The gentlebirth.org website is provided courtesy of
Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

General Prenatal Care - Practice Protocols

See also:

• Prenatal Checklists
• Miscellaneous Prenatal

Subsections on this page:

• Resources
• Guidelines for Newborn Care
• Group Prenatal Care
• Client-Based Care
• Pelvic Exams at Initial Appointment
• Prenatal RhoGAM for Rh Negative Mothers
• Fundal Heights/IUGR
• Finding Heart Tones
• Prenatal Cervical Exams
• Weight Gain
• Antepartum Testing for Women over 35 at Term

Resources

Protocols You Can Edit to Customize

Protocols: Standards Meeting Needs by Jill Cohen

Protocols vs. Guidelines by Suzanne Hope Suarez

National Guideline Clearinghouse™ (NGC), a public resource for evidence-based clinical practice guidelines, and a search on the word midwife.

Classic Protocols

British Obstetrical Protocols - Clinical Guidelines from the Royal College of Obstetricians and Gynaecologists (RCOG)

Criteria for Provision of Home Birth Services from the ACNM

2006/036 New NICE guidelines on postnatal care will give babies best start in life (Postpartum Care)

Outlines of Midwifery Care for Home, Birth Center and Hospital

Guidelines for  Perinatal Care from the British Columbia Reproductive Care Program and their list of Other Perinatal Guideline Links

Clinical Practice Guidelines from the Canadian Medical Association - These guidelines are produced or endorsed in Canada by a national, provincial/territorial or regional medical or health organization, professional society, government agency or expert panel.

Routine Prenatal Care from the Institute for Clinical Systems Improvement

Recommendations for the management of uncomplicated pregnancy in the primary care setting from The National Guideline Clearinghouse™ (NGC)
They have a special section on Pregnancy Complications.

HEALTHY BEGINNINGS: GUIDELINES FOR CARE DURING PREGNANCY AND CHILDBIRTH - This document has been reviewed and approved by the Clinical Practice Obstetrics Committee of the Society of Obstetricians and Gynaecologists of Canada (SOGC). The final draft was approved by the SOGC Council as a Policy Statement in November 1995.

Prenatal Care for the Normal Pregnancy

The National Institute for Clinical Excellence (NICE) in the UK offers a set of guidelines:
fetal heart monitoring in labour
induction of labour
antenatal care

CMQCC - California Maternal Quality Care Collaborative

Pocket guide to Prenatal Care from the U.S. Veteran's Admin.

Check out the Evidence Based midwifery from Sheffield University Hospitals written by Jane Munro and Helen Spiby - or the evidence based midwifery network under FANS web site (Foundation of Nursing studies) (www.fons.org).

An index to available guidelines and other documents written by Welsh maternity units
Extensive Maternity Care Guidelines

BEST PROFESSIONAL PRACTICE - MATERNITY CARE IN WALES

John Hunter Hospital Delivery Suite Procedures, Protocols and Guidelines for Practice - from an Australian hospital

Prenatal and Birth

PRENATAL AND INTRAPARTUM GUIDELINES OF CARE from PAC/LAC (Perinatal Advisory Council, Leadership, Advocacy and Consultation)

Birth Only

Delivery Suite Protocols from John Hunter Hospital in New South Wales, Australia.

The College of Midwives of British Columbia (CMBC) offers their Standards of Practice.

Faith Gibson has a terrific set of guidelines for homebirth midwives - Generally Accepted Practices for Community-Based Midwifery

Great list of midwifery resources from an Australian list.

Indications for Discussion, Consultation and Transfer of Care from CMBC Standards of Practice for the The College of Midwives of British Columbia

WHO Antenatal Care Randomised Trial for the Evaluation of a New Model of Routine Antenatal Care [Medscape registration is free]

"The protocol called for 4 visits: the first in the initial trimester, and then visits at 26, 32, and 38 weeks of gestation . . . The authors concluded that this new model of care could be implemented without impacting on maternal or perinatal outcomes and that it could potentially reduce the cost of prenatal care."

WHO antenatal care randomised trial for the evaluation of a new model of routine antenatal care.
Villar J, Ba'aqeel H, Piaggio G, Lumbiganon P, Miguel Belizan J, Farnot U, Al-Mazrou Y, Carroli G, Pinol A, Donner A, Langer A, Nigenda G, Mugford M, Fox-Rushby J, Hutton G, Bergsjo P, Bakketeig L, Berendes H
Lancet 2001 May 19;357(9268):1551-64

New Guidelines for Midwife Led Care in Labour  - from the UK

National Guideline Clearinghouse Disclaimer - The National Guidelines Clearinghouse (NGC) is an Internet Web site intended to make evidence-based clinical practice guidelines and related abstract, summary, and comparison materials widely available to health care professionals

Laboratory Testing During Pregnancy
Practice Guidelines
Recommendations of the Prenatal Testing Committee
Wisconsin Association for Perinatal Care
Date of Report: April, 1997

Welcome to PERISCOPE ON-LINE. . .the statewide information system that is designed to keep you informed about perinatal care issues in Wisconsin. The information in PERISCOPE ON-LINE is maintained by the Wisconsin Association for Perinatal Care and its Collaborative Network on Perinatal Continuing Education.

Protocols Pages from Department of Family Medicine, University of Iowa's

Primary Care Clinical Practice Guidelines from an MD at UCSF

Dutch Obstetrical Protocols

California Midwife's Guidelines of Practice

36-Week Home Visit for Homebirth Clients

Guidelines for Newborn Care

Neonatal Guidelines of Care from PAC/LAC (Perinatal Advisory Council, Leadership, Advocacy and Consultation)

Newborn Guidelines from the British Columbia Reproductive Care Program and their list of Other Perinatal Guideline Links

Group Prenatal Care

Centering Pregnancy - A Model for Group Prenatal Care, workshops by Sharon Schindler Rising MSN, CNM.  An empowering program for clients and professionals.  These sound similar to the group prenatals that June Whitson, CNM, did over the course of 20 years or so.  [Somebody once summarized her approach for me . . . Have women write out their fears and questions (anonymously if desired) to hand in to the facilitator.  Check in about the most positive and most negative aspects of pregnancy since the last visit.  Have individual appointments in the last month.]

I am using a variation of the Centering Pregnancy model.  It has been very successful.  I have an early group (< 30wks) and a late group (>30wks) that meet q 2 wks, they alternate.  There are books that clients use that have a format, diary, and information about their bodies and pregnancy.  Belly checks are done nearby the group in a screened off area.

Client-Based Care

I think all midwives (and all other birth providers) should spell out exactly what kind of care they provide. I think they should make their protocols accessible to their clients, and I think the rates of infections at their hospital should also be available. Without this information, how can you make any kind of informed choice?

We are in perfect agreement on this.

Yes, and I keep hoping that if enough people keep saying it, people will actually start doing it, and clients will start demanding it. One can hope.

Two documents to use as a starting point:

Anne Frye's Holistic Midwifery, p. 525: Statement of Informed Disclosure (Informed Choice Agreement)

She has about 24 fairly dense pages devoted to the subject. This is in addition to a few pages discussing the Initial Consultation meeting.

This is the most comprehensive discussion of informed consent for birth that I've heard of.

The second document I'll be using heavily is a 140-page document which I've heard called "The New Mexico Protocols". The many-times-copied version I have doesn't have any identifying information, but I've heard that it's the "Standards and Policies" manual from the New Mexico Midwifery Association.

The bibliography does list the most likely model for the document I have:

The Northern New Mexico Midwifery Center Inc. (1982). Policy and Procedure Manual. Taos, NM.

My hope for myself is to offer a complete disclosure as modeled by Anne Frye.

When it comes to protocols, though, my feeling is that "my protocols" will be parameters within which I'm comfortable working. Then I'll present clients with a long list of choices they can make within those parameters. I'm happy to make recommendations, of course, but the choice must rest with the client. They're free to choose to follow all my recommendations, as many probably would, but this approach should solidify in their minds that they can change any of this at any time.

Pelvic Exams at Initial Appointment

Pelvic exams may increase risk of UTI. (Aug 15, 1996)

How many out there do routine early pregnancy exams? I don't. I have done my share but I don't do them routinely. I don't think that pelvimetry tells me much.

