Monday, June 7, 2021

Labor & Delivery: Making Shared Decisions

Episode 62


Speaker 1 (00:04):
Coming to you from Beaumont, this is your HouseCall.
Dr. Asha Shajahan (00:14):
Pregnancy is complicated and confusing, but what if there was a way you could get evidence-based information, explore your values and preferences for birthing a child and have someone to hold your hand along the entire way? And then also with COVID vaccines available, should you get it during pregnancy? Should you not? Wouldn't it be great to have a trusted source to guide you through this process?
Dr. Asha Shajahan (00:39):
Don't go anywhere. The HouseCall podcast is going to go in depth on shared decision-making in pregnancy and childbirth. Hello. Welcome to the Beaumont HouseCall podcast. I'm Dr. Asha Shajahan,. We're here to help you and your families live smarter and healthier lives.
Dr. Asha Shajahan (01:00):
Today we're going to talk about shared decision-making and why it's so important in pregnancy and childbirth. We'll also talk about the COVID-19 vaccine and talk about if it's right for you during your pregnancy.
Dr. Asha Shajahan (01:12):
Joining us today is Dr. Kurt Wharton, an OB-GYN and medical director of the Family Birth Center at Beaumont Hospital in Royal Oak, Michigan. He's also a professor of obstetrics and gynecology at Oakland University William Beaumont School of Medicine. Dr. Wharton, thank you so much for being here today.
Dr. Kurt Wharton (01:29):
Thank you so much for inviting me. It's a pleasure to be here, and I'm very excited about sharing what I know with you and today's listeners.
Dr. Asha Shajahan (01:36):
Yeah. We are so excited to have you because we have a lot to talk about. I mean, we are in a pandemic, people are scared and confused. But we're going to talk about something that is pretty joyous: pregnancy.
Dr. Asha Shajahan (01:50):
Pregnancy is normally a joyous time in a woman's life, but it can also be a little scary and nerve wracking, and Dr. Google has a lot of confusing information out there that's readily available for people on their fingertips. So what advice do you have for someone who wants to get pregnant? What are the steps they should take you when they're planning to get pregnant?
Dr. Kurt Wharton (02:12):
Well, in order to have as healthy an outcome as possible, it's critical that you be as healthy as possible when you start.
Dr. Asha Shajahan (02:19):
Mm-hmm (affirmative).
Dr. Kurt Wharton (02:20):
I encourage everyone who's considering pregnancy to really optimize their health and their nutrition. There's up to a 30 pound weight gain expected in pregnancy, so it's good not to be overweight when you start, nor is it healthy to be underweight. We do want you to gain 30 pounds slowly and steadily over the nine to 10 months of pregnancy.
Dr. Kurt Wharton (02:41):
What we also know, that women who are obese and women who have diabetes or have obesity and diabetes can pass these traits on not only to the next generation, but it can impact the subsequent generation. So we know that women who have obesity and diabetes are much more likely to give birth to children who will develop obesity and diabetes.
Dr. Asha Shajahan (03:04):
If a patient is diabetic or pre-diabetic, would you recommend them being on a medication like Metformin if they're pre-diabetic beforehand? Because a lot of people in my practice are afraid of taking medications when they're trying to conceive.
Dr. Kurt Wharton (03:20):
I absolutely encourage women to take a medication if they're pre-diabetic. We know that optimal control of one's blood sugar is critical in the health of the pregnancy. When women have uncontrolled blood sugar, it's harder to get pregnant, the risk of miscarriage is much, much greater, and the chance of having other complications is increased as well. Those concerns far outweigh any concerns about a side effect for the medication.
Dr. Asha Shajahan (03:47):
You were talking about the importance of nutrition and having a proper weight, not being underweight, not being overweight. But what about things like supplements? What are your thoughts there?
Dr. Kurt Wharton (03:56):
We do know that if women take supplement of folic acid, just a mere 400 micrograms, the smallest dose sold, if a woman takes that while she's trying to conceive and definitely through the first seven weeks of pregnancy, 60 to 70% of all birth defects can be eliminated. That is a magical supplement.
Dr. Asha Shajahan (04:16):
Dr. Kurt Wharton (04:16):
We also know that if the folic acid is continued through pregnancy it reduces her chance of developing diabetes of pregnancy, what we call "gestational diabetes," as well as possibly reducing her risk of developing high blood pressure.
Dr. Kurt Wharton (04:29):
There are many women who are anemic when they become pregnant. Pregnancy requires an increase of blood, 40% more blood within the first seven weeks of pregnancy, and that requires iron. If a woman starts her pregnancy being deficient in iron, she'll feel very poorly very quickly.
