The Pregnancy, Providers & Procedures Guide : simplebooklet.com

Picture your dream birth. If everything could be perfect and go exactly as youplan...Where are you? Who is there with you? What's the space look like? Whatdo you hear? What do you smell? What comfort measures are you using?Okay, now use that perfect picture to actually make it a reality. The nextseveral pages in this section will guide you as you choose your birthlocation, type of birth, as well as your type of care provider. Each pagehas details about each choice to guide your thinking. 01FIRST DECISIONS GUIDEM O T H E R N A K E D B I R T H

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PHYSIOLOGICAL BIRTHMEDICALLY MANAGEDBIRTHINTERVENTIONSInterventions used only whenmedically indicatedInterventions usedpreemptively without medicalindicationHORMONESAllows for optimal hormonalfunctionCan interfere with optimalhormonal functionBELIEFBirth is a natural event thatSOMETIMES needs medicalinterventions.Birth is a medical event thatshould be under the care of atrained providerPROVIDERTypically under the care of aMidwifeTypically under the care of anObstetricianLOCATIONTypically at home but can alsooccur at a birth centerTypically in the hospitalTYPE OF BIRTH?

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HOMEBIRTH CENTERHOSPITALSAFETYIt's up to you todetermine what issubjectively safe for you. No study has shown thathomebirth is less safe thanhospital birth when momswere screened for high riskcomplications.No study has shown that out ofhospital birth is less safe thanhospital birth when moms werescreened for high risk complications.No study has shown thathospital is more safe thanout of hospital birth forlow risk moms.BELIEFWomen give birth, babies are"delivered" and MOSTdifficulties will resolve on theirown in time or by using lowrisk strategies and techniques.Women give birth, babies are"delivered" and MOST difficulties willresolve on their own in time or byusing low risk strategies andtechniques.Babies are "delivered'and difficulties should beresolved with medicationand interventions.EMERGENCYMost problems can beresolved on site, thoughACOG recommendsmaximum 30 mins from ahospital.Higher transfer rate than homebirth.Most problems can be handled onsite.All treatments to resolveproblems are available onsite.INFECTIONSafest environment in regardsto infection; lowest riskInfection extremely unlikelyHighest risk of infectionAMBIENCEComfort and familiarity ofyour own home with nostrangers.Usually peaceful, intimate, and quiet.Often noisy, lacks privacy,and impersonal withstrangers present.PAIN CONTROLAnesthetics unavailable,though other medical painrelief measures might be. Thecomfort at home reducesstress, anxiety, and pain.Access to bathtub for comfortmeasures.Anesthetics unavailable, thoughother medical pain relief measuresmight be. The comfort at homereduces stress, anxiety, and pain.Access to bathtub for comfortmeasures.Drugs available and oftenused. Other comfortmeasures like showermight be available.DYNAMICIt's your home, You're incharge. Your wants come first.It's someone else's business, thoughthey typically promise individualizedand respectful careInstitutional andbureaucratic. Policies andinsurance dictate careHASSLE FACTORYour family may not supportyour wishes. You might have ahard time getting yourmedical insurance to coveryour provider's fees. IF yourequire a transfer, you mighthave hassle during theadmission processPossibly lesshesitation/discouragement fromfamily members (compared tohomebirth). Insurance typicallycovers these births with no issues, ifyou require a transfer, the wholeprocess is more streamlinedYou might have a hardtime if you wantmidwifery style care or abirth withoutintervention.WHERE DO YOU WANT TO GIVE BIRTH?

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PROSCONSMIDWIFEMore flexible and individualizedcareSupport before interventionUse low-risk strategies tocorrect problemsAttend all birth locationsComplications result in atransfer to a different high riskproviderMight not attend hospital birthMight not be able to performprenatal tests or writeprescriptionsOBGYNCan diagnose and treat seriousbirth and pregnancycomplicationsin emergency situations youwouldn't need to transfer careCan preform cesareansMight pathologize pregnancyand birthHigher risk of interventionsincluding induction andcesareanWon't attend homebirthTYPE OF CARE PROVIDER?The different types of midwives: CNM: Certified Nurse MidwifeCertified Nurse-Midwives are trained in both nursing (RN) and midwifery. Their training is hospital-based, and the vast majority of CNMs practice in clinics and hospitals. Although their training occurs inmedical settings, the scope of practice allows them to provide care in any birth setting. CM: Certified MidwifeCertified Midwives are individuals who have or receive a background in a health related field other thannursing, then graduate from a masters level midwifery education program. They have similar training toCNMs, conform to the same standards as CNMs, but are not required to have the RN. CPM: Certified Professional MidwifeThe CPM is the only midwifery credential that requires knowledge about (and experience in) out-of-hospital settings. Their education and clinical training focuses on providing midwifery model care inhomes and freestanding birth centers. In some states, CPMs may also practice in clinics and doctorsoffices providing well-woman and maternity care. Traditional MidwifeThese are midwives who choose not to become certified or licensed. They believe that they areultimately accountable to the communities they serve; and that midwifery is a social contract betweenthe midwife and client/patient, and should not be legislated at all.

