“Mailbag #2!: with Dr. Stephanie Melka”

On our second mailbag episode, Dr. Nathan Fox invites OBGYN Dr. Stephanie Melka to answer some of the top questions from our listeners. They discuss LEEP (loop excision electrocautery procedure) and its risk for pregnant women; whether testing is necessary for women who would want to keep a fetus with a known genetic disorder; how to know if a doctor is good; a condition called android pelvis (referring to the way the pelvic bones are structured); and whether information is available to understand why some women don’t go into labor.

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Dr. Fox: Welcome to today’s episode of “Healthful Woman”, a podcast designed to explore topics in women’s health at all stages of life. I’m your host, Dr. Nathan Fox, an OB/GYN, and maternal-fetal medicine specialist practicing in New York City. At “Healthful Woman”, I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Melka, welcome back to the podcast. How are you doing today?

Dr. Melka: I’m great. How are you?

Dr. Fox: I’m just wonderful. So this is a mailbag podcast. We had one before with Spiegs, with Dr. Spiegelman. Big hit, people liked it, questions started flowing in, flooded with questions, which is amazing. Thank you all for sending in your questions. And I figure we’re gonna give Melka a chance at bat here.

Dr. Melka: Uh-oh, I’m on the hot seat.

Dr. Fox: You’re on the hot seat. You were telling me that you are being recognized in the office by people listening to the podcast.

Dr. Melka: I am. It’s really exciting.

Dr. Fox: Yeah. What was the last person who said they heard you on the podcast?

Dr. Melka: She didn’t know if it was an emergency to call, so she listened to the podcast. Should I call my doctor or not?

Dr. Fox: It’s a long time to wait to get an answer. All right. Well, that’s cool. So we’re gonna do the mailbag again for our listeners and for you, Melka, if you’re not quite familiar with the format of this game show. Basically, we’re gonna read a question from one of our listeners and then we’re gonna talk about it. Neither of us spent a tremendous amount of time preparing for this. We’re gonna try to take it, you know, really off the cuff and, you know, give our honest opinions on this. And if something really crazy is said, I’ll just edit it out, so it’s fine.

Dr. Melka: Great.

Dr. Fox: All right. So question number one from Brittany. Brittany, LEEP, what is your take on the risk associated with pregnant women who had a LEEP prior to pregnancy? I had a LEEP about five years ago, and my gynecologist described as conservative because she knew I wanted to have children in the future.

Fast forward five years, I saw a new OB for my pregnancy appointment and the OB says she thought I should see the high-risk team and get weekly ultrasounds based solely on the fact I’ve had a LEEP. This seems extreme to me since she couldn’t identify any physical evidence of an issue. Do you agree with the recommendation and would you consider me “high-risk” this early based only on the fact that I had a LEEP in my 20s? So maybe first, just for our listeners, explain what a LEEP is and then we will go into the details.

Dr. Melka: So a LEEP is L-E-E-P, loop excision electrocautery procedure. Basically, it’s removing sort of the outer layer of the cervix done for treatment of cervical, basically pre-cancerous things that might progress to cancer.

Dr. Fox: Right. And this is a relatively common procedure?

Dr. Melka: Not that common nowadays.

Dr. Fox: And why is that?

Dr. Melka: More data with Pap smears linking cancers and pre-cancers to HPV. So better interpretation of the Pap smear results. You know, years ago it was kind of like, oh, you have an abnormal Pap, let’s just do a LEEP. And you had more women that met criteria for it whereas nowadays things have shifted a little bit more conservative.

Dr. Fox: Right. And I think also because of concerns, A, you know, LEEP, it’s like a minor surgical procedure, so best to avoid those if you can. But also there was this concern about risk to future pregnancy, which made everyone sort of pause a little bit before doing them as routine. Okay. So you, you’ve done a LEEP on someone or you have someone who comes in that have a prior LEEP. Is there a concern in the pregnancy?

Dr. Melka: Yes. A little bit.

Dr. Fox: I think that’s a fair way to put it. Yes, a little bit. Yeah. Brittany, I think it’s probably somewhere between your first gynecologist and your obstetrician. The first one said, “Yeah, not much.” And the second one said, “Oh my God, like this is crazy.” It’s probably somewhere between, I mean, if you look at studies that compare women who had a LEEP to women who did not have a LEEP, there is a higher chance of preterm birth in the women who had a LEEP.

