“The 9th Month: Everything you need to know about the last few weeks of pregnancy” – with Dr. Sara Kostant

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. In “Healthful Woman,” I speak with leaders in the field to help you learn more about women’s health, pregnancy, and wellness. All right, Sarah, welcome back to the podcast. How are you doing?

Sarah: Can’t complain. That’s my standard answer.

Dr. Fox: Well, it’s nice to see you. It’s nice to have you back on. We’re getting requests. This topic is something I thought about recently how at the end of pregnancy, whether you call it the ninth month or the last four weeks, there’s so much that happens at that time compared to earlier in pregnancy, certainly compared to the middle of pregnancy. And I thought it’d be a good idea to, sort of, you know, put it all together into one podcast to hopefully be helpful of women for couples coming towards the end of pregnancy. Like, what are the things that are gonna happen? What do we think about? What are we gonna talk about? I imagined for you this is where conversations start getting longer.

Sarah: I think probably even starting in 34 weeks, patients will…a lot of times will ask, what should I be asking now? And I think there’s been so much, especially if someone’s had, you know, a fairly, let’s say, like, uncomplicated pregnancy. You know, the visits are fairly standard up till now. And I think as long as pregnancy seems to women who are actually pregnant, that the last few weeks can creep up on you. And then suddenly, you’re 36 weeks, you’re at your visit during the group B strep test, you know, the due date is less than, you know, some people say like, “A month from now, I could have had the baby.” And I’m like, well, even a couple of weeks from now, you can have the baby. And patients be like, “Oh.” I’ll explain, you know, in a week, 37 weeks, you’re considered term. You won’t be considered preterm. You may still not have the baby yet. But I think that really hits a lot of women when I say that.

Dr. Fox: They’re like, “Oh, my God, you’re right, I could have this baby in a week or two, I gotta get ready.” And, you know, it’s interesting, you look at prenatal care. So, on the front end, when someone gets pregnant, you know, there’s a lot. You know, the first visit’s an hour and then the second visit’s long and we’re doing all this, you know, bloodwork, and testing, and genetic stuff. And we’re taking a history, and examining, and talking about what to do, what not to do. So much it happens in the front. And then it, sort of, settles down during pregnancy. You’re coming every month, let’s say in a low-risk pregnancy, maybe every couple weeks, if it’s more high risk. And as long as there’s no blips, you know, no bumps in the road, everything’s okay but then, we start seeing people weekly at the enterprise, even, you know, total routine pregnancy, everything’s going perfect, we start seeing people weekly in our practice around 36 weeks. So that’s four weeks before the due date. And some of that is because there are things we need to check more frequently. And some of it is just because we need time to talk about all this stuff. And so people have questions and new questions come and you can’t, sort of, do it all in the one-hour visit because people don’t even know what questions they’re gonna ask and something changes every week. And so I find that the last, you know, visits, even though they’re so frequent that people are coming so often, they’re not quick.

Sarah: You know, we have a good list of things to talk about today. One of the comments I often get is I’ll tell patients that, you know, we’re gonna be seeing you weekly. And sometimes they’ll get alarmed. They’ll ask, “Well, what’s wrong?” And I’ll explain, “No, nothing, just, you know, you’re 36 weeks and even in a pregnancy that’s been completely low-risk, there are things that we look out for more in the last month.” And usually, they’ll be much more relieved after that. But just, you know, for women who have had a much higher risk pregnancy, sometimes they’ve been already seen once or twice a week. But for someone otherwise, who’s had a fairly low-risk pregnancy, coming in once a week sometimes seems a little daunting to them. So I basically will say, “No, it’s actually a great opportunity.” You know, even if everything’s fine at each visit, we can chat about, you know, a whole bunch of things.

Dr. Fox: I thought we’d break it down into first, on our end, what are the things we’re looking for? Like, why do we want someone to come in every week towards the end? And then we’ll, sort of, get into what are the things people ask us about in those last week? So, sort of, when someone says, what should I be asking, you know, this may be a good podcast for that sort of the things that a lot of people ask about or, you know, maybe you haven’t considered. In terms of the stuff we’re looking for, it’s not much different from the rest of pregnancy, except these things tend to get more common towards the end of pregnancy and so we have to check more frequently. So the first one is for preeclampsia and it’s, you know, for every prenatal visit, you know, get your blood pressure checked. And I’m like, well, I mean, my blood pressure checked. Like, I don’t know if I have high blood pressure. And it’s really because we’re screening for preeclampsia, where your blood pressure goes up. And that’s the same reason we have you pee in a cup and we dip your urine. If you’re like, “Why am I doing this?” It’s the same reason. It’s all part of preeclampsia. And since it’s more common as you get more pregnant, we wanna do this weekly at the end of pregnancy. For some people who have some concern or they’re higher risk, we may have them check their blood pressure at home every day potentially, but at least we want to see someone every week towards the end of pregnancy. And frequently, they’re perfectly fine. They look great. They feel fine. And suddenly we’re like, “Hey, your blood pressure’s high. Did you know that?” And they wouldn’t know because there’s no symptoms.