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02Before you get into the questions that you need to ask your care provider, Iwant to make sure you consider the following:NEVER make assumptions about your care provider's philosophy. Do not assume that a female provider is more understanding or supportivethan a male provider and do not assume that all Midwives supportphysiological birth.Do not assume that your provider has your best interest, and do not assumethat because your sister loved thatOBGYN that you will love them too. MAKING SURE YOURPROVIDER IS THE ONEM O T H E R N A K E D B I R T H

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My advice: Interview several providers from several different practices. You can ask your friends andfamily for personal recommendations for care providers, but make sure to also ask them what theyliked and didn't like about the provider. Your sister might have LOVED that her OB scheduled aninduction at 38 weeks before the holidays, and that might be something you're trying to avoid at allcosts... Ask open-ended questions without revealing your personal beliefs. You want your provider to answerthe questions based on their own beliefs, and not have them answer questions in a way that agreeswith yours. We want to avoid the all too common bait-and-switch. You can ALWAYS change providers. If someone is telling you that you cannot, they don't have your bestinterest. You need to feel comfortable putting yourself first, and if that means firing your provider(even late in pregnancy)... do it! Questions to Ask Your ProviderM O T H E R N A K E D B I R T H

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What is the likelihood that you will attend my birth? A lot of practices rotate care providersand cannot guarantee who will attend your birth.How do you support the natural hormones that help my baby and me through labor, birth,breastfeeding, and bonding?What would you say if I gained 50lbs in pregnancy?What medical treatments or monitoring do you regularly use for all women during laborand birth? If a provider recommends medical treatments for all or most women, you maywant to look for someone else.How many ultrasounds do you recommend? The World Health Organization recommendsONE scan before 24 weeks for low-risk pregnancies... that it. How do you handle long labor?What is your policy regarding the routine use of interventions? (electronic fetal monitoring,IV fluids, cervical checks, Pitocin for third stage management)How do you manage the birth of the placenta?Will you honor my right to informed consent? Can I refuse cervical checks?How would you handle my care if I went past 41 weeks? 42 weeks?Do you think the kind of birth I'm hoping for is possible?Do you recommend I hire a doula? Research is very clear that support from a douladecreases negative outcomes. General QuestionsM O T H E R N A K E D B I R T H

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What situations would lead you to transfer my care to an OB during pregnancy?What situations would lead you to transfer me to the hospital during my labor?Do you have a relationship with an OB practice?What would it look like if I transferred to the hospital during my labor, would you comewith me?What medical equipment do you bring to the birth?What kind of postpartum visits do you do?If I transfer to the hospital, would you still do my postpartum visits?Is there a 24-hour anesthesiologist available? A huge advantage to hospital birth(andmaybe the only advantage) is to have these types of services available to you...so if theyaren't available then you might want to reconsider.What is the RN to patient ratio?Can you tell me what the triage process is like?When would you recommend inducing labor?When would you recommend augmenting labor?What are the reasons you would perform a cesarean? How often do you perform cesareans?What do you think makes your cesarean rate so high, when the WHO recommends keepingthat number below 10% or births?How will you help me avoid a cesarean?What percentage of women have an epidural?What are your recommendations for labor positions, and pushing positions?How many people can I have in the room with me? Do I have the right to decline any interventions?What is the process like to sign AMA (against medical advice)?What do you recommend for non-medical pain-coping relief?How often do you attend non-medicated births?Can I keep my baby with me at all times?What procedures are routine for newborn care?What type of support do you offer to breastfeeding moms?How soon can I leave the hospital after birth? What if I want to leave sooner than that?Homebirth SpecificHospital SpecificM O T H E R N A K E D B I R T H