Now the thought process behind that, if it’s real, is that removing either a physical portion of the cervix or maybe some of the protective portion of the cervix, like that makes mucus and sort of, you know, keeps bacteria from getting in, by removing that you’ve increased the risk of preterm birth, that’s sort of the thought behind it, but it’s not entirely clear if it’s the LEEP itself. It could be that just having a problem that needs a LEEP, right, could be an issue that leads to preterm birth or it could be other demographic factors.

And so it’s not entirely clear in an individual person if the LEEP itself is what increases her risk. And also it’s unclear what can you do about it, that’s the other issue. And you know, people talk about cerclage, which is sewing the cervix closed, which we don’t do for people with their prior LEEP unless there’s extreme circumstances like they have their whole cervix removed during the LEEP, which is not desirable. Yeah.

Dr. Melka: From a surgical perspective, she brought up that it was at the shallow LEEP…

Dr. Fox: Yeah. Conservative is a word she used. I dunno if she meant political or… It was done by a Republican.

Dr. Melka: Yes. It’s very hard to know. Like, yes, you can sort of think, okay, I’m only taking off a little piece of the cervix, but months, years later when we look at the cervix, regardless of the type of LEEP they had, it very often looks normal. And there are times that I’ve looked at a cervix and been like, oh, this looks completely normal, I can’t even tell you had to LEEP. And then you do a cervical length and they have a short cervix on sonogram and vice versa like there are people that have had two LEEPs where you would think, oh, a lot of the cervix has been removed, but then they do absolutely fine. So even if I did the procedure and I knew, oh, I only took like a little bit of the cervix, I wouldn’t use that to decide how I follow them in the future. Like, I’d still follow them regardless.

Dr. Fox: Yeah, no, that makes sense. I mean, it could be with, again, how the cervix heals might be differently person to person. It could be how bad was there like inflammation before? I mean, we really don’t understand it well enough to sort of categorize it in a sense. Now, there’s some people who come in and say they have a history of a LEEP and we look and we like can’t see the cervix anymore, which is unusual. But that does happen from time to time and those are people we’re generally more worried about.

But like you said, you can’t really tell someone, “Oh, your cervix looks normal, the LEEP was small, therefore you don’t have risk.” Again, the risk isn’t crazy high, but there probably is some risk. In our practice, we do an ultrasound check in the cervix sort of from time to time, for some people, every four weeks, some people, every two weeks. I mean, it really depends on the exact circumstance. It’s unusual that we would do it weekly, you know, like your OB suggested. But again, I’m not saying we’re right and they’re wrong, it’s just that’s what we typically do. And it seems to have worked okay in our practice of balancing, like not worrying people too much versus being on top of something.

If nothing happens, there’s nothing about seeing a high-risk doctor that’s gonna be helpful. Meaning if the cervix is normal, you know, it really doesn’t make a difference who you see. It’s just a matter of having someone who either chooses to follow or says, you know, I know about it, but I’m choosing not to follow for reasons A, B, and C. Now, that’s not how we do it. But again, there’s definitely people who don’t do cervical lengths for someone with a prior LEEP. And, you know, there’s a lot of variation out there. Good question, Brittany. Hope that was a good answer for you. All right.

Dr. Melka: So this is good you had a gynecologist that actually does LEEPs on the podcast that I can answer this.

Dr. Fox: So, yes, one might think that as the host of this podcast, I just do things randomly, but no, Melka, there is a plan in place and I…

Dr. Melka: I don’t believe it.

Dr. Fox: I chose questions that I thought would be relevant to your practice of OB/GYN and I held back on some that might be more relevant to maternal-fetal medicine, though there’s a lot of overlap, obviously, but yeah, thank you for noticing that. All right, question number two is actually a two-part question. So 2A and 2B, and this is from Braha. Thank you for emailing us. Braha writes, I would love for you to address what testing is still necessary in pregnancy for someone who would keep their fetus even if it were born with a lifelong disability. For example, is there any reason to do NIPT, which is screening for Down syndrome and other genetic disorders or other tests? That was question one.

Question number two, which is unrelated. Also, this may have come up in a previous podcast. How do I know if a doctor is good/skilled? Thanks for the great podcast. And then Braha put in a note, “P.S., I especially enjoyed the episodes with Dr. Corum Luth and also enjoyed Dr. Melka as a guest.” So, see why I put that question in for you?

Dr. Melka: I like that you’re stroking my ego today. I really appreciate it.

Dr. Fox: Well, it’s Braha, it’s not me. She sent it in. That was fun…

Dr. Melka: Thank you. Braha.