Sarah: Yeah. And I think that’s the thing I always tell patients is that we’ll have patients whose blood pressure has been 100 over 60 the entire pregnancy, and then they’ll come in feeling great at 39 weeks even, and it’ll be 150 over 100. And they’ll have had no idea. And, you know, just as reassurance to everybody listening, most of the time, the last few weeks of pregnancy are going to go great without, you know, any complications at all. But these are definitely things that can pop up. And thankfully, if we catch them early enough, you know, they’re easy to treat. You know, we’ll deliver you. And especially once, you know, once you’re over 37 weeks and you’re term, you know, thankfully, if any of these things that we’re gonna talk about come up and we do have to deliver you, you know, we’re gonna be delivering a term baby. And so our threshold for delivery if we need to is very low.

Dr. Fox: Yeah, exactly. I agree. So what are some of the other things we’re looking for in these weekly visits besides preeclampsia?

Sarah: Well, one of the things that we’ll pay attention to, many women will know that we measure their abdomen with a tape measure just to, kind of, get an idea of how much the uterus is growing between visits. For some of our patients, they may have a medical indication where they’re already having ultrasounds to check the size of the baby pretty regularly every two to four weeks. But in women who are fairly low risk, we don’t do routine growth ultrasounds to check the size of the baby. But we will make sure to always measure the uterus just to make sure that, again, there is steady growth. And what we’re looking for is that the centimeters on our tape measure roughly corresponds with how many weeks the patient is. So, if a woman comes to our office for a visit at 37 weeks and I do a measurement, and I’m getting, you know, like, 33 centimeters on the tape measure, that might trigger me to say, “Hey, you know, we should get a growth ultrasound to check the size of the baby.” And this sometimes can come up more in the last few weeks because if there is going to be an issue with the growth of the baby, it’s a little more likely to sometimes happen then. The placenta may have worked well most of the pregnancy, but in some women getting toward the end of the pregnancy, it may not be working as well. And that might be reflected in the size of the baby. So we screen very carefully for that. And if the uterus is measuring fine on our tape measure, what we call fundal heights, that’s a term that we use, we just repeat it each week. But if there’s any concern with that, we can get a growth ultrasound. And even in that case, most of the time, the growth ultrasound is fine because the tape measure is really just a way to screen. So that’s definitely something that, you know, we’ll pay closer attention to at the end.

Dr. Fox: Yeah. And in the same regard in terms of, you know, the placenta and the health. It’s the same reason we always ask, how’s the baby moving? You know, is everything normal? Are you feeling kicks? Because towards the end of pregnancy, if there were to be any issues, it would usually happen then? But also the movements tend to change a little bit because the babies get more crowded, so they can’t really bounce around inside. And so, we’d like to just go over it and, you know, talk about it, what’s normal, what’s not normal, what to do if you think the movements aren’t normal, and sort of how we evaluate it. And again, almost always, everything’s perfectly fine, no matter what’s going on. But it’s something that, you know, a lot of women are gonna have questions about and maybe even potentially have concerns about. And so we like to be sure on our end that everything’s okay and that women know how they can evaluate at home and what to call for. And for some people who are at higher risk, we formally assess how the baby’s moving, either with an ultrasound. There’s also something called the nonstress test. We do it more with an ultrasound. But these are all measurements, whether it’s her perception of the movements or the formal testing, just to ensure baby’s healthy, everything’s okay. We’re plowing forward.

Sarah: And one thing I also emphasize, just with regard to fetal movement is I tell patients, the quality, like, the types of movement may be different from when you were, you know, 28 weeks pregnant or 32 weeks pregnant, but you shouldn’t feel a sudden drop off in the number of movements. So if from day to day, the movement is pretty much the same over the last week, but maybe you feel more wiggles instead of strong kicks, but you definitely feel the same overall number of movements with the same pattern that you’re used to. Some babies move more in the morning, some move more at night. That’s okay. But if you feel from one day to the next, there’s a drop-off in the movement to definitely give us a call. I don’t routinely tell patients to do kick counts at the end unless they tend to have trouble, like, knowing when the baby’s moving. And I’ll usually give a minimum of about three movements in a half-hour as the minimum that I would want them to get. But I’ll even tell them if that’s still much less than usual for you, you should still give us a call.

Dr. Fox: Right. Exactly. And I do the same way. I don’t have people formally do these kick counts unless there’s a concern and I want them to do it or if it’s someone who, sort of, continuously is concerned or doesn’t really feel the baby as well, or doesn’t really, you know, know how to assess it. That’s one way to, sort of, give reassurance. But it’s important, like, we say things like, you know, three movements in half hour, that does not mean that you’re gonna feel six movements every hour throughout the day because when you’re busy and you’re running around and doing stuff, you don’t always feel the baby move. It has to be during, like, a dedicated session where you’re only focusing on the baby. We also always ask about bleeding because sometimes bleeding can be benign. It could be from the cervix, it could be after having sex. It could be for a lot of reasons. But there are forms of bleeding, like, if the placenta is separating early that are concerning. So we always ask about it and then go into it if it’s happening. And again, the same concept, because if it’s gonna happen, it’s frequently gonna happen at the end of pregnancy. And we just wanna make sure everyone knows, you know, what’s normal, what’s not normal, when to call, when you don’t have to call. Like, all those types of things, we like to preempt it so people don’t, you know, at 02:00 in the morning, not know what to do. And then maybe they’re, you know, concerned and they don’t call because they think it’s nothing and we would have wanted them too, and maybe the opposite as well. And then the other thing is we like to know what the position of the baby is.