Dr. Asha Shajahan (04:48):
Yeah, so folic acid, iron. And these are things that are common in prenatal vitamins, correct?
Dr. Kurt Wharton (04:54):
That is correct. There are many things in prenatal vitamins, many of which are beneficial, many are not. So we know, and the recommendations of the World Health Organization right now restrict supplementation to folic acid and iron, and, truthfully, iron when indicated.
Dr. Asha Shajahan (05:11):
Got it.
Dr. Kurt Wharton (05:12):
Yeah. Now unfortunately many prenatal vitamins, actually the most common prenatal vitamins sold, are gummy prenatal items. They're delicious, easy to swallow, but they don't contain iron. So women have to be careful if they are found to be iron deficient. Gummy prenatal vitamins won't be helpful for them.
Dr. Asha Shajahan (05:30):
Yeah. So you see your PCP, maybe get your blood drawn and get an annual physical, see what your blood levels are. If you're iron deficient, start taking iron supplements. And if you're not, then just stick with the folic acid.
Dr. Kurt Wharton (05:41):
That's it. Be prepared.
Dr. Asha Shajahan (05:43):
Okay. So let's say now you've kind of optimized. You decided that you want to get pregnant. You're on your folic acid. You've at the optimal weight. And then, ta da, success and you're pregnant.
Dr. Asha Shajahan (05:56):
So now that you're pregnant, what are the next steps? And then how does shared decision-making play a role in that?
Dr. Kurt Wharton (06:04):
Those are very good questions. The next step is to find a healthcare provider that you feel comfortable with. You want to have a partner in the progress of your pregnancy, and that's where shared decision-making comes in.
Dr. Kurt Wharton (06:18):
Historically, the interaction between patients and physicians was very different. It's what we call more of a "paternalistic" attitude.
Dr. Asha Shajahan (06:25):
Mm-hmm (affirmative).
Dr. Kurt Wharton (06:26):
Often a patient would present to her healthcare provider with a problem. If it's a physician she's seeing, the physician would interview her, take a history, perform an examination, perhaps perform some diagnostic tests and then reach a diagnosis.
Dr. Kurt Wharton (06:42):
Treatment was then offered, but usually not with options and not with really the patient be given a choice. Well, since the '80s, we've really tried to turn that around. We use a process called "shared decision-making" because, after all, patients are individuals. They deserve to have their autonomy respected.
Dr. Kurt Wharton (07:02):
Everyone comes into a physician's office with their own personal beliefs, their cultural beliefs, and their thoughts and their reactions are formed by their past experiences. We're all different, and that has to be respected.
Dr. Kurt Wharton (07:17):
Now, with shared decision-making, it requires that the physician or the midwife in pregnancy provide thorough education. As a physician, we do many dramatic things that are just glamorized on television. But one of our primary roles, really, is to educate our patients, to tell them how to improve their own health so they can be active, they can be a true member of the team.
Dr. Asha Shajahan (07:40):
Yeah, so it's more of a discussion, really. So instead of like, "Here, take this, do this," it's more like, "Okay, what are your beliefs? What's most important to you, and how can we make this the most pleasant experience for you possible?"
Dr. Kurt Wharton (07:56):
That's correct.
Dr. Asha Shajahan (07:57):
So what are some examples of shared decision-making in pregnancy? I mean, we talked about beliefs and things like that. But maybe people are wondering, "Okay, what is it that I need to discuss with my doctor?"
Dr. Kurt Wharton (08:08):
Well, we start out with a discussion of nutrition, exercise, sleep, other behaviors that we think are beneficial in pregnancy. More critically, we talk with our patients about the importance of vaccinations.
Dr. Kurt Wharton (08:22):
Now in the past, we've found that flu vaccination is extremely important during pregnancy. Despite what many people believe, pregnant women are at greatest risk each flu season of succumbing to the effects of the flu.
Dr. Kurt Wharton (08:35):
The concern about pertussis or whooping cough had disappeared for a long time with childhood vaccinations, but it's come back and it's extremely dangerous for a newborn to be exposed to the pertussis.
Dr. Kurt Wharton (08:50):
We believe that pregnant women should be vaccinated around 28 weeks of pregnancy with the pertussis vaccine. It's called the "Tdap" vaccine; it's tetanus, diphtheria, pertussis. But we find that allows the mother to develop antibodies, which cross the placenta and enter the baby's blood.
Dr. Kurt Wharton (09:07):
So when the baby is born, it has this passive immunity which will last for the several months that are required before the baby can start to receive its own vaccination. We think this is very safe, but people have concerns about vaccine, so it's important to discuss. There's an awful lot of misinformation that's spread mouth-to-mouth and on the internet.
