“Mailbag 24: What does the Fox say” – With Dr. Nathan 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 OBGYN 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.

Welcome to “Mailbag 21: What does the Fox say” Our first question is from Michelle: “Hi, Dr. Fox. Thanks for your incredibly helpful insight on the show. I recently had a preterm birth, singleton, after being admitted to 25 weeks due to a dilated cervix with bulging membranes. It was too risky for a cerclage, so I ended up on modified bedrest in the antepartum wing. I had no signs prior. Anatomy scan at 22 weeks was great. No contractions prior. No infections via swab exam. Is a dilated cervix an element of cervical insufficiency? Could cervical insufficiency be avoided in future pregnancies? I understand bedrest is controversial, but would that be something to consider for future pregnancies in case of true cervical insufficiency or is a cerclage the only proven solution? Thanks again, Michelle.”

Thank you, Michelle, for your question. I am going to answer it. I’m also going to direct our listeners. If you want a full discussion on the topic of cerclage, I did a podcast with Dr. Rebarber in 2022, and we also did a Mailbag podcast in 2024 all about cerclages. It was Mailbag 14. Okay, for your question… There are several questions in there. In terms of an overarching principle, you mentioned cervical insufficiency, formerly known as cervical incompetence. We don’t use that term anymore, number one, because it’s just kind of mean to say something’s incompetent. But number two, it’s not really correct. Incompetence implies all good or all bad, whereas insufficiency sort of implies not good enough for the job at hand, which is really sort of what we’re talking about. And the idea behind cervical insufficiency is that conceptually there might be or there probably are people who, for whatever reason, their cervix, which is the bottom of the uterus, is not strong enough to hold in a pregnancy. And because of that, it shortens and dilates early, and these people are at high risk for either losing the pregnancy in the second trimester or an early preterm birth in the third trimester. So, conceptually, that’s what it is. And it makes a lot of sense conceptually.

The problem with the diagnosis is it’s a little bit vague. For example, why would someone have this condition? Why would someone develop this or why would someone be born with this, number one? Number two, how do we know if someone has this condition, right? Is there anything we can do when someone’s not pregnant to test them for this? The answer is no. Or, if someone has a short cervix or dilated cervix, do we know that that’s the reason? And the answer is no. There is a lot of reasons someone can have a short or dilated cervix in the second or third trimester that has nothing to do with the strength of the cervix. So, for example, you were mentioning things like contractions, right? If someone’s having contractions, their cervix is going to shorten and dilate. There’s nothing wrong with their cervix, they’re contracting. Or if someone has an infection or some sort of inflammation, it’ll cause their cervix to shorten and dilate. But again, not a problem with the cervix itself. It’s a problem with the infection or inflammation.

So, part of the difficulty in sorting this out is it is very hard to know for certain whether someone has this condition or not. And what ends up happening is if we really believe someone has this condition, this sort of nebulous condition where the cervix is “weak,” what we call cervical insufficiency, then presumably the treatment would be something to strengthen the cervix. And the treatment we have for that currently is a cerclage where we sew the cervix closed either prior to it happening, if they have a history of it, or maybe while it’s happening, if their cervix is short or dilated. And that’s the treatment. And so you would like to do a cerclage on people who have this condition, and you would like to not do a cerclage on people who don’t have this condition. And that’s where sort of all the difficulty lies in all the research, all the differences in opinions and all sort of the clinical knowledge that has to come into this type of decision is that it’s not easy. It’s complicated.

Okay. So, in terms of your situation, when someone’s cervix is dilated at 25 weeks like yours was, so you said that your doctors felt it was too risky for a cerclage. So, that is probably true and it’s very unusual to place a cerclage after 24 weeks, at least in the United States. Very, very, very few people would do it. Reason number one is that a concern that it’s risky that during the procedure, your water could break or could cause you to go into labor and then you would deliver. But number two, it’s also because we’re not sure that the reason is that your cervix is weak because if there were really a problem with your cervix, we think it probably would have manifested earlier than 25 weeks. And so that’s sort of the reasons why I would agree that it’s unusual to have a cerclage placed at 25 weeks.