Sarah: Yes, definitely.

Dr. Fox: Yeah. And we really like that baby to be head down if they’re planning a vaginal delivery. And so that’s something that we do assess, you know, just by touch with our hands. But we usually always check with an ultrasound, even if it’s just, you know, in the exam room and bedside just to be 1,000% sure that we’re correct with our exam that the baby’s head is down. If it’s not, we talk about, you know, what to do based on how far they are. And sometimes we get surprised.

Sarah: Yeah, in residency, actually, we would examine the patient’s abdomen. Like, I remember one of my attendings would just show me how to put my hands on the abdomen and just kind of tell, you know, whether the baby’s head was down or up. And we didn’t have ultrasounds in our clinic. And when patients would… If we had any question about it or we just couldn’t tell, we would do an ultrasound. And I think usually toward the end, like maybe around 36 weeks, we would do a quick one just so we could really double-check. And we definitely would have some patients who we would say like, “Oh, they’ve been breeched the whole time.” And in our office, our practice is that at every visit, we do an ultrasound to check the heart rate, instead of just using a Doppler, a heart monitor. So, you know, we always see the position of the baby, whether the baby’s breech, which is bottom first, or head first, or transverse, which is basically just the baby decides to be completely sideways. So we don’t get many surprises nowadays in 2020.

Dr. Fox: We don’t get many surprises in that regard. But sometimes, the surprise would be the baby’s been, like, head down the whole time and then suddenly it’s breech at 36, 37 weeks, and you’re like, “Whoa, how about that?” It doesn’t happen a lot but it definitely can happen. And I think in terms of, like, summing up what we’re doing on our end, we’re doing a continual assessment. Is this patient better off staying pregnant or getting delivered? And that judgment that we make can change on any day based on how the baby’s growing, what the heart rate is like, what her blood pressure is like, what her symptoms are like? Whether she’s contracting out, whether she’s bleeding or not. And so sometimes, you know, when we see people, most of the time we see them, they stay pregnant, right? We say, “Go home, come back in a week. Come back in a half week,” whatever it is, but occasionally, we’re like, “Oh, things are changing. It may be better for you, it may be better for the baby to deliver.” And that’s, sort of, one of the things we’re always thinking about on our end, without overtly talking about it in that sense. We’re not saying, “Hey, I wanna check if I wanna keep you pregnant.” But that’s, sort of, one of the things that goes on in our mind, particularly when things start getting borderline.

Sarah: A lot of patients will ask also sometimes around 36, 37 weeks, you know, if I can predict, kind of, in advance if something’s gonna come up. And I really can’t and even especially from patients who have had things happen, you know, in a prior pregnancy, it’s really hard to tell, which is why, you know, we see patients once a week, but I always encourage patients to really, you know, keep track of how they’re feeling, you know, give us a call if anything comes, even if they had a great visit, anything comes up in-between visits, just let us know, anything that doesn’t seem right to them. I tell patients, kind of, trust their intuition a bit. The other thing just to go back quickly to preeclampsia, one of the things that I will tell patients about, even patients that have not had any issues with high blood pressure is I do tell them to call if they get, like, an unrelenting severe headache. They start having blurry vision at home, even if they had a great visit normal blood pressure three days earlier, if they start having any pain around their stomach or their right side, kind of, even near their rib cage, those are all symptoms of preeclampsia. And I would want someone to call if they had that and not just dismiss it as, “Oh, I have a headache.” You know, sure, if you have a mild headache, you know, definitely patients can take Tylenol, but if it doesn’t go away, that’s something that, you know, we would wanna know as well.

Dr. Fox: Yeah. And it’s the same thing even though the visits are let’s say weekly, we would always rather people call and I say, “No, it’s okay,” than not call, meaning someone should not say, “Well, my baby’s not moving well, but I have a visit in three days, I’ll wait to talk about it then.”

Sarah: Exactly.

Dr. Fox: Or, you know, I don’t feel right but I’ll wait until my visit. Like, no, we would rather someone call, like, at the moment, just tell us what’s going on because these are the phone calls we take. I mean, this is normal to get these phone calls and we’ll generally be able to say pretty quickly, “You should come in or you’re fine or stay home and monitor, and then we’ll decide in two hours what to do.” But always, you know, err on the side of letting us know something has changed if you don’t feel right, compared to, “Oh, I’ll just wait for my next visit.”

Sarah: Yeah, if you were in our office that day and then that evening, you have some concern, you’re not feeling well, you’re not feeling the baby move, you have a really bad headache, all of a sudden, call. Absolutely.

Dr. Fox: Exactly. A hundred percent. Because things change. Things can change relatively quickly, as well. So what are the things that in your experience, you know, pregnant woman ask about in the last month? What are the things that come up? So this is to answer the question, what should I be asking about? We could say, all right, what do people ask you about?