In my practice, it is more than just pelvimetry that I do a first visit pelvic exam. I will do a PAP if they are due for one, I do cultures for gonorrhea and chlamydia, I assess the genitalia, vagina and cervix for lesions and sores, and I do microscopy of vagina secretion samples for trich, white blood cells, clue cells and such. And I do like to do pelvimetry, sometimes it is very interesting especially if they bring a history of section because "the doctor told me I was too small". It's also good info to have later down the road if you end up with slow descent or arrest etc. especially if they did not have a gynecoid pelvis. It's a 'midwife thing' :-)

I did them routinely, but not really for pelvimetry. The first reason was so that I could carry on about what an incredible pelvis this woman has, my goodness, you can grow any size baby you want, lovely, lovely. (Invariably was tremendously reassuring to the woman). The only time I found anything bonewise that I used for predicting labor was a mom whose pubic arch was narrow and sharply angled. I showed her what I felt, and suggested that she might want to be sure not to be on her tailbone at all during late labor to take "take full advantage of all that room in the back". She ended up birthing a big baby sitting back with no problem at all!

The second reason was to feel her cervix. If it was unusually long or unusually short, I always made a starred note about it, for reference later on, in case of wanting to evaluate for early contractions (premature) or whatever. That way my partner knew too, in case she was the one who checked later.

Not routine, but in primips I like to do it if they are OK with it. Just to be sure there are no "surprises" at the end of pregnancy (oooh, very tiny pelvis or some rare thing...). Some of the primips I've had have never had a pelvic (or pap)! If I find a questionable pelvis (very rare I know), I will think in my head what positions to try in labor and watch how the baby descends in late pregnancy. I hate to say this, but I don't want to look really dumb at the end of pregnancy or on a transport by bringing in some woman who may have been laboring for hours (or days) and look like I couldn't even notice that she has an extremely contracted pelvis. I think the client would also think I am incompetent for not picking it up. Here she'd been planning a warm home birth all this time and come to find out she has some problem that almost guarantees she can't have a vaginal birth. Now, I say all of this with the full expectation that I will never actually find this to be the case in a client of mine. After all, I am not doing many births and most people, even with anthropoid or android pelves (or a mixture) can do just fine. So...

The really good thing I usually get out of doing a pelvic on a primip in early pg is to tell her how normal she is and how much room she has and how she can certainly fit an 8lb'er through there. (primips always think 8 lbers are huge!) I show them my plastic pelvis model and explain everything I am going to check for and how it will feel (i.e. the ischial spines). When I used to work with my partner, one would hold the model pelvis up and the other would do the pelvic, explaining as we went.

Again, we focused on giving the woman confidence through this exam. If she is very relaxed during the exam - I say "Wow, you are so relaxed, you are going to have no problem during the birth!" If she is very tense I say "Can, you relax just a little bit, right here where you feel my fingers? Oh, that's great! You are going to have no problem during the birth!" My own brother bragged for weeks about how his wife's pelvis was big enough to drive a Mack truck through (his words, not mine) and how she was going to have "no trouble" in childbirth. A self-fulfilling prophecy.

Our practice does routine pelvic exams on initial ob visit, not so much for pelvimetry (although that is sometimes a component, if we feel pelvis may be contracted i.e. prior c/s for CPD) but for vag cultures, esp. gonorrhea/chlamydia. Recently we have begun culturing for GBS at initial visit too. Is this common elsewhere? Of course this is a good time to reassure women how BIG their pelves are!! (And I routinely do).

I NEVER do early pelvic exams, and rarely do them late in pregnancy either. I have never had a client ask for an early exam.

I find the idea of early or late pregnancy vaginal exams for pelvimetry lacking in physiological basis and part of a pathological attitude to childbearing women.

As pointed out in other discussions on this list (for example when talking about separating Symphysis P) the pelvis of a labouring woman is acted upon on by hormones such that the pelvis is NOT a rigid fixed basin/funnel typed structure, add to this a woman who is encouraged to assume whatever position is most comfortable for the descending fetus. Different movements will result in alteration of diameters in each level.

Thus for active labouring women All diameters can and do change due to the combining of these influences, so why introduce a foreign subjective object into a woman's non labouring pelvis to make any judgment about it's size shape when labouring ????

Then there is the impact of a hard surface such as a bed/examination on the pelvis which I presume would be the case for those doing pelvic examinations to measure diameters!

Would these same practitioners encourage their women patients to labour and give birth or rather be delivered (saved from their tight pelvis) on a bed??? I remember our friendly OB saying something like he used to believe in CPD but now he sees it as often as he sees Rocking Horse manure! I think that says it all!!!!

I agree with you completely- pelvimetry doesn't have to be "clinical"- it can be a great opportunity to set up a positive attitude about birth, and can be downright educational (if you have a model pelvis available to you to explain with)- I find it to be a great opportunity, especially with VBACs, to start them thinking positively about natural birth, from the first prenatal exam.

I'm also someone who has to do early vag exams, for pap and cultures. I don't think pelvimetry helps much. I try to use them as much as possible for education. what I do is give the woman a mirror. Many have never seen their cervix, and often don't even know the names for the outside anatomy. They are frequently hesitant, so I don't offer the mirror, just give it and show how to use it. Most will look, once it's there. Seeing their cervix is nice for later, in labor, when I may ask them to visualize it softening and opening with the contractions. That's hard if they have no idea what one looks like.

Also, I think that many women want to know about their bodies and just explaining what you're doing during the exam and showing a model pelvis can be very empowering for a woman who has always had conventional medical care.

At the initial exam, I let them know when and how many standard vag exams women have and then explain that many women, however, choose to have two... one for the PAP and one when the membranes rupture. I let her decide how many she wants, but that two is the minimum.

Prenatal RhoGAM for Rh Negative Mothers

NOTE - Although RhoGAM in the United States used to be preserved with thimerosol, a mercury derivative, most of the RhoGAM in the United States is now preservative free, so there are no mercury derivatives in it.  It doesn't hurt to ask about it, though, just to be sure!

NOTE - Although this test is now possible, it is not routinely available.  We can hope that it becomes routinely available soon!

Testing the baby's Rh factor is now available prenatally.  For about 38% of women, this means they would not need the 28-week RhoGAM shot!
RhD Genotyping from lenetix.com.
I'm told the testing costs about $500; you probably want to check with your insurance first to make sure they cover it!

Stephanie Stern, MS
Genetic Counselor
Lenetix® Medical Screening Laboratory, Inc.
174 Mineola Boulevard
Mineola, New York 11501
Ph: 516 320-6375
Fax: 516 248-4436
E-mail to username sstern; the domain is lenetix.com
www.lenetix.com

Fetal Nucleic Acid Technology - SEQureDxTM, a Sequenom Technology is a revolutionary approach to genetic screening. Rather than harvesting placental tissue cells (as is required for chorionic villus), or entering the uterus to sample the amniotic fluid surrounding the baby (as is done with amniocentesis), SEQureDx Technology extracts DNA material safely and comfortably from the blood of the mother.  The first application is the analysis of fetal RhD, i.e. Rhesus or Rh status.

Determining Fetal Rh Status from Mother's Blood

Noninvasive prenatal RHD genotyping by real-time polymerase chain reaction using plasma from D-negative pregnant women.
Zhou L, Thorson JA, Nugent C, Davenport RD, Butch SH, Judd WJ.
Am J Obstet Gynecol. 2005 Dec;193(6):1966-71.

CONCLUSION: Fetal RHD genotyping in this study correctly predicted fetal Rh status in 92 of 98 (94%) cases.

Fetal RhD genotyping by maternal serum analysis: a two-year experience.
Gautier E, Benachi A, Giovangrandi Y, Ernault P, Olivi M, Gaillon T, Costa JM.
Am J Obstet Gynecol. 2005 Mar;192(3):666-9.

CONCLUSION: The present report demonstrates that a reliable fetal RHD genotype determination can be achieved with 100% accuracy. It is therefore possible to consider that such an assay could be systematically proposed to all RhD-negative pregnant women in order to more effectively utilize RhD prophylaxis.

An associated editorial.

Management of pregnancies with RhD alloimmunisation. [full text]
Kumar S, Regan F.
BMJ. 2005 May 28;330(7502):1255-8.

"Anti-D immunoglobulin is no longer necessary in women with threatened miscarriage with a viable fetus and cessation of bleeding before 12 weeks' gestation"

If you are really interested in the science, history, and ethics of Rh immune disease, I HIGHLY recommend the book Rh: The intimate history of the conquest of a disease by David Zimmerman.  It was published in 1970-something, is out of print, but can still be found at www.abebooks.com.

Rh isoimmunization Guidelines and free full text articles

Metacollection of relevant links

By rights, a Kleihauer should be done on *all* Rh -ve mothers of Rh +ve babies postpartum, although I know that this isn't the standard of care everywhere.  The generally accepted figure is that at least 75% of women have some degree of feto-maternal haemorrhage after a birth (usually expressed as a percentage figure in the lab report).  Although the Kleihauer is a reasonably accurate test, I'm aware enough of lab errors and the things that can go wrong to be very unwilling to bank on it as a means of determining whether or not someone needs RhIG.