Okay. So, to answer your question, does your dilated cervix mean you have cervical insufficiency? We don’t know. I would say if it presents for the first time at 25 weeks, that’s a little bit unusual but not certain one way or another. If someone has it earlier in pregnancy, let’s say you have the same story but you were 16 or 17 or 18 weeks, it would make it more likely but, again, not definite. But it would make it more likely. Could it be avoided in future pregnancies, which is your next question? Well, you can’t avoid cervical insufficiency if you have it, right? If you have the diagnosis, you have it. But if we think someone has that condition, we avoid the problems, ideally, by doing it earlier in pregnancy. So, if I believe someone has cervical insufficiency for whatever reason, based on their history, based on prior pregnancies, this or that, typically we would do a cerclage in the next pregnancy sometime before it would be an issue. So, whether that’s 12 weeks or 13 weeks or 14 weeks or somewhere in that range is when you would do it. Or if someone presents in this pregnancy for the first time and let’s say their cervix is very short or dilated and I think that they have cervical insufficiency, this is the first time it’s happening, I might place a cerclage at that time.

Again, the difficult part is deciding who does and who does not have cervical insufficiency versus another diagnosis. And since we don’t always know, what we sometimes do in the next pregnancies, instead of placing the cerclage, just follow very closely with frequent ultrasounds to check the length of the cervix. And if it starts getting very short, very early, that would give more evidence that maybe this is cervical insufficiency and we would place a cerclage. So, a typical sort of conclusion that doctors are going to reach about someone who had a dilated cervix at 25 weeks like you did is in the next pregnancy, either they would conclude we need to place a cerclage or they would conclude, “I’m not really sure. Let’s follow you very closely in the second trimester. And if your cervix remains nice and long, there really shouldn’t be a problem with your cervix. We won’t place a cerclage,” versus if it gets short in the second trimester, that plus your history of what happened to you before is enough evidence to say, “You probably have cervical insufficiency. Let’s place a cerclage.” So, that also answers if a cerclage is the only proven solution. Well, it might be if you need it, but it might not be if you don’t need it.

In terms of bedrest, you are correct. It is very controversial about whether it works or does not work at all. Certainly in the setting of a short cervix and avoiding preterm delivery, what I would tell you is that the data is not good. There aren’t great studies evaluating this, but the data that we have suggests that bedrest is not helpful, meaning it does not keep people pregnant who have, whether it’s cervical insufficiency or history of a preterm birth or short cervix at this time. And so it’s not typically recommended. With that said, since the data isn’t perfect, we usually do discuss maybe some activities not to do or to avoid and whatnot. And that has to be very individualized. All right, Michelle, great question. Great topic.

Our next question is from Nicole: “Hello, big fan and toaster here.” Welcome to our toasters. “I had a scan at 28 weeks and the femur and humerus,” this is of the fetus, I presume, “are measuring 25 to 26 weeks and they are behind. The rest of the baby’s measuring 27 to 28 weeks. They said,” I assume the doctors, “his bones are mineralizing and not evident for skeletal dysplasia but will monitor me again for placental insufficiency. I’m concerned about skeletal dysplasia based on these numbers. Do you have a cause for concern or is it more likely a normal variant? It could be maybe fetal growth restriction. Thank you.”

All right. So, Nicole, to answer your question, just some background. So, when we’re evaluating fetal size on ultrasound, what we’re doing is at the end, we’re estimating a fetal weight and we’re also saying how big is the baby measuring week wise, meaning your 28 weeks as a baby measuring 28 weeks or 27 weeks or 26 weeks or 29 weeks, 30 weeks. Okay, so we usually get two results. One of them is an actual weight in grams or pounds, which comes along with that percentile. If you’re average weight, you’re about the 50th percentile. If you’re larger, you may be 70, 90, whatever. And if you’re smaller, lower numbers. And we also get sort of the gestational age equivalent. Those are obviously related to each other, but those are the data we get.

Now in order to get the weight, we don’t actually weigh the baby on a scale, obviously. What’s typically done is you get several measurements of the baby. We do typically, most commonly, two measurements of the head. One of them is the circumference around the head. What I tell people, it’s sort of like your hat size. And we also get the distance between one side of the head at the other. Think of it as a distance, not exactly but around from ear to ear. So, that’s sort of like your headphone size is what I tell people. Then we get one measurement of the baby’s belly. It’s like a waistline but a little bit higher. We call that the abdominal circumference. And then we measure the length of the femur, which is the thigh bone. So, the baby’s thigh bone, we measure that length. We’ll sometimes also measure the humerus, which is the upper arm bone. But it doesn’t typically go into the calculation to estimate the baby’s weight. Fine. So, we get those measurements and then we get an overall weight and a percentile. But with each individual measurement, you will also get, hey, this measurement for this part of the baby is a certain percentile or certain week.