Dr. Fox:…that was not prompted. All right. So let’s start with the first one. And basically, I guess the question is, so we do genetic screening in pregnancy. There’s the kind where we check if the parents are carriers of a condition, and those are usually like childhood conditions, like cystic fibrosis, Tay-Sachs, and whatnot. And then there’s the kind of genetic screening we do on each pregnancy for this fetus, things like for Down syndrome, Trisomy 18, Trisomy 13.

And I guess Braha’s question to sum it up is let’s say I’m someone who termination of pregnancy is just, it’s off the table. It’s not an option for me for whatever reasons whether it’s religious, whether it’s moral, whether it’s, you know, they’re just scared of it, whatever it might be. Is there a point in doing genetic screening, if you are of that opinion and you hold that?

Dr. Melka: It comes down to do you want to know about this condition in advance or be surprised at the time of delivery. I’ve had few patients over the years that have had no screening and delivered a baby with a genetic abnormality. And it’s a hard thing to deal with in general, let alone going into labor, you know, sort of expecting everything’s gonna be fine, and then finding out something that’s gonna significantly change, like, you know, your kid’s lifespan or their health.

Some people then look back and are fine with it. “Oh, it doesn’t matter, you know, I would’ve felt worse knowing. I would’ve gone through all of pregnancy having this hang over my head.” But then others would want the information to be able to prepare, know what this means, you know, what is this gonna mean for my child? What can I do in advance to learn about it?

Dr. Fox: Yeah. I sort of, when I had the conversation with people and they sort of bring up, “Well, you know, is it worth it? I wouldn’t terminate. I don’t think so.” And I always tell ’em like, you don’t have to decide at 10 or 12 weeks of pregnancy really heavy decisions like, would I terminate if my baby had this versus this. like that’s real gut-wrenching stuff and it’s not necessary to deliberate that internally.

And if you’re in a relationship with your partner, like at that time, it’s just, that’s a lot. Like, that’s a lot of stuff and I say it’s not really necessarily about that because for some people they’re gonna get an abnormal result and they’re terminating, it’s the right thing for them, and other people that get an abnormal result and they’re not. And that’s the right thing for them. But it’s not really the point of the screening. The point of the screening is not to make a decision about terminating a pregnancy, it’s to make a decision about do you want information. And different people want information for different reasons to different degrees.

So like you said, there could be some, they know they’re not gonna terminate, but feel like, yeah, I would definitely wanna know if my baby had a certain genetic condition because I wanna prepare, I want to read about it, I wanna learn about it, I wanna talk to doctors about it. I wanna figure out do I need to deliver in a different hospital potentially, or do I want to move to a school district that has better services or like, whatever it might be, they said, “I’m the type person who I’d rather be prepared so when the baby’s born, it’s not a new shock to me and I don’t have to start doing this from scratch while I’m with a newborn.”

Whereas others, like you said, would be like, like, “You know what? I’d rather just go about my pregnancy and like, you know, bliss and just not know what’s going on, and likely it’ll work out at birth and if it doesn’t, I’ll deal with it then.” And those are personality decisions. It’s not necessarily right or wrong. And I think that that’s an important distinction. A lot of people feel that they either can’t or shouldn’t do genetic screening because they are of the opinion that, you know, abortion’s off the table. And I always remind them, you don’t have to do anything with the results.

Again, and I say if you’re someone who would like to know in advance, and again, 99% of the time you’re getting information that’s reassuring, like, your baby does not have a genetic syndrome. So if that’s gonna make you feel less anxious, that’s a good reason. Or if you’re the type of person who likes to prepare and likes to know, maybe you would wanna know in advance if you happen to be someone who’s gonna have a baby with a condition. And so I think that that’s not always clear to people when they’re making decisions about genetic screening. But it’s important. We have a lot of people who come in who at the outset say, “No, I’m not doing genetic screening.” And some of them, after you talk to ’em about it say, “Oh yeah, maybe I would, you know.” Good. All right. Good question.

Dr. Melka: Also wanna throw out because this comes up a lot that a lot of these genetic disorders are not picked up on sonogram. Meaning people can have every sonogram we do, NCAL, early anatomy, detailed anatomy, fetal echo, growth, and everything looks normal and it doesn’t always pick these things up.

Dr. Fox: Yeah. You can absolutely have a baby who appears normal on ultrasound and it’s not that the ultrasound’s wrong, when they’re born, they also appear normal, but they could have a genetic condition. And so it’s nice to have a normal-appearing baby on ultrasound, but it’s not sort of some guarantee that there’s no genetic condition. So a second question. How would you know if your doctor is any good? I would say this is like the question out there, and the short answer is I don’t have an answer. We can talk about it, but I too struggle with this. Like if I’m going to my own doctor, I have no idea if he or she’s any good. What do you do?