Sarah: Well, one big thing is, how do I know when to come to the hospital? And there’s different variations of that. How do I know if my water broke? A lot of what patients are asking is like, “How do I know when I’m going into labor?” And so I’ll go over the signs and symptoms of labor and ruptured membranes. I’ll tell patients that, you know, just to start with the water breaking, ruptured membranes that, you know, it’s normal to have discharged throughout the pregnancy. But if the water breaks, you’ll usually start having watery fluid come out, not just discharge. It’s sometimes not… Unlike the movies, it’s not always a huge gush that makes a puddle on the floor. So it’s not always very obvious. But it’s definitely… What I tell patients is it’s gonna be continuous. Like, if you feel like something comes out and you’re not sure, you know, wait a half-hour hour, but you’ll keep having a trickle of fluid come out. Like, you’ll change your underwear, more fluid will come out. And a lot of patients will, like, think about that, “Well, what if it’s this much?” And again, it’s one of those things where I always say, if you just feel something trickling out, just give us a call. I don’t expect you to tell 100% that your water broke. Again, puddle on the floor, yeah, it’s very obvious. Sometimes the only way to tell is for us to do an exam. And if I need to have patients come to the hospital to do an exam or come to our office, you know, we’ll see them. I don’t expect them to tell 100%. That’s one of the things that I go over. And then the big question also is about contractions. You know, what do they feel like? How close together should they be? So, what I tell patients who have never delivered before is that contractions will be uncomfortable. I think some women feel that they may miss contractions and not know they’re in labor.

Now, again, I do counsel patients who have had a vaginal delivery before a little differently because their labors can go much quicker. But for someone who’s going to be, you know, hopefully having a vaginal delivery for the first time, I’ll explain to them that you may start to feel in the last few weeks of pregnancy an abdominal tightening. It may radiate to your back. It may radiate down your legs. You know, it may just be something you notice. And it can happen sometimes more at a particular time of day. And those are what we call Braxton Hicks contractions that are, kind of, the uterus just getting ready. But that’s not labor, when someone is going into labor, the contractions will become regular. So they won’t just be, you know, every you know, 10 to 20 minutes. They’ll be usually every starting every 5 to 10 minutes. And they will get uncomfortable enough that during a contraction, a woman won’t really be able to do much else. Like, she will have a hard time talking to anyone. She may need to take some deep breaths through. And that’s the point where I’ll tell patients, “If you’re having contractions like that every five minutes and otherwise, things are fine, the baby’s moving, you’re not bleeding, I would give us a call.” If there’s any other concerns sooner meaning, like, you know, someone’s contracting two times an hour, but they’re having some spotting or they’re contracting two times an hour, but they’re having some fluid leakage, like, definitely call earlier. But if everything else is fine, a mom can wait until she’s contracting, say, like, every five minutes or so before I would say okay, you can, you know, head into the hospital.

Dr. Fox: Yeah, I think what you said is very similar to what I tell women. In terms of water breaking, I say same thing. I say usually, like, 9 out of 10 times it’s pretty obvious. Someone calls us, “My water broke.” Like, this is clearly something that’s different and my water is broken. And then all right, we bring them to the office, come to the hospital, whatever it is. And for the 1 out of 10 where it’s not obvious, well, it’s not always obvious. Sometimes there’s a small leak or sometimes the water isn’t broken and it’s something else. And in those situations, if we can’t figure it out over the phone, we’ll bring them in, right, whether to the office or the hospital, whatever, we’ll do an exam and we’ll determine yes or no. And that happens. That’s totally fine if it’s unclear. And with contractions, the best is when I get asked probably every day, “What do contractions feel like?” What I’ve been told is, again, it’s this idea, you know, if a woman knows what a menstrual cramp feels like. It’s that multiplied, right? It’s the same location, the same concept. But when it’s a contraction for labor, it gets really intense, like you said. Another word for intense is painful. So if the contractions don’t hurt, you’re not in labor. If you can sleep through them, you’re not in labor. If you’re not sure if you’re in labor, you’re not in labor, right? It’s one of these things where when someone goes into labor, they’re relentless. They just keep coming, right? The contractions, they sort of come and go. You get two, you get one, then you don’t get one for an hour, then you get three in a row, and then you don’t get one for a week. Like, that’s sort of on and off is not labor. And like you said, if it’s every 10, 20 minutes, it may be going into labor, but probably not yet. And I say the same thing, if they’re painful, they’re regular, they’re lasting, like, 30 seconds to a minute, they’re not going away, they’re every 5 minutes or so, almost certainly you’re in labor and we’re gonna bring you into the hospital.

Occasionally, you’re not in labor and that sort of stops. But most people by the time all those things are happening are in labor and we’re gonna bring you in. And again, worst-case scenario, you call too early and we tell you on the phone, “Wait a little bit,” or we bring you in and check you and say, “Wait a little bit.” And it’s fine. As I say, if someone calls me and they’re contracting every 10 minutes, okay, like, these are the calls we take. It doesn’t bother me. And I’ll say, I may wait, we’ll do this, we’ll do that. And so there’s any question about it, call. But like you said, if the water is broken, you think the water is broken, it doesn’t matter how many contractions you’re having, that’s the same thing to us as, like, going into labor. So we wanna know about that. But that’s something that comes up a lot. So I would say that’s probably number one on the list of things that people ask about, particularly in first babies or if maybe it’s their second or third, but they were induced last time or they had a C section last time or something where they don’t know what it’s like to go into labor because that happens. We have, you know, people who are not first-time moms who still don’t know what contractions feel like or they had an epidural, right, you know, right away, so they don’t really know what it is. I think another thing that people ask me all the time is, “When am I gonna go into labor?” And so how do you answer that.