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Follow up on vague answers. If they say "I only do that when necessary," ask them what they would deem as necessary.If they say "it's very case by case basis," ask them to describe some of the different cases for you. "Are they giving me facts or their feelings?" "Are they actually answering my questions or are they avoidant?" "Do I feel dumb when I'm asking them questions?" Understanding and Assessing Your Provider's AnswersAsking your provider questions is only the starting point. Here are some tips to lead you in the rightdirection after you've asked the questions...Don't give them the easy out. Don't let them brush off your questions! Questions you need to ask yourself:If you asked "How often do you perform an episiotomy?" and they responded, "I don't know exactly,but wouldn't you rather have a nice clean cut rather than a tear?"... That is a feeling-based answer. Ifthey responded, "I do them on about 10% of first-time mothers when they've been pushing for overan hour"... That is a fact-based answer.Remember to follow up on the vague answers and don't be afraid to ask them to explain more indepth. Most moms won't keep pushing for actual answers, so they aren't going to be used to apatient like you.Make sure you feel comfortable asking them to explain simple procedures until you understand. Ifyou're not comfortable with them in this type of setting, imagine what it will be like when you're inlabor... It's important to know that these questions are justa starting point and I encourage you to ask manyclarifying follow-up questions. Throughout thiswhole process, do not take their words at facevalue. Examine their mood, attitude, and theenergy in the room. M O T H E R N A K E D B I R T H

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Are they using scare tactics? Are they condescending? Are they ridiculing you? Are they patronizing you? Are they turning your partner against you? Understanding and Assessing Your Provider's AnswersDon't Ignore the Red Flags!Did they say something like, "Would you rather have a good experience or an alive baby?" Or, "Wouldyou rather have a natural birth or a healthy baby?" Or, "We can do that if you don't care that yourbaby might die." These types of statements are scare tactics, and your provider is avoiding level-headed and respectful conversations. Do they treat you like you're stupid? Did they say "I'm the one with the medical degree"? Orstatements like, "Don't you know that women died all the time during birth before doctors?" Yourprovider does not respect that this is YOUR birth and YOU are in charge. Do they brush off your desires? (Especially your desires of a low intervention birth). Did they say, "Ibet you read that on social media."Or, "You want a natural childbirth? Why, broken bones are naturalbut we still give you pain medication for those." You can't expect a provider like this to see you as theultimate authority of your own birth. Do they say things like, "You don't need to learn your options, don't you know I have your bestinterest in mind?" Or, "You could never understand it as well as I do, so why don't I make thedecisions?" These types of statements might seem fine until you get a chance to reflect on them... butthey are NOT signs of a supportive provider. Do they say things like, "I bet your husband can agree that it's best to leave it up to me." Or, "Whatdoes your husband think about your radical preferences?" Or does your doctor turn to your husbandand ask, "Is she this stubborn at home?" M O T H E R N A K E D B I R T H

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03Not only can you fire your care provider at any point during yourpregnancy, but I URGE you to fire them if you aren't receiving qualitycare. A provider who isn't respecting you during pregnancy will notrespect you during birth.Switching providers sounds like it's a huge ordeal, but I promise youthe weight that will be lifted once you find a good provider is well worthany short-term stress. Think of it this way, you're signing up for someshort-term stress in pregnancy in order to find a deeper sense of calmleading up to your birth. FIRING & CHANGINGPROVIDERSM O T H E R N A K E D B R I T H

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Remain calm. Easier said than done, for sure... but staying level-headed is a great way to keep theball in your court when looking for a new provider. Send an email to your old provider canceling future appointments. Tell them that you are switchingyour care and would like them to email you your chart. (Email is a great way to avoid aconfrontation that might put you in a negative emotional space.) When trying to find a new provider, stay positive — as in, don't bash your old provider. Keep theconversation focused on why this new provider is such a great fit. Go into your appointment with your new provider knowing what you want and don’t settle for less.It's amazing how other people can sense your level of confidence, and when you have self-respectand set the bar high, others typically follow suit. Remember that a hospital will NEVER turn away a laboring woman. So, if you're really late in thegame, don't ever fear that you'll be left alone to labor without options. Here are my tips: Changing Providers During PregnancyM O T H E R N A K E D B I R T H

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Talk honestly to your care provider about your situation. Over the years, I've learned that a lot ofmoms don't know that some care provide rs take payment plans and even offer discounted services.You won't know unless you ask and you might be surprised at the answer.Even if they can't offeryou a payment plan, they might be able to pointy ou in the right direction. Switch insurance plans. Most health insurance plans will let you join outside of open enrollment ifyou meet certain criteria. Call and ask! Also, state-run health insurance has generous plans formothers and babies, and in some locations even covers homebirth midwives. Pay for the birth out-of-pocket. This is likely to be several thousand dollars at minimum, but thereare ways to keep the cost down. If you're hoping for a home birth, but can't afford a midwife, it'sreally important to consider the cost (both financial and emotional) of giving birth in a place youdon't feel comfortable. If you have a low-risk pregnancy with the average health insurance plan,you can save a lot of money in the end by giving birth at home or at a birth center. Give birth unassisted/freebirth. You always have the option of giving birth without hired support. Ifyou'd prefer to have a trained medical professional present, look for a student midwife or atraditional midwife who charges a minimal fee. It happens all the time... a mom really wants to give birth in a certain location, with a certain provider,but it's just not covered by her health insurance... If money or insurance is the issue, here are my suggestions for you:Navigating Your Choices Due to InsuranceM O T H E R N A K E D B I R T H