RhIG is expensive.  I'm quite confident that if the Kleihauer were sufficient to determine whether or not a woman required RhIG, our health care system up here would have adopted that as policy long ago.  However, isoimmunization can be such a disaster, that, understandably, no one would ever take the risk that something didn't go awry in the testing or the report.

We're far enough removed from the times when babies had complete exchange transfusions (sometimes in utero) for hemolytic anemia and when stillbirths from hydrops fetalis caused by isoimmunization were common that we think we can be cavalier about this.

Screening for D (Rh) incompatibility from the National Guideline Clearinghouse

When mom is Rh negative and dad is Rh positive is there any value to the blind prophylactic RhoGAM shot at 28 weeks? By blind I mean there hasn't been any bloodwork to confirm sensitization or any episodes of bleeding.

The thing that's hanging me up is the postnatal requirement that the mom gets the shot within 72 hours after birth to prevent sensitization, and the fact that the 28 week shot is given in case one of those seemingly mythical microbleeds has occurred. If a microbleed has occurred, wouldn't the RhoGAM have to be administered within 72 hours also????

I am not quite understanding your point about a blind prophylactic shot at 28 weeks. No one I know does the shot "blindly" . We always check for antibodies prior to giving RhoGAM. For one reason, it won't do any good to give RhoGAM in the presence of antibodies.

I am going to quote from Susan Blackburn's book, Maternal, Fetal and Neonatal Physiology in order to help answer your questions:

Normally during pregnancy, the small amounts of fetal blood (<0.05 ml) that cross the placental and enter the maternal circulation are too small to trigger production of antibodies by the mother's immune system. In a few women however, as little as 0.01 ml of fetal blood has been reported to cause maternal immunization (sensitization). Approximately 1 to 2% of Rh-Negative women develop anti-D antibodies during their first pregnancy.
With delivery and placental separation or with other traumatic events, larger quantities of fetal blood (>0.5 ml) may enter the maternal circulation. This amount of fetal blood (if the fetus is Rho(D) positive) is sufficient to stimulate formation of both anti-D antibody and memory cells in many women. Formation of memory cells results in immunization [sensitization]. Once a woman is immunized, she is immunized for life. During subsequent pregnancies even a very small amount of blood from a Rho(D) positive ferus entering her system may be enough to trigger memory cells to produce antibodies against the D antigen on the fetal RBC. The antibodies that are produced in this secondary response are predominantly of the IgG class and are thus able to cross the placental to the fetal circulation and hemolyze fetal RBC's. With each subsequent exposure.... the immune system's response is as intense as previous responses, and ....may respond more rapidly and intensely with each subsequent pregnancy.

The mechanism of RhoGAM in preventing sensitization may be due to:

1. clearance of antigen from the mother's system
2. blocking of the antigen brought about by the attachment of RhoGAM to the antigenic sites of fetal cells in the mother's circulation, or
3. some sort of more central type (systemic) inhibition of antibody formation

There is evidence that giving the RhoGAM up to 13 days after birth still confers some protection.

Regardless of what seems like it ought to be true, we have hard empirical evidence that the 28-week shot does reduce the incidence of Rh immunization from 1.8% to 0.1%.

For both of these factoids and many, many others on this subject, see the amazingly thorough discussion in chapter 70 of one of my favorite OB books, Albert Reece's "Medicine of the Fetus and Mother" (Lippincott 1992).

Actually, RhoGAM is not given at 28 weeks to prevent isoimmunization from bleeds that already have occurred, but to prevent isoimmunization from bleeds which might occur from 28 weeks - delivery.

And the reason for the 28 week time is that RhoGAM is supposed to be effective for approximately 12 weeks.

My memory of the stats around prenatal RhoGAM is that 2% of women will be sensitized prenatally if they don't receive RhoGAM and the routine administration of RhoGAM at 28 weeks to all non-sensitized women with Rh pos FOBs reduces that to almost zero.

The truth about RhoGAM is that no one knows what the window period of effectiveness is. For all we know, the postpartum shot from the previous baby might still be operating several years later. The 72 hour window was established by the man who first developed RhoGAM (At Columbia Presbyterian Hospital in New York, using some NYS prison). He tested it on prisoners several hours away from his laboratory. He and the warden picked out three days after exposure for administration kinda out of a hat and he never (nor did anyone else, as far as I know) did any research on what the limits are. All we know is that it works when given within 72 hours, but no one knows what the upper limit of effective time period is.

We also know that the vast majority of sensitization occurs at birth.

Previous sensitization with Antibody M already puts the baby somewhat at risk, I can only assume that your doctor is thinking to take prenatal RhoGAM to reduce your chances of developing yet another type of sensitization, thus compounding your problems in any future pregnancies, since it would have no impact on your current anti-M status. I still feel that RhoGAM during pregnancy is controversial and perhaps quite ill advised and encourage you to use one of the newly available preservative free types available in the US if you decide to go with it. call 1-800-344-6087 to find out how to get it in your area.

I have a client who is 9+ weeks, Rh-, and bleeding enough to have clots. She has done this with her other 2 viable pregnancies -- don't know yet if this pregnancy is viable.   Regardless -- should she have RhoGAM now? (She's had 28 week RhoGAM with the other 2, and 72 hour RhoGAM) And, is this early, prenatal RhoGAM protecting THIS baby, or the next one?

I just updated our OB Guidelines.  I am forwarding the info on RH Negative mothers.  Any questions let me know.  Hope this is helpful.

RH Negative Management:
If father of the baby or donor is Rh positive or unknown, the patient is a candidate for RhoGAM prophylaxis in the following cases:

1. Micro RhoGAM - Should only be given if a pregnancy terminates before 13 weeks (TAB, SAB, Ectopic, Molar)
2. Full dose is given:

• If patient elects not to receive RhoGAM at 28 weeks, repeat antibody screen every 4 weeks until delivered.
• If at any time the patient's antibody screen is positive obtain MD consultation.

>Postpartum -

• If direct coombs is positive obtain cord bilirubin
• If newborn is Rh positive, have RhIg given to the mother within 72 hours of delivery. (Current recommendations is one vial if fetal RBC's < 25ml and two vials if 25-50 ml and so forth.)
• If mother is a RhoGAM candidate and is also Rubella Non-Immune, administer the RhoGAM and hold the rubella vaccine until 3 months postpartum.

There's a movement towards declining RhoGAM.

anti-d: exploring midwifery knowledge by sara wickham

The above article is incorrect in talking about RhoGAM as a vaccine.  Actually, RhoGAM is the opposite; instead of evoking an immune response, it suppresses the immune response.

Back when I was a green apprentice, one of the clients developed Rh sensitization; the midwife never offered her RhoGAM.  She was a first-time mom with an uncomplicated labor and birth.

In the early days of Rh research, they found that ABO incompatability is protective against sensitization. (Levine,L. American Journal of Public Health 38:645-651, 1948)(Wiener, A. Proc.Soc.Exp.Biol., Med 58:133-135, 1945)

I have read a few articles stating that there is a theoretical risk that if the woman is carrying an rh- GIRL and she is given prenatal rhogam, the baby girl can be sensitized to all future pregnancies.  This hasn't been proven, and I don't know how true it could be, but it does remind us that there may risks of which we are yet still unaware.

Since Rh Immune Globulin is just that -- antibodies, with a lifespan of about 120 days -- I don't know, from a physiological perspective, how that could cause sensitization, which requires an antigen to trigger the immune system response.

RhoGAM for Early Miscarriage

Blackburn and Loper's text on maternal, fetal, and neonatal physiology states  that "the initial RBCs are primitive megaloblasts and appear at 3 to 4 weeks, followed by normative megaloblastic erythropoiesis at 6 weeks." (p. 178).

RBCs appear quite early, but the Rhesus factor doesn't appear until later - I'm not sure exactly when, though.  I think the party line is that RhoGAM is "harmless", so they give it anytime there's a possibility of sensitization.  Many practitioners won't take a woman's word for when conception occurred, and they don't want to worry about liability risks for not giving RhoGAM when appropriate.

Do Rh-negative women with first trimester spontaneous abortions need Rh immune globulin?
Hannafin B, Lovecchio F, Blackburn P.
Am J Emerg Med. 2006 Jul;24(4):487-9.

CONCLUSION: In summary, there is minimal evidence that administering Rh immune globulin for first trimester vaginal bleeding prevents maternal sensitization or development of hemolytic disease of the newborn. The practice of administering Rh immune globulin to Rh-negative women with a first trimester spontaneous abortion is based on expert opinion and extrapolation from experience with fetomaternal hemorrhage in late pregnancy. Its use for first trimester bleeding is not evidence-based.

