Northwest Health | Spring 2004 By Julia Coffey

Women give birth to babies every day — and most of the time pregnancy and birth proceed without complication. But that doesn't stop parents-to-be from worrying: Are we ready for parenthood? Eating right for the baby? Exercising too much? Should we use a midwife? Try natural birth? What if the baby is premature?

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It's little wonder that Amazon.com lists 24,000 books on pregnancy alone. Yet, even with all that published advice, one new mom says, "You can't get too much information when you're pregnant — especially since every woman's experience is different." Here then are some helpful suggestions and stories from the frontlines — Group Health caregivers and parents who know both the joy and the trepidation of bringing a new life into the world.

Which Practitioner Is Right for Me?
One of the first choices a pregnant woman faces is choosing a caregiver. In addition to obstetricians/gynecologists, many family physicians care for pregnant women and deliver babies. Midwives continue to grow in popularity, with the number of births attended by certified nurse-midwives (CNM) doubling in the past decade. CNMs are registered nurses with midwifery certification. Licensed midwives attend a smaller number of births in the United States — mostly home births — and their training varies, depending on state licensing requirements.

"Women often have misconceptions about what a midwife is," says Jennifer Gastineau, a certified nurse-midwife at Group Health's Eastside Midwifery Services in Redmond. "They think it means having their baby at home, without pain medication, and with lower-quality care. That's not true. We perform all our deliveries at the hospital, prescribe pain medication, and have the same statistical outcomes as physicians."

The biggest difference between physicians and nurse-midwives, she says, is that nurse-midwives focus solely on pregnant women. "When a woman is in labor, we're able to be with her more than a physician is. Laboring women feel safe and supported, which can make for faster labors and fewer cesareans."

"A nurse-midwife offers excellent care to low-risk women," says MaryBeth Hasselquist, MD, obstetrician/ gynecologist at Group Health's Capitol Hill Campus in Seattle. "They tend to have more time for prenatal appointments, and are extremely supportive and nurturing. I think women who choose midwives tend to view pregnancy, labor, and delivery as a normal part of life and not as a medical problem."

This straightforward attitude may be why Mary Clogston was so calm during the birth of her daughter Alice, even though she was five weeks early. Alice stayed in the Special Care Nursery for about two weeks due to jaundice and dehydration, and Clogston was allowed to stay in an unoccupied room in Family Beginnings, Group Health's Capitol Hill birthing center, so she could breastfeed her daughter.

"They were such warm and caring people," she says of the four midwives who helped her during her pregnancy and birth. "They would always ask me how I was feeling, not only physically but psychologically. You just love your midwives by the time you're done."

"The biggest benefit of having a nurse-midwife at Group Health is that you get the best of both worlds," says Gastineau. "You get all the focused attention and one-on-one time with the midwives, and the whole safety net of delivering in a hospital with physician backup."

For a potential high-risk pregnancy, which includes women with diabetes, high blood pressure, chronic illness, or those who have had a C-section, it's best to see an Ob/Gyn, says Diane Dakin, MD, family physician at Olympia Medical Center. "If all is normal, see a family doc or nurse-midwife. We like to care for pregnant women because not only is doing obstetrics fun, it's a good way to bond with the entire family and follow the children throughout childhood." Dr. Dakin has delivered 900 babies to date and is still seeing the first baby she delivered.

Kate Berens, who had her first child, Lily, in September, chose family physician Barbara Detering, MD, Capitol Hill Family Health Center, for that reason. "I wanted a family doctor as opposed to an Ob/Gyn or group of midwives so I could see someone consistently before and after birth," she says. "Now Dr. Detering does Lily's well-baby checkups."

Which Tests Are Really Necessary?
At their initial visit, pregnant women get a panel of tests to check for anemia, Rh blood type, blood incompatibilities, syphilis, hepatitis B virus, and immunity to German measles and chickenpox. HIV tests are also encouraged. Later in the pregnancy, women are tested for gestational diabetes.

Group Health offers prenatal risk screening for chromosomal problems at 16 to 18 weeks. "There is a fairly high false-positive rate with these screening tests," says Dr. Dakin. "Many times the follow-up amniocentesis will be normal. Any time you do a test, you have to be prepared to get a scary answer. Some people can handle it and some can't. The question is: Is more information beneficial or not?"

Tammy Pedersen experienced a false positive firsthand. Her doctor, David Morrison, MD, an obstetrician/gynecologist at Mid-Columbia Women's Health Specialists in Kennewick, offered her a triple screening test, which includes a measurement of human chorionic gonadotrophin (hCG), a hormone produced by the placenta during pregnancy, as well as estriol and alpha-fetoprotein (AFP), which may detect Down syndrome or open spine defects.

"The test came back positive for something around the Down syndrome," says Pedersen. "When we did an amnio, it came back fine. This experience was very scary. A lot of people elect not to have the triple screen because of the high rate of false positives."

One of the most sensitive methods for predicting fetal health is an amniocentesis, the collection and analysis of an amniotic fluid sample. It tests for chromosomal defects that cause conditions such as Down syndrome, and is offered to Group Health patients over the age of 34 years and those with a family history of genetic problems. The woman and her partner decide whether or not to have the test. "In my practice, most, but not all, of the women in these categories accept the offer for an amnio," says Dr. Hasselquist.