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04Everything in Pregnancy and birth has risks, and it's up to you todecide what's best for you and your baby.*** I want to reiterate that in NO WAY am I telling you to decline thesetests and procedures. You need to decide according to your ownbeliefs and preferences. I also want you to remember that you havethe right to decline in EVERY SINGLE circumstance unless you’ve beenclinically diagnosed as incompetent to make decisions. ***PRENATAL PROCEDURES &UNCOMMONCOMPLICATIONSM O T H E R N K A E D B I R T H

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Blood PressureHigh blood pressure in pregnancy without any othersymptoms usually won't harm you or your baby. Insevere cases, it can lead to low birth weight orpreterm birth. It's important to consider yourstarting blood pressure rather than just the currentnumbers because what's considered "high" could benormal for you, and what's considered"normal" could be high for you. High blood pressurecould be a sign of stress (from the doctor's office) orlack of good sleep.High blood pressure" during pregnancy is definedas 140 mm Hg or higher systolic, with diastolic 90mm Hg or higher.A sudden increase in blood pressure after the 20thweek of pregnancy could be a sign of preeclampsia.Though, in rare cases, symptoms may not start untilafter delivery. Preeclampsia also includes signs ofdamage to some of your organs, such as your liveror kidney. If you have a high blood pressure readingyour urine may be monitored for protein, whichis a sign of decreased function of your organs.Weight Gain in PregnancyThe suggested weight gain duringpregnancy has changed drasticallyover the generations, which tells me thatthe recommendations aren't entirelyrooted in research. Your provider willprobably recommend you gain about 35pounds, but many women have healthypregnancies gaining as little as 10 poundsor as much as 70 pounds. Less than 35%of women stay within the recommendedweight gain guidelines. Excessive weightgain may increase your risk of gestationaldiabetes, high blood pressure, andcesarean section, but it's more importantto take overall health into considerationthen rely just on weight gain.M O T H E R N A K E D B I R T H

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SugarIf high levels of glucose are found in your urine,it might be an indication of gestational diabetes.Additional screening may be recommended,such as blood glucose testing, and can be usedtoconfirm a diagnosis of gestational diabetes.ProteinYour kidneys are working overtime during yourpregnancy because of your extra blood volume.They filter the waste products in your bloodall while keeping things, like proteins, that yourbody needs to thrive. After being filtered, thewaste is released into your urine. If high levels ofprotein make their way to the urine, that’susually because something isn’t functioningquite right in the kidneys and could potentiallybe a sign of preeclampsia.A reading of more than 300 mg/d of protein inyour urine is considered high. Beyond that, youmay or may not have any related symptoms ofkidney stress like swelling in the ankles, wrists,or eyes, increased urination (this is common inpregnancy in general), back pain (also commonin pregnancy), foamy or brown/bloody urine.Keep a watch out for additional signs that mightindicate preeclampsia, like severe headaches,blurry vision, pain in your abdomen,nausea/vomitingUrine AnalysisKetonesKetones are by-products of fatbreakdown in your body. When foundin your urine, they indicate that you'renot eating enough calories at regularintervals during the day or that yourblood glucose is too high. Ketones in yoururine can be completely normal, butelevated levels may be a sign that youand your baby are not getting enoughenergy fuel in your diet. Some studieshave shown that excess ketones in apregnant woman's urine may affectdeveloping brainBacteriaIn 2% to 15% of pregnancies, women willdevelop a bacterial infection without anyof the typical symptoms that areassociated with a UTI. If left untreated, upto 30% of mothers will develop a kidneyinfection.M O T H E R N A K E D B I R T H

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AnemiaDuring pregnancy, your body produces moreblood to support the growth of your baby. Ifyou're not getting enough iron, folate, or B-12,your body might not be able to produce theamount of healthy red blood cells it needs tomake this additional blood. It's normal to havemild anemia when you are pregnant. But youmay have more severe anemia from low iron orvitamin levels or from other reasons. Anemia canleave you feeling tired and weak. If it is severebut goes untreated, it can increase your risk ofserious complications like preterm delivery.InfectionsYour provider will want to test for STIs duringpregnancy which can cause some complications. HIV: You can pass HIV to your baby duringpregnancy, birth, or breast-feeding. However, ifHIV is diagnosed before or early in pregnancy,steps can be taken to reduce the risk oftransmission.Hepatitis B:The greatest risk of transmissionoccurs when pregnant women become infectedclose to delivery. Transmission can be preventedif at-risk infants are treated shortly after birth.Chlamydia: Chlamydia during pregnancy hasbeen linked to preterm labor, premature ruptureof the membranes, and low birth weight.Chlamydia can be passed from women to theirbabies during a vaginal delivery. If diagnosedduring pregnancy, chlamydia can be successfullytreated with an antibiotic.Syphilis: Syphilis during pregnancy hasbeen linked to premature birth, stillbirth,and, in some cases, death after birth.Untreated infants have a high risk ofcomplications involving multiple organs.Gonorrhea: Untreated gonorrhea duringpregnancy has been linked to prematurebirth, premature rupture of themembranes, and low birth weight.Gonorrhea can be passed to the babyduring vaginal delivery.Hepatitis C: Some research suggests thathepatitis C during pregnancy increasesthe risk of premature birth or low birthweight. This type of liver infection can bepassed to the baby duringpregnancy.Blood TestsM O T H E R N A K E D B I R T H