Dr. Asha Shajahan (09:26):
Yeah. Let's talk about that. I'm glad that you brought up the vaccines and we're going to get into the COVID vaccine in a minute. But I think the perception is, "Yeah, sure. I'll take a vaccine, but I'm so scared to do it during pregnancy because is it going to harm my baby?"
Dr. Asha Shajahan (09:41):
What you're saying is that actually it can protect your baby. And not only protect the mother, but protect the baby as well.
Dr. Kurt Wharton (09:47):
That's correct. For a long time, they thought that some of the preservatives in vaccine were responsible for autism.
Dr. Asha Shajahan (09:52):
Mm-hmm (affirmative).
Dr. Kurt Wharton (09:53):
And this was publicized internationally. Well, it was found out to be false, and the person who was transmitting this information, I'm not quite sure what his agenda was, but it was somewhat evil.
Dr. Asha Shajahan (10:03):
Okay. So for the flu vaccine, is this something that you should get before you're pregnant, during pregnancy? Does it matter what stage? I mean, you were saying pertussis is at 28 weeks, about. So what about the flu vaccine?
Dr. Kurt Wharton (10:15):
The flu vaccine should be given each year during the regular time, usually starting late summer, early fall. It's effectiveness by the time we reach this time of year in early spring is really minimal, but it is important that a woman receive the vaccine each year as the virus changes each year.
Dr. Asha Shajahan (10:30):
But the season is usually like September to maybe February, you would say?
Dr. Kurt Wharton (10:34):
I would say.
Dr. Asha Shajahan (10:36):
Okay, great. So now since we talked about vaccines, I'm going to have to just jump into the COVID vaccine. I do a lot of vaccine advocacy, town halls, and the biggest question is: "Is this going to affect my fertility?" for someone who's not pregnant yet. Then the other question that comes up is" "Is this going to affect my menstrual cycles?" And then the third thing is: "Is this safe in pregnancy and breastfeeding?"
Dr. Kurt Wharton (11:00):
There's a lot of misinformation, mistruths that have linked the vaccination with infertility, and it's absolutely not true. The official statement of the American College of Obstetricians and Gynecologists is the recommendation that all eligible women receive the vaccine who are pregnant, as well as all women who are breastfeeding, as well as all women who are planning to become pregnant soon.
Dr. Kurt Wharton (11:26):
We know that the vaccine is a messenger RNA vaccine, so the virus is not actively transmitted through the vaccine. Fetal cells are also not transmitted through the vaccine. That's another common misunderstanding.
Dr. Asha Shajahan (11:39):
Mm-hmm (affirmative).
Dr. Kurt Wharton (11:40):
So we think everyone, with the rare exception of that person who is unable to receive the flu vaccine, many medications, should absolutely receive the vaccination. What we do know is that if a woman does not receive the vaccination, she's at increased risk.
Dr. Kurt Wharton (11:56):
At the beginning of the pandemic, we thought that pregnant women would be an increased risk more than the rest of the population, as we see each flu season. That has not been true, but the pregnancy can be adversely affected.
Dr. Kurt Wharton (12:10):
At Beaumont Royal Oak Hospital, we deliver close to 7,000 babies each year.
Dr. Asha Shajahan (12:15):
Dr. Kurt Wharton (12:15):
During the current pandemic, we have had our share. Right now, 8% of the pregnant women who come to our labor and delivery unit, we find to be COVID positive, and many of them are sick and end up fighting for their lives.
Dr. Asha Shajahan (12:29):
Dr. Kurt Wharton (12:29):
We haven't lost the mother yet, but it's been close, and we're not through with this yet. And I can't predict what the future will bring.
Dr. Kurt Wharton (12:37):
But what we have found and my colleagues across the country have found is that women who do not get vaccinated and get sick with COVID are at much higher risk of being admitted to the hospital, of much higher risk of requiring supplemental oxygen, much higher risk of being intubated. And they are at much greater risk of delivering their baby at a significantly premature date.
Dr. Asha Shajahan (13:00):
Yeah, I think just the whole process of childbirth itself can be overwhelming, and to complicate that with a COVID infection just sounds like a nightmare. In terms of antibodies, many pregnant women, they've delivered, and they're saying, "Okay, if I have the COVID vaccine when I'm breastfeeding my child, will those antibodies be given to my child, and then will my child be protected from COVID?"
Dr. Kurt Wharton (13:23):
I'm so glad you mentioned that because the answer is yes. Once the vaccination starts to have its effect, the body produces IgM antibodies followed by IgG antibodies. And these IgG antibodies cross the placenta and enter the baby.
