Notes - Expecting Better

May 23, 2024

Chapter 1: Prep Work

Some pregnancies are planned, some are a surprise. If you're trying to conceive, before getting pregnant it's important to get your body ready. This involves taking prenatal vitamins, specifically folic acid. Studies have shown that babies born to mothers who took folic acid had a lower incidence of birth defects.

Another thing women need to know in order to get pregnant is when they ovulate. Doctors often recommend using an ovulation predictor kit. However, a cheaper, though slightly less effective, option is to chart your basal body temperature. Ovulation predictor kits are about 99% accurate, while temperature charting correctly identifies the day of ovulation about 40% of the time, but can narrow the fertile window to 6 days about 70% of the time.

While there's a lot of advice about when to have sex during the fertile period, the best time is the day you ovulate.. The highest probability of getting pregnant is from sex on the day of ovulation, about a 30% chance. This decreases to about a 10% chance two days before ovulation, 5% three days before, and less than 1% four days before.

Chapter 2: Data-Driven Conception

When making decisions during pregnancy, many women find themselves frustrated by the lack of data-based evidence from medical professionals to back up their recommendations. This is especially true given the conflicting information and opinions about these recommendations readily available on the internet.

One of the most common things women get advice on is alcohol, caffeine, and tobacco consumption during pregnancy. There are many recommendations that differ between countries, medical professionals, and even books.

While advice may vary about moderate consumption of alcohol and caffeine, the advice regarding tobacco is clear - don't smoke. Nicotine replacement therapy is a safe and effective way for pregnant women to quit smoking.

Chapter 3: The Two-Week Wait

The two-week wait refers to the time between ovulation and when you can take a home pregnancy test. During these two weeks, after the egg is fertilized it must travel to the uterus and implant. The chance of the egg implanting is between 30% and 50%.

Once implanted, the egg begins producing hormones, which are what home pregnancy tests detect in your urine. If your period is late and you get a negative test, you should wait a few days and test again, as hormone levels may not be high enough to be detected yet.

Many women are anxious about the possibility of miscarriage during this time. The risk of miscarriage is highest in the first trimester but decreases as the pregnancy progresses. One study found that miscarriage rates are lower for women who experience nausea than those who do not.

Chapter 4: The Vices: Caffeine, Alcohol, and Tobacco

There is plenty of information available on the internet about pregnancy, but much of this information is based on opinions, personal anecdotes, or faulty science. Making good decisions during pregnancy, like many other areas of life, is about having all the information about the possible outcomes of those decisions and then weighing those pluses and minuses to come to a decision that works best for you.

There is a lot of conflicting and confusing information about caffeine, alcohol, and tobacco consumption during pregnancy. Doctors and other medical professionals often err on the side of caution and give recommendations that are overly restrictive.

However, data overwhelmingly show that light drinking and caffeine consumption are fine during pregnancy. Light drinking is considered up to 1 drink a day in the second and third trimester and a couple of drinks a week in the first. Studies find that light drinking during pregnancy has no negative impact on a child's IQ or long-term behavior.

Moderate caffeine consumption, between 3 and 4 cups of coffee per day, is also fine during pregnancy. Some studies have found that women who drink coffee during pregnancy, up to 4 cups per day, have lower rates of miscarriage than those who don't.

While moderate caffeine and alcohol consumption are fine, heavy drinking during pregnancy can cause serious cognitive deficits and birth defects in babies. And even moderate smoking is not okay.

Chapter 5: Miscarriage Fears

Miscarriage is often thought of as something that happens early in pregnancy. However, there are two types of miscarriages: chemical and clinical. A chemical miscarriage occurs in the first 5 weeks after conception. A clinical miscarriage happens after 6 weeks of pregnancy, when a doctor can see evidence of pregnancy on an ultrasound. After a normal ultrasound at 6 weeks of pregnancy, the miscarriage rate is between 6% and 10%. After 8 weeks, the miscarriage rate is around 2%. And at 12 weeks, the miscarriage rate is only about 1%.

