Birth and Babies

Amniocentesis

An amniocentesis is available for women over 35, for women with a family history of genetic disorders, and for expectant mothers who have had a quad-screen suggesting the possibility of a genetic disorder.   

Amniocentesis diagnoses the possibility of:

• Chromosome problems (such as Downs syndrome)
• Genetic diseases (such as cystic fibrosis, sickle cell disease)
• Neural tube defects (such as spina bifida)

Aside from testing for chromosomal abnormalities or birth defects, an amniocentesis can also test the baby’s lungs to see if they are mature if the mother is showing signs of premature labor, or if the mother will need to be induced early.  The amniocentesis can also determine the sex of the baby. 

How is it done?A needle, guided by ultrasound, is inserted through the abdomen into the amniotic sac to collect fluid surrounding the baby.  The amniotic fluid holds cells shed from the baby, and is an accurate way to test for chromosomal abnormalities and some birth defects.   

Results can be had in about 2-4 weeks, and findings are quite accurate. 

Amniocentesis is not without risk.  It can cause miscarriage in about 1-2 pregnant women out of 200.  There is also an increased risk of infection.

Chorionic Villus Sampling (CVS)

Having a CVS done will diagnose chromosomal abnormalities, such as Downs syndrome, Tay-Sachs disease, cystic fibrosis, or sickle cell anemia.  Because the placental tissue does not include amniotic fluid, some birth defects, such as spina bifida, can not be tested for. 

How is it done?A thin tube, guided by ultrasound, is inserted through the cervix and up to the placenta where a small amount of the placental tissue is removed (B) OR tissue is removed via a needle inserted through the abdomen (A) similar to the amniocentesis.   

This is generally done between 10-12 weeks, and  is available for women who will be 34 years of age or older when they deliver, or for those with a family history of genetic disorders diagnosed by CVS.  The CVS is not routinely available for pregnant women, and a meeting with a genetics councilor is required prior to the procedure.                                                                                                    CVS is considered more risky than the amniocentesis, causing more miscarriages, limb defects, and also carries the risk of infection.  Results can also be confusing to read, requiring more testing to understand the results. CVS is not as accurate as the amniocentesis, but the benefit for some is the chance to learn early in pregnancy that there could be chromosomal abnormalities.

 This test can be done to determine the possibility of your unborn baby a open neural tube defect, Downs syndrome or Trisomy 18

 Remember that no test or procedure is completely accurate when trying to determine if an unborn baby has a genetic defect.  These tests measure the possibility of a open neural tube defect, Downs syndrome or Trisomy 18, and both false negative and positive results do happen. 

The quad screen is generally done between 16-18 weeks, and results can be had in 2-3 days. 

Blood is drawn from the mother, and four specific biochemical markers (alphafeto-protein (AFP), human chorionic gonadotropin (hCG), unconjugated estriol (eC3), and inhibin-A) are measured.  These levels, in addition to other information, can determine the possibility of a disorder.  

What if you get a positive result?If you do have a positive result, if you choose, you can have an ultrasound and/or amniocentesis or CVS done to determine the possibility of a birth defect.  Generally a genetic evaluation will be done prior to further procedures.  

Who takes the test?This test is available for all pregnant women.  Many people will not take the test because the results can be so shaky, and they will not end a pregnancy because of a chance that their baby will have a disorder.  Others will take the test (and further procedures if necessary) to prepare themselves for the possibility, and then others will end the pregnancy.

When your baby is born in a hospital, it seems nearly immediatly the cord is cut and the baby is whisked off to a bassinet sitting under a warmer.  The reason for this is quite simple: your baby is born wet and they are unable to heat themselves when they’re born.  So, a warmer makes sense to keep the baby warm while it’s getting examined, cleaned up, footprinted and swaddled.

A baby will benefit more from skin-to-skin contact with mom though, instead of sitting under a warmer for any length of time.  Moms body, combined with a blanket, will keep the baby wonderfully warm and also comforted because your baby will recognize your smell, enjoy the feeling of your skin, and be soothed by the sound of your voice and heartbeat.

When we had my son born at home I held him close, skin to skin, until his cord stopped pulsing.  We cleaned him up the best we could with a towel and made sure all was well as soon as he was born of course, however the exam didn’t come until later.  Once the cord was cut, I got up to shower and was settled into bed.  My midwives then did the newborn exam, I got the honor of putting his first diaper on (cloth, of course!) and my daughter chose that moment to wake up - as soon as my son was cleaned, examined, swaddled and back in mommy’s arms ready to nurse for the second time (first time we nursed right after birth as I was waiting for the cord to stop pulsing).  My daughters timing was perfect! My son was born at 5:53AM - and I loved being up in labor all night while my daughter was asleep….  But this time, I hope to labor during the day so my daughter can watch the birth. She is so excited!

This measures fundal height, or how much your uterus is growing.  Your uterus is measured from the top (the fundus), to your pubic bone.  Did you ever hear “I’m measuring large for dates” or something similar?  This comment is referring to how many centimeters your uterus has grown past your pubic bone.  Generally, how many weeks pregnant you are should match closely with how high your fundus is (starting at about the 2nd trimester) - if you are 24 weeks, you should measure around 24cm.

