Tuesday, September 13, 2011

What is a True High Risk Pregnancy/Birth?

While pregnant it's easy to feel overwhelmed with information and opinions from others.  What can also be stressful is not being sure what is a true risk and what is a potential risk.  I'm writing this blog for that purpose.  Pregnancy is filled with adventure and and joy from the time you take the test, to the time you have an u/s, up until birth.  What happens when something comes up during an appointment?  You panic and try to do whatever possible to keep your baby and you healthy.

The first thing I want to address is breech position!  Is this a true high risk?  Does the positing of your baby affect your pregnancy?  Because your baby is breech does this warrant an cesarean section?  Here's an article about breech birth and c/s. Quoting from the article a few lines:

Since 2000, C-sections have been the preferred method of delivery in breech births. Studies suggested that breached births were associated with an increased rate of complication when performed vaginally.
As a result, many medical schools have stopped training their physicians in breech vaginal delivery.
Now let me explore a few other aspects of breech.  Breech is a variation of normal.  Your baby may be breech for many reasons.  There many techniques used to flip or spin baby.  You could do a external cephalic version, acupuncture, and Webster's technique to say the few.  On the Spinning Babies website you can find information on all of this.  The information is out there you just have to ask.  Here's a quote from the spinning babies website: 

The breech position can be a normal response to the shape of the space inside the mother's womb. Usually, the womb is aligned to encourage the baby to be head down. Whether the reason that any particular breech baby doesn't or can't settle head down in the womb is normal or not varies just like the situations about head down babies vary. Not all head down babies have easy births; and not all breeches have difficulty. Far from it. Most breeches have smooth births when birth is spontaneous (scroll down).
Most of the time breech babies aren't given a chance. They usually induce the mom and schedule a c/s.  Did you know that  breech babies can turn during labor?  How about a twin birth where baby "B" is breech and baby "B" turns as baby "A" is born.  Did you now that most breech vaginal births have no problems, in fact it's usually smooth.  The increased death rate is due to malformations already present, prematurity and intrauterine fetal demise! States the overview on Medscap.com by Dr. Fisher.

Now lets talk about previous cesarean section, does this make you a high risk birth?  Many may say yes because of uterine rupture.  But to the contrary by the ACOG's own admission, there is no evidence to back up this recommendation. This is the reason, of course, this recommendation has been placed in Level C and is thus ACOG's confession that since there is no data, they will simply have to go on the basis of "expert opinion." This is a sad regression to the days of "trust me, I'm a doctor" in spite of the new direction of medical care to evidence-based practice. 

Furthermore with recent studies the uterine rupture rate is much lower than you think. Quoting from 20 Peer Review of  Publications uterine rupture is 0.7%.  Here's the quote:
Meta-analysis of pooled data from 20 studies in the peer-reviewed medical literature published from 1976-2009 indicated an overall incidence of pregnancy-related uterine rupture of 1 per 1,536 pregnancies (0.07%).
This is for all pregnancies with or without a previous scar.  ACOG also recommends a trail of labor after cesarean (TOLAC).  So from the this information given by Medscap we can conclude that a previous cesarean doesn't make you high risk.  This is NOT to say that there's no medical reasoning for cesareans.  This is to say that because you had a c/s before doesn't mean your pregnancy is high risk. Here's another source on VBAC's and how they carry less risk than repeat/elective cesareans (RCS,ESC).

This brings me to my last point! POSTDATES!!! Everyone gets in a frenzy when baby doesn't arrive on their "estimated due date" (EDD)  The truth being that no one can accurately pin point conception due to sperm living for up to 5 days inside the uterus.  According to Dr. Caughey the definitions and cause of postdates is this:
Postterm pregnancy is defined as a pregnancy that extends to 42 0/7 weeks and beyond.[1] The reported frequency of postterm pregnancy is approximately 3-12%.[1, 2] However, the actual biologic variation is likely less since the most frequent cause of a postterm pregnancy diagnosis is inaccurate dating.[3, 4, 5, 6] Risk factors for actual postterm pregnancy include primiparity, prior postterm pregnancy, male gender of the fetus, and genetic factors.[7, 8, 9, 2, 1]


Yes some women do know when they conceive because they are in tune with their bodies.  But why are we categorized the same when it comes to the date of conception using your last menstrual period (LMP).  Some women go 28 days, some 30 days, and so on.  We can't put all women in the same box.  As long as mom and baby are doing fine and there aren't anything of concern why not wait for labor to start on its own. ACOG states that a pregnancy is 38-42 weeks gestation not 37-40 weeks.  Many people say that risk arise the further you go past your date here's what the ACOG had to say about that:

postterm pregnancies. Most women who give birth after the due date have healthy newborns.
You can find this information here on this article and also go to their website to find more.

Summary

There are TRUE high risk pregnancies and births, such as HELLP syndrome, preeclampsia, eclampsia, (not solely based on blood pressure), IUGR,  TTS syndrome, (in multiple pregnancy), ICP, placental conditions, etc.  These require extensive monitoring during your prenatal visits and during labor.  I would add that diet and exercise can play a major role in some of these symptoms and disorders.  As long as you and baby are doing good and there's no sudden medical change in your pregnancy you can go on to birth your baby.  Ask questions and research your options before making any decisions.