“Mailbag #3!: with Dr. Caroline Friedman”

Dr. Fox: Welcome to today’s episode of “Healthful Women,” 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, Dr. Caroline Friedman, welcome back. How you doing?

Dr. Friedman: Thank you. Good. It’s good to be here. It’s been a while.

Dr. Fox: It’s great. You look like you just ran a marathon, you got on your athletic gear.

Dr. Friedman: I literally just walked from the hospital.

Dr. Fox: Amazing. Good. It’s hot outside, so…

Dr. Friedman: Summer heat, yeah.

Dr. Fox: Summer heat. Good stuff. Well, thank you for taking time literally out of your busy schedule to come here talk to me, talk to our listeners.

Dr. Friedman: Of course.

Dr. Fox: We’re doing a mailbag. This is the third mailbag. We had Spiegelman, we had Melka, and now we got Friedman.

Dr. Friedman: Nice.

Dr. Fox: Maybe we’ll do like an Oscars. You know, people can vote for their favorite mailbag.

Dr. Friedman: I don’t want to be up against those two.

Dr. Fox: They did a great job so they’re big shoes to fill. So, again, thank you to our listeners for sending in questions. And we’re gonna get right to it. So, our first question is from Amber. All right. Amber says, “Hello, I had a baby 2.5 years ago. He was a big boy, 9 pounds 3 ounces. He had shoulder dystocia and ended up with a humerus fracture from delivery. He healed quickly and has no long-term deficits. But it was traumatic in the moment. I’m now pregnant with my second child and I’m fearful of delivery.” So, you see someone and they have a history of shoulder dystocia. Maybe just very quickly review for our listeners, in case they have not heard our shoulder dystocia podcast, what is shoulder dystocia and why do we care?

Dr. Friedman: Yeah, so basically, when a baby delivers vaginally, this is typically when we’re talking about shoulder dystocia, the head is the first part to deliver. And that’s often the most difficult in terms of effort and for the baby to fit through. And then typically speaking, the shoulders will, and the rest of the body will sort of just follow naturally. But rarely, a shoulder dystocia can happen when the shoulders don’t follow right away, and so the head delivers but then the shoulders are stuck behind the pubic bone. And the obstetricians need to employ some additional maneuvers to help release that where they’re stuck, and allow the shoulders and the rest of the body to deliver.

Dr. Fox: Right. And then why is that an issue, in theory?

Dr. Friedman: Well, we have to get the baby out. And the longer the baby is “stuck there,” you know, you worry about, is the baby getting oxygen, and blood flow, and all of that during this time? And sometimes when a delivery is complicated by this, there can be some sort of injury to the baby just by the natural forces, or depending on the maneuvers that are used, that could cause either some nerve damage or like in this case, sometimes broken bones like to the arm, or to the clavicle of the baby, or even sometimes, you know, the mom can sustain more injuries as well like tearing and other pelvic issues.

Dr. Fox: Right. And, you know, again, you can refer to the podcast for the full discussion about it. But basically, there is a concern that if you had one, it can happen again.

Dr. Friedman: Right.

Dr. Fox: So, that’s essentially, what Amber is asking about. So, if you’re someone whose last birth was complicated by shoulder dystocia, how do you counsel her in the next pregnancy about what to do?

Dr. Friedman: Yeah, so it can…you know, like most things, it’s complicated. But we do know that women who’ve had, or patients who’ve had a shoulder dystocia in one pregnancy are at slightly higher risk of it happening again. And that risk or percentage is hard to specify, but it’s somewhere probably around 30%, based on the best data that we have to look at. So, it’s not a guarantee. You know, 70% of the time, it won’t happen again, but 30% of the time, it will. And, you know, every time it happens, it could have some serious consequence.