Too large of a measurement could indicate twins, a large baby, or other issues such as too much amniotic fluid.  A bigger than average measurement could also just be due to this being a 2nd or more pregnancy, or even your baby’s position - a breech baby sitting high in the uterus will measure large.  Too small of a measurement could indicate that your baby may not be thriving as he or she should, or it could simply be due to your baby’s position.  If your baby is lying sideways, your measurements are sure to be off!

Fundal height is not an accurate way alone to estimate how far along you are or how much your baby is growing, but used in conjunction with other methods it is a “peice of the pie” to make sure things are going well.  Your pattern of measurements should remain consistent to a point - if your measurements were staying average and then your measurements dropped all of a sudden, or if they fluctuate a lot from visit to visit, an ultrasound may be scheduled to rule out any problems.  But there is nothing to worry about if your measurements are “off” by a couple cm - different factors come into play which may not get you textbook measurements at each visit, however if there is a large jump or drop, or your measurements are jumping or dropping in large increments, it is likely that your care provider will want to schedule additional tests and/or an ultrasound to get a bigger picture of your baby’s growth, development, and wellbeing inside your uterus. 

I also want to note that there is no reason to worry if you’re “off” by a few centimeters at your visits.  And you’ll get a smaller measurement when your baby has “dropped” or has become engaged in your pelvis prior to labor. 

Insurance companies and hospital policy limit the amount of time you can have with your OB or hospital-based midwife.  Last I heard, many insurance companies only covered 15 minute appointments - but you rarely get even that much time with your care provider!  Hospitals continue taking in more and more clients which reduces the amount of time your doctor or hospital based midwife can spend with you.  That will carry over into labor and delivery - with fewer and shorter check-ins with the person who will be helping you birth your baby.  This is one reason why it’s great to have someone experienced that you can build a relationship with during your pregnancy, such as a birth doula or labor assistant, who can be with you during your labor and birth so you can have continuous support (for you AND your partner).

People are amazed when they hear my prenatal visits (with my homebirth midwives) are at least an hour long.  This is a common occurance among homebirth and free standing birth center midwives.  No, insurance doesn’t cover homebirth (and rarely birth centers) however you do get the time to bond with the people who will be assisting at the birth, and sharing one of life’s greatest miracles with you!  In return, they get to know you, your desires, those of your partner (yea, they actually involve your partner as much as he wants to be involved.  my husband delivers our babies with a midwife watching - but he wants to be right there and not just standing off on the side waiting to cut the cord). 

I do get amazed when the insurance/homebirth topic comes up.  Homebirths are so much cheaper in comparison to hospital births - think of the money they’d save with the lack of intervention, medication, etc. - only what is needed is done!  I was recently sent a bill for a few months of prenatal care back 2 years ago when I was pregnant with my son (why am I getting a bill in the first place?  two years later??  When my insurance covered it completely?  anyway - being taken care of).  I had started prenatal care at a hospital before my husband and i decided for sure on a homebirth.  Just for 4 prenatal visits, the bill was near $800.  Nothing out of the ordinary, no ultrasound, just those early prenatal visits.  Already we’re near the cost of a homebirth - including all prenatals and continual care by my midwifes during my entire labor, delivery, and a few hours postpartum at my home.  And I don’t have to share them when I’m in labor :-). 

 Imagine there are people out there without insurance, or with insurance but they still have to pay high deductables or copays, having to pay these rates out of pocket for a hospital birth.  Imagine their frusteration when they realise a out of hospital birth could have been cheaper, and it was what they wanted in the first place!  I’ve talked to people like this, and it’s inspired me to bring up this option in every class I teach - I teach to all couples - those desiring a medicated birth, planning a cesarean, or wanting a natural birth.  Homebirthing couples, hospital birthing couples, and birth center birthing couples.  It’s never too late to change care providers, and women need to know their options.  Many times I find couples never even knew homebirth was an option!

Then there is the other side of the coin - people who have insurance but have to pay out of pocket for their births and sometimes the copay/deductible of a hospital birth is far greater than that of an out of hospital birth!  Amazing!

Anyway I guess this is more of a rambling than a “why do they do that” but I’m interested in hearing your thoughts either way.  I don’t cover insurance issues during my classes unless asked, so I don’t know all the details surrounding it.  I’d love to know why insurance won’t cover a homebirth when they’re proven safe.  I can imagine there would be a lot of red tape surrounding that issue though if insurance started covering it, but then women would truley have a choice as far as where they can birth.  For some, the cost of a out of hospital birth is not obtainable (though let me say this - homebirth & freestanding birth center midwives want to see women have the birth they desire.  Many are willing to work out payment plans with low monthly payments, and some will even do bartering).