Dr. Kurt Wharton (13:39):
We are doing studies across the country, including a study at Royal Oak, where we're measuring the antibodies in the umbilical cord blood of the babies. And again, babies are at risk. They are born with a naked immune system.
Dr. Asha Shajahan (13:51):
Dr. Kurt Wharton (13:51):
We have to do everything we can to protect them.
Dr. Asha Shajahan (13:53):
Yeah. And then what do you also think about spouses, family members and that kind of thing as well, in terms of getting the COVID vaccination, then also the flu and the Tdap?
Dr. Kurt Wharton (14:02):
Certainly everyone needs to be vaccinated for the flu each year. Now, in the past, we used to encourage all family members to receive the Tdap vaccine because we're administering the Tdap vaccine after delivery.
Dr. Kurt Wharton (14:14):
Now that we recommend the Tdap vaccine be given 12 to eight weeks before the due date, that isn't quite as mandatory that we insist that family members and friends be vaccinated. But when it comes to COVID, everybody above the age of 16 needs to be vaccinated.
Dr. Asha Shajahan (14:33):
Here's my other question about the COVID vaccine that people are concerned about. The thought is it's relatively new, and how do we know that years down the line, this isn't going to affect either, again, we talked about fertility or affect my child or affect something? I think the fear is that this vaccine is going to be in your body for years and years, and that it could affect your child or affect your health.
Dr. Kurt Wharton (14:58):
The science behind the vaccine is new. The ability to produce the vaccine so rapidly is new. Now, unfortunately, this vaccine is directed against the coronavirus, and the coronavirus is the class of viruses that give us all colds each year, and the coronavirus rapidly mutates.
Dr. Asha Shajahan (15:17):
Mm-hmm (affirmative).
Dr. Kurt Wharton (15:19):
So we may need to boost your shot in a year to address this. We really can't predict the future. Hopefully, we'll get the majority of people in this country and across the world vaccinated, so we'll eliminate the virus that way. But if we're not able to do that, we're going to have to keep continuing to fight it with repeat doses of the vaccine.
Dr. Asha Shajahan (15:39):
Yeah. The other thing I wanted to emphasize, which we've talked about before on this podcast, is that mRNA vaccine technology has been around for about 10 years, so over a decade. So the technology itself is not relatively new. It's just because we have this novel coronavirus, and so it was produced within the last year.
Dr. Asha Shajahan (15:57):
Then the other thing too, is the adeno vector vaccines, which would be like the AstraZeneca or the Johnson & Johnson. Those do not have mRNA in it, and that technology has also been around quite a bit longer. So I think vaccines have been around for a really, really long time and they've proven to be helpful and protective.
Dr. Asha Shajahan (16:19):
So if you're scared and worried about getting the COVID vaccine, I suggest having a conversation with your doctor to really go through all of your concerns because it really is life or death with this virus.
Dr. Asha Shajahan (16:32):
All right. So we've tackled the COVID vaccine and the other two major vaccines that you think are helpful in pregnancy. We talked about pre-pregnancy, you're pregnant and you've had your shared decision-making and you've gotten all your vaccines. And now you have had your baby, okay.
Dr. Asha Shajahan (16:50):
The birth process. So what I see a lot is a lot of women are like, "I want to go au naturale. I don't want any pain medicine. I just want a normal spontaneous vaginal delivery."
Dr. Asha Shajahan (17:02):
But then as they get closer to the actual due date, they suddenly can't see their feet anymore. The back hurts and they're tired, and they start nudging like, "Okay, can we get this baby out already?"
Dr. Asha Shajahan (17:15):
What are your thoughts about induction and having babies prior to 40 weeks? And then we can also get into thoughts about C-section or planned C-sections.
Dr. Kurt Wharton (17:29):
Well, that's a big topic to discuss, and I'm happy to tackle it. Ideally, we want every woman who can to have a vaginal delivery. That is the way nature designed it.
Dr. Asha Shajahan (17:38):
Mm-hmm (affirmative).
Dr. Kurt Wharton (17:38):
In the early 1970s, the cesarean section rate was 1-3%. By the 1980s, we thought it had skyrocketed because it was close to 10%.
Dr. Asha Shajahan (17:48):
Dr. Kurt Wharton (17:50):
Some hospitals in this country it's over 45 to 50%.
Dr. Asha Shajahan (17:54):
45 to 50? That's crazy.
Dr. Kurt Wharton (17:55):
We think the overall rate should be somewhere around 15%. Now, there are some babies that should be born by cesarean section. There are women who've had surgery in their uterus; it's not safe for them to go into labor.