Dr. Fox: Right. And so, it’s tough because this is one of the situations where how you phrase the counseling can really sway someone one way or another. If I set this on, “There’s a 30% chance of a shoulder dystocia and your baby can be seriously harmed,” that sounds pretty bad. And it’s true, that does sound bad. But the chance the baby’s going to be injured if there’s a shoulder dystocia is ballpark 10%, give or take. And of those injuries, the majority of them are temporary.

Like Amber’s first baby had shoulder dystocia, had an injury, broken humerus, a broken arm, that sounds horrible, but in newborns, that’s a temporary injury. They heal up fine. I’m sure there’s gonna be no long-term consequences. Baby’s gonna be great. So, the chance that you’re going to, A, have a shoulder dystocia has to be multiplied by the chance that it’s going to injure the baby, has to be multiplied by the chance that it’s gonna be a long-term injury. And that ends up being actually pretty rare event. So, it goes from 30% to somewhere like 1% of a permanent injury. And the only way to know you’re avoiding it is to do a C-section.

And so, that’s the balance that basically, Amber, you’re going to have to go through with your doctors, your midwife, whoever it might be. Do you prefer a C-section, which, again, is not a walk in the park, or do you prefer to deliver vaginally knowing that there’s this risk of it happening again, which most of the time will be fine but there is a chance of an injury? And it’s very hard to know the right answer to that. Yeah. So, what have you found that most people do in that circumstance?

Dr. Friedman: I think it’s really a mixed bag, I think, you know, it’s a balance like everything, of the potential risk and the potential benefits and feeling what you’re most comfortable with. I think it also depends. You know, Amber’s baby was over 9 pounds. I think if this pregnancy, maybe she goes into labor a little bit earlier, the baby is not expected to be quite as big. If she comes in really active labor, you know, 8 centimeters, you may have a conversation in that moment and say, “This is probably going to be okay. You know, maybe doing a C-section at this point actually might be more dangerous.” Versus if she’s 41 weeks, and we think it’s even a bigger baby and maybe there’s diabetes involved in this time or other risk factors. So, you really just have to, you know, have that conversation and make the decision with the patient where everyone is comfortable.

Dr. Fox: Yeah, no, I agree. It really has to be individualized based on her wishes, and her fears, and the actual circumstances, right? Because like you said, if someone has shoulder dystocia with a 6-pound baby, and now she’s expected to have a 10-pound baby, I’m a lot more concerned than if it’s the opposite of that. And does that mean, for sure, you know, that the weight is going to be the factor? No, but it’s a factor. And ultimately, it’s how many C-sections are you willing to do to prevent one permanent injury? And there’s no right answer to that. Is it 100, is it 200, is it 1,000? I mean, you know, if your baby is the one that has permanent injury, you would say a billion, right?

Dr. Friedman: Right.

Dr. Fox: But if you’re someone who had a C-section “unnecessarily,” you’d say, “No, that’s crazy.” And so, it’s hard. But I think, Amber, the main thing is have a conversation with your midwife or doctor about what do they think the chance of it happening again? Is there any way to mitigate that? And ultimately, are you comfortable delivering vaginally again, or do you want a C-section? And I think they’re both reasonable and they both just have their pros and cons. All right. Thank you, Amber.

All right. Next question is from Elizabeth. All right. “Hi. Love the pod.” Thanks, Elizabeth. “It got me through my entire first pregnancy. And I love listening even months after.” Wow, awesome. All right. “When I was pregnant, I was diagnosed with mild gestational hypertension at 32.5 weeks, and was induced just a few weeks later at 37 weeks. So, such short notice.” I know. “So, my question is, am I doomed forever to have gestational hypertension or is each pregnancy its own thing? And if I don’t have hypertension again, will I be induced at 37 weeks again just in case?”

All right, Elizabeth, thanks for the question. So, Caroline and I were discussing before, you know, you got diagnosed at 32 weeks and you were induced to 37 weeks. That’s actually not a short time, that’s a fair amount of time to have gestational hypertension and be stable. So, actually, good job. We’re pleased with that. That’d be great. Sometimes you have to be induced two days later. So, that’s good.

