babies 30 years, 40 years, 50 years from conception and on and on.
Now, for just a little moment, let's step aside into comparative reproductive biology and talk about bears. Bears in winter. Bears and some 100 other animals do something called embryonic diapause. Cool name, huh? Well, I think it's cool. This is a natural process wherein a bear egg gets fertilized by a wandering bear sperm and progresses a few days and then stops growing, pauses through mechanisms we don't understand very well, for months. It just hangs out in the fallopian tube until a bear goes into hibernation, and then the preimplantation embryo implants and grows while a bear is hibernating. The goal is to postpone the birth until the appropriate environmental or metabolic conditions for the animal, in this case, the bear. The bear cubs aren't born until near spring when there will be an abundance of food. These pre-embryos in suspended animation are not frozen. They're in the mother but not growing until later.
By the way, to the best of our knowledge, humans can't really do embryonic diapause in the mother's body, but we can put our embryos in the freezer, probably indefinitely. In the in vitro fertilization world, usually a number of eggs are produced either by the biological mother or by an egg donor and then fertilized. In the U.S., we're trying to decrease the rate of risky twin, triplet, and quad births by putting back only one or two pre-embryos. In the U.S., we offer the chance to freeze the rest of preimplantation embryos, which for the sake of easier, we're just going to call embryos, but they only have about 8 to 100 cells.
Now, these aren't frozen in an ice cube tray in a regular fridge, but are very carefully frozen so as to not make ice crystals in the embryos and kept in liquid nitrogen. There are probably millions of cryo preserved embryos in the world with regulations about what can be done with them differing from country to country. For instance, currently, embryos cannot be frozen in Italy. In the U.S., there aren't really any rules and regulations except that IVF embryo labs must be certified. Being able to freeze unused embryos from an IVF cycle allows couples to have another chance of becoming pregnant or have another baby, or have a lot more babies if they want. But what happens if they don't want, couples who have the family size they want, who get divorced, or who get too old?
In the U.S., we offer couples three options. They can donate the embryos for research. They can thaw the embryos without transferring them to a uterus and the embryos will die, or they can be donated to an embryo bank that allows for embryo adoption. The case of the baby recently born from an embryo created 24 years ago arose from a couple that received the embryo from an anonymous donation to an embryo bank that specializes in embryo donation, the National Embryo Donation Center. This child born to an infertile couple who desperately wanted children is possibly the best outcome for unwanted embryos.
There are issues, however. The genetic parents are anonymous, so it'll be hard for the new parents and baby to know their genetic heritage. Of course, with more and more people choosing to search out their ancestry with genetic testing, children and adults from donor sperm, donor eggs, and donor embryos are finding genetically linked persons and figuring it out on their own. In Great Britain and Australia, there are laws which prohibit anonymous donation of eggs, sperms, and embryos, and the genetic parents must be on file for the child to know about when they turn 18.
In the U.S., advanced reproductive technology is less regulated than in Europe, so the origins of the frozen embryos, the so-called snow babies, can be anonymous. But between the donation of extra embryos from the couple 24 years ago and the so-called adoption of the embryos a year ago, when the embryos were in the bank, who owned them? Who was responsible for them? What was their legal status? Should they even have a legal status? If there are egg banks and sperm banks, what do we think about commercial enterprises that create embryos, you pick the color, ethnic background, whatever, of the genetic egg and sperm donors, and they will make embryos for you for sale? There's a little bit, actually a lot, of the yuck factor going on there for me.
In the end, it's probably a good thing that couples who have excess frozen embryos don't have to destroy them if they don't want to. And it's a good thing that they don't have to use them if they already have the family that they want and want no more children. That means there's a place for an embryo adoption center. It also means that couples who cannot make their own embryos for some reason but want to experience pregnancy and having a baby from birth can do so, but we're still left with some sticky issues like who's responsible for the embryos for quarter of a century, or half a century, or a century who have no legal parents, and what right does the grown person have to know who they are? So in this season of snow and miracle babies, thanks for joining us and the snow babies on The Scope.