Dr. Asha Shajahan (18:08):
Mm-hmm (affirmative).
Dr. Kurt Wharton (18:08):
There are women who have infections that would put the baby at risk if they had a vaginal delivery. Sometimes the baby's in the wrong position. It's presenting sideways instead of head first. It may be presenting breech, with feet first. And if facilities aren't prepared, it's uncommon now to deliver babies breech, so cesarean is normally recommended.
Dr. Kurt Wharton (18:31):
But with cesarean section comes a risk. It's a major operation.
Dr. Asha Shajahan (18:35):
Mm-hmm (affirmative).
Dr. Kurt Wharton (18:36):
It requires either a regional anesthesia, like an epidural or a spinal anesthetic. Or in some infrequent situations, it requires a general anesthetic, which also puts the baby to sleep as well as the mother.
Dr. Kurt Wharton (18:50):
With any operation, there's the risk of infection. There's a risk of significant bleeding, much more bleeding than we normally see with a vaginal delivery. And there's also the risk of injury to the bladder, the intestines, other organs inside the body. The recovery is longer, both within the hospital and once you're at home. The delay in recovery can be many, many weeks.
Dr. Kurt Wharton (19:14):
We also know that if a woman has repetitive cesarean sections through the same scar or even through a new scar in the skin and the uterus, that the risk of the placenta misbehaving increases. What do I mean by misbehaving?
Dr. Kurt Wharton (19:28):
Well, the placenta is our best friend when we have the pregnancy. It is the organ for the baby that attaches to the mother's uterus, to the inner lining, and is able to procure all the nutrients and water and oxygen that the growing baby needs.
Dr. Kurt Wharton (19:44):
Now, if the placenta doesn't encounter a healthy lining of the uterus because of a significant scar from previous surgery, there is no problem. The placenta grows right through the scar in search of healthy tissues because it grows like a cancer. It's dedicated. It's passionate about providing the oxygen, the water and nutrition for its baby.
Dr. Kurt Wharton (20:05):
So it remains our friend, which is fine until we deliver the baby. Now we have a placenta that's not a regular placenta; it's a cancer. And this situation can result in massive hemorrhaging, massive blood loss that requires transfusions and more surgery. Women will often lose their uterus, pieces of their bladder, intestine.
Dr. Kurt Wharton (20:27):
It's very serious. In some situations, women lose their life all because of cesarean sections. So cesarean section can save the life of the mother. It can save the life of the baby. But we have to be very, very careful with the use of cesarean section.
Dr. Asha Shajahan (20:42):
Yeah. So if it's an absolute necessity, no one should feel guilty that they had a C-section. But at the same time, if you don't really require one, probably really shouldn't be pushing for one either.
Dr. Kurt Wharton (20:54):
No. There are people who come to the doctor and ask for what we call an "elective" ceasarean section. And there are situations where that's a very reasonable concern and the woman's request should be honored.
Dr. Kurt Wharton (21:06):
She may have had medical problems in the past, or perhaps surgeries where having a vaginal delivery would really not be a very good idea and a cesarean section would be fine, especially if she's not planning on having a large family or many more children. Because again, each time she has a cesarean, her risk of this abnormal placentation increases.
Dr. Asha Shajahan (21:28):
Can we talk quickly about what are some of the major indications for C-section, like maybe if you have gestational diabetes or the child's very large? Just make one or two or three things that people would think like, "Okay, maybe I will end up with a C-section."
Dr. Kurt Wharton (21:42):
Well, in the case of a woman having her first C-section, the number one reason is what we call "labor dystocia," where she is in labor and despite all the tricks, she can't reach complete dilation. Her cervix will not dilate to 10 centimeters, so she cannot try to push the baby out. That's the number one cause.
Dr. Kurt Wharton (22:02):
The number two cause is what we call "non-reassuring fetal status," meaning we're concerned about the safety of the baby.
Dr. Asha Shajahan (22:09):
Mm-hmm (affirmative).
Dr. Kurt Wharton (22:10):
We will frequently monitor the baby's heart rate either continuously or intermittently during labor. If we're concerned about the baby, we will monitor continuously rather than intermittently. And if the baby does not behave in a healthy fashion by the way we're recording its heartbeat, you have to make that tough decision sometimes to deliver the baby.
Dr. Kurt Wharton (22:31):
Other conditions I mentioned before. There can be, we call "mal-presentation." The baby's not coming out in the head-first position; it's coming out feet first or sideways.
Dr. Asha Shajahan (22:39):
Mm-hmm (affirmative).