All right. So, someone has a history…again, I guess the theme is last pregnancy stuff. So, last pregnancy, someone has gestational hypertension, meaning the blood pressure goes up during pregnancy, related to pregnancy, not a chronic condition. How do you manage them in the next pregnancy and what’s the chances it’s going to happen again?

Dr. Friedman: Yeah. Well, so like most things, you know, once you’ve had something once, you’re probably at risk for it again, just because of whatever underlying risk factors were there to begin with. Plus, it’s happened once. But as usual, there’s not necessarily a guarantee, there’s a lot of factors that could go into it. And every pregnancy, you know, the placenta, all sorts of things are making your body react differently. Typically, we’ll start by sending some baseline labs just to have values to compare to later in the pregnancy if we need to. And we do recommend taking a baby aspirin or a low-dose aspirin in the pregnancy to reduce your risk of the blood pressure happening again. But it’s not a guarantee.

Dr. Fox: Right. It’s interesting. If I had to quote someone, I’d probably go with 30% again.

Dr. Friedman: It’s like a good number.

Dr. Fox: Yeah, I mean, some of it depends. The earlier it presented and the more severe it was, the more likely it’s going to happen in the next pregnancy versus the later, the more mild. Thirty-two weeks is pretty early. But if you made it mild till 37 weeks, not so much. And some of it is also what happens to your blood pressure afterwards, how long did it take to get better, but you know, we have a conversation.

We do follow the next pregnancy closer in some capacity, there’s no perfect way to do it. You know, sometimes we let people check their blood pressure at home so that they don’t have as frequent visits or some of them don’t come to the office more frequently or sometimes both. Check the baby, this or that. I don’t typically recommend delivering someone in the next pregnancy early if they don’t have hypertension. So, if someone had gestational hypertension the first pregnancy and then the second time around they’re doing perfectly fine, we’ll usually wait until at least 39 weeks, unless there’s other…

Dr. Friedman: Right. Unless something else comes up.

Dr. Fox: Yeah, other circumstances or other things, you know, unrelated to hypertension. So, I think, Elizabeth, most likely it’s going to be fine. There’s probably a little bit more follow up they’ll need in the next pregnancy but it probably won’t mean an early delivery unless, again, you have it again.

Dr. Friedman: Right.

Dr. Fox: Good. All right. Number three, this is, I think, going to be a quick one. But it’s a great question. And this is something we get a lot in the office. It’s from Hannah. Hannah says, “Thanks for your awesome, informative, and interesting podcast.” Well, Hannah, thanks for that. “I wanted to ask you about the safety and/or data of laser hair removal during pregnancy. Thank you”. So, that was a quick compliment and question. So, yes, we have a lot of people ask us about laser hair removal during pregnancy. We were discussing before that we are slightly different on our answer to this question. So, usually, when that’s the case, there isn’t great data. So, how do you talk to people about this when they ask you?

Dr. Friedman: I tell people that there is really no data. This is something that has not been studied and probably won’t be studied. It’s hard to do any studies in pregnancy, let alone once, you know, about sort of cosmetic things. It’s most likely safe, can’t really imagine or theorize why it wouldn’t be. But if you’re nervous about it, or you’re not really sure what you want to do, and it’s primarily for cosmetic reasons, then maybe best to defer and wait until after pregnancy.

Dr. Fox: Right. I guess, I’d say the same thing but I say it quicker. I say just don’t laser the baby, which usually gets a chuckle. But again, for the same reason, I can’t understand a way how that could harm a baby, it just…you know, you’re talking about applying, you know, heat or an electric current to hair which essentially, burns the follicle, which is a millimeter under the skin somewhere else in the body. And so, I don’t really understand how that could harm a fetus inside the uterus. It just doesn’t make any sense to me. And like, why would it hurt a fetus and not your kidneys, or your liver, or your intestines, which just, you know, are also inside your body? So, I’m generally okay with it. Again, if someone wants to avoid it because they just want to avoid stuff, God bless, that’s fine. But I don’t tend to have a problem with that. I don’t think a lot of people have written on this or studied it as far as I can tell.