This article implies that events before 12 weeks' gestation don't warrant  RhoGAM:

Management of pregnancies with RhD alloimmunisation. [full text]
Kumar S, Regan F.
BMJ. 2005 May 28;330(7502):1255-8.

"Anti-D immunoglobulin is no longer necessary in women with threatened miscarriage with a viable fetus and cessation of bleeding before 12 weeks' gestation"

Fundal Heights/IUGR

Intrauterine Growth Retardation (IUGR) from  Harbor/UCLA

Maternal Hemodynamic Factors Related to Fetal Growth Restriction [Medscape is free.]

Maternal cardiac function in fetal growth restriction.
Bamfo JE, Kametas NA, Turan O, Khaw A, Nicolaides KH
BJOG. 2006 Jul;113(7):784-91.

Intrauterine growth retardation. [Free full text from AFP]
Vandenbosche RC, Kirchner JT.
Am Fam Physician. 1998 Oct 15;58(6):1384-90, 1393-4.

Prenatal Ultrasound May Lead to Cesarean in "Midwifery and Childbirth News" [from

I view fundal height measurements as a very, very rough approximation of appropriate growth. I don't even begin to worry until FH is >3-4 cm off dates. I view FH 2-3 cm different than dates as consistent with dates, and continue going by the dates for EDD. FHs have way too many variables to use to determine EDD....will a 110 lb woman at 26 weeks measure the same as

a 300 lb woman at 26 weeks? Of course not. Full bowel, full bladder, fetal position, amount of fluid, maternal position, examiner style will all cause differences in FH measurement.

Finding Heart Tones

I carry a 3 mega hertz dop and can usually pick up fht's by 7 wks. If I cannot I send them for an u/s.

But what model? using what kind of probe? I use Medasonics and Huntleigh Dopplex, am really good at picking up FHTs early and have NEVER gotten them prior to 8 2/7 weeks by menstrual age; then, mother must be "thin" with very anteverted uterus. In the tall with deep pelvis and/or retroverted uterus, it can take longer, up to 11 weeks. After I do a bimanual, I can usually tell if I am going to get FHTs or if it's too early; I tell them it's not even possible most of the time until >9 since if I can't get it, anxiety sets in and I have to go scan them to calm everyone. However, if the uterus is S<D and hx is firm, I scan to confirm dates/viability. Otherwise, checking too early is NOT time effective (sorry, got  a schedule to try and keep) not to mention cost (unless they are bleeding/pain) since many MAB/SABs occur between 7 to 9 weeks anyway.  What is your trick?! to finding these really earlies? 

I am amazed that few are able to pick up fhts as early as I do.  The only thing I can think of is that I have lots of patience.  Like I tell the ladies, while I am searching, these are teeny, tiny little hearts and it may take me about 7-8 minutes to find them.  What I THINK happens is that I start scanning in the middle above pubis and keep going all around.  I press firmly and then light.  I think that the way I scan causes the babe to float around until I can finally catch it.  Once, and only once, I picked up fhts at 6.5 weeks.  I picked up my neighbor's twins at 8 wks. but the doc couldn't.  So thin or not, with me doesn't seem to matter.  If they are heavy, I move the excess skin up out of my way with my left hand.  I use an IMEX pocket dop with 3 mgH. 

Are we both talking the same number of weeks? menstrual age? So do I; I also tell them I am attempting to track something smaller than a grain of rice (the heart) and that it will take me a while. For the majority of women I see, 2 or 3 minutes, seems like an eternity,   What I THINK happens is that I start scanning in the middle above pubis and keep going all around.

Once I have made a mental note of how the uterus lies in the pelvis, I locate the arteries on each side of it, then souffle in the middle; this is where I expect/find the FHTs, most of the time.

Since I use very little pressure, I believe the fetal "movement" is largely beyond my control.

I move the panus for both FHTs and fundal height measurements because it gets in the way! I'll start trying the anteverted moms at 8 wks and see how many I get. However, if I don't get anything, it proves nothing; one way or the other; if they come back in 2 weeks with a miss, they will be pissed and say I should have known! I'll have to pick my early "listens" very carefully!

I must have missed something here. Why are you listening this early?  Are these women who are thinking they have miscarried?  Surely you don't do this on every Mom and baby?

To confirm viability EVERY mom and baby, unless she declines (RARELY)

Are others doing this?  Nobody's worried about effects of ultrasound especially so early? I guess this surprises me a lot. 

I don't try to pick FHT's up w/ a doppler at all unless there is some indication that the doppler is needed & this means for the entire pregnancy. I do have concerns on safety of ultrasound. Hasn't been proven harmful, but I'm conservative in my use of anything tech beyond fetoscope, long prenatals & w/ lots of hands on & conversing time/listening, etc., but will not hesitate to use tech when indicated or any question.

I like to get fhts with a dop at 12 wks not to r/o miscarriage but to r/o hydatidiform pg.

Not I.  When doing an initial prenatal on a woman less than 18-20 weeks, I tell her that I will probably not be able to hear FHTs, as they are usually audible with a fetoscope around 20 weeks (occas sooner).  I do always try, however, so that I can document a rule-out.  It helps if later we have a dating issue.  I explain why I don't automatically use a doppler and how I will use it if there is reason for concern.  Only a few times have I had women request the doppler earlier (and these are usually those with a hx of miscarriage who need that reassurance).  They are usually not only patient to wait until 20 weeks, it would usually be their preference.  Most are aware of what they want when they come to me, but of those who are not, they are interested to realize they not only have a choice but that there may be a reason they wouldn't want doppler use.  It's interesting how some decisions are made once there is more information given. 

I agree it usually only takes 2-3 minutes but some are tricky and take a little longer.

I agree that finding the lie of the uterus is a must.  What amazes me is that I could've gone over one place quite a few times and then all of a sudden there it is.  I agree fetal movement is not in my control none-the-less I catch myself using different pressures as I am scanning.

I listen for fhts with Doppler on all primary visits, unless mom insists to only use a fetoscope.  That is rare.  And most of my moms (unless they are primips) don't come in to see me before 4 months unless they are spotting or having problems. 

I think that time and patience is the key. Those really are very tiny hearts and dopplers are like tiny tight-beamed flashlights; very directional. You can be off just an inch and not get the heartbeat. if it is important to get the fht, then I think several minutes is not too long to listen. Another thing I see from folks who have hard times with early fhts --- I think they move the Doppler around too much and too quickly.. kind of racing it over the abdomen. better to pick a spot and move very slowly --

I agree with the locating position of uterus, there are some babies you are going to have a hard time hearing early. But the one trick I have that works VERY well, place 2 to 3 pillows under moms hips. Wait about 3-4 minutes, and your going to get clear tones. 

Agree! I place the transducer firmly in one spot and then arc around to cover an area. I think this is better than moving the transducer across the skin-too much static and artifact noise. Isn't it fun "fishing"?

Prenatal Cervical Exams

I have to say . . . this study reminds me of the stupidity of assuming that any variance from the norm is bound to become pathological.  Instead of using this as an excuse for the increased c-section rate, why don't they try to come up with some therapies to help ripen the cervix prenatally instead of just waiting until the time of induction and trying to effect all the effacement at one time.  It would also be very helpful to know whether these women were more likely to end up with a c-section simply because the effacement/dilation took longer and they exceeded artificial time limits imposed for the duration of labor.

Long cervix at mid-pregnancy predicts cesarean delivery
By Lucy Piper
28 March 2008
New England Journal of Medicine 2008; 358: 1346-53
 

Cervical length at mid-pregnancy and the risk of primary cesarean delivery.
Smith GC, Celik E, To M, Khouri O, Nicolaides KH; Fetal Medicine Foundation Second Trimester Screening Group.
N Engl J Med. 2008 Mar 27;358(13):1346-53.

CONCLUSIONS: The cervical length at mid-pregnancy is an independent predictor of the risk of cesarean delivery at term in primiparous women.

The US Public Health Service published a nice document on prenatal care a few years ago - the panel included family docs, CNMs, ob's, researchers, and nurses - their recommendation is no cervical exams at all until 41 weeks. Their rationale is that the results of the exam will not change management during the 36-40 week visits, so why introduce microbes and cause the patient discomfort.... I agree, and have been teaching this to residents for several years. Patients are usually relieved. ( of course they recommend pap/cultures/pelvis assessment early in pregnancy, and that most tests be done prior to conception)

Caring for Our Future: The Content of Prenatal Care. A Report of the Public Health service Expert Panel 1989

Primips are a little different -- if the head is really low and the cervix feels applied and thinning then I am more optimistic that the baby will not go way overdue, which is my primary concern with primips.  Just as important to me is which side the baby is on, which I DO obsess about and don't need to do a vaginal exam to determine.  If the baby is on the right the head will not be as low, the cervix not be as effaced and the baby will go overdue and the labor will be longer and harder.  This holds true nearly every time, but nothing is 100%.