Dr. Kurt Wharton (22:40):
Again, there are some infections. Now, unfortunately, about 17% of babies are born primarily by cesarean section, and 15% or more are born just because the woman had a cesarean section before.
Dr. Asha Shajahan (22:56):
Dr. Kurt Wharton (22:57):
Now, the majority of women can be offered what we call a "trial of labor" in her second pregnancy following a cesarean section. That's a very safe procedure where the risk of there being a significant injury to the uterus is less than one-half percent. But this needs to be performed in a hospital that can, if necessary, perform a second cesarean section quickly.
Dr. Asha Shajahan (23:18):
You were mentioning how the rates of C-sections went up. What are the reasons for the rate of C-section going up? Do you think it is part of shared decision-making or do you think shared decision-making actually decreases C-section rates?
Dr. Kurt Wharton (23:34):
Ideally shared decision-making will decrease the cesarean section rate. Many patients will come in and request before labor or during labor. Labor can be very frustrating. It can take hours. It can take days. The baby will sometimes give us concern, so we perform maneuvers such as starting IVs and having the mother change her position frequently. Many women say "I'm so scared. I just want a cesarean section."
Dr. Kurt Wharton (24:02):
But with shared decision-making you can educate the patient, reassure her and say, "It's safer. It's in your best interest to continue."
Dr. Asha Shajahan (24:10):
Mm-hmm (affirmative).
Dr. Kurt Wharton (24:11):
But again, she can say, "I refuse. I really want you to do this," and we have to respect that as well.
Dr. Kurt Wharton (24:17):
But why are we seeing more? A variety of reasons. The average woman giving birth today is older.
Dr. Asha Shajahan (24:24):
Mm-hmm (affirmative).
Dr. Kurt Wharton (24:25):
Each year it goes up quite a bit. We have more what we call "co-morbidities." Women have more medical problems. They're older, and the older you get, personally speaking, the more medical problems you have. So we see much more high blood pressure. We see much more diabetes. We see more obesity. And these factors contribute to cesarean section.
Dr. Kurt Wharton (24:48):
The ability to do cesarean section, quite frankly, has led to the increase in cesarean section. The fact that to have a cesarean section today is actually much safer than it was 40 years ago.
Dr. Kurt Wharton (24:59):
We're much better at surgery or are much better at controlling infection. We have the availability of blood banks at most hospitals now. So women aren't quite the same risk of having a major operation, so there's been a kind of a relaxation of the approach of physicians and patients towards this significant surgical intervention.
Dr. Asha Shajahan (25:17):
I think it's so funny. When I talk to people who've had C-sections, it's like, "Yeah, I had a C-section." It's a major surgery, and I think a lot of people forget that. That if you're going in to get your gallbladder removed or you're going in for other kind of surgery, it's like you have a recovery time.
Dr. Asha Shajahan (25:34):
I imagine having a major surgery and then having to take care of a newborn on top of that, and your body's going through all these changes. So, I mean, it's a lot to deal with that.
Dr. Asha Shajahan (25:45):
The other thing I was thinking of discussing a little bit is about some of the new guidelines in terms of induction. Can we talk about that?
Dr. Kurt Wharton (25:55):
Certainly. Yeah. For many years we taught, myself included as an educator, taught what we had been taught, that if you induce labor, there's going to be a higher risk of ceasarean section. The reason for that was, in the past we tried to be scientific and examine the problem. We looked at women who were induced compared to women at the same stage in pregnancy who entered labor spontaneously.
Dr. Kurt Wharton (26:20):
Well, to no surprise, the women who entered the hospital spontaneously in labor had shorter labors and had a lower chance of cesarean section compared to the woman who came in early labor or were induced. But again, you're comparing apples to oranges.
Dr. Asha Shajahan (26:36):
Mm-hmm (affirmative).
Dr. Kurt Wharton (26:37):
So a study was done in 2018 called the "ARRIVE trial" led by Dr. William Grobman at Northwestern. It was a very large study, extremely well performed. What they found is if a woman is pregnant for the first time and is 39 weeks along in pregnancy, which is one week before her due date, if she's induced, she actually has a much less risk of having a ceasarean section compared to an identical woman who isn't induced for the next two weeks.
Dr. Asha Shajahan (27:13):
Mm-hmm (affirmative).
Dr. Kurt Wharton (27:14):
What we find is the risk of complications that we see at the end of pregnancy are avoided. So scary as it might seem to be induced, it actually can be quite a safe thing to do. Again, that comes back to shared decision-making. It's a difficult concept, even for many physicians and midwives to understand.