Dr. Friedman: Yeah, me neither.

Dr. Fox: Okay. Well, Hannah, off you go. All right. Question number four, which is actually four and five. It’s a two-part question. Rose, thank you for sending in your questions. And yes, you are allowed to send in more than one question in one email. All right, here we go. Number one, from Rose, “I’m really enjoying the podcast and I’ve learned so much.” Note, I only read the ones that give compliments, of course.

Dr. Friedman: Yeah, I did. I was wondering.

Dr. Fox: Yeah, I was talking with Melka that it’d be great if someone really just started insulting me, and I would love to read those on the air, just a total ring fest on me. But it hasn’t happened yet. All right. So, “I’m really enjoying the podcast and have learned so much. My questions are, firstly, why are hospitals still restricting laboring patients from eating during labor? From what I’ve heard, the study they’re basing it on is very outdated and labor is often compared to running a marathon, which is obviously physically exhausting. So why are we making women essentially fast for the duration of their labor, which can last many hours and basically leave them with very little energy when it comes to pushing?” Great question, Rose. All right, Friedman, you’re on. Talk to me.

Dr. Friedman: All right. Well, this is a common discussion with patients and amongst myself and other colleagues. You know, it is probably a bit of an antiquated rule about the no eating in labor. And basically, it comes from the anesthesiologists. And so, you know, if you’ve ever had surgery, or know people who’ve had surgery, you’re usually instructed not to eat anything or drink anything for however many hours before the procedure. And the reason being is that if you end up needing general anesthesia, for whatever reason, and have to put a breathing tube in, there’s a potential risk that you could aspirate, or what they call, when you basically choke up food that’s in your stomach or fluids in your stomach, and it ends up in your lungs and can be a cause of infection and other complications. And so, they want to make sure they’re not putting anybody at unnecessary risk because of anything in their stomach. And in labor, it’s a little confusing because 99.9% of the time patients aren’t getting general anesthesia. They’re having anesthesia, either through spinal or an epidural in their back…

Dr. Fox: Or not at all.

Dr. Friedman: Or not at all.

Dr. Fox: Right.

Dr. Friedman: And so, you sort of wonder, “Okay, well, like, I get that theory, but it’s unlikely they’re going to need it. And then if they do, it’s unlikely that anything’s gonna happen. And then if it does, it’s unlikely to cause a problem that’s sort of like the shoulder dystocia.” You know, if, if, if thing. So, it’s hard because I think they know this and they recognize that it’s unlikely but they still want to maintain that caution and try to protect people as much as they can.

Dr. Fox: Yeah, it’s tough. I think that the data supports eating in labor. Like you said, for almost everyone, it’s completely safe. And it’s going to make them feel better, right? Just, I mean, you know, who doesn’t want to eat for that long time? I certainly would have a hard time going that long without eating. And as you said, Rose, labor does involve physical exertion. Both knowingly and unknowingly, your body is working, whether you feel like you’re working or not. And most do, especially if they’re on an epidural. But even if you have one and you feel no pain, your body is working. And so, calories are helpful. And it’s just more pleasant of an experience. And there’s some data that it actually improves outcomes in labor if mom is fed to some degree. And then there’s people who don’t want you to do it, because they think there’s some level of risk. And again, what is your threshold of risk to say, “No one should eat in labor?”