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Blood Type + RH FactorAntibodiesIt's common to test pregnancy moms forrubella antibodies. Rubella, also calledGerman measles or 3-day measles, isn't aproblem for most people. It causes a mildfever and rash that go away in a few days.Most kids get vaccinated for it with the MMR(measles-mumps-rubella) or MMRV (whichalso includes chickenpox) shots.But if you get the disease when you'repregnant, it can be very serious.If you get it in the first 4 months, your babycould have eye, hearing, orheart problems or be born too soon.The theory is that if you already have therubella antibodies (from prior infection orfrom a vaccine in childhood) then you're in theclear, and if you don't have the antibodies,you should avoid travel to places with highrates of the virusYou might want to know your blood type if youdon't already... If you're Rh-negative and yourbaby is Rh-positive, AND if your baby's bloodmixes with yours somehow (this isn't normal butcould happen in a cesarean or a traumatic eventlike a car accident) your body might startcreating Rh antibodies. If you are Rh-negative,you may want an antibody test to confirm. Theseantibodies could potentially spread to yourbaby's blood, where they'd attack and destroyyour baby's red blood cells.Your doctor might recommend a shot ofmedicine called Rho(D) immune globulin(RhoGAM) to stop your immune system frommaking Rh antibodies. These antibodies mightnot cause trouble for your first baby, but theshot will also help prevent trouble if you getpregnant again.A positive test means you already haveantibodies in your blood and the shot won'thelp. Your doctor will watch you and your babyclosely.I want to remind you that many people carry Rhantibodies and have absolutely no issues withtheir pregnancy or baby. Weigh the risks to theshot against not receiving it and make your owndecision.M O T H E R N A K E D B I R T H

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Fundal HeightMeasuring the fundal height is a great substitute for an ultrasound for those who want to avoid it. Thisis the measurement from the public bone to the top of the uterus, which is called the fundus. At 12weeks, At 12 weeks, the fundus should be just above the pubic bone. The fundus should be just abovethe public bone, and by 16 weeks it should be growing at a rate of about one centimeter per week.Starting at week 20, the fundal height in centimeters should correspond with the number of weeksgestation (+/- 2 centimeters). If your fundal height grows much faster, it could be an indicator of twins,and if it grows less it could indicate high blood pressure or an infection.Pap SmearA Pap smear is typically done in early pregnancy to check for any abnormalities. It's important to knowthat pregnancy accelerates the growth of all of your cells, so it may be important to you to monitor thisthrough Pap smears during this time. They will also be looking for an inflammation of your cervix dueto possible STIs. Remember you can always decline any procedure for any reason.Cervical ChecksCervical exams are common in late pregnancy in some parts of the world and incredibly uncommon inothers. There really aren't any benefits to checking your cervix for dilations or effacement in latepregnancy, and they can introduce foreign bacteria inside your vaginal canal near your cervicalopening, which increases the risk of infection.Your dilation and effacement should not be used to predict when you will go into labor or how muchlonger your labor will last. As curious as you might be to know your dilation and effacement toward theend of your pregnancy, it's important to know that what you would find out actually won't tell youmuch of anything.There isn't much research on the risks and benefits associated with cervical exams in late pregnancy.One study shows a threefold risk in your water breaking with weekly vaginal exams starting at 37weeks, and another study shows no difference in any outcomes between those receiving cervicalchecks and those not receiving them.Cervical checks might satisfy your curiosity or your doctor or midwife’s curiosity, but it doesn’t show tohave an effect on your outcome either way. The evidence simply does not support it. If you don’t wantvaginal exams, either because the evidence doesn't support them, they make you uncomfortable oryou just simply don’t want them, you can decline. Your reason is your own and you don’t need toexplain it to anybody.M O T H E R N A K E D B I R T H