Even after 12 weeks, the miscarriage rate continues to decrease, though at a slower rate. So, while waiting to announce a pregnancy until after the first trimester is a common practice, biologically there is no significant decrease in the miscarriage risk at 12 weeks.

Chapter 6: Beware of Deli Meats!

Most pregnancy food restrictions exist because of concerns about contamination. These bacteria can cause severe illness in pregnant women and, in some cases, can be passed on to the baby through the placenta, potentially causing birth defects or even death.

Listeria is the biggest concern because it can grow in refrigerated temperatures. This is why pregnant women should avoid deli meat unless it's heated until steaming.

Pregnant women should also avoid foods that may be contaminated with toxoplasmosis, which can be found in undercooked meat and unwashed vegetables, as well as cat litter and garden soil.

Raw eggs should also be avoided because they can be contaminated with salmonella.

Chapter 7: Nausea and My Mother-in-law

Nausea and vomiting during pregnancy, often called morning sickness, is one of the most common symptoms. It typically begins around 6 weeks of pregnancy and resolves by about 13 or 14 weeks. While morning sickness is incredibly common, it usually only involves a few days of actual vomiting.

There are several treatment options for morning sickness, including vitamin B6 and anti-nausea medications, though the evidence for the effectiveness of these treatments is mixed.

Hyperemesis gravidarum is a severe form of morning sickness that involves frequent vomiting, dehydration, and weight loss. This condition is rare and can be dangerous for both the mother and the baby.

Chapter 8: Prenatal Screening and Testing

The goal of prenatal screening and testing is to determine if the fetus has a chromosomal abnormality. Most chromosomal abnormalities are caused by having three copies of a chromosome instead of two.

There are two types of prenatal screening: noninvasive and invasive. Noninvasive screening, which uses a blood test or an ultrasound, can determine the probability that a fetus has a chromosomal abnormality, like Down syndrome. However, it can't say for sure if the fetus has the abnormality.

Invasive testing, which uses a needle inserted into the uterus, provides more definitive information about whether or not a fetus has a chromosomal abnormality. However, invasive testing also carries a small risk of miscarriage.

There are two types of invasive tests:

Chapter 9: The Surprising Perils of Gardening

Toxoplasmosis is a parasitic disease that can be transmitted to humans through contact with contaminated cat feces. Toxoplasmosis can also be found in contaminated garden soil. Pregnant women should wear gloves while gardening and wash their hands thoroughly after gardening to minimize the risk of infection.

Chapter 10: Eating for Two? You Wish

While many women are told they're "eating for two" during pregnancy, this is something of a myth. Most women only need about 300 extra calories per day.

The Institute of Medicine (IOM) issues guidelines for weight gain during pregnancy, and there is a lot of pressure on women to adhere to these guidelines. However, these guidelines can be confusing and unnecessarily stressful.

The IOM recommends that women with a normal BMI gain between 25 and 35 pounds during pregnancy. Women with a BMI in the overweight range should aim to gain between 15 and 25 pounds. And women who are obese should gain no more than 15 pounds.

Weight gain in excess of the recommended amount has been linked to larger babies and postpartum weight retention. Babies born to mothers who gained less than the recommended amount were more likely to be small for gestational age.

Chapter 11: Pink and Blue

Many women wonder if they can learn the sex of their baby before the 20-week anatomy ultrasound. There are several methods available, though the evidence for their effectiveness is mixed.

One study found that the fetal heart rate was slightly different for males and females, but this difference is too small to be used to reliably predict the sex of the baby. Other methods, like looking at the position of the placenta on an early ultrasound, also lack scientific support.

Blood tests that isolate fetal DNA from the mother's blood can be used to determine the sex of the baby with high accuracy, but these tests are expensive and not routinely covered by insurance.

Chapter 12: Working Out and Resting Up

Exercise during pregnancy can help reduce stress, improve sleep, and prepare your body for labor. It can also help reduce excessive weight gain during pregnancy.

However, there are some exercises that pregnant women should avoid, like contact sports and activities with a high risk of falling.

Kegel exercises are a type of pelvic floor exercise that can help prevent urinary incontinence during and after pregnancy. They may also make pushing during labor easier.