Dr. Asha Shajahan (27:36):
Yeah. I think that's phenomenal because a lot of people don't know that, that at 39 weeks you can have a discussion, or prior, about possibly being induced. Because like you said, the traditional way was wait until the baby's ready to come out, and most people just want to go nuts by that time. It's like, "Get this baby out."
Dr. Asha Shajahan (27:56):
So in terms of shared decision-making, are there any tools or resources that a woman could check out or families can check out to sort of wrap their minds around it?
Dr. Kurt Wharton (28:10):
Fortunately, yes. I'm pleased to say that this is a great topic. I was participating in a conference this morning, and the primary focus of the conference was just this topic, shared decision-making. But you can go to Wikipedia. They have an outstanding description of the history and a definition of shared decision-making.
Dr. Kurt Wharton (28:29):
But again, finding that provider who will listen to you and treat you with respect, and most importantly, listen to what you have to say, that's really the key to having the success with shared decision-making.
Dr. Asha Shajahan (28:43):
Yeah. And I think shared decision-making is something that is used not only for pregnancy. It's for everything in your health, so it's something to really think about, look into, and then start having those conversations with your doctor. And then hopefully when you're ready to have a baby, you find an OB-GYN or a midwife that will also do the same.
Dr. Asha Shajahan (29:02):
Let's talk a little bit about breastfeeding. A lot of people, they'll try and then they give up. Other people are like, "Not happening, not doing it." What do you see in your practice, and what's your advice in terms of breastfeeding?
Dr. Kurt Wharton (29:17):
I'm so glad you brought that up. Breastfeeding is something I believe is important to discuss long before it's time to breastfeed. I start talking about breastfeeding once we've confirmed that the pregnancy is healthy and is going to stick around.
Dr. Asha Shajahan (29:29):
Early on, huh? Okay.
Dr. Kurt Wharton (29:30):
Very early on because there's, again, a lot of misconceptions about it.
Dr. Asha Shajahan (29:33):
Mm-hmm (affirmative).
Dr. Kurt Wharton (29:34):
A lot of people think that baby formula, after all it's scientifically prepared, is just as good as breast milk.
Dr. Asha Shajahan (29:39):
Mm-hmm (affirmative).
Dr. Kurt Wharton (29:41):
That's the manufacturers would want you to believe, but it's not true.
Dr. Kurt Wharton (29:45):
The American College of Obstetricians and Gynecologists is extremely passionate about encouraging women to be exclusive breast-feeders for the first six months of the baby's life and then having a combination breastfeeding and offering a foods for the second six months of life.
Dr. Kurt Wharton (30:01):
And it just doesn't happen. People think, "Well, I'm a woman. I have breasts. The baby will come out and I will breastfeed. It will be just be wonderful."
Dr. Asha Shajahan (30:09):
Mm-hmm (affirmative).
Dr. Kurt Wharton (30:10):
It can be. It can also be the most challenging, difficult, painful, scary, frightening experience a woman has after surviving childbirth.
Dr. Asha Shajahan (30:17):
Yeah. It's traumatizing, even.
Dr. Kurt Wharton (30:19):
And it just doesn't happen naturally. There are skills. You have to let your body adapt slowly. If you decide to become a marathon runner, you don't go barefoot and run a marathon the first day. You work into it very slowly. You prepare, you protect your skin, you wear shoes.
Dr. Kurt Wharton (30:34):
In breastfeeding, you make sure your skin remains moisturized and that you don't over-nurse. Women often think because they love their babies so much, they'll put the baby on the breast for half an hour.
Dr. Asha Shajahan (30:44):
Mm-hmm (affirmative).
Dr. Kurt Wharton (30:45):
Well, at first the baby gets the initial milk, what we call "colostrum" in five minutes on each side. When the milk is fully engorged, really 20 to 30 minutes is an awful lot of time on either side. Unfortunately, skin will wear down.
Dr. Kurt Wharton (31:02):
And if breastfeeding experience starts out poorly, women are much more likely to stop. That's bad for the baby because we think there's nothing more nutritious, especially when it comes to passing on those antibodies we talked about before.
Dr. Kurt Wharton (31:17):
But also women are challenged emotionally afterwards. They're disappointed in themselves, frustrated and often afraid to try again with a second child.
Dr. Asha Shajahan (31:25):
Dr. Kurt Wharton (31:26):
We want to avoid that as much as possible.
Dr. Asha Shajahan (31:28):
I had a really close friend of mine and she had her baby. I went to go visit her, and I remember I walked in and she's like, "Okay, everyone. Asha's a doctor. Everyone get out." I'm like, "Okay, what's going on?"