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UltrasoundsThe term ultrasound refers to the ultra-high-frequency sound waves used for diagnostic scanning. Apicture of the tissues is built using a pattern from the echo waves that return to the machine.Ultrasound is used for two main purposes in pregnancy: to routinely scan for abnormalities around 20weeks, and to investigate probable complications. The world health organization currentlyrecommends that unless medically indicated, there be no more thanone scan, and only before 24 weeks. The routine use of ultrasound, without medical indication, is bothcontroversial and questionable as it doesn't show to improve outcomes for mothers and babies.Typically a provider within the medical system will recommend a scan to determine the baby's duedate around 7 to 8 weeks pregnant. This estimated due date can be pretty accurate within 3 to 4 days…but it's important to know that after the second trimester, the due date measured by ultrasound is notevidence-based.Ultrasound is also commonly used around 20 weeks to detect fetal abnormalities. But it's important toknow that this diagnosis can lead to false positives and it can also misdiagnose. There's a study thatshows that in highrisk women, nearly 10% of all scans were uncertain which can lead to increasedanxiety and no answers.Mainstream organizations say that ultrasound comes with no risk to the mother or baby, but thatshould raise a red flag for you because no long-term studies have been done. Ultrasounds havebecome so routine that controlled human studies are now deemed unnecessary… And they have beengrandfathered into FDA clearance, meaning that ultrasound studies have stopped since the 1980sdespite the fact that the FDA raised its regulations for the strength of the signal.Research shows no mortality benefit for routine ultrasound use in normal pregnancies and anincreased risk of cesarean section with third-trimester scans. I believe that the partnership betweenthe technology companies and the ISUOG (International Society of Ultrasound in Obstetrics andGynecology) is worth considering when trying to understand why ultrasound scans are so highlyrecommended without the research to back it.I want to be clear that evidence does not outright show that a single ultrasound examination at low tomedium exposure will cause definite harm to a baby. However, parents should be cautious aboutoverusing this technology, especially with high or repeated exposure. And of course, you need toalways remember to weigh the risks and benefits in each individual scenario. M O T H E R N A K E D B I R T H

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Gestational DiabetesThe TestTwo Part Glucose Screening (Common in USA)For the initial glucose test, you'll drink a glucose solution and one hour later, you'll have a blood test tomeasure your blood sugar level. A blood sugar level of 190 milligrams per deciliter (mg/dL) indicatesgestational diabetes. Blood sugar below 140 mg/dL (7.8 mmol/L) is usually considered "normal" afterthe glucose drink, although every provider has different guidelines for "normal." If your blood sugarlevel is higher than "normal", you'll be asked to take another glucose tolerance test to determine if youhave GD.For the follow-up glucose testing, you'll drink a glucose solution with even more sugar and your bloodsugar will be checked every hour for three hours. If at least two of the blood sugar readings are higherthan expected, you'll be diagnosed with gestational diabetes.AlternativesMany providers will offer an alternative to the test by having a mom eat 50g of sugar (gummy bears,jelly beans hard candy, etc) and then take a blood sugar reading after one hour.As always, you can decline all tests.The RisksIf you have gestational diabetes, your baby may be at increased risk of: excessive birth weight,respiratory distress syndrome, low blood sugar, and you could have an increased risk for preterm birthor preeclampsia.PreventionThere is no guarantee that you can prevent gestational diabetes by altering your lifestyle — but themore healthy habits you can adopt before pregnancy, the better. If you've already had gestationaldiabetes in a previous pregnancy, these habits may also reduce your risk of having itagain in future pregnancies.Choose foods high in protein and fiber. Focus on proteins, fruits, vegetables, and whole grains. Myfavorite recommendation for diet in pregnancy is called the Brewer's Diet.Exercising during pregnancy can help you from developing gestational diabetes. Move your body in away that feels good to you. Short bursts of activity — such as taking the stairs instead of the elevator— all add up too!M O T H E R N A K E D B I R T H

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Gestational Diabetes Cont.TreatmentMoms with GD are often recommended to induce labor at or near full term, but can, of course, declinean induction. If you choose to decline an induction, remember you can always reassess and decide toinduce atanother time.The research is all over the place with this one. There is no evidence to support inducing labor forevery mom diagnosed with gestational diabetes. And the one scientific trial that looked at earlyinduction for GD showed no benefit to inducing between 38-39 weeks and waiting for spontaneouslabor (unless another complication came up).There was an observational study that showed that there would need to be 1,500 inductions for GD tosave the life of 1 baby. And other observational studies have shown that health outcomes for babiesinduced at 39 weeks for GD are less likely to have breathing problems, but when induced at 38 weeksthey have more health problems...It's really not clear if the potential benefits from elective induction apply to mothers with well-managed blood sugar levels since this data was not included in the studies.Besides induction, there is strong evidence that nutrition counseling, blood sugar monitoring, exercise,and medication can lower the risks of having gestational diabetes. M O T H E R N A K E D B I R T H