Medicine and the past. Lesson to learn about the pelvic examination and its sexually suppressive procedure

The Myth of a Vaginal Exam by Robin Elise Weiss, LCCE.  [Ed.: Note that in the related article, How to Perform Vaginal Self Exam, the instruction is for visual examination, which is very different from the manual or digital examination (meaning with fingers, not electronics) that is usually done to assess cervical dilation.  It's unfortunate that this related task is rated as being very hard, which discourages women from doing the cervical self examination that is an easy maneuver when you're not pregnant; it's often taught as a component of Natural Family Planning since the cervical softness, opening and height in the pelvis provide information about where you are in your hormonal cycles.]

In Britain, vaginal exams are not done routinely as part of prenatal care.

I let them know when and how many standard vag exams women have and then explain that many women, however, choose to have two... one for the PAP and one when the membranes rupture. I let her decide how many she wants, but that two is the minimum.

During the 3rd Tri, reminding her again about the vaginal exam when her membranes rupture (or if she chooses, when she arrives, when membranes rupture, urge to push, etc.).

Why? We see many clients who for religious reasons refuse vaginal exams; so we don' t do them. We explain the "usual" of course, and that VEs may help by giving additional info in certain instances -- -- but if a mom wants to refuse a VE, Pap, etc; then why not go along with her wishes?.

Pelvimetry

I Stopped doing x-ray pelvimetry in the 70's. I have seen too many huge babies delivered from tiny pelvis without difficulty and v.v. too many small babies need c/s in mothers with huge pelvises. The forces of labor and how the presenting part presents into the pelvis is what causes the dystocia not x-ray or other measurements. I agree that labor is the best determinator of pelvic size.

What is the predictive value of prenatal vaginal exams? (written by JN)

ONE thing it s predictive for is that she will be "dropping trou" each month and looking to someone else for the answers that are coming from HER BODY. Who has the direct line anyhow???  LOL

More than anything it keeps the woman's focus on her "care"provider as the source of information about her own body and not so subtly conjures the concept that someone can determine a due date from this info.

In some circles I know that the discussion about whether or not to have a ve is regarded as a small point. Okay, I'll concede that..yes, it a small part but of A MUCH BIGGER AND IMPORTANT PICTURE!! If women are not prepared to assert themselves on the issue of routine pregnancy ve's, they are going to find it pretty darn difficult to assert any other aspect of their care. If a caregiver is routinely carrying out ve's in pregnancy, which is definitely not evidence based and has been shown to cause harm and no benefit, they are also likely to be practicing other areas of non-evidence based care.  I think that is a HUGE POINT!! ,

Here is an excerpt from a mail written by my dear friend Nikki MacFarlane who is also the director of Childbirth International.

"...lets look first at the psychological consequences of having the ve.

Mother A has a ve at 38 weeks and is told she is 2cm dilated. Initially she may be elated. It seems that things are happening. Great! Now, if she goes into labor within the next week, probably no problem. But what if she doesn't? What if she is now at 41 weeks and no labor? For three weeks she has been on tenterhooks waiting for labor to start. How despondent do you think she might be feeling about now? How much confidence do you think she has in her body? How fed up do you think she might be feeling?

What did the ve actually tell her? It told her that she was 2cm on the day she had the ve. It did not give her any other useful information. She was unable to make any choices or decisions as a result of the information. She may have been feeling more and more morose for the past 2 weeks. What effect is this mental state going to have on her going into labor and her level of anxiety? Actually, she knows SOMETHING is happening simply by the fact that she is 38 weeks pregnant - the baby may be moving down, her cervix may be softening and moving forward, her hormone levels may be changing dramatically, her ligaments may be softening. None of this was determined by the ve. In fact, she may have been 2 cm since she was 34 weeks pregnant. Lets say she had a doctor who did ve's at 34 weeks - by the time she was 38 she would have felt despondent because there had been no change. Yet at 34 weeks she would have been worried in case her baby was born prematurely. A real roller coaster of emotion as a result of information that did not enable her to make any choices or decisions, that did not empower her, and that offered no benefit for her or her baby.

Now lets look at mother B. She has a ve at 40 weeks and is told that it is tight, closed and long. She is told that she will not be having her baby in the next 1 week and that an induction has been scheduled for the following Monday. If she is a VBAC she has probably been told that she should just plan the elective section - in fact, she may even be being wheeled into theatre before I have time to finish this email! So, she has the ve. What is her state of mind? How positive is she feeling? What if she has had lots of signs of labor but now had a ve that says she is a long was away from having her baby? Could she be feeling confused between what she thought she was experiencing and what her caregiver has now told her? Now lets say she has the baby that night. What did the ve do for her? Did it offer her information that meant she could make a decision?

OK. Now look at the physical issues. Ve's suck - they are at best slightly uncomfortable, at worst downright painful. I have never met a woman who says she enjoys them or looks forward to them. So how does experiencing an uncomfortable, possibly painful procedure multiple times affect our hormone levels?

What about the significant risks? There is a correlation between multiple vaginal examinations and premature rupture of the membranes. Lets say a woman has a ve - a routine one in late pregnancy - and as a consequence her membranes rupture at 37 weeks. She does not go into spontaneous labor within 24 hours. Her caregiver has a policy of inducing labor if ruptured membranes for 24 hours (and of course most would not wait that long!) So now she is having an induction. Many caregivers insist on women being in hospital once membranes have ruptured, so she has now been out of her home and in a hospital environment for 24 hours. She is tired and fed up, probably not eaten properly, certainly not very well rested. Now she is facing a pitocin drip since prostaglandins are contraindicated with ruptured membranes. She is probably on continual monitoring. She is most likely to have an epidural. Her baby is at high risk of distress. She is twice as likely to have a cesarean. All because of that little ve.

Now lets say she was group b strep positive. She may or may not have been previously tested - irrelevant really since group b strep comes and goes and while she may have been negative for it some weeks before that is not necessarily the case now. So she has now had multiple ve's, has ruptured membranes and has had them for more than 12 hours. Her baby is at significant risk of contracting group b strep. If the baby does contract it, at best he or she will be exposed to antibiotics, possibly a spinal tap, and a stay in NICU for monitoring. At worst it will contract meningitis, septicemia or die. All for that little ve.

Vaginal examinations are thought to be so perfectly innocent. They are thought to be reassuring. And for several of you, you found that to be the case. However, separate your own experiences and choices for one moment and think about the reality of vaginal examinations.

While you may have felt they gave you the confidence that something was happening in terms of labor starting, were they any more helpful than a reassuring caregiver who helped you identify all the other signs that something was happening? Were you aware of the significant risks at the time you chose to have them? If you had known, would you have gone ahead do you think?

Most importantly, while they reassured you, what were you able to do differently as a result of the ve? Did it enable you to make between choices?

The only time I can see a vaginal exam in pregnancy as being truly beneficial is when a woman is having to make a decision and the information may help her do that. For example, a woman experiences frank red blood at term. The caregiver knows she does not have placenta previa, so does a speculum exam to see if the blood is cervical or not. They may then investigate further if it does not appear to be cervical to ensure the baby is doing ok. But then again, most of the information derived from a ve can be obtained in these circumstances from an ultrasound. Some women may not have instant access to an ultrasound and in those circumstances the ve may be beneficial."

There are those of us who believe that this VE habit is just part of the Obedience Training the US women get when they enter the Med. Model of birth care.  If you impose enough needless procedures (and VE is far from the only one), especially including procedures which require the woman to be naked/draped while the examiner is fully dressed, and which require the woman to be lying down while the examiner stands over her...well, it is a pretty good way to gain psychological dominance over another person and thus have women nicely prepped in advance of labor.  Because in labor, they need women to be utterly compliant, to make for ease of doing whatever they want that leads to our high csec and instrumental delivery rate along with high rates of many other needless and purposeless interventions, high incidence of birth trauma/ppd and Breastfeeding failure, and so forth.

Anyway I have to assume that this is the true reason for doing so many VEs both before and during labor....because any halfway intelligent person quickly learns that VE is really NOT a good way to figure out 'what is going on' and 'when baby might come'.  It is just another way that US women are coerced through deceptions about 'what is good for you/baby' during the course of medical care, just as with the necessity/efficacy of the GTT and a host of other non-evidence based but fear-and-submission inducing procedures that are common.