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No woman wants an 'unnatural childbirth.' But what is defined as a 'natural' or 'normal' birth? Women's expert Dr. Kirtly Parker Jones talks with a certified nurse…
November 02, 2017
Dr. Jones: Natural child birth, what is that? No woman wants an unnatural birth. But let's talk about normal labor or physiologic labor and how we can support it. This is Dr. Kirtly Jones from obstetrics-gynecology at University of Utah Health and this is The Scope.
Announcer: Covering all aspects of women's health, this is The Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: Today in The Scope studio, we're talking about normal or physiologic birth with Celeste Thomas, a certified nurse midwife and clinical director of birth care health care with the University of Utah College of Nursing. Welcome Celeste. So we all want a normal birth, but humans have these big babies and as a former of OB, all births looked a little risky to me, so let's talk about normal vaginal birth, or you use the word physiologic birth.
Celeste: Yeah, I prefer physiologic, because all birth is normal, right?
Dr. Jones: Yeah. Sort of.
Celeste: I mean, kind of. I mean, for us humans you're right, we do have big brains and so we have to come out sooner than a lot of mammals have to. So let's talk about physiologic birth though, right? Because when we talk about physiologic birth, we're talking about the things that drive birth, which are the hormones.
Dr. Jones: Oh, I'm all about hormones. Go for it.
Celeste: Right? So we're always about hormones at many different parts of our lives. So a lot of this stuff about keeping the room calm or comfortable sounds really nice, right? But it also serves a physiologic end, which is that when hormones are doing what they need to do, then birth runs more smoothly. We know this, because we know that there are things like: prostaglandins, oxytocin, beta endorphins, catecholamines, norepinephrine, epinephrine. All of these things actually build up and change as birth gets nearer, as spontaneous labor gets nearer, and they really serve good purposes. So we know for instance that epinephrine and norepinephrine and cortisol have effects on the fetal brain, pre-labor effects, so things that happen in the brain that are prepping that baby's brain for birth itself.
Dr. Jones: You mean like for getting squeezed?
Celeste: Yeah, for dealing with less oxygen.
Dr. Jones: Wow. I'd always wondered that we aren't weren't born with traumatic brain injury.
Celeste: Yeah. So they have preparations that happen in the fetal brain for dealing with less oxygen, because birth does lead to decreased oxygen for most babies just in the normal process and babies' brains ideally need to withstand that. And we know that there are synthetic versions of things that we use. For instance oxytocin, we will sometimes use a synthetic version called Pitocin, that's in the hospital, but we know also that the synthetic version of oxytocin doesn't necessarily act in the exact same way as naturally occurring oxytocin.
For instance, the synthetic version of oxytocin which causes contractions doesn't easily cross the blood-brain barrier. So this barrier to get into the brain in the same way that naturally occurring oxytocin that comes from the mother does. So there are things about that that are not exactly the same. So I think that the question is, what in the process . . . So sometimes there are ways to kind of safeguard the physiologic process even when things don't go exactly in the way that we were hoping, right, or even when things kind of go differently.
So some of the ways though that we can safeguard that process and allow these hormones to do what they need to do is we can allow labor to begin on its own when we are able to. We can allow labor to begin that way. And that means that we get this pre-labor up regulation in the uterus and allows that uterus to contract more efficiently with the oxytocin. We can get that pre-labor up regulation in the baby's brain as well to withstand decreased oxygen during labor. It also means we want to avoid excessive stress in labor. So a certain amount of stress in labor is normal and can actually beneficial but if that stress reaches a level that is excessive we've seen in a lot of studies that labor can actually shut down.
Dr. Jones: Well, so there's some good reason for that. I mean when you think about how long labors can be in humans. And maybe the tigers are coming or maybe you need to run away. And the fact that you could actually in early labor run away if you were afraid or if you weren't safe or if your baby wasn't safe, you could run away. Maybe it's a hurricane coming. Well, that's a long time to put it off. But we've known in women if they have a big scary thing, their labor can stop and then you end up having to start it up with external hormones and things like that.