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Group B StrepAbout 20% of healthy women will test positive for group B strep in pregnancy.Most women with GBS do not have symptoms, but in newborns, GBS can cause sepsis (infection of theblood), meningitis, or pneumonia. Without antibiotics, about 1% of these babies will become infectedwith group B strep, and 20% of infected babies will die. So, if nobody was treated for group B strep, outof every 1,000 women positive for GBS, one baby will die.If you test positive or are considered "high-risk", your doctor will probably recommend that youreceive IV antibiotics every 4 hours during labor.With antibiotics, the baby's chance of becoming infected drops from 1% to 0.2%. So now you need toask yourself, "Would I rather antibiotics enter my baby (in one of the most crucial stages of their life tobuild their biome) or lower their chance of infection by 80%?" Studies have found that IV antibioticsduring labor affect the infant’s microbiome by decreasing beneficial bacteria and increasing potentiallyharmful bacteria.Taking probiotics may lessen your chances of being colonized with GBS. If you test positive for GBS atyour prenatal screening there is a 14% chance you won't have GBS at the time of your birth. (Thatincreases to 43% if you take a probiotic).Remember you can decline the GBS test in the first place if you want, and many homebirth midwivesdon't even test their patients.Just because you might decline antibiotics in pregnancy doesn't mean you can't monitor your baby andreassess as labor progress. M O T H E R N A K E D B I R T H

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During your pregnancy, the specific vaccines your doctor will recommend will be determined byyour age, lifestyle, medical conditions, travel, and previous vaccinations.Some vaccines, like the MMR vaccine, is not recommended during pregnancy at all.Typically the CDC recommends that all pregnant women get two vaccines during every pregnancy:the inactivated flu vaccine (the injection, not the live nasal flu vaccine) and the Tdap vaccine (eventhough the TDAP booster typically is only recommended every 10 years).The statements below are taken from the vaccine inserts under the "pregnancy" tab (and you canfind the inserts through a simple search on the CDC website):Flu vaccine"Available data with use in pregnant women are insufficient to inform vaccine associatedrisk of adverse developmental outcomes."Tdap vaccine"There are no adequate and well-controlled studies of Tdap in pregnant women in the U.S."Covid Vaccine"Available data with use in pregnant women are insufficient to inform vaccine associated risks inpregnancy"Vaccination In PregnancyM O T H E R N A K E D B I R T H

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Marginal Insertion PlacentaA marginal cord insertion occurs in 8.5% of pregnancies, and it's where the umbilical cord attaches tothe side of the placenta instead of the central placental mass. So, the umbilical cord is attached to theplacenta in the wrong place, and this can cause an issue because the placenta is thinner at the edges.Therefore, the placenta less able to structurally support the umbilical cord.Your doctor will want to monitor your placenta, and it's usually not a cause for alarm by itself.Sometimes marginal cord insertions can even correct themselves over time.Placenta Previa Placenta previa is when a baby's placenta partially or totally covers the mother's cervix. Placenta previacan cause severe bleeding during pregnancy and delivery and is diagnosed through ultrasound, eitherduring a routine prenatal appointment or after an episode of vaginal bleeding. Most cases of placentaprevia are diagnosed during a second trimester ultrasound exam.It's important to know: In most women diagnosed with placenta previa early in their pregnancies, theplacenta previa resolves. As the uterus grows during pregnancy, typically the distance between thecervix and the placenta increases.If placenta previa doesn't resolve during your pregnancy, the goal of treatment is to help you get asclose to your due date as possible. Almost all women with unresolved placenta previa require acesarean delivery.Placenta AbruptionPlacental abruption happens when the placenta partly or completely separates from the wall of theuterus before birth. This can decrease or block the baby's supply of oxygen and nutrients and causeheavy bleeding in the mother, but that's not always the case.If it happens earlier in the pregnancy, doctors will watch the baby's development and the mother'shealth closely through ultrasounds. In most cases, with proper monitoring, a baby will survive a partialplacental abruption.Placenta ComplicationsM O T H E R N A K E D B I R T H