Weight Gain

See also: Large/Heavy Women and Birth

Excessive Weight Gain During Pregnancy Linked to Heart Disease Risk in Offspring

I would like to poll what everyone is saying to counsel women abut weight gain in pregnancy?

Would your counseling be the same for someone overweight, underweight, or at her desired weight?

The reason I am asking this question is because I casually met a client who has been seeing another midwife and she very proudly told me that she has gained NO weight so far and she is at 18 weeks. She was told that she should gain no more than 15 pounds for the entire pregnancy because she was starting out overweight, she is 5' 3" and was 160 at the beginning of pregnancy. I asked this woman what she was doing to not gain weight and she said she is eating about 2 1/2 meals/day and cut out all in between meals. She is not doing any specific exercise. I didn't do a diet recall with her as it wasn't appropriate at the time.

This encounter did in fact get me thinking as to what is appropriate weight gain in pregnancy? I should say that I personally have never told a woman that she should only gain 15 pounds in pregnancy.

There is a reasonable reference with recommendations that we can use. The Institute of Medicine published "Nutrition during Pregnancy and Lactation" in 1992 - the panel authors are good scientists and very sensible. It's the source of variable weight gain recommendations based on pre-conception weight. (29-40 pound weight gain for underweight, 25-35 for normal weight, 15-25 for overweight, >=15 for obese, and the definitions for normal weight etc. are body mass index. There are separate recommendations for twins. You can buy copies from 1-800-624-6242 (this is an old number - it may be on the Internet by now, I haven't checked)

I personally rarely counsel much regarding weight gain , I think it's far less important than counseling good nutrition. But I would never counsel a woman to limit her weight gain to 15#.

I do sometimes find that "very overweight" women may loose a few pounds while maintaining an excellent diet and still grow good sized healthy babies. I have several full quiver clients who seem to be better motivated during pregnancy to stick with a healthy diet. These particular ladies start out 200-330# and often loose about 20# when pregnant.

At the other end of the spectrum, I followed the SPUN diet for 3 of my pregnancies. I not only ate all that food, I grew most of it ,too. Started those pregnancies at 104#. The first I gained 50#, second and third, I gained 92# and 96#. And I felt wonderful. And I lost the weight within 10 weeks pp. But I looked like the Aids commercials that were popular at the time. ( How many of you remember Aids - the diet candy -- and the SPUN diet?)My last pregnancy, I gained 22#, and never lost more than 12#of it.

I'm not so sure I buy into the concept that being overweight - by the contemporary standards set by the powers that be- is so unhealthy. In my clientele I have a fairly large percentage of big women. I don't see that any more of them are hypertensive than the rest of us. Also, they are generally as energetic. It's inconvenient to work around the fat, but so what?

Anyway, so much of the weight gain issue has less to do with health and more to do with self image. I think that it's important for us to put the emphasis on good amounts of healthy food, and feeling good about one's self. I think it's okay to tailor the counseling to meet personal needs. The 160# lady who really views herself as fat needs body image counseling and some help in figuring out how to maximize her intake while minimizing fats and sugars. And I wouldn't mind learning something from the couple of the 200# ladies I know who feel so sexy.

It's so amazing to me the way different sized individuals can grow such healthy babies.. I just had a client that definitely has an eating disorder - she's 5'6, and started out at 98#, and got up to 115#. Last week she had a 9# baby. Very lucky, I think.

I tell my women to eat a whole foods diet, no junk, very little or preferably no refined sugar, and whole fruits instead of juice. I counsel them on this and on protein. I let them know that most of my women gain between 30 and 40 pounds which will give them about 10 to 20 to lose afterwards. I have a very good program for losing weight but pregnancy is no the time. An obese woman may find that by eating this type of diet she ends up weighing less after she delivers than when she started.

I also like all my women to walk daily, 20 to 30 minutes.

I counsel women that if their diet is appropriate and they listen to their bodies, they will probably gain the right weight for them and this particular pregnancy. I talk about the need to have a fat store for breastfeeding, and how difficult it is to lose that fat store if you don't breastfeed. I talk about body image issues, about how their mothers may have been starved or put on diet pills during the pregnancy that led to them, and about all kinds of psychosocial issues related to food and weight gain. I try not to cram this into just one visit, but make some comment at most visits about how they are growing a healthy baby, etc. Pregnancy is a time when women are very motivated to make changes (unless they are so much into survival mode that nothing sinks in!). I have seen moms have healthy babies and stay healthy themselves ranging from a weight loss of 30 pounds (she started out >300 lb., ate lots of complex carbs, fresh fruits and veggies, and limited fats to olive oil and butter very sparingly, had a 10 pound baby) to gains around 90 pounds (was 5'10'', 105 pounds at the beginning of her pregnancy, ate lots and lots of healthy food, had a 9 pound baby). I think setting up magic numbers is probably inappropriate. just my two cents worth.

This is something I just don't understand, and I would like some feedback on it. I occasionally am contacted by women who are overweight who have been told by their physicians or whoever that if they are overweight, they should only gain 10-15 pounds, and maybe even lose during pregnancy. I've always been mortified by that, and I tell them that the baby does not/should not live off the mother's fat stores, so it makes no sense to me to gain any less than any other average woman, and certainly not LOSE!!! But I am interested in discussing this topic...am I just way off here? I just don't understand the physiology of why they "should" gain so little or even lose weight, even eating well!! Why does it matter if they are overweight to start with?? Perhaps somebody out there with a strong knowledge of physiology can explain this if indeed it makes sense. Or is it just society's way of keeping these women to a minimum because of prejudice against the obese?

I think the assumption is that they are over weight because their diets are so poor. If that is true them the idea is to improve their diets. In so doing, she will often lose weight.

I once had a friend that was quite over weight. Her problem was that she was a junk food junky. After counseling her about good nutrition she went on the lose 40 pounds during her pregnancy and her baby was 9lbs. She was amazed because she said she ate ALL the time!

To me the emphasis should be on a GOOD diet not weight gain!

BTW, in Texas, it is against the law for us to take an obese client!

Don't know if I'm the right one to address this, but most women who are overweight are this way due to too high an intake of calories and too low output through activity. When they eat a diet that is nutritious and lower in fats and refined foods, they can continue to eat a high amount of calories but unless it's the same very high intake, they will lose weight. It doesn't take 3,000-4,000 kcals/day to nourish a woman and her unborn child, but this may have been her usual caloric intake before pregnancy. This may be the first time in a person's life when she has been properly counseled on what to eat, and with this information some women change their lifestyle and do eat much more nutritious foods. Haven't you heard women in your practice say no one had ever told them before that french fries can't be considered a vegetable? So many of the women I see eat fast food several times a week, and hold many fallacies about what good food really is. I've seen women who were over 300 pounds lose 40 or more pounds during pregnancy, have a 10 pound baby, and never regain all the weight. They didn't go hungry or try to limit their weight gain. They simply changed their eating habits from a high-fat, low vegetable, lots of refined foods diet to one that would nourish their bodies better. They filled up on healthy foods and didn't crave sugar as much. They may also have been more concerned with getting enough nutrients in and eating regular meals at home and didn't go to McDonald's as often.

I lost 85 pounds in about 8 months, simply by eating a nutritious low-fat diet and exercising. Many women just need some education about what to eat and they are able to change their lifestyles to where they will continue to improve their health. Maybe our society is a bit prejudiced against the overweight, but we need to recognize that obesity isn't healthy, and women should be educated about how to improve their health by improved nutrition. It's a very empowering feeling to know that you can take charge of your life and your health, and it doesn't take someone else or something else (pills, surgery) to do it, you can do it yourself.

The western mind loves to be able to easily quantify things. That's why the obsession with vitamins and weight gain. They are external measurable variables. They are so much easier to deal with then the whole notion of a good diet. If a woman is eating a good diet and getting plenty of exercise she'll gain the right amount of weight. As for a woman who is 5' 3" and 160 lbs I think her lack of weight gain thus far indicates that she is eating wisely. I think any significant weight gain or loss would make me evaluate her diet. I think a 15 lb wt gain in this profile would be great. So would 30 lbs. One thing is for sure she'll be gaining weight soon.

I think we all need to put as much energy into caloric expenditure as we do intake. Having a high caloric, high protein diet and a sedentary lifestyle leads to a chronic low level of hyperglycemia and big babies. I sure see this a lot in my homebirth moms.