So, there’s different ways hospitals or labor floors go about this, and they’re not uniform. Some of them say, “Yeah, you could totally eat in labor, it’s fine.” Others say, “Certain people can eat in labor, but others with certain risk factors can’t if, whatever, you had a prior C-section, or, you know, you’ve got some medical issue, or something that puts you at high risk, you can’t.” Others will say the same rules but then they differentiate what kind of eating. Like, you can eat this, but you can’t eat this, or you can drink this, but you can’t drink that. And you’re gonna see everything because different people have different philosophies on this. And I think that’s a good question to ask around.

Now, the issue is, frequently, the person who you’re asking has no control. People ask me this all the time and I’m like, “I’m fine if you eat in labor, but the hospital policy is that you can’t.” And I don’t make that policy. I’m a guest in their house. And so I don’t really have any…just like, I can’t decide, you know, what paperwork to fill out on admission. I just have no authority.

Dr. Friedman: Right. Not up to us..

Dr. Fox: Yeah. And so, it’s tough. I would say, if it’s your obstetrician or midwife who is making that call, that’s a good question to ask them. If it’s the hospital, you can ask them. But frequently, rules are rules, and they don’t tend to bend too much on these things, or it takes a very long time. But you will definitely…if it’s very, very important to you, there are places that allow it and places that don’t. And that’s something you could inquire about. But it might mean you have to switch doctors or midwives, because we usually only deliver at one place. It is tough. But, Rose, I agree. I think that this is a very good question. I think more people should be asking this question and lobbying for this, because that’s what the data supports in my opinion.

Dr. Friedman: Yeah. And keep in mind, like, there’s no cameras. Nobody’s watching you at all times.

Dr. Fox: Oh, dear. All right. All right. So, Dr. Friedman subtly said you won’t be imprisoned. Okay, we’re just gonna…

Dr. Friedman: You didn’t hear it from us.

Dr. Fox: Yeah, you didn’t hear it in this podcast. All right. No problem. So, all right. Great discussion there. But it happens a lot. A lot of people ask this question. One of the interesting things actually, as I remember something Bender told me, that for whatever reason, the hospital lets you have clear liquids, which don’t have to be clear, and don’t necessarily have to be liquid. Like black coffee is a clear liquid even though you can’t see through it. Jell-O is a clear liquid, even though it’s not a liquid.

Dr. Friedman: A liquid.

Dr. Fox: Coffee and milk is not a clear liquid because it’s got some…it’s basically, how long these things sit in your stomach. But it’s…yeah, if it matters to you, ask in advance what the rules are. You can try to push back, but just a warning, it’s not likely to be fruitful, unfortunately. All right, Rose. Good question. We’ll let you ask another one.

Number two. Secondly, “I’m also wondering why doctors usually have patients push in the sitting position and holding their breath versus pushing on hands and knees, or sideline with an epidural, and bearing down exhaling while pushing.” So, this is basically, pushing in labor, what’s the right position? What’s the best breathing? And why are doctors instructing people how to push versus just letting them do it the way they want to do it?

Dr. Friedman: Yeah, that’s a good question. I’m not sure that the question statement is always the truth. I think there’s a lot of…it’s hard to really know what doctors are doing. And I’m sure some doctors do it some way, and whatever. But I think we instruct our patients because pushing is really hard. And it’s not something that people do like routinely until they come to have a baby. And it takes a lot of energy, as we were just discussing. And so spending that energy in a way that’s not productive can really be detrimental to the patient. And so, trying to encourage and instruct your patient on the most effective way of pushing is to everybody’s benefit.

Dr. Fox: Right. There are studies I remember that looked at, we’ll call it, coached pushing versus sort of like, spontaneous but natural pushing, but that’s predominantly people without epidurals because then you sort of feel that sensation working. Likely that’s going to be fine in terms of how to push in sort of the best way, the best timing, whatever. But the issue with people with epidural is some of them feel a tremendous urge to push and others don’t. And so, sometimes you really have to work with them. What are the right muscles, how to do it?