Dr. Melka: I ask my friends that are also doctors.

Dr. Fox: Yeah.

Dr. Melka: I’m gonna mess up the quote, but it came from some legal case many years ago about like, was something pornography or not? The judge said like, I don’t know how to define it, but I know it when I see it. And I don’t think you can define a good doctor, but you know when you have a visit with them and I think you have an inherent trust. They could tell you something and your instinct is not, “Oh, I don’t believe that.” Or, “Oh, that doesn’t sound right,” or, “I wanna ask someone else.” But your instinct is like, “I trust this person.” And it’s okay to ask for second opinions, you know, not to say you should never do that, but I think people, when they find the right doctor, they just have that sort of comfort and connection.

Dr. Fox: Yeah. I think there’s also sometimes, you know, people ask me and who should I go to and this or that. I try to break it down. There’s really broadly two reasons you’re gonna be seeing a doctor, right? One reason is I need someone who can like do something, right? I need someone to take out my appendix. I need someone who can, you know, fix my shoulder. Like, you know, either a surgeon or I need a colonoscopy, like I need someone who’s got skill. And I think that there are ways to assess that, you know, how long have they been doing it? Do they do a lot of procedures? Are they practicing at a high-volume place? Have they done it for people that you know and had a good experience?

Like those types of things as sort of like one aspect. And the second aspect is, I need someone who I’m gonna have a relationship with, who’s going to like, care about me and is going to, you know, ask the right questions and make the right diagnosis and recommend things that are good for me and listen to me. Like that sort of relationship aspect. And obviously, you’d like both, but sometimes you only need one or the other. So if you’re looking for someone, you know, because you need a liver transplant, it’s not as relevant to you how kind they are. Like it’s great if they are like, you’d love them to be, but ultimately, you want someone who knows what the hell they’re doing, right?

That’s like the most important. You have the kindest person in the room, but they’ve never done a transplant before. Probably not a good choice. But another side, if you have, let’s say, you know, you have hypertension and you’re gonna be seeing someone a few times a year for the next 30 years, that interpersonal aspect is so critical to getting good care and sort of feeling comfortable and listened to. And so you have to think about what do I need.

And then for the second one, you have to sit in the room with them. I mean, personalities mesh or they don’t mesh and if someone doesn’t mesh with you, it doesn’t mean they’re a bad doctor. They just may not be a doctor for you. I mean, it’s like dating, right? You meet someone and you just like it clicks, doesn’t…

Dr. Melka: See, you just know if it clicks or it doesn’t.

Dr. Fox: Yeah. It clicks or it doesn’t. And that’s true with doctors. And if you feel like you’re having a doctor, it just doesn’t click. Again, if they’re there to like do one thing for you and then you’ll never see them again, it may not be as relevant. But if you’re gonna be seeing them for, let’s say, a full pregnancy or you’re gonna be seeing them for years, or you have a chronic condition like, yeah, you really need to click with them and you’re allowed to see other people and see, you know, if someone’s better for you. I guess that’s the best way I could say.

I would say online ratings, unhelpful. They don’t give you much into it. You know, how their office is run doesn’t tell you if they’re a good doctor. You can have great doctors who have sort of disorganized offices and you can have not great doctors who have very organized offices. I mean, it’s nice if they’re organized, but ultimately, you know, in the room face-to-face, like, do you trust this person? And that’s usually a gut feeling.

Good. Good question. All right, next is from Esther. “Hi, Dr. Fox. Thank you for an amazing podcast.” Thank you, Esther. “I love it.” Thank you. All right. That’s it. That’s all she wrote. No. Esther said, “I would like to hear more about an android pelvis. Are there any recordings on that topic yet?” So now there will be All right. It sounds a little space aged, but basically, there is such thing as an android pelvis, I wouldn’t focus so much on the term android, but there’s a concept about the shape of the pelvis and there are categories, and you can Google them. There’s android and gynecoid and anthropoid and there’s all always different terms to them. But conceptually, what are we talking about, Melka, with this?

Dr. Melka: The way the bones of the pelvis are put together and that lends to basically is there room for a baby to fit through during labor. The best way I have ever found to describe this to patients is the pelvis is like a pretzel. Like you have pretzels and I need my hands to do this. They’re like tall and narrow, you have pretzels that are wider, you have ones that like that little middle part is smaller, a little bigger. Like that’s kind of the best explanation I have. It all sort of looks the same, but there are these subtle differences.