Celeste: Absolutely. And sometimes even just going to the hospital, the smells of the hospital, the people talking to you, the bright lights, that can sometimes slow labor down. And we'll see that sometimes when a woman will get to the hospital and her contractions were two minutes apart at home, but now they're 10 minutes apart and kind of sluggish and not really picking up. So keeping the lights low, making sure she has the people around her that feel safe and comfortable to her. Keeping the questions to minimum, just whatever you need to know but not being excessive with that. Making sure that she has access to a doula which is a trained birth support person. Allowing her to move and eat as she needs to. These things are going to decrease those stress hormones and hopefully keep them in that optimal range.
Dr. Jones: Well, so let's back up just a sec, because certainly I could be in clinic and one in five women in the last couple of weeks of pregnancy will say, "Can't you just induce my labor? I just don't want to be pregnant anymore." That's a common . . . now on the one hand some of them say, "No, no, no, I don't want an induction," meaning start the synthetic hormones. But many women assume that doctors want to induce their labor. And maybe they live far away and they're afraid they won't get there on time, or maybe their husband's leaving to be deployed. I mean, there are thousands of reasons, and we've tried to do fewer and fewer inductions. And I think we're really dropping the number of inductions that we're doing. But women ask for it.
Celeste: Yeah, absolutely. I mean it's hard to say . . .
Dr. Jones: I want to tape your comments and say, "Oh no, your baby's brain isn't ready."
Celeste: Yeah. I mean, there are sometimes really good reasons to induce. We have to weigh the risks and benefits. But when we don't have a really good reason to do it, we need to talk with women about what the risks are. So maybe a baby's brain who isn't as primed to go without oxygen, maybe the baby's brain is not going to do us well in labor as the baby whose brain is primed. So it's something to talk about and really discuss with women, and let them know about the research that we have and the outcomes. They're better for spontaneous labor.
Dr. Jones: Well also women are given this due date which, not necessarily your patients, but mine used to think it was their God-given right to deliver by their due date, and so I'd say, "Here's an approximation. Here's your due date, but it could be a couple weeks on either side. So don't start counting down until it's a week or two after this date that we've given you."
Celeste: I almost feel that we kind of give women a disservice, by not giving them a range and just saying, "You could have your baby between this and this."
Dr. Jones: Right.
Celeste: And that would be totally normal, right? Dr. Jones: Right. Well, what are other good ways to support physiologic birth?
Celeste: The other things that are really important have to do a lot with the postpartum period. So when babies come out, making sure that as little as possible there is as little disruption to the process of baby being on the mother's skin as possible. And this is really interesting too because there are things about that postpartum period that we kind of tend to rush in the hospital. And I'm saying this because I've seen it and I've done it too. Where it's like, that baby is on her chest and it's kind of bobbing around and you're just like, "Baby go to the breast. It's over there." But it takes baby a while to get there.
Dr. Jones: But baby's got a headache.
Celeste: And sometimes baby has a headache. But that, it's interesting in the studies looking at babies who bob and are kind of looking around and don't necessarily get the breast in their mouth yet.
The mother's oxytocin goes much high than babies who are just latched on right away. So there seems to be some reason why these things are happening, so as much as possible to kind of watch for those danger signs of course and make sure mom's not bleeding too much or doing those things. But really allowing mom and baby in that little ecosystem, right? That's really important to a baby survival, allowing that to happen.
And the really interesting thing about these things is that, let's say you end up with a C-section. Well guess what? There's physiologic things we can support even in a C-section. We can allow skin to skin. We've been doing that in the operating room, right? So you can do skin to skin. There's a lot of studies now going on with the vaginal microbes.
Dr. Jones: Oh, we did a study. Listeners, you can actually tune in on that.
Celeste: Yeah. So again, there's a lot of stuff we don't know, but there's a lot of things that we can see physiologically that happen in nature that we can try to really safeguard.
Dr. Jones: Yeah. Well I always liked doing deliveries in the almost dark and especially after the baby was born, to turn off the lights so the mom and the baby aren't squinting. The poor baby, the lights are too bright. All I need is a spot at the other end so I can make sure the bleeding isn't happening and get the placenta delivered and let the mom and the baby be in the dark and quiet. And it gives me a chance for my blood pressure to come down as well, as the deliverer, so until the baby is out my blood pressure is up. So I like the dark.