In terms of whether you should push holding your breath or breathing out, again, it’s trial and error, right? Sometimes, you know, when I’m pushing with someone, you try different ways. We can tell when a push is effective, we can see the head moving, we can feel the head moving, we sort of see what’s going on, is she getting tired, is she not getting tired? And so, we’ll just go with the one that seems to be working best.

Dr. Friedman: Right. Exactly.

Dr. Fox: You know, as long as it’s comfortable for her. And so that’s true with how they’re breathing versus holding their breath, how long they push at a time, you know, how many times per contraction, what position…

Dr. Friedman: What position.

Dr. Fox: God bless if someone wants to push on their hands and knees, or on their side. Some people push better that way, some people push worse that way. And it’s really just, you know, I think the point is, you want someone who’s not married to one specific way to push and that they’re open to different positions or methods. But on the patient side, you should also be open to the fact that whoever’s with you is going to have a pretty good sense of what’s working and what’s not. And so, I think it’s a two-way street, as we say, with this, finding that. And sometimes people pick it up real quick. And sometimes it’s 30, 45 minutes before like, “All right, now we’re cooking with gas…”

Dr. Friedman: Right. Exactly.

Dr. Fox: …as we say. I agree, it can be very, like, distressing to people to put in that effort and then it seems, like, nothing’s happening. Like, “What?” Yeah, it’s tough.

Dr. Friedman: Right. Or, like, sometimes I think that, you know, patients are pushing for a long time. And they feel like they’re doing a good job but nobody is really giving the feedback because they’re scared to give the feedback or give instruction. And then you’re sort of tired and frustrated.

Dr. Fox: Yeah, I mean, a lot of this is also…there’s so much variation. Also, like who’s in the room with you when you’re pushing. And ideally, the person who’s in the room with you, whether that’s your obstetrician, your midwife, whether they’re not there and the nurse is pushing with you, or a med student, or resident, or your doula, whoever is there pushing with you, should be able to give you some feedback on whether it’s effective or not. And if you’re in a situation where you’re with someone who can’t give you that feedback, you know, I would say that’s not ideal, right? It doesn’t have to be always like 100%. We tend to be there with our patients when they’re pushing. I like to be there because I like to give that feedback because I think it’s more effective. But sometimes it’s not possible. Sometimes you have two people pushing at the same time, you have to go back and forth. Okay. But ideally, there should be some evaluation, so you get a sense that what you’re doing is right.

So, Rose, your second question, there isn’t one ideal way to push. But there’s a lot of variables that go into what would be the best for an individual person in an individual labor again, you know.

Dr. Friedman: Exactly.

Dr. Fox: And it’s hard to predict that on the front end. Another thing is some positions you can’t do with an epidural. If you’re like, “I want to squat.” Like, okay, you can’t, you don’t have strength in your thighs to squat if you have an epidural. If position matters to you when you’re pushing, that may impact your decision to get an epidural or not. I wouldn’t encourage someone to choose an epidural based on the position they think they want to push in, but, you know, whatever people want, that’s all good.

All right. So, we’re also cooking with gas, we’re rolling through these here. All right, so the next topic, the next question is actually our last one for today. And it’s from Leslie. All right, Leslie. She writes, “When I was five days postpartum, I ended up in the emergency room. I had a kidney infection, and kidney abscess, and was septic.” Yikes, not good. “It was a very scary experience, needless to say, and it makes me nervous about having more children in the future. I have a couple of questions. One, what do you think is the most likely cause of this infection? (My urologist suggested it was a complication of my epidural. The epidural caused urinary retention that was undiagnosed and then led to infection/abscess.) Two, am I at higher risk of this happening again in the subsequent birth? And is there anything I can do to mitigate the risk?”

So, let’s first talk about kidney infections in general. And I would say I beg to differ with the urologist. I don’t think it’s a known complication of epidural.

Dr. Friedman: Yeah, it’s unlikely.