Dr. Fox: Right. And the reason there’s categories is that essentially, the baby’s coming through like a tube, I guess I would say, that, you know, has bones all along the side and it can be wide from side to side, and narrow from front to back, it can be wide from front to back and narrow from side to side. It can be wide all around…

Dr. Melka: See, like a pretzel. I should be getting pretzels out…

Dr. Fox: Yeah. It could be wide all around it. And also, you could have like an oval that’s more side to side, an oval that’s more front to back. The best thing is a big circle, obviously, the bigger the better. And so that traditionally based on physical exam or even an X-ray, which is frequently done at the end of pregnancy, they would take the pelvis and categorize it into one of four potential shapes.

Now, obviously, there’s gray areas between all of these four shapes, but they sort of said, all right, you’re more like this, more like this, more like this, and more like this. And based on the shape of the pelvis they would say either, you know, your chance of a C-section is higher or if you have this shape pelvis, I would not do a breach delivery, but if you have this shape pelvis, I will do a breach delivery.

And there’s all these sort of ways it was used clinically. Nowadays, not as much for few reasons. Number one, it wasn’t that helpful actually as it turns out because the shape of the pelvis molds and changes during pregnancy, as does the shape of the baby’s head during labor. So you have two things you’re trying to fit, you know, A through B, and before labor there are certain shapes and in labor, they’re both different shapes. So it’s not all that predictive.

And number two, all the time we think someone has “a horrible pelvis” and the baby delivers fine, no issues. And we feel pretty stupid when that happens, but we’re correct, we assess the pelvis correctly. It’s like it’s narrow, it’s this, it’s that. But you know, it’s not that reliable. So we use it, you know, we do describe it and we talk about it, and it’s sometimes helpful to us clinically in certain circumstances, but I’d say most of the time it’s, you know, ultimately, we just have to wait and see how things play out in labor.

Dr. Melka: Yeah. I think it can help give women a sense of what to expect, that sometimes knowing going into labor, okay, you have this type of pelvis and your baby’s very big like this might not happen kind of can help set the expectation of a higher-than-average chance of a C-section.

Dr. Fox: Yeah. And I think for our listeners, if you’re trying to Google what we’re talking about, the thing to Google is probably clinical pelvimetry, P-E-L-V-I-M-E-T-R-Y. I think that’s right. And if you go to Google, then go to the images, you’ll see sort of like the diagrams they put in books and maybe this, and you sort of get a sense, but we don’t rely too heavily on it to make important decisions. Like Melka says, sometimes for expectations, like, you know, hey, you’re trying to VBAC, the pelvis isn’t so great. I’m not sure like maybe this is the reason a C-section the first time. But it’s usually not something that’s like a deal breaker in either direction for us, it’s just part of the picture.

Dr. Melka: I get this a lot with GYN patients that come in because they’re planning a pregnancy. So they wanna establish care first and then they’ll say, “Oh, like years ago my doctor said I have a bad pelvis,” you know, it’s always bad pelvis or, “I don’t have birthing hips.” That’s my other favorite because I don’t entirely know what that means. And it does come up at GYN visits too. You know, and again, I’ll do an exam, and most of the time it’s like, yeah, I think this is fine.

Dr. Fox: You know, I mean it is true that if you look at…

Dr. Melka: And if somebody thinks that their pelvis is not ideal for labor and they want a C-section, that’s great. But I haven’t used it as something that I would rare exceptions say like, “Oh, you don’t have a good pelvis, you need to have a C-section.”

Dr. Fox: Yeah. I mean there is definitely differences. I mean, if you look at human skeletons, males have a different shape pelvis than females overall. And so the thought is like as you get closer to a “male pelvis”, it’s harder. But again, it’s pretty vague. I would say. Good question. All right, next. This is from Jamie.

Dr. Melka: Would you like me to read?

Dr. Fox: No, it’s Jamie wrote a very detailed email which we appreciate. “Hi, Dr. Fox. First I just wanted to say I love your podcast.” By the way, if you’re emailing in questions and you start by buttering me up, it’s much more likely to get read on the air.

Dr. Melka: I’m starting to think they didn’t actually write this you’re just adding it.

Dr. Fox: I am a cut and paster through and through. “I’m an emergency medicine PA and my husband is an emergency medicine physician.” All right. Jamie and husband, good job. Thanks for helping everyone. “I’m pregnant with our first baby! I started listening to your podcast since we both realized early on that we knew little about normal pregnancy since all we see are the emergencies. Your podcast has not only provided education for us in regard to my pregnancy but as well as in our daily practice.” This is really awesome for me, by the way.