Celeste: Yeah. Absolutely, and I tend to do a kind of mindfulness exercise when I'm even in that second stage when she is pushing, so I really feel my feet on the ground, I want to stay really present, I don't want to get too anxious, want to kind of create that space for her. But also be vigilant, of course.
Dr. Jones: The other thing is that I've often seen and I can't say I've participated because I'm not a yelling person. But when women are pushing and people want them to push firmly, although I don't think there's any evidence that they have to push hard. The body will make them push hard. But they start yelling at someone to push. And you see this on TV. "Push, push." And I'd rather be sweet talked. So talk about your own practice in this regard.
Celeste: Well, think about it. I mean, in the physiology about birth, they actually call it the fetal ejection reflex. So in some ways it's like a reflex, in that when the baby's head reaches a certain point, you will push, and if you can feel it, you will push. So especially with a woman who doesn't have an epidural, you don't need to . . .
Dr. Jones: It's uncontrollable.
Celeste: Yeah, it's uncontrollable. If you have a woman with an epidural, they do some times need a little more guidance, but again, they'll get the hang of it. And really having to direct them in pushing, there's no evidence that that is beneficial.
Dr. Jones: I just don't think it's beneficial at 60 decibels or 80 decibels. I think you could probably coach someone. But when you watch it on TV, they're kind of yelling at the mom to push, and can't you sweet talk that baby out?
Celeste: Yeah, and it's a less like a sport and more like a bowel movement than anything else, right? I mean it's like there is a certain amount of . . .
Dr. Jones: We'll hold that thought. Let's just hold that thought. Well as we put things together, I want to briefly talk about home births and the safety of home births and some studies from Europe and compare the European experience with the American experience.
Celeste: Yeah. Absolutely. So there's been a number of studies on out of hospital birth, especially home birth in the Netherlands, in the United Kingdom for low risk women. And this is an option that's completely integrated into their health system, meaning these are midwives who work with the National Health Service. They have a set criteria of risk that they look at to see if someone is eligible for an out of hospital birth and they have set criteria for transferring when they need to.
Dr. Jones: And the transfer time is short. They're not a hundred miles from the hospital.
Celeste: Yeah. They actually have to be within about 15 minutes I think it is. So in that scenario, home birth can be a really safe option for low risk women. If you look here in the United States, we have a different health system. It's not comprehensive. It can be rather fractured. And so this ability to kind of transfer seamlessly into the hospital when you're having a home birth is not as smooth. And so there are some challenges that way. When you look at outcomes you can see that Cesarean rate for low risk women is lower when they are out of the hospital. And that's true regardless of if it's a birth center or if it's a home birth. The Cesarean rate is lower for low risk women than low risk women who are having their babies in the hospital.
Dr. Jones: Right, and that the women who aren't transferred. And clearly when get transferred the story is over in terms of . . .
Celeste: But you still need to follow those women, those transferred women, and that's something we're actually doing here in the state of Utah, is that we are now capturing the women who transferred in to see what are their outcomes like? And to be expected, the outcomes are not as good, right? If you transfer.
Dr. Jones: Right. But once you've gone from low risk to high risk at home, then that ends up being a bigger problem than going from low risk to high risk in the hospital.
Dr. Jones: But birth is a physiologic phenomenon and there are many, many of us on the planet, so we must be doing it pretty well. Even though the stories from 150 years ago are heartbreaking with the number of moms and babies that we lost, I think that we really do very well in various settings with people who are informed and supported. The biggest issue is supported. And we all want the safest and most comfortable birthing experiences for mom and we offer options that let women make some choices in their birthing experience. And thanks for joining us on The Scope.
Announcer: Want The Scope delivered straight to your inbox? Enter your e-mail address at thescoperadio.com and click "Sign me up" for updates on our latest episodes. The Scope Radio is a production of University of Utah Health Sciences.
Join Erin Clark, MD and Amy-Rose White, LCSW in a discussion on Postpatrum Post-Traumatic Stress Disorder during a Pregnancy Care ECHO session from Friday, October 6, 2017.