Sarah: Like, I’ll preface it with like, “I don’t know.” They’ll want to have a cervical exam. And because they’ll say, because I want to get an idea of when I’m gonna deliver. And I’ll say to them, “I can do an exam but I’ll tell you from that I can’t predict for sure when you’re gonna deliver.” A woman could be three centimeters dilated, and stay three centimeters dilated for two weeks, especially if she’s had babies before. I’ve examined patients in the office who were maybe one centimeter dilated, their cervix was still very thick. So, definitely not in labor. And within 24 hours, they started contracting and then delivered, like, the next evening. And I would never have, you know, guessed that from their exam. So I stress to them that the one thing that’s predictable is that this is just unpredictable. What I do tell patients is that if a woman starts noticing that she’s having increasing contractions, not necessarily regular enough that she’s in labor, but things were quiet, and then one day, she starts noticing that she’s just overall contracting more and maybe they get, like, a little stronger, a little more regular, but they’re still really not that bothersome, like, that’s probably the best sign that maybe something’s gonna happen in the next 24 hours. But even then, women can have those type of contractions for two or three days before going into labor. So that’s probably the only thing I can point to as things may be gearing up to start. I would feel bad. I’d wanna give an answer. And I used to try to kind of say, “Well, you know, maybe not tomorrow, but it could be in another week because you are a little bit more dilated.” And then the next week, the patient will show up and, like, glare at me in the hallway. And I’m like,

“Oh, you’re back?”

Dr. Fox: Yeah, these predictions backfire usually.

Sarah: Yeah, exactly.

Dr. Fox: And I agree, I tell people, “I’m more than happy to tell you how far dilated your cervix is, but it’s not gonna really change anything.” Yes, if you’re two centimeters dilated, statistically, you’re more likely to go into labor in the next week than if your cervix is zero centimeters dilated. So if you’re gonna, like, go to Vegas and start gambling who’s going into labor first, fine, that’s gonna be helpful. But it’s not an individual person. I have no idea. Right? It’s all gonna be closed and their water may break tonight. They may go into labor tonight. They could deliver six hours from now. There’s really no way to know. But I agree that the symptoms, particularly the contractions increasing is probably a better predictor to me and it’s more helpful. And so, you know, sometimes what we’re examining people, it’s just because they wanna know, people are curious. And also sometimes it’s nice to know, like, if they’re already three centimeters dilated, if they start getting painful contractions and they show up in the hospital, there’s a much less chance that they’re gonna get sent home, whereas if their cervix is closed and they start getting contractions. So okay, there’s some value of that. And then, for some women whose cervix is open and it’s towards the end of pregnancy, we can actually try to push things along and get them to go into labor by what’s called either stripping the membranes or sweeping the membranes. This is something I ask women, you know, “Do you want me to do this? Do you want me to not do this?” And then they’re like, “What are you talking about?” And we pause and explain what it is. But ultimately, how do you explain that to women? What’s going on there?

Sarah: Women who have delivered before will sometimes just ask me to do it and so they usually know. But for patients who have never had it done before, I’ll usually explain that I’m going to do an exam, if they want an exam. Obviously, you know, someone can decline an exam if they don’t wanna have one. And I’ll explain to them, “I can if you’d like, gently, like, when my finger is in the cervix, which is how I assess dilation,” basically, you know, my fingers are pretty small. So, say, like, two fingers is maybe about two centimeters, I can gently, like, literally just sweep my fingers around to, kind of, like not to break… I’m not trying to break the water, I’m just trying to sweep around the inner opening of the cervix to basically help stir up chemicals we call prostaglandins that can then trigger contractions. And the thought is, if that’s done, it may kickstart labor. Some women have never heard of this before and I’ll bring it up. I also tell patients, “If your cervix is totally closed, I can’t really do it because I won’t be able to get up far enough to the inner opening of the cervix to try to do that.” But I’ll tell patients, if you’re one or two centimeters dilated, I could go ahead and do it. It’s not mandatory, and some patients will, kind of, be like, “No, I don’t know.” And then some patients are like, “Go for it.”

Dr. Fox: Please.

Sarah: Whatever I can do, like, to get this going. And I will tell patients, it could just make you cramp for a bit and then ultimately, nothing will happen. I’ll also tell patients, you know, I’m not super aggressive when I do this. I’ll tell patients, “I’m just gonna sweep my fingers around a few times. I don’t wanna make you too uncomfortable.” I do tell patients that they could have a little spotting. Should just be like the wipe the next time they go to the bathroom, have a little spotting just for me touching the cervix. I would not expect any heavier bleeding. And, you know, I won’t do it in someone who’s obviously had any… Like if someone’s had a history of, like, vaginal bleeding in the third trimester, like, I won’t do it, even if they don’t have a placenta previa and the placenta is in the normal place. Some patients I’m not gonna, like, even bring it up to.