So, for you, when they measured the femur and then the humerus, they said that they were measuring a little bit smaller. And the question you’re asking is, “Is that concerning?” Obviously, I would have to see the details to know the answer. But what I would tell you is that typically it’s not concerning, meaning most of the time we see this, it’s not concerning. And why is that? There is variation in how babies grow and how bones grow and sort of some babies are going to have a normal size head and shorter legs. And some babies are going to have a smaller head and longer legs just like there’s difference in humans and how tall we are and how large our waists are and how broad our shoulders are and how big our heads are. That’s going to differ between adults. It’s going to differ between children. It’s going to differ between fetuses as well.

So, most of the time we see sort of differences or some things are measuring bigger, something smaller. It’s usually just this is how people are built. They’re all built differently. It’s perfectly fine. Now, there obviously are situations that can be concerning related to having short limbs. What you mentioned was sort of a catch-all diagnosis called skeletal dysplasia. So, skeletal dysplasia is basically a category for conditions where the baby has a disorder that the bones aren’t going to grow normal. And there are many, probably hundreds of known conditions where that can happen. Some are more severe than others. In fact, some of them are lethal. Some of them, the babies don’t even survive. So, this can cause a lot of anxiety, obviously, for people if they’re told that the limbs are a little bit short and then they Google skeletal dysplasia and they’re like, “Oh, my God, some of these conditions are absolutely horrible.”

What you were mentioning in your question is that typically if the baby has one of these conditions where it’s a real diagnosis, there are usually going to be other things seen on the ultrasound related to how the bones look themselves, not just the size. Like are they the right shape? And are they straight as opposed to bent? Are they bright white, which is what we normally like to see versus not as white? And so there’s certain features that we might find that would indicate, hey, this is more likely to be not a problem or this is more likely to be a problem. So, that’s one thing. And also how profound is the shortness, right? So, if you’re 28 weeks and the bones are measuring 15 weeks, that is a massive difference. And that’s much, much more likely to be a significant problem or a real diagnosis versus something that’s lagging by a week or two. Most babies whose bones are lagging by a week or two are going to be perfectly fine.

And so sometimes this is an issue with just how the percentiles come out. Sometimes we’ll check a femur length and it comes out in the third percentile. And that seems pretty significant and pretty profound. But when actually you look at it, it’s measuring maybe just a week behind, which isn’t such a big deal. Or if the femur is supposed to measure, let’s say, 3 centimeters and it measures 2.6 centimeters, right, which is a 4-millimeter difference, meaning even by the eye, it’s hard to see the difference between those, it could be a massive difference in percentiles. And so when these situations come up, what I normally do is I try to really get into the weeds of what’s going on. So, we’ll look obviously at the measurements and see how they compare to what they should be. Number two, we’ll look at the bones themselves to see if they look normal, which is again what your doctors did. We’ll look for any other issues going out the baby, any other parts of the baby that may or may not be lagging in growth. And then we’ll sort of see how profound is it. And then we’ll try to get a sense. Is this something that’s more likely to be problematic or more likely to be really nothing? And then if it’s at the time appearing problematic, obviously we talk about which one it might be. What does it mean? What kind of testing do we need to do? Sometimes we’ll do an amniocentesis to check for certain genetic conditions and so forth.

But if it looks like it’s likely or probably or most likely just nothing and just the bones are lagging by a little bit but probably not an issue, what we’ll typically do is say come back in two weeks. Some will measure them again. And so two weeks later, if the bones are measuring about two weeks larger, then they grew normally over those two weeks. And again, then the chance that it’s going to be an issue goes down. So, as an overall answer to your question, I don’t know, but I would say what you’re describing does not sound particularly concerning. The fact that the baby looks perfectly fine otherwise but the bones are measuring a week or two behind, usually that’s not much and probably they’re going to have you come back in a couple of weeks to check again. And if the bones are growing and they’re staying about a week or two behind, it’s more likely going to be nothing significant. But obviously if things come up and change or look more concerning than based on exactly what’s going on, they’ll do that. And for people who are sort of potentially going to be in this situation, it’s very, very important not to just look at the percentile or just look at what’s going on but to make sure that whoever is giving this information really knows what they’re doing and understands this so they can find out what’s important but also not scare you to death unnecessarily because these are definitely situations where a lot of people get scared probably unnecessarily.