I remember reading once (I think it was in one of Ashley Montague's books...Life Before Birth) that the only way that maternal diet affects fetal weight is negatively, which means that a poor diet can contribute to a stunted baby, but that, with the exception of diabetes, you can not make a baby grow bigger than it's set point, no matter how many calories the mother takes in. Fetal birth weight is determined by genetics, and with very few exceptions the baby will not get over a certain size. That's why women with big babies have very little problem getting those big babies out, but when diabetes is involved the babies are more likely to have serious labor or shoulder dystocia, one of the reasons that doctors get so nervous about diabetes.

I have seen many women gain 60-100 lbs. during the pregnancy and have a medium sized baby (7-8 lbs.) And of course I have likewise seen well nourished women of medium build and modest weight gain who have >10 lb. babies.

One of the reasons I like to encourage my client's to gain 30-40 lbs., with little regard to pre-pregnancy weight, is that I can not be sure that a women is going to take any of my nutritional advice once she leaves the office, so if she is eating enough to gain a lb. a week, then there is at less a chance that some of the food she is eating is nutritious...I hope! :-) The exception to this is when the woman is morbidly obese.....In these cases I explain to her how many calories it takes a day to support her body at it's current weight (the easiest way to figure this out is to multiply her weight by 10-sedentary, 11-moderate activity, 12-high level of activity; for instance with a woman weighing 230 lbs. who has a couple of small children and walks three times a week I would multiply 230 X 11 = 2530 calories a day to just support her 230 lbs.) That is a lot of calories! So I explain to her that she can eat nearly TWICE the amount of food of a woman who weighs 115, and if she keeps it to that many calories and makes them high quality calories, she will most likely gain only a few pounds, if any, during the pregnancy, and perhaps weigh less then when she started. They like this idea!

When I went to my first MANA conference years ago, one of the things that interested me the most was the wide range of clients that the different midwives I talked to had. I have noticed that in the last 12-15 years I have seen my clients changing from the "earth-mother" anti-medical intervention type to a more urban, lower middle class, would have a hospital birth if they could afford it, type......women who don't qualify for aid and yet have jobs that don't offer insurance. These people usually have normal American diets (high protein, low veggie, high calorie) and have never been inside a health food store. They want to buy a one-a-day type vitamin and don't have the income to buy much more than a Walmart brand prenatal vitamin. Herbs usually sound intriguing to them but have no knowledge of herbs and want instant results when I finally talk them into getting some (they think the herbs should act like an OTC drug!!)

When I realized that this change was taking place, I began to "allow" women to not take kelp, alfalfa, chlorophyll, high-potency vitamins, red raspberry leaf tea, 6 week formula, etc....all the things I had learned to rely on to make healthy babies and good births! The results??? NO DIFFERENCE!!! Sizes of babies have remained the same, my transport rate has actually gone down (was 3-4% and now it's about 2%, but I think this has more to do with my level of experience going up), no increase in PPH (I've never carried pitocin until recently, and have never transported for a serious bled without a retained placenta and actually, I see fewer retained placentas in the last few years, and remove my own retained placentas now), no increase in babies who need resuscitation or 02 to pink up, everything seems just the same, only my client's are spending way less money on various supplements, which I encourage them to buy better food with!!!!

I do think that weight gain is important, and I especially get on those skinny, little moms who just about faint when they see 115 on the scale ("Oh, my God, I never thought I would ever see the scale say THAT!!!!") I usually tell them that what they are doing to their baby is kind of like the runt of a litter of puppies. The runt is genetically supposed to be the same size as the other puppies, but the nutrition just didn't get to him, he looks normal and with love will grow pretty close to normal size, but he is a little hyper and runs into doors and things like that!!! The brain needs fuel to grow and if the calories aren't there the brain will not grow properly and neither will all the organ systems that will help him to reach his genetic potential.

Couldn't agree more! I just thought that you might be interested in a new longitudinal study about nutrition in pregnancy that was published in Nature (vol 388, p434) this week and was announced at an international nutrition congress in Canada. Causing much excitement among the science press at least.

The team at the MRC nutritional unit in Cambridge have done a detailed analysis of birth and death records since 1949 of 1000 people from the Gambia. Basically they have compared people born during the harvest season (Jan. to June) with those born in the wet, "hungry" season - when most adults loose about 6kg.

The team found that all the infants died at a similar rate no matter when they were born. The surprise finding, however, is that by the age of 15, those born during the hungry season had a mortality rate FOUR times as high as those born in better times. And by 25, mortality was TEN times as high. The effect was largely because of fatal infections - so it's strong evidence that the immune system is totally primed by fetal nutritional status and that this effect on defence mechanisms is there with you for the rest of your life.

True, the patterns of feast and famine are much clearer in somewhere like the Gambia, but this could be the first really sound scientific evidence that something pretty serious could be happening in the womb when fetal nutrition is compromised. Although this work was done in a developing country, it supports the work done in the UK by Barker's team (in my old alma mater) which suggests that poor fetal nutrition increases the risk of heart disease later in life. Generally, in developed countries, infections are less of a problem but it's becoming clearer just how the immune system influences the occurrence of cancers, allergies etc.

Since pregnancy lasts longer than either of the seasons, the team want to do further work to define if there is a "sensitive period" and when it happens. They think that it may be the fetal thymus - where Tcells develop - that could could be especially vulnerable; the consequences of this could lead to an impaired ability to build up immunological "memory".

I counsel my women VERY individually about diet. I know that a truly overweight mom can gain very little, if any, and still grow a healthy baby, but this is done on a very healthy diet plan. I would really be worried about this woman's baby and would want to see a diet sheet right away!!.

My thing with clients is "How do you eat? What do you eat?"

I am not concerned as much with numbers on a scale as I am with PROPER nutrition throughout pregnancy. I am amazed at how many women do not have any idea about correct diet throughout pregnancy and what a difference it makes in their general health as well as the labor , delivery and post partum period.

I do have my clients weigh themselves each visit, but I also keep a close check on how they are doing with their eating habits. ON AN AVERAGE, my clients gain between 25-45 lbs. But, if they are taking in what they need to be, their body will determine the pounds gained. Many women have a "JUMP" somewhere in their second trimester. I have seen it over and over. So, I'm not concerned when a mom comes in between four and six months and has gained seven to ten pounds in a month. I would be concerned if she did that every time, but knowing what the body needs at different stages of pregnancy helps monitor the overall picture.

By the way, the babies born to these women average between 8 - 10 pounds. Healthy and no problems with birthing. They are off to a good start.

My bottom line: Don't JUST look at the numbers, look at the intake.

Interesting subject. I am almost afraid to admit that I have stopped routine weight checks on the women in my practice. I rely on nutritional counseling, diet sheets, and how the woman looks and feels. If I have any concerns, either low or high gain, then I will check. So far this has worked very well and the moms love it.

Plus carting around my scale in my car while I do home prenatals has made it totally inaccurate anyway!

well, I'll admit it too - -- I don't do routine weights anymore either. I ask them to weigh themselves a few times (just so I have something to chart[GRIN]), and tell them that we just want to make sure that they are still GAINING weight and I don't really care how much...

I have a client now who is 16 wks pregnant 5'4 and weighs 180. We have ask her to use our diet sheet in order to keep track of her proteins, fruits, vegies etc. We also have her walking a 1/2 hr a day working up to 1 hr. It's obvious this is all very new to her and she will probably loose some weight with this pregnancy. We told her she may only gain 15 or 20 lb and that would be fine as long as she was following the diet sheet.

I have also seen ladies gain 60 lbs and have 61/2 lb babies or gain 20 lbs and have 11 lb babes. Just goes to show we are all individuals and need to be treated that way!

Around here I don't think anyone would bat an eye at 5'4 and 180. We'd figure she'll weigh somewhere around 200-220 at birth and would be surprised at any less than that. Most midwives here are quite comfortable with heavy moms -- and wouldn't consider her to be a heavy mom!

We discuss the DEFINITIONS of "good diet" with everyone, of course...

I tell them average gain (here) is 35 - 50 pounds and if they are a bit underweight then they should expect the higher amount and if they are overweight then the lower range. I can't see that starting weight affects this very much...

For anyone over 200, we encourage a gain of around 25. I think this is the minimum for best outcomes... (and really, if a mom weighs 280, then 305 at term ain't much difference!).

Few midwives in this region are concerned about weight gain -- unless it is too low! most would be nervous with only a 15 pound weight gain -- regardless of prepregnancy weight..

I'm not sure where the idea of keeping women's weight down during their pregnancies came from - maybe someone could help me out here. I suspect - but have no firm evidence for it - that this could be right. There IS an enormous amount of prejudice against people who are "overweight"; but this is probably as much a cultural "thing" as much as anything. For example, in some cultures overweight is a sign that a family is doing well and prospering. Weight gain was never seen as a problem - at least until more recently when the risks of diabetes, arterial disease, hypertension etc. became clear.