Dr. Fox: Right. Right. And one of the misconceptions I think a lot of people have is us doing an exam is going to put the patient into labor. When I tell people is that it absolutely won’t, unless we try, and even then it might not work. So a typical exam without sweeping the membranes will not stimulate labor. So if that’s someone’s concern, like, “Oh, I don’t wanna go into labor this week, don’t do an exam.” You know, it’s not gonna happen. Obviously, there’s a lot of reason you may not want the exam and have nothing to do with labor. It’s just uncomfortable, fine. But if we try to put someone into labor, it does work to some degree, meaning, she’s more likely to go into labor in the next week, compared to us not doing it. But again, it’s the same thing where it’s not a guarantee in either direction. It just improves the odds. Some women choose not to have it done because it’s uncomfortable or they don’t want the idea of potentially bleeding or they don’t wanna go into labor in the next week. They’re like, “No, no, like, my other kid’s, you know, kindergarten graduation is Monday. Like, I really wanna lay low until then. And there’s a lot of reasons, but it’s a discussion. A lot of doctors used to just do it without telling women, which is bad practice. We don’t do that. And it was just, sort of, something… It’s not because they were intending to, like, you know, harm women. It was just sort of taught as part of routine prenatal care. You examine, you strip the membranes and fine. But nowadays, that’s really not considered cool. So yeah, we ask people or tell people. You know, we talk about it before we, you know, consider it.

Sarah: Yeah. And I’ve had patients say to me, I think just from past experiences, not in our practice, because I think we’re good at, you know, talk about before, but they’ll say, like, if I discuss whether or not they want to have an exam, they’ll say specifically, “Oh, you’re not gonna do that thing that’s gonna make me contract, right?” And I’ll say, “No, all I’m doing is just examining, just to literally see how dilated you are. That’s it.” And they’ll be like, “Oh, okay, that’s fine. As long as you don’t do that other thing that, like, makes me cramp or…”

Dr. Fox: Right. “Because my last doctor examined me and it was really uncomfortable. And that night, I went into labor.” I was like, “Oh, okay.”

Sarah: And just a word about exams also is some women really do not wanna be examined at all in the last few weeks. And I don’t push patients that they have… There’s no rule that you have to have an exam. If a woman’s at a prenatal visit, not contracting, not leaking fluid, she’s 38 weeks pregnant and just really does not want to be examined, that’s fine. I’ll tell them, “Look, ultimately, when you come in and your water breaks and you’re in labor, and you come to the hospital, you know, we’ll examine you.” If you don’t really feel that you need to know how dilated you are, if you really don’t think you’re in labor, it’s not a problem. Like, it’s not mandatory.

Dr. Fox: It could be very painful… You know, some women just anatomically, it’s very painful or they have, you know, a condition called vaginismus, where it’s very painful to be examined. And, like, we don’t wanna, like, hurt anybody. Obviously, like, okay, so the majority of women, the vast majority of women can tolerate an exam. It’s okay. Like, it’s not as painful as they thought it would be, and fine. But obviously, there are women for whom it’s not a good idea to do. And there’s some women who, like, don’t get examined to have an epidural in. I mean, and it’s fine. Like, if that’s what happens, that’s what happens. That’s okay. But again, it’s a discussion. And so everyone has to be, you know, comfortable with what’s going on with their own care and their own exams. And that’s important on our end, also, and it’s why we talk about these things. And like you said, you know, doing an exam in the office is not a life-saving procedure. If she doesn’t want it, I’m not doing it. Like, it’s okay, we’re not gonna, you know, twist someone’s arm to get examined. Because like we said, it rarely has that much implication unless we’re trying to determine, are you currently in labor? And if she has no symptoms, she’s not in labor.

Sarah: Right. I did have a patient who requested an exam who was not having any symptoms, but she’d had multiple deliveries before.

Dr. Fox: Right. Yeah, she’s seven centimeters dilated, so.

Sarah: Exactly.

Dr. Fox: Yeah, that happens.

Sarah: With twins. I was like, “Maybe you should go to the hospital now.”

Dr. Fox: That does happen. And another question I get asked all the time is, “What can I the patient do to put myself into labor? What are the things I can do that are gonna put me into labor?” Sadly, nothing.

Sarah: There’s an unbelievable treasure trove of information on this on the internet. I’ve learned things when patients tell me, “I read that this can put you into labor.” And I’m like, “Hmm.” I’ll tell patients that really, there’s nothing that I can recommend they do specifically to make themselves go into labor. I will tell patients… There are a few things that I’ll tell them to avoid doing. You know, there are some things that are not harmful. I don’t know if they’re gonna work, but they’re not harmful at all. I’ve had patients ask me about acupuncture. I’m not against acupuncture at all. And if patients want to do acupuncture with the hopes of going into labor, that’s fine. I don’t know if it’ll actually work. Some patients will ask me about drinking certain teas. And I’ll say if it’s a fairly standard herbal tea, like sometimes it’s a tea. I don’t know what any of the things are and then I’ll say, “I don’t know if maybe you should drink that.”