“I recently went into labor and delivery for uterine contractions that lasted for over four hours or four minutes apart but without cervical change and I had a negative FFN,” fetal fibronectin. “Ultimately I went home, I was given terbutaline and the contractions seemed to calm down, but I still had some contractions, some random, some that are more regular, seem to go away.” I’ve been doing a lot of research as to why I’m getting these contractions at 27 weeks.

I’ve looked into uterine irritability, which I think I have, and Braxton Hicks contractions. I’m not sure what I’m experiencing, but was hoping maybe you could do a segment in this since it seems like there’s very little definitive research out there on the topic.” Thanks, Jamie, strong work for sending an email. All right, so I guess we’re talking about preterm contractions, but not necessarily preterm labor. So how do you talk to people about preterm contractions?

Dr. Melka: Physically they feel like different things to different people. Some people say it feels like a period cramp, some people they feel like if they put their hands on their belly like they can feel the uterus getting tight but they don’t feel pain. Some people say they just feel a lot of pain all over the belly and everything in between.

Dr. Fox: Yeah. And they’re pretty common. They’re more common as you have more children, meaning someone’s first pregnancy, it’s a little bit less common. Some of that is because it’s actually less common, and some of it is because people don’t always realize that what they’re experiencing is a contraction the first time around, and the second or third they’re like, “Oh, I had that last time. That’s a contraction.”

But it actually does happen more frequently as you have more children. Sometimes they’re called Braxton Hicks which I guess is after someone named Braxton and someone named Hicks. I mean, that’s like the best branding ever because everyone talks about it. Ultimately…

Dr. Melka: What can we discover that we can call the Melka Fox something?

Dr. Fox: We’re gonna talk about that, it’s probably gonna be a food item though like a sundae or something. I mean, it’s essentially Braxton Hicks contractions are not unique sort of qualitatively. It basically means contractions that are not labor and you could also just call them contractions that are not labor. For us, the way we define labor, whether it’s at full term, whether it’s preterm, is essentially a regular painful contractions that is also opening your cervix, right? At the same time.

I mean, you can have a cervix that sort of opens at the end of pregnancy without contractions. We don’t call that labor and you can have contractions like you had, Jamie, where your cervix doesn’t open. And we also don’t call that labor, but pre-term contractions are a thing, they’re common now. When they happen regularly, they can be concerning that they might end up being preterm labor.

But the data is that most people who come into the hospital for preterm contractions, like, over 80% of them don’t deliver preterm. And since that’s 20% do, since the general rate of pre-term deliveries is 10%, it’s not much higher. Maybe you’re someone who contracts a lot, it’s not much higher chance of delivering early. But it’s something that we do check for. So the test you had, something called the fetal fibronectin is a pretty good test that if it comes back negative, that’s the good one, it indicates you’re not in preterm labor. You’re not likely to deliver in the next two weeks.

If it comes back positive, it doesn’t mean you will, but it just means there’s a higher chance. There’s other things we do, you can do a cervical length. But this is a very common situation like, you know, when we’re in the hospital as residents, I mean, at least every hour someone’s coming in for this type of, you know, “I’m contracting, am I in labor pre-term?” Right. A term it’s not as consequential because you’ll figure it out and it doesn’t really make a difference. But pre-term it is an issue and most people ultimately do just get sent home.

Yeah. So common, can be frustrating, can be painful. There are people who are in preterm labor, so you have to get checked. Like you can’t blow it off, but it does not mean that anything’s gonna happen. And that’s sort of the day-to-day, the vast majority of people have what you have, Jamie, are not gonna deliver preterm.

Dr. Melka: And it’s hard when you’re on call and you get a phone call from these patients to say, “Oh yeah, stay at home. It’s probably nothing.” You know, like you can often start with, okay, it just started, why don’t you hydrate a little, rest? But more often than not, like you have to play it safe just because you don’t know until you bring them in. So these are often the ones that we bring in but know that there’s a good chance of going home.

Dr. Fox: Yeah. And as we discussed in our “Is This Emergency” podcast, I don’t remember the exact things we discussed, but basically, I’m sure what we said is, you know, there are ways that we sort of had a sense whether they’re real or not. Meaning if you can’t feel them other than putting your hand on your belly, you’re probably not in labor. If you could fall asleep, you’re probably not in labor. If they’re irregular, coming and going infrequent, they’re here, they’re there, that’s really not labor. But once they get to the point where they’re regular and they’re painful and you can feel ’em, that’s something that needs to be checked out.