Why is urine collected at each prenatal visit?
It’s pretty important to give a urine sample (at least 1-2 oz) at each prenatal to help measure the levels of protein, sugar, and possible bacteria in your urine.  My midwives leave the urine testing up to me by having me collect and test my own sample, however if you are at a hospital or health clinic you will be asked to urinate into a small cup and leave it in the bathroom or hand it to a nurse.

Because conditions can change throughout pregnancy, it is important to remember to drink a little extra water before each prenatal, to ensure you can contribute at each appointment

So what is important about protein?  Protein in the urine, or Proteinuria can indicate a UTI, kidney infection or a sign of pre-eclampsia later in pregnancy. 
As for sugar, usually there is no sugar, or very little, in the urine.  When there is sugar present, that can be a sign of gestational diabetes, where excess blood sugar spills into the urine.  Generally pregnant woman are given the option to have a glucose test between 24/28 weeks to test for this.
Bacteria in the urine is a sure sign of an infection.  Left untreated, a UTI can cause significant problems, even if there are no symptoms present. 

Ketones are also tested for.  If high levels are found it can lead to ketoacidosis  Treatment for this is often in a hospital, but your doctor will investigate why the levels are there to begin with – if your eating or drinking is to blame and you are able to keep food down without a problem, hospitalization probably won’t be required.

In hospitals all over the US, umbilical cords are cut right after the baby is born.

In birth centers or at homebirths around the world, typical protocol involves letting the cord stop pulsing before it’s ever clamped and cut.

Why the difference?

First let me clarify - we’ll be talking about vaginal deliveries of full term, healthy infants.  Medical reasons on the part of mother or child may require quick seperation. That being said, these are the babies who need their blood the most, and may undergo more intervention than they would have if they would have gotten all of their blood in the first place.  talk to your doctor before you are in labor about this and ask about emergency protocol - there is a lot that can be done bedside while baby is still attached.

Some may argue that doctors are short on time and as a result, cords need to be clamped and cut right away.  Other silly myths surround this issue including the blood draining out of the baby if you wait to clamp and cut.  Another one is that the baby will get too much blood and jaundice, plethora, hyperviscosity, or polycythemia, etc. (which has been proven false) Still more research tells us to leave the cord alone until there is no activity in it - something many hospitals seem to ignore.

Delayed clamping and cutting actually holds benefits to the baby.

First of all - if the cord is still intact, is not clamped, and is still pulsing, the baby is still getting oxygen.  This is one reason that a baby not breathing directly after birth isn’t a huge emergency - baby is still getting oxygen.  The placenta can continue to “breathe” for the baby for about 5 minutes after birth, giving the baby time to acclimate and “unfold” its lungs before taking that first breath.  The blood contains maternal antibodies, iron and other nutrients that are important for the baby.

The baby is still getting the all-important blood that is actually his or hers to begin with which helps the brain, heart and lungs.  It’s not “extra” blood, “placenta” blood, or even the mother’s blood.  It’s the baby’s blood that happens to be running through an organ within it’s mothers body.

Actually, delaying the cord cutting can actually help mom too - when the placenta is given time to rid it’s self of the blood within, it seperates more easily from the uterus and there is less blood loss for mom!

When the transfer of blood is complete, the cord will collapse and it is safe to cut the cord at that point.  It took about 15-20 minutes when I had my son at home, but it can be longer or shorter in many instances. Most umbilical cords are around 2 feet in length, long enough for mom to hold the baby skin to skin on her chest so the baby doesn’t get cold (in fact, moms body does a better job of keeping baby warm, anyway… forgo the warmer - hold your baby!), mom can even nurse during this time and get aquainted with her baby.

Another clarification: delayed cutting of any time length has it’s benefits.  Whether it’s just a few minutes, or waiting until the cord has stopped pulsing completely.

What are the risks of early cord clamping? Early cord clamping has been shown to cause: newborn anemia, respiratory distress leading to brain damage and/or death (rare, yes, but it happens), inadequate blood supply resulting in a need for transfusion, possible heart defects resulting from problems closing off the hole in the heart valves following birth, and more.  There are also suggestions that the rise in autism is due brain damange resulting from early cord clamping.

There is even the possibility that early cord clamping in Rh- moms causes them to develop blood sensitization in their next pregnancies as a result of the clamp creating a backflow of sorts, of the babys blood into the maternal “wound” create by the placenta as it detaches.

Whew!  Some practitioners are still stuck on the belief that early cord clamping is best and they may not budge… Luckily, there are others out there who will, or who are already doing this.  Whatever you choose, be sure your care provider is someone who shares your beliefs about the type of birth YOU want to have and is willing to help make it happen.  There is nothing worse than having to dread the upcoming birth because you want it to go one way and you know it simply won’t happen, even in the best of circumstances due to “protocol”, staff, care provider or otherwise… 

I thought it would be fun to start a category for common and routine procedures OB’s and midwives do for their clients and explain the reason behind them.

 Such as… Why do we listen to the fetal heartbeat? Why is my uterus measured at every visit?  What is the importance of electronic fetal monitoring? and so on and so forth.

So check back, I plan to have a few up soon!