Midwives play an important role in the birthing experience, should a pregnant woman choose to have a midwife. Dr. Kirtly Parker Jones speaks with certified nurse midwife Celeste Thomas about the…
October 19, 2017
Dr. Jones: "I don't know nothin' about birthin' babies, Miss Scarlett." That is something no mother should ever hear, except on the big screen. Trained midwives have helped women and their babies safely through birth for a long time here in the West. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Health. No, it's not "Gone With The Wind."
Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: Building on the rich tradition of midwifery in the intermountain west, the Certified Nurse Midwifery program at the University of Utah is one of the top 10 programs in the U.S. Certified nurse midwives at the University of Utah help women with their choices in their birthing experience. Today in the Scope studio we're talking with Celeste Thomas, a certified nurse midwife and Clinical Director of Birth Care Healthcare at the University of Utah College of Nursing. Welcome, Celeste.
Celeste: Thank you so much.
Dr. Jones: So are there other kinds of midwives who practice in Utah?
Celeste: Yeah, so there are three types of midwives here in Utah. I am a certified nurse midwife, so I have gone through a master's or doctoral program after becoming a registered nurse to become a certified nurse midwife, and that's similar to a nurse practitioner.
And there are also midwives who are licensed by the state of Utah that are called licensed direct entry midwives. These are midwives that primarily do out of hospital births, so that would be home and birth center births. And they are also licensed by the State of Utah, and they usually go through an educational program but can also do a portfolio-based apprentice program as well in order to sit for their board exams. And then there are midwives who are not licensed in the state of Utah, and Utah allows midwives to practice even if they are not licensed. It's one of the few states that does that.
Dr. Jones: So your training, as you mentioned, was you had an undergraduate degree and then you got a nursing, an RN.
Celeste: I got an RN.
Dr. Jones: And then a special extra three or four or five or however many years it might be with a lot of hands-on training. I'd see the midwives in our program on labor and delivery at the U pretty frequently.
Celeste: Yeah, and a lot of their training is hands on. About half, 50% of their training is hands on and the other 50% is didactic or in the classroom.
Dr. Jones: Well, let's talk about that hands-on part. There are some aspects of the natural birth experience that women are kind of afraid of. Many women are worried about their bottoms. Getting a baby through there's no small task, and they might be choosing a midwife for many reasons, but one might be that they don't want an episiotomy, a cut that makes their vaginal opening a little larger. Now as we OBs don't commonly do episiotomy for a normal vaginal birth, but even we think that midwives might have a knack for getting the baby out without a tear. What is your magic?
Celeste: Oh, well, it's not magic. It's research.
Dr. Jones: Okay. Tell me about the research. You mean, you don't pass it down from midwife to midwife for the last 300 years?
Celeste: Well, it is very interesting. Maybe 20 years ago a lot of OBs were still doing episiotomies, and as the research came around to show that that was really not helpful to keeping that perineum, which is that skin between the vagina and the anus intact, that really has fallen out of favor and it's pretty rare to find an OB nowadays who does an episiotomy. Now as midwives, we rarely did episitomies, so we just kept rarely doing them and that's worked for us.
Dr. Jones: Oh. That was your knack?
Celeste: But the other things that we know about keeping the perineum intact, there are some things that we know in the research do work. So one is perineal massage. So this sounds really lovely, like massage.
Dr. Jones: Well, it sounds a little X-rated.
Celeste: It might. It really is gentle stretching. And doing that before you go into labor in the studies has been shown to decrease the number of tears, especially for moms who are having a baby for the first time.
Dr. Jones: So moms do it at home?
Celeste: Moms do it at home and with their partner. This does not have to be done by a health provider. So starting at 35 weeks and they only have to do it about once or twice a week. It doesn't have to be all the time in order for it to have the benefit.
Dr. Jones: Oh, well, that's good news.
Celeste: Yeah, so that's something kind of easy they can do.
Dr. Jones: Well, when you think about how much stretching actually, and often it happens over a period of just maybe 15 or 20 minutes. And for someone who hasn't had a baby to see where they are before and then see what has to happen, you're amazed that that tissue can stretch so easily and then come back to its almost before state.