Okay. Good question, Jamie. And our last mailbag question for today is from Miriam. All right. “I would first like to thank you for an amazing podcast. There’s a theme today. It is very informative and entertaining. Miriam, that part I like. One, is there any data or information to understand why some women don’t go into labor? With my first baby, I did go into labor with a few days of steady contractions and the baby was born at 42 weeks. Second baby, my water broke at 40 weeks, four days and I needed a few interventions and the baby was born 28 hours later. The next four babies…” Wow, strong work, Mirriam. “The next four babies, I was induced at 42 or 41 weeks. I tried every recommendation to put myself into labor, but I had no success.” And then the follow-up question is, “Would you recommend induction at 39 weeks?” Okay.

Dr. Melka: I love it. We don’t know what causes labor.

Dr. Fox: It’s crazy, huh?

Dr. Melka: I know. This always blows people’s minds. Of all the things we can do in the medical world, knowing when someone goes into labor is not one of them.

Dr. Fox: It’s really remarkable, we know what happens when someone goes into labor. Like we have the physiology mapped out, all these pathways, but we don’t know why that switch flips on one day versus another day. The same reason, that’s why it’s so hard to understand preterm labor because we don’t understand term labor. And there is definitely people who in all or most of their pregnancies, always go past their due date. There’s other people who always go before their due date. There are some people who sometimes one, sometimes the other, we see everything. And it’s really fascinating.

You have someone who one baby is two weeks late, one baby’s two weeks early and you’re like, why? I don’t know. Like we just have no idea why. I will say that one correction I’ll make to your question is everyone goes into labor at some point. No one’s pregnant forever, it’s never happened, right? In the history of humanity, there’s never been someone who is pregnant the whole time, like forever.

The question is, at a certain point we tend to say, all right, like enough is enough. And that’s generally because of the concern over the risk to the baby of staying in for too long that the placenta may not work and it could be this. Also by that time, most people are begging us to be done. There’s smoke coming out of their ears and they’re just like, “This is enough. I gotta get outta here.” So we don’t know why you go past your due date every time or why someone might go past their due date every time. And again, for some people, it’s a pattern. For some people, there is no pattern and it’s really fascinating.

That is sort of the best I can do for you. It just you know, sorry, we just don’t know. It sometimes runs in families, you know, sometimes says, oh my mother always went late, my sisters go late. And other times, no correlation whatsoever to what happened with someone’s mother, their sisters, whoever. It’s really very interesting. It’s one of the interesting parts of our job is trying to sort this out for people. And then there’s the best thing where you go to the OB and they’ll do an exam, say, “Oh you’re gonna go into labor in the next five days.” I’m like, oh my god. That is such a that’s such a tough prediction to make for someone.

And we try like if the cervix is more open and softer or the head has dropped, it’s more likely that things are happening. But we are definitely wrong as often as we are right with this. So don’t trust your doctor with these things. Okay. So with that being said, let’s say someone’s like, “Listen, I don’t wanna go past my due date. I don’t wanna deal with this,” either because I don’t want to, you know, it’s just uncomfortable. Or I got stuff going on and I don’t wanna be pregnant this long or they’re like, you know, if there’s some risk, “I don’t wanna take any of that risk. I’d rather be delivered.” So what’s the deal with getting induced at like 39 weeks, or 40 weeks, or 41 weeks? Like what’s the story there?

Dr. Melka: That’s a very broad question.

Dr. Fox: Well, yeah, here we go. Hit it any way you want.

Dr. Melka: So there’s a lot of different factors that go into it in terms of the decision-making. You know, have you delivered vaginally before or not? Are there, you know, not that being induced is high-risk, but it’s different risk than waiting for labor and those risks aren’t always okay to some people. Can the hospital or birthing center handle it? You know, not all of them will accommodate elective induction, meaning induction without medical indication just because they don’t have space and they prioritize the patients that have a medical indication. So for some people, it’s not always an option.

I mean for, you know, in this case, we’ve had deliveries before. You get induced, the likelihood of you delivering again vaginally is 99%, you know, very, very small chance the induction doesn’t work or that there’s an emergency, you know, the baby’s heart rate drops. But that I think is likely to happen in labor anyway. So personally, I’ve done game, we induce these people very often. We haven’t yet been recommending it, we still do let people wait if they want to.

Dr. Fox: Yeah. I think part of the confusion here is that forever we were taught and we said that inducing is a bad idea. And the reason we said it was a bad idea was because it was thought to increase your chance of ending up with a C-section. Now with that said, even when we said that, we sort of categorize people differently, meaning someone who’s had four or five kids before vaginally, we didn’t really think it increased the risk of a C-section so much because it was so low to begin with, it’s really hard to, you know, to mess that up.