In the UK they seem to have now stopped recommending that women gain any particular amount of weight. A Guide to Effective Care in Pregnancy and Childbirth (ECPC) pointed out that there appears to be no firm scientifically-based evidence about what is the "right" amount of weight gain during a pregnancy. So what generally seems to happen here now is that pregnancy is viewed as a time when women can get some sound nutritional advice - they all see a dietitian.

But we are all - scientists and health professionals alike - a bit concerned here; the message about "wellness" doesn't seem to be getting through to people, pregnant or otherwise. Part of the problem is probably more to do with the western obsession with food that is not particularly good for us i.e. of poor nutritional quality; a lot of sugar, salt, hidden fat, acidic drinks, etc.; all of which make the food palatable (and quick). People are loosing the art of preparing food for themselves and of enjoying the sharing of food i.e. eating meals together as families.

Another major problem is the fact that so many people are trying to "mould" their bodies into a shape that they were never designed to be. The Cindy Crawford, Naomi Campbell, Claudia Schiffer - type body may be what people see as "the ideal". In fact, in terms of human morphology, that kind of body shape is simply not achievable for about 98% of the population. Why, oh why are people all chasing a dream? The vicious cycles of diet/binge/diet are actually really bad - and there's more and more scientific evidence to support it.

However, it seems to get drowned in among all of the "health bandwagons", fashions and fads - they are generally loosely based on something that sounds pretty scientific to those without a sound background in physiology or nutrition and - more importantly - somebody is usually making money out of it! Where there's a profit to be made, then someone will wrap up their product in something that sounds impressive - and sell it.

Sorry to be a cynic here, but there is a prejudice against the obese and overweight. Generally people who are not themselves overweight think along the lines that people are overweight because they eat badly/learned bad nutritional habits early on/ do not take enough exercise/are lazy........da, de, da, de, dah............................... (I'm not overweight and on a rant here, BTW). There ARE physiological differences - we're just not sure what they mean eg the role of a group of chemicals called leptins, the role of "brown fat", genetic predisposition and so on. A part of the problem is that it's very difficult to find any volunteers for nutritional studies who have never been on a diet (particularly women) which may in itself profoundly do weird things to metabolism

It's kind of hard to explain without going on too long. You're midwives, though. You know how sometimes it seems that women's physiology is only understood properly by women (and some exceptional men like the ones on this list) - because it's different from men's???? Not some kind of odd, mutant form of male physiology - which is kind of how it's been treated for most of this century - but NORMAL for women???? Do you know what I mean? Well, it MAY be that physiology of obesity is different from the physiology of those who are not. But it's not at all clear how it's different; some glimmers are coming.

Whatever they are, making sweeping judgments about people's weight doesn't seem to help. Far better to give people decent nutritional advice and help them to accept their bodies for the wonderful, amazing things they are. Making them feel guilty about their weight or afraid that they are going to die young doesn't necessarily seem the appropriate approach - but that's very much a personal opinion.

As for during pregnancy; well I'd have to go along with ECPC's recommendations;

They inevitably point out the problems associated with studying diet and the lack of adequately controlled trials but conclude:

"there is no evidence that dietary restrictions of any sort confers any benefit....................................................; dietary restriction can cause marked decreases in birthweight although the extent to which such decreases in birthweight are associated with perinatal mortality and morbidity is unknown................there is no justification for allowing pregnant women to go hungry or for imposing dietary restriction or major manipulation of the dietary constituents upon them. "

I think the basic philosophy, which I have seen to be somewhat true is that if a woman is obese, she probably does not have the best eating habits, and she gets pregnant, and totally changes her eating habits, then she will lose weight and still feed her baby well. In order for her to keep gaining weight, she would have to continue eating the way she was. When someone becomes obese over a period of time, it is generally because they have added more and more fatty foods into their diet over time. If they discontinue, or gradually eliminate these foods from their diet, they will lose weight. With good nutritional counseling (NOT DIETING), the mom is bound to lose some stored fat. This is all assuming that the obesity is due to poor/malnutrition, and not a physiological disorder.

I like to talk about good nutrition and not pounds. There are a few women that I will not put on the scale because they have such negative emotional responses to weight gain. I make them bring me diet histories and I go by fetal growth. I also scare them into eating well by talking A LOT about brain development. This is such a big issue in our body conscious society that I try not to add to the stress.

This is my philosophy re diet:

I encourage all women to eat nutritious foods, to cut down consumption of "junk" (my definition is foods that are high in calories which give little in the way of nutrition). I give everyone the same basic handouts that encourage healthful eating, describe nutritional requirements, and ways to accomplish diet improvement without too much "pain".

From there, I tailor my approach to the individual situation. For the woman who starts out heavy, I try to identify issues she may have around her body and screen for things like binge eating, bulimia, etc. I try as much as possible to build a positive outlook toward her body. I tell heavy women things like " if you continue to eat a normal healthy diet in pregnancy, you have less chance of having a low birth weight or premature baby" (which is true!) even if they don't gain as much as their thinner sisters. I prescribe nothing in terms of what they should gain but simply tell them the average range of gain that I see and emphasize that I only get upset if I think a woman is not gaining enough. And what I do see, is that many healthy women eating a healthy diet in pregnancy who started out heavy don't gain as much as their thinner sisters, or even lose a bit in early pregnancy. As long as the baby is growing, the woman feels well, we have reassurance that she is not starving herself (I do have people do periodic diet diaries and get counseling from my assistant on this), I don't make a fuss. I will counsel re decreasing fats and sugar if need be, but I don't say thou shalt gain any particular number of pounds.

Women who are underweight when they start pregnancy get a lot more encouragement from me to put on some weight, particularly if they are worried about "fat" These women, IMHO, are at much more risk of low birth weight infants, PTL, IUGR. Again we do diet diaries, and screen for eating disorders, and issues around body image that could be counter-productive to health. And we spend a good deal of time educating women why nutrition is important and helping them feel as in control of this as possible. And of course, personally, few things are more beautiful than a healthy glowing pregnant woman except those lovely nursing newborns and their healthy moms.

Hi, as an obese mom who lost weight during pregnancy...I did nothing different than usual. I ate well with absolutely no reduction in food. I did not do anymore exercise than usual. My doctors said that it was ok for a larger mom to not gain much or to lose weight. I think the mom's metabolic rate increases during pregnancy or something. Like during breastfeeding, you burn more calories producing the milk. I breastfed for 14 months and gained 20 lbs as soon as I stopped. As long as the mom is getting enough food, nutritionally balanced, the baby is getting that food, not living off mom's fat stores. If she is on a diet...a strict one...then I could see the baby living off the fat stores. Back in 1963 my mother was put on a 900 calorie per day diet when pregnant...trying to make her lose weight. That baby was tiny. And she lost 30 lbs....she said she felt terrible.

I felt great. I had lost 10 lbs...I was healthy, my baby was healthy. I did not feel any pressure from medical professionals or people around me to lose weight in my pregnancies or to gain weight. It was left alone. I was sent to a nutritionist early to make sure I was eating well enough. No problem there.

I just want to post from the other side of the spectrum.... When I was pregnant, I conceived at 200 lbs. I am 5'4 and big boned, I felt I was in great shape, I had a hard physical labor job, walked 5 miles a day and was healthy. My OB was a military doc who was 6'2 and thin as a rail and told me if I gained anymore than ten lbs I would be an automatic C-section. Well the bastard ( pardon my French) scared the crap out of me. In my 12th week of pregnancy I found out I was carrying twins, and he freaked even more telling me that women who were morbidly obese ( yep that is what he called me ) don't carry pregnancies well, or deliver well. ( I don't think anyone delivered well with him, due to his tude ). So my neighbor who I thought at the time was a hippie, happened to know a midwife. So she took me to see her, and listened to my story, and told me I was just really healthy, and she'd be happy to deliver my babies at her birthing place. This was in 1981, and in the deep south, she said she had been birthing the babies in her town for years. Well as it turned out, I lost my twins at 25-26 week due to a nasty fall down some steep stairs, but the 26 weeks I was pregnant, I ate well, no junk, no soda, lots of veggies, herbal tea, proteins ( I can recall TONS of protein ) lots of fruit, juices, etc., and I lost 15 lbs and was declared healthy, and I didn't feel like I didn't food, I had so much food it was just the right kinds of food, and I cut out the crap. So I really believe the baby takes from Mom first, is that right?

Antepartum Testing for Women over 35 at Term

Antepartum Testing of Women Over 35 Prevents Unexplained Stillbirths at Term [Obstet Gynecol 2004;104:56-64] - [Medscape registration is free]