Okay. Our next question is from Jocheved: “Hi, I love your podcast. It has been such a great resource for me.” Thanks, Jocheved. “I’m currently 12 weeks pregnant with my first. And I was wondering if you can address nutrition in pregnancy. I hear so much conflicting information, and I spend so much time worrying if I’m eating enough or the right foods. How important is it really? And what should I prioritize? For reference, I tend to stay away from most processed foods, junk food anyways. Thank you.”

All right, Jocheved, terrific question. We’ve had a couple of podcasts on this, maybe not directly answering your question, which we should probably do one, but we did one on nutrition in pregnancy in twins in 2022 with Barbara Luke. And we did one on general nutrition with our nutritionists in our practice, Casey Seiden also in 2022. You can check those out for some more information. So, you are correct. There is a lot of conflicting information out there. And the reason I would say there’s conflicting information is that I think we all know sort of intuitively that it’s good to have good nutrition in pregnancy and in life, obviously. But the reason it’s confusing is, okay, what does good nutrition mean? What exactly is good nutrition versus bad nutrition? Is there one diet that’s definitively better than another? Are there foods that are definitively better than another? Or if let’s say we’re all willing to agree that fruits and vegetables and lean proteins are better than cakes and cookies, okay but how much does it matter if I eat cakes and cookies? Is there a threshold? If I have a certain amount a day or less, it’s not going to affect anything about me or the baby. If I have more, it will.

We don’t really know the answers to all those questions. Again, we all sort of get that it’s probably good to have good nutrition, but we don’t really know the details in terms of exactly what nutrition is best, number one. Number two, what are the consequences if your nutrition isn’t as good? Is it just, “I’m going to feel a little bit lousier,” or is it going to actually impact the baby’s growth or development or anything like that, or is it going to cause gestational diabetes and all these questions and how is it…? On top of that, another layer is it’s probably different for different people, right? There’s probably so much genetics involved in this that we don’t understand that for some people, they can probably eat certain foods and do perfectly fine. And other people, when they eat those foods, it’s going to affect them more. And so when we see conflicting information, a lot of it is just differences in opinions on what someone believes is the best or ideal nutrition in pregnancy, and that could be related to how many calories should you get, how many of this food group versus that food group, should you avoid this, should you avoid that. And I would argue that probably most of the opinions that are going to be seen online are not backed by terrific evidence. There might be some sort of evidence that’s circumstantial, that’s not really perfect on this.

What seems to be the case is that for most people with singleton pregnancies, carrying one baby, fortunately our bodies are sophisticated enough to get whatever nutrients are needed to the baby, and that most people probably, no matter what they do with nutrition, are going to do okay, or their babies are going to do okay. Now that doesn’t mean that everyone should just eat crap and have horrible diets. That’s not what I’m suggesting. I’m saying that, if you look around the world and people have babies and healthy babies in some real dire circumstances related to nutrition, lack of food or not having healthy food options or having really weird and unusual diets, and the vast majority of them still have healthy babies. So, number one, I think fortunately, humans have evolved to be resilient in terms of reproduction, that in most circumstances, it’s going to work out okay anyways. And so I try not to… I certainly do focus on nutrition and encourage good nutrition in pregnancy, but I also try to remind people that likely the stakes aren’t that high. Because for most people, it probably doesn’t make a big difference.

And so that’s really the global answer to your question. Now in terms of what I typically recommend, I think I really just take a common sense approach. I think that people should try to eat healthier foods, and honestly, whatever that means to you is probably fine, since I can’t tell you definitively what are the healthiest foods, right? I would say if people think that something is healthier versus something else, choose the healthy one, right? And things that most people would say are unhealthy, right? Sweets and cakes and stuff like that, do your best to eat as little as possible. It doesn’t mean you have to avoid them entirely. But if you sort of just refocus your nutritional goals during pregnancy, if that’s sort of like a motivation to get a little bit healthier with your food, great, probably going to be helpful. Hard to say exactly in what way it’s going to be helpful. But again, like I said, I think common sense is we all agree it’s probably a good idea to do that.