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M O T H E R N A K E D B I R T HUltrasounds are ONLY right about half the time when theypredict a bigbaby. I'll repeat... you have the same chance offlipping a coin and landing on "tails" as your doctor has whenusing a scan to predict your baby's size. So next time yourprovider tells you your baby is too big... you are more thanwelcome to laugh. Which other diagnostic tool can be wrongFIFTY PERCENT of the time and still be used across the world?In the USA, 33% of women are told they will have a big baby,yet only 10% of babies are born over 9 lbs. Studies even showthat even just the “suspicion” of a big baby increases the riskof Cesarean (without improving the health of the mother orbaby). Basically, if your doctor thinks you have a big baby, theyare more likely to diagnose your labor as "stalled", or pressureyou into a Cesarean.Should you induce for a suspected big baby? Not necessarily.Induction might lower the chance of shoulder dystocia from7% to 4%, but research doesn't show that induction for big ababy improves outcomes. Induction actually might increaseyour risk that you will have a severe tear.Should you plan a cesarean for a big baby then? That's up toyou, but the research absolutely doesn't support it. It wouldtake 3,700 unnecessary Cesareans to prevent ONE case ofpermanent injury due to shoulder dystocia in a baby.Hot tip: ask your care provider if they regularly train on how tomanage shoulder dystocia because training has been shown todecrease the chances of your baby experiencing permanentinjury due to being "too big".Suspected "Big Baby"U N C O M M O N C O M P L I C A T I O N S

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M O T H E R N A K E D B I R T HIUGR is diagnosed when the ultrasound-estimated fetal weight is below the 10thpercentile for gestational age. Diagnosis byultrasound alone has proven to beinaccurate in up to 50% of cases.Babies with IUGR are at greater-than-normal risk for a variety of health problemsbefore, during, and after birth. Theseproblems include low oxygen levels while inthe womb, a high level of distress duringlabor and delivery, and an increased risk ofinfection after birth.It's hard to know which cases are just"normal" small babies and which smallbabies are due to IUGR. The cause of trueIUGR can be linked to genetic factors,congenital anomalies, infection, multiplegestations, maternal nutrition,environmental toxins, placental factors, ormaternal vascular disease.IUGRU N C O M M O N C O M P L I C A T I O N SU N C O M M O N C O M P L I C A T I O N S

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High Levels: Polyhydramnios is the excessiveaccumulation of amniotic fluid and occursin about 1 to 2 percent of pregnancies. Mostcases of polyhydramnios are mild and resultfrom a gradual buildup of amniotic fluid duringthe second half of pregnancy and cause noissues or symptoms. Severe polyhydramniossymptoms result from pressure being exertedwithin the uterus and on nearby organs andsymptoms can include shortness of breath,swelling in the lower extremities and abdomen,uterine discomfort, fetal malposition.Polyhydramnios is associated with prematurebirth, premature rupture of membranes,placental abruption, umbilical cord prolapse, andpostpartum hemorrhage. Low Levels: Oligohydramnios is a condition inwhich the amniotic fluid measures lower thanexpected for a baby's gestational age. There isno evidence that isolated oligohydramnios atterm is a risk factor for poor outcomes.However, induction for isolated oligohydramniosleads to higher Cesarean rates.The most commonly used methods to diagnoseoligohydramnios are 2 ultrasound techniques:the amniotic fluid index (AFI) and the "singledeepest pocket". There are several factors thatmake it difficult to get an accurate ultrasoundmeasurement and it's important to understandthat there is no agreement among researchersabout the cut-off value that predicts pooroutcomes.Amniotic Fluid LevelsLow Levels Continued: If you have lowamniotic fluid and you're over 36 weekspregnant, your provider will probablyrecommend induction. If you're less than36 weeks pregnant, your health careprovider will most likely do extramonitoring through ultrasounds.Hot tip: drink more fluids — especially ifyou're dehydrated. If a woman with lowamniotic fluid levels at term drinks atleast 2.5 liters of fluid per day, sheincreases the likelihood that her amnioticfluid levels will be back up to normal bythe time of delivery.M O T H E R N A K E D B I R T H

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Preeclampsia (also called toxemia) is the name for a group of symptoms that form the mostcommon (and very serious) complication in pregnancy. Preeclampsia includes signs of damage tosome of your organs, such as your liver or kidney. Possible signs of preeclampsia include high blood pressure, elevated protein in your urine, swellingin your face and hands, persistent headache, vision problems (blurred vision or seeing spots), painin your upper right abdomen, trouble breathing.Your health care provider will want to check your blood pressure and urine at each prenatal visit. Ifyour blood pressure reading is high (typically 140/90 or higher), especially after the 20th week ofpregnancy, your provider will likely want to run additional tests. They may include blood tests otherlab tests to look for extra protein in the urine as well as other symptoms.Preeclampsia can be serious or even life-threatening for both you and your baby. The risks caninclude placental abruption, preterm birth, damage to your organs. If preeclampsia turns into full-oneclampsia, which happens when preeclampsia is severe enough to affect brain function, it can causeseizures or coma.PreeclampsiaM O T H E R N A K E D B I R T H

The Pregnancy, Providers & Procedures Guide

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