Dr. Fox: But tea filled with pitocin.

Sarah: Right.

Dr. Fox: Yeah. Yeah, that’ll work. Yeah, the teas are fine. The raspberry tea or whatever it is, and things they ask you usually about… I’m gonna walk around the block a lot. Like, God bless, it’s good for you but it doesn’t work to put you into labor. I mean, these things have been studied. I’m gonna have sex. Again, God bless. You’re welcome too. It’s healthy, but it’s not gonna put you into labor. It may cause you to cramp a little bit. But, you know, if it was that easy to put people into labor, we would not have an issue with induction of labor. Right? It just doesn’t really work. A foot massage, that’s a good one. A foot massage, put everything, if it puts you into labor, okay, but it’s really doesn’t seem to work. And so yeah, there really isn’t anything that we know of that’s gonna be effective in putting you into labor.

Sarah: I hesitate also a little bit, castor oil is something that some people have seen or seems to take. And again, what I’ll tell patients, you know, it may just cause you to have a lot of, like, loose stools, and bad GI cramping and then at the end of the day, you’re not anywhere else near labor, except you just have a lot of cramping.

Dr. Fox: Yeah, a lot of people swear by castor oil. And the data’s kind of mixed on it. And the studies aren’t great that are out there. I don’t know, maybe it works, maybe it doesn’t work. It’s certainly not like a terrific way. And if it doesn’t work, you get your stomach’s upset and get diarrhea from it. It could be quite unpleasant. And so we don’t do it routinely. So, in addition to these things that people frequently ask you about, what kind of things do you bring up with them? Something, like, hey, make sure to think about this or have you thought about this or have you considered this?

Sarah: The things that I bring up, you know, first of all, things just to bring to the hospital or, like, what to have ready because at 36, 37 weeks, I’ll usually tell patients, it’s good to just get some things together.

Dr. Fox: The packed bag.

Sarah: The packed bag.

Dr. Fox: The jump bag. I got my jump bag, ready to roll.

Sarah: I mean, most of the time, most women will have plenty of time, like, even if something happened, they would still be able to put it together. But I think it helps… Since this is a process, especially for someone who’s never had a baby before, there’s so much unknown and I think it’ll just make someone feel relieved, a little bit of the anxiety to have that setup. So, I’ll usually go over, I’ll tell them, “Look, bring, like, the basic, you know, toiletries, you’d want for, like, a one or two-night stay.” Whatever you forget, you know, most hospitals will have it. So, if you forget your toothbrush, it’s fine. It’s not like end of the world. I tell patients because hospitals are, as we all know the best, and I’m saying that kind of a joke, best place to sleep, I’ll tell patients to throw in like an eye cover earplugs, phone charger, big one like just have that in there. Make sure to have, you know, most people have it in their wallet but ID and insurance card. For women who want to labor in their own gown, there’s all these gowns that you can get now that, you know, instead of a hospital gown, you wear that gown. And it still allows for exams and breastfeeding. You know, pack that, slippers. You don’t have to bring a lot of clothes for the baby, just one outfit for the baby to go home in. And you don’t have to bring the basic stuff to care for the baby like diapers, ointment. Also for moms themselves, the hospital will have plenty, like pads, mesh underwear, all the things you’ll need to take care of yourself. If you have any type of perinatal tear, which we talked about in our other podcast. So the basic things that you’re gonna need to take care of yourself, like, definitely some of those things you’ll wanna have for home, but the hospital will have all of that.

Dr. Fox: Yeah, I agree. I think that having the bag packed is nice if it’s gonna reduce anxiety, like you said because all right, something’s ready to roll. But if it’s gonna cause anxiety, people are gonna put it in and they gonna have to get this, you don’t need to bring anything with you. Like, it could all get worked out on the back end, right, because either when you go into labor, you can grab a few things, or someone can bring it to you from home. I mean, there are other options of the hospital has it. And there’s nothing, like, critical but some practical things that you said, you know, phone chargers is key. If there’s, like, snacks, you know, if there’s certain, let’s say, you wanna drink vitamin water, when you’re in labor, pack some vitamin waters or, you know, whatever it might be that you think you want. If you’re planning on an epidural and so you’re not gonna be in much pain during labor and you wanna read something, you know, bring a magazine, bring a book, bring your iPad, you know, things like that, you know, sort of, in a practical sense. But none of that is, like, critical for your labor. You know, so if you don’t pack a bag, you forget something, it’s okay. And I think other things in terms of logistics that people sometimes don’t think about if you have pets, if you have other kids, you need to plan, right? What are you gonna do with them if you go into labor? And what are you gonna do with them if you go into labor at 3:00 in the morning? And what are you gonna do if you’re at work? You know, just think out. Like, how am I getting to the hospital if I’m here? How am I getting to the hospital if I’m somewhere else? Who’s bringing the bag? Who’s getting my kids? Who’s taking my dog? And just try to have that worked out. And, you know, plans blow up, obviously, but it’s nice to have some sense. Sometimes we have people show up to the hospital, and they’re bringing their two-year-old with them and they don’t let the two-year-old in.