Pregnant women should also be careful about getting overheated. Activities like hot yoga or spending time in hot tubs should be avoided.

Chapter 13: Drug Safety

The FDA has a classification system for drugs during pregnancy that categorizes them based on their safety for the fetus.

Categories A, B, and C are considered safe to use during pregnancy, as there's no strong evidence of harm to the fetus. The difference between these categories is the amount of research that has been done.

Categories D and X are contraindicated in pregnancy due to evidence of harm to the fetus.

Category C drugs are the most difficult to assess as there is mixed evidence about their safety. In these cases, it's best to talk to your doctor and weigh the risks and benefits of taking the medication.

Chapter 14: Premature Birth (and the Dangers of Bed Rest)

A baby born before 37 weeks of pregnancy is considered premature. The earlier a baby is born, the higher the risk of complications, including death. Babies born prematurely are also at a higher risk for disabilities, like cerebral palsy and intellectual disabilities.

If a woman goes into labor prematurely, doctors may try to delay delivery using tocolytic drugs. This delay gives time for steroids to be administered to the mother, which can help speed up fetal lung development.

Despite its common use, there's no evidence that bed rest is effective at preventing or delaying preterm labor. In fact, bed rest can actually increase the risk of complications for the mother, including blood clots and muscle atrophy.

Chapter 15: High-Risk Pregnancy

High-risk pregnancy refers to any pregnancy that has an increased risk of complications for the mother or the baby. These complications may be related to maternal health, fetal health, or placental problems. It is important to talk to your doctor to understand the specific risks and treatment options for your particular situation.

Chapter 16: I'm Going to Be Pregnant Forever, Right?

While many women feel like they'll be pregnant forever, for most women, the average pregnancy lasts about 39 weeks. Only about 10% of pregnancies last longer than 41 weeks. There's a lot of anxiety surrounding the due date, but the timing of labor can vary greatly.

Chapter 17: Labor Induction

Labor induction is the process of artificially starting labor. There are several methods of induction, including:

There are a few reasons a doctor might recommend induction, including:

Chapter 18: The Labor Numbers

The first stage of labor, which involves the dilation of the cervix, can last for days. However, the active phase of labor, which begins when the cervix is about 3 centimeters dilated, is usually much shorter..

Friedman's Curve, which was developed in the 1950s, was the standard for labor progression, stating that most women dilate at a rate of about 1 centimeter per hour. However, more recent research has shown that this rate of dilation is too optimistic, and many labors progress more slowly.

Chapter 19: To Epidural or Not to Epidural?

An epidural is a type of pain relief that numbs the lower half of the body. It is highly effective at reducing pain during labor. However, it can also have some side effects, including:

Chapter 20: Beyond Pain Relief

Continuous fetal monitoring is the practice of continuously monitoring the baby's heart rate during labor. This is often done using an electronic fetal monitor (EFM). While it may seem like more information is always better, continuous monitoring can actually lead to unnecessary interventions, including C-sections. Intermittent monitoring, which involves checking the baby's heart rate periodically, is just as effective at identifying babies who are in distress and is associated with fewer interventions.

Some women choose to create a birth plan, which is a document that outlines their preferences for labor and delivery. However, it's important to remember that labor is unpredictable, and things don't always go according to plan.

Chapter 21: The Aftermath

After the baby is born, the doctor will clamp and cut the umbilical cord. Delayed cord clamping, which involves waiting a few minutes before clamping the cord, has been shown to have benefits for both the mother and the baby. These benefits include higher iron levels for the baby and a decreased risk of postpartum hemorrhage for the mother.

It's standard practice to give babies a vitamin K shot after birth. Vitamin K is essential for blood clotting, and a deficiency can lead to serious bleeding problems.

Chapter 22: Home Birth: Progressive or Regressive? And Who Cleans the Tub?

Home birth is becoming increasingly popular in the United States. There are several potential benefits to home birth:

However, there are also some risks associated with home birth:

If you're considering a home birth, it's important to choose a qualified and experienced midwife. Certified Nurse-Midwives (CNMs) are the most highly trained type of midwife and are best equipped to handle any complications that may arise.