So even in the “old days” when we were not so pleased with inductions, someone like you, Mirriam, would’ve said it’s probably fine, like whenever, don’t do it too early such that the babies end up in the NICU. But you know, once you get a certain point, usually around 39 weeks from your due date, it should go fine. It should go fast. You should deliver vaginally. And like you said, Melka, if you don’t, it probably would’ve been the safe thing if you wanted to labor on your own. It wasn’t the induction, but we were always concerned if someone it’s their first baby or you know, they had a C-section before this or that.

So there has been, and we’ve talked about this on the podcast before, there’s a lot of data now, very good data that actually says the opposite. That says if you get induced it does not increase your risk of a C-section, you’ll have a longer labor experience than if you wait and go into labor on your own which is part of the reason it’s harder to accommodate because someone’s taking up a labor room for 24 hours versus four hours or whatever, but it’s not gonna increase your chance of a C-section if it’s done correctly and patiently and sort of, you know, in a certain manner.

So we don’t really have the same concern about inducing anyone at 39 weeks that we used to other than, again, it’s maybe a little more drawn out, particularly for the patient. For us, it doesn’t really make a huge difference, but for the patients, it’s a little more difficult in that sense. And so we don’t really worry about the risk of a C-section. Because of that, there is some internal debate, and by internal, I mean amongst the world of like obstetricians, whether we should be encouraging people to be induced at 39 weeks, discouraging 39 weeks and waiting, or somewhere in between. There has not been a consensus on this. Generally, I tell people somewhere between 39 and 41 weeks is fine. And some people wanna go on the earlier side of that. Some people on the later side of that, there’s reasons medically why I would recommend early, you know, but it’s still being hashed out

Dr. Melka: And much like we can’t predict when someone will go into labor, we can’t predict how your induction will go. You know, so we can tell you, okay, you know, first baby, normal sized baby, this, that, the other thing. Okay. Your baseline chance of a C-section is what? Thirty percent, just throw a number out. I can’t tell any single person, are they gonna be part of that percent or are they gonna have a vaginal delivery?

So then the next thing I ask patients to consider with induction is, well, how would you feel if the induction didn’t go well? You know, if it didn’t work and you had a C-section, are you gonna say, “I don’t care, you know, I just wanted the baby out, I was done, I was happy,” or are you gonna look back and say like, oh, I should have waited? I feel like I just, you know, did it too soon. Maybe if I waited things that would’ve been different, not to say they would, you could have had…

Dr. Fox: Right. It’s an emotional response.

Dr. Melka: Exactly.

Dr. Fox: Yeah. It’s just, you know, what would have been. And like you said, with timing, sometimes the induction, we start at 10:00 p.m. they deliver at 6:00 a.m. and sometimes we start at 10:00 p.m. and they deliver 6:00 a.m. two days later and there’s everything in between. It’s really hard to know. Obviously, if someone’s cervix is more dilated and more soft, and especially if they had kids before, it’s much more likely to be on the fast side. But it’s variable, who knows?

All right. Good questions. Melka, your first mailbag. How’d it go so far?

Dr. Melka: I love it.

Dr. Fox: All right, wonderful. We’re gonna do more. Thank you all for sending in your questions. Please continue to send them. Again, the more you flatter me, the more likely it’ll go on the air. No, I’m kidding. We take good questions, so it’s all good.

Dr. Melka: If anyone wants to start insulting him, I’ll give you a dollar. Just let me know.

Dr. Fox: Actually, this is a good point. If someone really insults me, I’m actually more likely to read that on air. I think that’d be awesome. This would be just like a total, like the Fox roast.

Dr. Melka: That could be my first guest host, I can just read all the roasts that people send in.

Dr. Fox: That’s perfect. “Fox, you’re an idiot.” Oh, I’d love to read that. Awesome. All right. Thank you all…

Dr. Malka: Thank you.

Dr. Fox: We’ll see you all next week. Thank you for listening to the “Healthful Woman” podcast. To learn more about our podcast, please visit our website at www.healthfulwoman.com, that’s healthfulwoman.com. If you have any questions about this podcast or any other topic you would like us to address, please feel free to email us at hw@healthfulwoman.com. Have a great day.

The information discussed in “Healthful Woman” is intended for educational uses only. It does not replace medical care from your physician. “Healthful Woman” is meant to expand your knowledge of women’s health and does not replace ongoing care from your regular physician or gynecologist. We encourage you to speak with your doctor about specific diagnoses and treatment options for an effective treatment plan.