And so then, you know, dad’s going home with a two-year-old and you’re there alone. And so try to have some plan in place for that. If you’re planning on… If your pediatrician, for example, if you know who it’s gonna be, like, have the name, maybe have the phone number. So we can tell them that the baby was born. You know, if you’re planning a breast and you have a boy, like, what mole are you going to call when the baby’s born because these are not things you wanna scramble with after birth. There’s enough going on after the baby’s born. It’s nice to have some of those things, sort of, tucked away before you come in to deliver.

Sarah: I’ll often give patients a list of pediatricians that are just in the area, like around like 34 to 36 weeks. I think it’s good to have that set up already. And other things also, you know, many of our patients are, you know, may decide to get an epidural. But that’s a question like, am I gonna get an epidural? Am I not gonna get an epidural? It’s also okay to say, you know, I don’t know if I’m gonna get an epidural. But just even have like a basic idea, you know, you can totally play it by ear. The one thing is for patients that I think really do wanna try to labor, have an unmedicated labor and delivery, I do encourage them to consider having a doula with them at delivery, especially if it’s their first delivery. And that’s something that also earlier in the pregnancy or probably by 36 weeks if that’s something that interests a patient, she should speak with a few and have someone that’s, kind of, set to be in her delivery because sometimes doulas book up for certain months. They may already have some for that month and be filled up. So I’ll tell patients to try to, you know, make sure to book someone earlier.

Dr. Fox: Yeah, I mean, I agree a lot of that sometimes decisions that have to be made. Also, sometimes there’s an option to store cord blood, which is its own podcast. It’s a whole topic. But if you’re gonna be doing it, bring the kit with you.

Sarah: Yeah.

Dr. Fox: And if you’re not gonna be doing it, fine. And if you don’t know what we’re talking about, then maybe it’s a conversation to have beforehand to figure it out. But again, just those types of things and some people are good with lists, and some people are not good with lists, but the things that you can, sort of, address before you deliver will definitely take away some of the stress after delivery. Because just the idea, now how you have this newborn. There’s all this stuff you have to do. It’s nice to have some of those, you know, crossed off your list, so to speak. I think that, you know, overall, sort of, as an overarching thing, you know, so much starts to happen at the end of pregnancy, you know, logistically, medically, in terms of, you know, the labor, the baby. And a lot of stuff is happening. And one of the nice things about it on our end is we really get to see people a lot. And, you know, when you see someone once a month, you know, it’s nice, but it’s been so long and you’re spending. You know, you don’t really know what’s going on, but you see someone weekly, you can sort of even pick up on a conversation you had a week ago or, you know, so little has happened in the past week in their lives and it’s almost like an ongoing relationship, which is really nice. And I think it’s really nice for us, obviously, because we get to know people, where they’re at, what are their fears? What are they looking forward to? You know, what are they excited about? What are they not excited about? And I think it’s also really nice for the pregnant women themselves. Some of them, it’s annoying that they come in, and it’s far away. And, you know, we get it. But in addition to just improving the health outcomes, I think they get a really good sense of the personalities of the doctors and who might be there when they’re in labor and get to ask questions, you know, because talk about labor when you’re 12 weeks, it’s just not really that helpful. But you get a good sense of who’s on call this weekend and, you know, and what’s going on. And I think that it’s a lot of fun towards the end of pregnancy in that sense. And I think that part of the reason it could be fun is the more frequent visits makes it less anxiety-provoking, and more, I would say, pleasant in that sense. At least, that’s been my experience over the years. I don’t know you feel about that.

Sarah: It’s really fun to see patients in the last few weeks and then to end up being at their delivery because I have sometimes met patients really literally the last few weeks. I’ll be like, “Wow, you know, it’s great we got in a visit.” Because the patients rotate through our practice, they meet everyone, and sometimes just because of scheduling, I’ll see them, you know, 37 weeks or 38 weeks, and I’ll be at their delivery. But it’s especially nice because I just saw that patient. And, you know, we just went over all of the things about labor and delivery and, you know, what to bring and a lot of things that we just went over. And then, you know, I’m there with them, like, during the actual labor and delivery. So that’s always nice.

Dr. Fox: Yeah, it’s pretty cool to, you know, say, “Hey, remember we talked about this?” And one of the other interesting things is obviously, you know, the vast majority women remember who delivered them, but a lot of them will also come and say, “You’re the one who sent me to the hospital. Like, you’re the one who saw me when I came in, and my water was broken and said, ‘All right, time to have your baby,’ and I had nothing to do with them afterwards.” But they always remember the person who… You know, or you’re the one who I spoke to about, you know, the epidural or my birth plan. And people remember those conversations because they’re so practical. They really are a part of the event. Very few people come back and say, “Oh, yeah, you’re the one who counseled me about my nuchal ultrasound at 12 weeks.” You know, whatever. But it’s like towards the end, it’s so exciting and you’re part of that story and part of that process. It’s a lot of fun. Wow. Sarah, last month of pregnancy, ninth month. Good stuff. A lot going on. Thanks for coming on the podcast. Great topic. I’m glad we got to cover it. I think it’d be really helpful for people.

Sarah: I hope it will be.

Dr. Fox: 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@helpfulwoman.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.