Dr. Fox: I mean, you can get urinary retention from an epidural. But, number one, that doesn’t typically lead to an infection and it’s only temporary. You don’t go 5 days with a urinary retention, you go maybe 12 hours.

Dr. Friedman: Right. And it can happen without an epidural also, just from, you know, the…

Dr. Fox: Labor.

Dr. Friedman: …trauma of labor, right.

Dr. Fox: Yeah. Yeah. So, I don’t think that’s the cause. I would say that pregnant and postpartum women have a higher risk of getting kidney infections. That’s well known from the moment you get pregnant till weeks after you deliver. The thought process Is that everything sort of dilates and relaxes. And so there’s more potential backup of bugs from the vagina into the bladder or from the bladder…

Dr. Friedman: Up Into the kidneys.

Dr. Fox: …into the kidneys. And so, pregnant women who have bacteria in their bladder have a higher risk of getting bacteria in their kidneys, which can be very, very bad. And that’s a bad infection. And it happens, again, early pregnancy, middle pregnancy, close to labor, and postpartum. And that, I would say, is the most likely thing just related to pregnancy. The only, like, intervention is if you got a C-section, there’s an injury. But these are very, very, very, very rare.

Dr. Friedman: Yeah, I doubt that.

Dr. Fox: It’s almost always just what we call ascending. Okay, so let’s say she’s coming to you next pregnancy, and she had this really bad kidney infection after delivery. What do you tell her is the chance that it’s going to happen again in the next pregnancy? And what might you do about it?

Dr. Friedman: You know, I’m not good with percentages. Like everything, I think it’s probably a little bit of a higher risk, because maybe there’s something with her anatomy or, you know, something else that puts slightly at higher risk. But it’s probably not going to happen again. Because it’s rare, it was probably just bad luck. You know, what we would probably do the next time around is monitor the urine. You know, maybe not at every visit, but frequently, a few times during the pregnancy, at least, just make sure we’re not missing any kind of underlying urinary infection that if untreated could progress to a kidney infection so that we could catch it early and treat it if we need to.

Dr. Fox: Yeah, I mean, one of the interesting things about pregnancy is someone pregnant or not pregnant can have what we call a urinary tract infection, or acute cystitis, which is basically a bladder infection. And bladder infections, if you ever had one, you know what they are, burning, you know, when you pee, and you have to go all the time, and it’s painful. And when you finish, you feel like you still have to go, those symptoms, anyone that’s had it, they know, very classic. And those are treated with antibiotics.

There is something called asymptomatic bacteria, right, where you find a lot of bacteria in the urine, but someone has no symptoms. They don’t have the symptoms of an infection, but they have bacteria in urine. And typically, that’s not treated, because that comes, that goes and you don’t treat it. But in pregnancy, we do treat it. If we find it, we treat it because, as we said, it’s more likely to lead to an infection when someone’s pregnant. And so, the thought is if someone had a severe infection, like in their kidneys, or maybe they got multiple bladder infections, in the next pregnancy, we’ll just do very frequent urine cultures. And if there’s bacteria over a certain amount, we’re going to treat it, symptoms or not. That’s one strategy.

The other strategy is just to say, “You know what, take an antibiotic once a day, every day, the whole pregnancy.” Which one you choose, or do you do both is not uniform. Different people do differently, but I would say that, basically, Leslie, in your next pregnancy, they should do at least one or the other. Either check your urine very frequently to make sure there’s no asymptomatic bacteria in your bladder, again, above a certain amount, or put you on an antibiotic every day, or both. And that will generally prevent it, not always, but generally prevent it from happening again. But I would not discourage you from getting pregnant because of that.

Dr. Friedman: No.

Dr. Fox: Yeah. Good stuff. That was quite the mailbag. We rolled through it. I think that Spiegelman and Melka have their work cut out for them to beat you with this. Good job, Friedman. Thanks for coming.

Dr. Friedman: Anytime.

Dr. Fox: Awesome. 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 and 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.