Celeste: It's pretty miraculous, but we like to help it out if you're a first-time mom. And the research is pretty strong on that one too.
Dr. Jones: Okay, now let's talk about water birth. What is that?
Celeste: Well, water birth, it has been getting more popular recently, and really women laboring in water is the thing that seems to be supported in the research. So we know from the research that women who labor in the water have shorter labors. They have less need for any medications or an epidural, and they have greater satisfaction and greater mobility to be able to move, because as you know when you have a baby inside you, it can be difficult to kind of get into certain positions, right? It's hard enough just tying your own shoe.
So being able to move in the water is really lovely. And for a lot of women who don't want to use medication, being in the water during labor is really beneficial. The question is then when the baby comes out, is there a benefit to being under water? And from what we can see in the research there is no benefit.
Dr. Jones: But there's no harm either?
Celeste: For low-risk women, we don't have a lot of evidence, but from what we have there doesn't seem to be a lot of harm. We have a study ongoing here at the University of Utah about water births specifically to look at potential harms. But yes, it is a good option as far as we know for low-risk women, and a lot of women just don't want to get out in that really intense moment when the baby's head is kind of maximally stretching things.
Dr. Jones: How deep is the tub?
Celeste: So the tub in order for it to have its benefit needs to be at least 27 inches deep.
Dr. Jones: I would think it'd have to be deeper if you really want to have some buoyancy.
Celeste: You have to at least be immersed usually up to your chest in order to have those benefits.
Dr. Jones: Okay. Now the next question is, do you have to come as the midwife in your bathing togs, or do you have to just get your scrubs right in there or you just bend over and get back pain? How do you get in there?
Celeste: This is a good question. So body mechanics is important. The thing to remember is that you don't have to support the baby's body in the same way as you do when baby's born with gravity. So when you have a woman who's delivering, it's important to be able to get to the baby if you need to, but you're watching for that baby and you really are not doing a lot of hands-on in that moment when the baby's coming out. You just need to be able to reach the baby and bring the baby up above the water when the baby comes out.
Dr. Jones: Well, I was thinking again, if we go back to the episiotomy question when we are delivering a woman in a bed, this is OBs, we're careful to kind of support the head and make sure it doesn't come out too fast and gentle the head out. But that's kind of a low position to be in in the tub.
Celeste: Which is why we don't get into that position in the tub. It's pretty hard to get there, and depending on the mom's position. We do try to coach her through that crowning process so that she does it nice and slowly.
Dr. Jones: Crowning, when the baby's head is just about to be born but isn't it quite born yet.
Celeste: Yes. But in general she is letting the baby out, and then we are bringing the baby up to the surface when baby comes out.
Dr. Jones: Okay. But you don't get to have an epidural in the tub?
Celeste: No epidurals in the tub, no.
Dr. Jones: Okay. No narcotics in the tub?
Celeste: No narcotics in the tub because of the risk of dizziness. And currently at the University of Utah we also don't allow people to have nitrous gas also in the tub because of that risk of dizziness.
Dr. Jones: Right, right. Well, we have tubs at the U.
Celeste: We do. We have four rooms with tubs, but only one of them is technically deep enough to push your baby out under water. But you can absolutely use them . . .
Dr. Jones: For laboring.
Celeste: . . . and sit in the tub for labor, and that really is where the benefits come from.
Dr. Jones: Right. So getting back briefly to certified nurse-midwives, you primarily practice inside the hospital but create an environment which we'll talk about a little bit more that you think is as homey as you can be, given that you're close to all the other things that a hospital can offer.
Celeste: Yeah, so the majority of certified nurse-midwives give birth in hospitals, but there are certified nurse-midwives who do home birth and birth center births as well. We can catch a baby anywhere.
Dr. Jones: Oh, you can catch a baby anywhere. I'm glad to hear that.
Well, so whether you choose a physician, a certified nurse midwife, or a team of both, because sometimes people have complications, they need the entire team to be with them. For your OB care and delivery, our goal is to provide the safest and most comfortable passage for moms and their babies through pregnancy and birth. And thanks for joining us on The Scope. Thanks, Celeste.
Celeste: Thank you.
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