In terms of things that you need, you need folic acid when you’re pregnant. And so most people are going to get that through supplementation with a prenatal vitamin or folic acid. Again, probably you can get it through your diet. But since we don’t want to always be counting these things and relying on our diet to get this, we usually take a supplementation of that and calcium. So, you want to get about a thousand milligrams a day. So, if you have a diet that’s rich in dairy products or calcium rich foods, then probably that’s fine. But otherwise you should take calcium supplementation. And if you eat a well-balanced, healthy diet, you honestly probably don’t need the rest of the stuff in the prenatal. But most people just take a prenatal to cover their vitamins. Things in pregnancy that tend to be needed is some source of iron. Otherwise, people get iron deficiency in pregnancy. So, if someone eats meat, that tends to be fine. If they don’t eat meat, red meat, that is, they probably need to find some other sources of iron. Fish is very healthy in pregnancy. So, people who eat fish once or twice a week, that’s great. If they don’t, often we’ll tell them to take like a fish oil supplement. A lot of prenatals have fish oil in them.

And that’s sort of what we do. Just, again, common sense, broad strokes. If people have unique circumstances that they can’t eat certain foods, or they don’t like certain foods, or they’re allergic to certain foods, or for whatever reason, then it may have to get a little more tailored. We encourage people to meet with a nutritionist in pregnancy if they have any specific concerns about that or any unique circumstances that need to be worked out. I qualified all my statements earlier that I was talking about singleton pregnancies. As many of with twin pregnancies, like I said, we had a podcast on this before and we published on this. I’m a little bit more aggressive with nutrition and pregnancy in twins because the data does indicate that for twin pregnancies, nutrition, particularly how much calories you’re getting and protein do seem to matter in terms of outcome. So, in twins, my attitude is common sense plus, right? So, all of our twins will formally see a nutritionist and we’ll talk about it and weight gain and all these things. But in singleton pregnancies, I really fall back more on the common sense approach.

Okay, next question from Macy: “Hi, Dr. Fox, I’m 8 weeks pregnant, and I live in Canada. My sister-in-law is getting married in Cape Town. I’ll be 21 to 22 weeks during the scheduled trip. Do you think I need to back out? I want to attend the wedding of course, but without knowing how good the healthcare is there, I’m questioning what kind of complications may occur and whether you think being 100% comfortable with the healthcare necessary at that time. I really hope you have an opinion here. Thank you very much.”

All right, Macy, great question. We actually did a full podcast on this in June of 2021 with Dr. Caroline Friedman. So, you can go to that for the long version of this answer. But the short version of this answer is this is a really common question in pregnancy. I probably get asked, I don’t know, every single day I’m seeing patients about some trip, “Can I go? Is it too far? Is it the right place? Am I too far pregnant? When should I go? Should I cancel?” All these things. And I think the overarching principles in this is that typically we’re not concerned about the travel itself, meaning getting on the plane, going through the airport flying around, landing, taking off, all that stuff is not typically the concern. I suppose maybe at the very end of pregnancy, if you’re taking a really long flight, the concern is maybe you’ll go into labor and deliver on the plane. But that’s not usually the concern we’re talking about. So, it’s not really the travel.

The issue is wherever you’re going, if something were to happen, you’re there, right? And so is that a problem? Is it not a problem? Well, it depends on a lot of things. It depends where you’re going, right? And as you said, what is the healthcare like there? And also, how significant would it be to you if you were “stuck” there? So, someone let’s say… My practice is in New York City and someone says, “Well, it’s going to be Christmas break and I’m going to be 20 weeks and I’m going to fly home to my family in California, 5, 6-hour flight. What do you think?” I’ll say, “Well, the likelihood of something happening at 20 weeks is not that high. And if something happened in California and you were sort of stuck there for a while, how big of a deal would be?” “It’s not a big deal at all. I’m from there. My family is there. I know the doctor is there.” Then it’s a much less situation. Whereas if they said same situation, “I’m 20 weeks and I’m thinking of going on safari for three weeks.” And I would say, “Well, the likelihood of something happening while you’re on safari is not that high. But how would you feel if you had a symptom or this and there’s no doctors there and you can’t reach anybody?” You’re like, “Oh, my God, that’d be like the worst thing in the world.” “So, maybe you shouldn’t go,” right? Because you don’t really know if there’s going to be a problem or not. Now, the likelihood of a problem is pretty low in the second trimester, but it’s not zero. And it doesn’t even mean a real problem. What if you just had symptoms? You have cramping, you had some spotting or you didn’t feel well or whatever it might be. There could be a lot of actual issues if you can’t get healthcare but also just the stress of sort of, “Oh, my God, now I have to find a doctor or healthcare where I am.”