"There is a small risk of losing a baby due to an amnio. Each couple needs to assess whether or not the benefit outweighs the risk of pregnancy loss. If a woman wouldn't terminate under any circumstance whatsoever, then the benefit of an amnio is minimal."

Chorionic villus sampling (CVS), a test done during the latter part of the first trimester of pregnancy, is sometimes done instead of amniocentesis. Like amniocentesis, CVS can identify certain problems with the fetus, such as Tay-Sachs disease and hemophilia, and chromosomal birth defects such as Down syndrome. "The advantage is that the results are back earlier," says Dr. Hasselquist.

Ultrasound is not as accurate as amniocentesis. "The data doesn't show it has any impact on pregnancy outcome," says Dr. Dakin, "but almost all women do it because it's easily accessible, low risk, and helps confirm the due date in case of early labor. In terms of making a huge difference in detecting birth defects, it's not helpful."

How Common Are Complications?
Most pregnancies progress smoothly, and regular prenatal checkups give practitioners the opportunity to catch complications early. "By far the greatest risks are caused by smoking, drinking alcohol, and eating poorly," says Dr. Dakin. "Addressing these things will take care of many major potential problems."

Before conception, all women should take folic acid supplements. Women with diabetes should make sure blood sugar is well-controlled.

Drinking more than three to four cups of coffee per day increases the risk of miscarriage in the first trimester. Dr. Dakin says it's not known whether there may be a slight risk with only one cup of coffee per day. "We're trying to be prudent, even though these risks may be minimal.

"Don't paint a house during pregnancy," she cautions, "stay away from toxic fumes, and avoid medications that may cause defects. I tell people, 'Don't take medications, even for a cold.' You can live with the symptoms of a cold — why risk a birth defect for that?"

Common complications during pregnancy include mild toxemia of pregnancy (high blood pressure), anemia (insufficient red blood cells), and preterm labor (the early onset of uterine contractions). Gestational diabetes develops in some women during pregnancy because their bodies are unable to produce enough insulin to keep blood sugar (glucose) within a range that is safe for a woman and her fetus.

The treatment for a complication may require lifestyle changes or medical intervention. For example, some women with gestational diabetes can control it with diet and exercise; others may need insulin shots.

Morning sickness is one of the most common complaints of pregnancy. But member Ranee Woodall suffered from hyperemesis, a severe form of morning sickness, and became so dehydrated that her body started shutting down. Her doctor, David Chambers, MD, who sees Group Health patients at Ironwood Family Practice in Coeur d' Alene, put her on intravenous fluids immediately and prescribed a strong medication that curbs nausea in chemotherapy patients.

"It didn't totally stop the nausea," says Woodall, "but it slowed down the vomiting and allowed me to carry the pregnancy through to term with a normal delivery. I believe that both my beautiful baby boy and I are alive today because of Dr. Chambers' knowledge."

Can I Be Pain-Free and Alert During Delivery?
Fortunately, a woman today also has plenty of options when it comes to pain management during childbirth. Fifty years ago, women often were knocked out in what was referred to as "twilight sleep," with no memory of the birth. Thirty years ago, drug-free, natural birthing was all the rage. Today, many women are asking for epidurals.

Dr. Dakin was in training during the zenith of natural childbirth. "Unfortunately, fewer women are going natural these days compared to 20 years ago," she says. "Now women are saying, 'Give me an epidural at the first contraction!' At least 60 to 70 percent of the patients where I deliver use epidurals.

"Although I think there's definitely a place for epidurals, and they allow some women to labor comfortably enough to avoid a C-section during a long labor, they can be restrictive. Once the epidural is in, the patient can't walk around or use the bathtub. And every intervention increases the potential for more complications."

There are many non-medication pain-relief choices: a bath or shower, insertion of sterile water into acupressure points on the sacrum (the thick, triangular bone at the lower end of the spinal column), walking around, massage, bouncing on a birthing ball, or sitting in a birthing chair. "Sometimes we'll prescribe a pain medication like Nubane just to take the edge off," says Dr. Dakin, "or to get through a transition."

Kennewick patient Tammy Pedersen braved natural childbirth four years ago with the birth of her first daughter, Paige. But 16 months ago, during the birth of her second daughter, Payton, she opted for an epidural. "Maybe I was smarter," she laughs. "Natural birth was very stressful for me, very painful. I highly recommend getting the pain medication because it allows you to enjoy the delivery more."

Kate Berens chose a combination of medications. "I asked for a narcotic painkiller and an epidural," she says. She also used the immersion tub at Capitol Hill's Family Beginnings birthing center, as well as a birthing ball.

Both Berens and her husband, Mark, were impressed by the overall experience. "It was trouble-free," says Mark. "We wrote a birth plan about what we hoped for and talked with the doctor about our philosophy." Kate wanted to minimize the pain but still experience the birth. "The nurses were great," she says. "When I started to hurt, they said, 'well, let's try the hot tub first,' and then offered help by increments, which was consistent with the way I wanted to approach it."

Getting through labor is a scary thought for many women. Midwife Gastineau hosts a pregnancy discussion group on Group Health's Web site and says that most questions she fields are fear-based. "Women are terrified of labor, so a lot of what we do as midwives is to empower them," she says. "After all, our bodies know what to do. We just need to trust ourselves. Most women will do fine — all they need is reassurance and a little nurturing."

This article was reviewed for accuracy in October 2009.