Dr. Asha Shajahan (31:39):
Then she just looks at me and goes "Help. I don't know how to breastfeed a baby. It's not working. I tried the football hold. I tried this, I tried that." I said, "Well, did you ask to have a breastfeeding consultation?"
Dr. Asha Shajahan (31:56):
It was just one of those things that I think, especially if it's your first child, people just assume that baby comes out and you are just already a mom and you know what you're doing. I think there's a lot of coaching that needs to be involved. And I think the more we talk about it and the more we ask questions, we can be more successful.
Dr. Asha Shajahan (32:17):
Because the worst thing is thinking, "I'm supposed to know how to do this." And it's like, I don't think anyone is programmed to be a mother. It's something that is learned.
Dr. Kurt Wharton (32:27):
That's absolutely right. And at the hospital, we have professionals, lactation specialists, who work with women. The physicians, the labor and delivery nurses, everyone wants the woman to be successful.
Dr. Asha Shajahan (32:38):
One thing I do hear from a lot of my friends. Most of my friends are working mothers and they tend to be the ones that have babies later. They say, "I can't do breastfeeding with work, and in addition to that, my significant other needs to also feed the baby too. It's not just going to be on me." What is your advice there?
Dr. Kurt Wharton (33:00):
Well, again, plan ahead. Get as much help as you can. Now, with breastfeeding, the significant other can't actually perform the physical act, but can be very supportive of everything else. It takes a team.
Dr. Asha Shajahan (33:13):
What I also say too to some of my friends is "You can pump and they can help with that." What are your thoughts about pumping and then delivering it that way?
Dr. Kurt Wharton (33:23):
When necessary, pumping is a wonderful thing. The milk could be stored for quite a long time.
Dr. Asha Shajahan (33:28):
Mm-hmm (affirmative).
Dr. Kurt Wharton (33:29):
Yeah. But some babies do initially have what we call "nipple confusion."
Dr. Asha Shajahan (33:32):
Ah, yeah. Okay.
Dr. Kurt Wharton (33:33):
Because they have to work to get milk from the breast. And when they get milk from a bottle, they just open their mouth and guzzle away. So they often get a little lazy.
Dr. Asha Shajahan (33:43):
Yeah. And I think that's another misconception, is they'll say, "It's better for the baby because clearly the baby doesn't want my milk." But it's like, we've got to train and go from there. Any last thoughts that you'd like to add?
Dr. Kurt Wharton (34:00):
I can't emphasize enough the importance of everyone getting their COVID vaccination. We all need to work on this together, and without a team effort, we're not going to be successful.
Dr. Asha Shajahan (34:11):
Yeah. I think that's super important. I think, again, you're an OB-GYN, you're a leader in the field, and I think we just need to really talk to trusted messengers. And the message is get vaccinated; COVID vaccine is safe in pregnancy.
Dr. Asha Shajahan (34:29):
Dr. Wharton, I think we're out of time, and I know we could talk about a lot of other things. Maybe we'll do a podcast soon about post-delivery and all sorts of things about the first year of life. You've just been a wealth of knowledge, and I was just glued to everything you had to say. So thanks so much for being with us today.
Dr. Kurt Wharton (34:48):
It was my absolute pleasure. Thank you for inviting me.
Dr. Asha Shajahan (34:50):
I also want to remind you to send along any questions or suggestions to We're always scouting out for the best questions for our future mailbag episode.
Dr. Asha Shajahan (35:01):
You also might want to check out some of our other podcasts around pregnancy. One is infertility, and another one is about the fourth trimester.
Dr. Asha Shajahan (35:13):
We leave you today with this healthy thought: Pregnancy and childbirth can be overwhelming, especially during a pandemic, but it doesn't have to be. Think about how you can prepare for your pregnancy and plan for your childbirth.
Dr. Asha Shajahan (35:28):
Dr. Wharton recommends the COVID 19 vaccine during pregnancy, before pregnancy, and even after. It's safe and there's no evidence it impacting your fertility or hurting your baby. You want everything to be perfect for this beautiful baby that's on the way.
Dr. Asha Shajahan (35:44):
And with things so scary in the world right now, shared decision-making is more important than ever before. Dr. Wharton shared so many important tips about shared decision-making. Know that you can work together with your clinician to make evidence-based decisions based on your preferences and guided by your values.
Dr. Asha Shajahan (36:05):
This is what shared decision-making is all about and why it's so important to participate in it. And when you're holding that healthy baby in your arms, you'll be so glad that you did.
Speaker 1 (36:18):
Continue your journey to living a smarter, healthier life. Visit to access information and resources related to today's podcast.

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