So, whenever someone’s asking me about a specific trip, can I go, should I go? Usually the variables that we’re going to talk about are, number one, what is the likelihood of a problem happening? And that’s related to sort of the risk factors in general, right? Is it a high-risk pregnancy or not? Is it twins or singletons? Does this person have a history of problems or not? Obviously, what’s unique to them, plus how far pregnant they are. The earlier you are, the lower the chance of a complication. And the later you are, the higher. As you get more pregnant, things start to happen. Now, again, there’s no point in pregnancy where there’s 0% chance of anything happening to anybody. But different people will decide based on, let’s say, a less than 5% chance versus an over 80% chance, obviously. And the second thing is, where are we going? Is it somewhere where there is reasonable healthcare? Even if it’s not your own doctors, at least you know that you’ll be safe and there’s people who could take care of you there. And number two, is it a place where it would cause you great stress and grief if you had to try to look for healthcare somewhere? Do you know people there? For a lot of people, let’s say, is it the same country that they live in, or the state that they live in, or whatever it might be? And that’s usually how we decide. And so I don’t know the ins and outs of healthcare in Cape Town specifically. I presume it’s pretty good, but I just don’t know that. And obviously, some of it might depend on your family in Cape Town. Like, if you had to stay for a week or two, would that be your family you’d stay with? So, those are the types of things we would discuss. So, I can’t answer your question specifically. And probably by the time this question is airing, the decision has already been made. But that’s sort of the things that we would go through in terms of answering that question.

All right. Our last question is from Rachel: “All right. Thank you for your podcast. I’ve been listening since my pregnancy with my second child, who’s now five, and find it so informative and helpful.” Thank you, Rachel. “I recently had my fourth child, and all of my deliveries—except my first—I’ve had a postpartum hemorrhage. With each delivery, it’s gotten worse. In my last delivery, I bled so much that I had almost every intervention they do.” She mentioned oral misoprostol, injection, Pitocin, manual clearing of clots, “And honestly, it was much worse than the delivery for me. I was so ill afterwards, I was not able to hold my baby for two hours after delivery and missed his first feeding. I was cold, my whole body shaking, crying hysterically, blacking out in extreme pain. It was traumatic enough that I’m considering not having more children, even though we would otherwise like a larger family. Are there strategies or measures someone like me could take to prevent hemorrhaging? I had discussed this with my doctor during the pregnancy but didn’t think it was a big deal and they said there was nothing to do.”

Okay. So, first of all, Rachel, I’m sorry you had such a traumatic birth with the hemorrhage. I’m glad you’re okay now. Secondly, we did do a podcast on postpartum hemorrhage in May of 2021. My guest was Dr. Doe, so you can all turn to that for the long form about postpartum hemorrhage. But in general, postpartum hemorrhage is essentially when, after birth, someone bleeds much more than “typical.” That could be right at the time of delivery. Sometimes it could be several hours later. Sometimes it could even be several days or several weeks later, which is more rare but anything is possible. What you’re talking about, Rachel, is really right after delivery heavier bleeding. And there’s a lot of risk factors for that happening. And most people, it happens out of nowhere, but there are risk factors for it. And the strongest risk factor is someone with a history of postpartum hemorrhage. So, if it happens to someone in their last birth, then in this upcoming birth, the chance of it happening is very high.

And so your question specifically is, okay, you have this happen to you. You know that if you get pregnant again, you’re at high risk of it happening again. What can we do about it? And I would disagree with your doctor if that’s what he or she told you that there is nothing to do about it. In fact, when we know that people have a history of a postpartum hemorrhage, there’s a lot of things we might do differently in the next pregnancy. And so, first of all, one of the things we like to do is, while you’re pregnant, if we think you’re at risk for postpartum hemorrhage, again, someone like you has a history in the past or maybe someone has risk factors for it like maybe twins or whatever, the first thing we like to do is to really be on top of whether their blood count is as high as possible during pregnancy, right? So, many pregnant women are mildly anemic or even moderately anemic in pregnancy, and for most people we don’t want them to be anemic, but it doesn’t really have tremendous consequences because usually they’re a little bit anemic. They deliver and then their blood count goes up and they’re perfectly fine. And so it’s not usually the end of the world if they’re a little bit anemic.

However, if someone hemorrhages, right, if they lose a lot of blood based on where their blood count started, that’s going to be one of the variables that dictates whether you’re going to feel lousy like you did and whether you might need a transfusion of blood products, get a blood transfusion. So, for example, think of it like a tank of gas in your car. If you start with a full tank, right, you can go a lot longer before your car runs out of gas versus if you start with a half tank. So, the same is true with your blood count. If you start with a higher blood count, you’re able to tolerate blood loss more readily than someone who starts at the lower blood count. So, the first thing I would do in your next pregnancy is check your blood count frequently, probably put you on some sort of iron supplementation to get it up. If it’s even borderline, give you more iron. And if it’s hard to tolerate orally, maybe give you intravenous iron so that at least when you go into labor, your blood count is as high as possible. That’s number one. Number two is at the time of delivery, there are standard things that we do to lower the risk of postpartum hemorrhage. The first thing… And this is an all deliveries. One of the things is we give Pitocin after delivery. Typically in the U.S., almost everybody gets Pitocin after they deliver intravenously to sort of contract the uterus, which helps reduce bleeding. So, that’s done almost universally after delivery. Other things that we do is we sort of massage the uterus and we do something called an active management of the third stage, which is where instead of just waiting for the placenta to plop out, we put a little traction on it and rub the uterus to try it to come out a little bit quicker. It helps lower the chance of bleeding. That’s something we do to about anybody.

But as someone with a history of a postpartum hemorrhage, particularly one as significantly as yours, what we might do is actually prophylactically give you additional medications like all the things that you mentioned that they were doing to treat the hemorrhage, which are proper things to do to treat a hemorrhage. We might start doing them before you hemorrhage right after you deliver, not only give you Pitocin, but maybe give you a second medication or a third medication. That’s number one. Number two, what I’ll frequently do is give the Pitocin as we normally do, give a second medication sort of prophylactically. But number three, I don’t leave the room. I’ll frequently stay there after the delivery. Usually someone’s had several babies. They don’t have as much tearing. You don’t have to be there for 10, 15, 20 minutes to sort of repair any laceration. Sometimes there’s no laceration at all. And I could really clean you up and walk out of the room two minutes after the baby’s born. But normally what I’ll do is I’ll wait a little bit longer in the room. If there starts to be even a little bit more bleeding than normal, we’ll even get more aggressive at that time and sort of not let it get out of hand. Now, does that always work? No. Sometimes all these measures don’t work and sometimes people hemorrhage despite all the medications we’re giving them. And sometimes we have to do additional measures like more interventional or even surgical. But I would say is, in my experience, certainly more often than not, and probably the majority of the time or the vast majority of time, if we do those measures, even someone with a history of a postpartum hemorrhage will typically not hemorrhage in the next pregnancy or will hemorrhage a lot less than they would have otherwise. And hopefully they’ll just feel a lot better.

The other thing that can be done is if you have a hemorrhage, we could transfuse you blood earlier. Now, people don’t typically want a blood transfusion. And I get it. But if you felt so lousy after the delivery, the one thing that’s going to make you feel better quickly is getting blood. You get a transfusion of blood, your symptoms are going to get much better much quicker. So, that’s another thing that we can potentially do in the next pregnancy. For someone like you, I don’t typically discourage them from getting pregnant again. Obviously, people make choices and that’s totally fine. But usually we’ll talk about all the things we can do coming up to delivery and during and right after delivery to really try to prevent or minimize the bleeding. And then if you start bleeding, we can treat you sooner with blood so you don’t feel as lousy when it’s done.

All right, thank you all for your amazing questions. We’ll see you next week.

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