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Medical Choices During Pregnancy

Jos
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Before my ALI journey, I had a pretty basic idea of what conception, pregnancy and childbirth entailed. You decided you were ready for a baby, you got pregnant, you went to your appointments and did what the doctor said, you went to the hospital and had your baby. BAM. Easy peasy, right?

When things took much longer than anticipated for us to even conceive, it was a shock to everything I thought I knew — but on the upside, it spun me into an alternate world of educating myself by researching statistics and options and asking questions about why doctors recommended we try different drugs or do different procedures in the quest to make a baby. I ended up following a mix of Eastern and Western methodologies during our TTC journey, and I truly believe there is a lot of benefit to be had and knowledge to be learned from BOTH of those ideologies.

Once we got pregnant, I was a fairly low-key pregnant woman who had educated myself on my birth preferences and thankfully had the ideal birth experience for me. I just went with the flow of what my hospital-based midwife recommended testing-wise during pregnancy (which honestly was a lot more hands off than the typical OB testing regimen), and it honestly never occurred to me to research much about it because I was so focused on the birth experience.

This time around, my insurance deductible is horridly high and we are planning a home birth for a variety of reasons, so this catapulted me into researching many of the “routine” tests and procedures that are currently done during pregnancy. When one is suddenly paying out of pocket for every test, money is a huge incentive to research and decide if the test or procedure is actually necessary or even beneficial.

*Please note – the estimated costs I included below are just that – total estimations, based on what I have paid in the past or what I found online. Costs can vary WIDELY (by hundreds of dollars) so you’d have to call your specific medical facility and/or lab to find out your actual costs.

Okay, so please bear with me and this long-winded post. There are a plethora of routine tests that are usually done during your prenatal visits, though this is by no means a comprehensive list if you are considered “high risk” for some reason (FWIW – this is also a term I take some issue with for reasons too lengthy to add to this post right now). I just thought I’d lay it all out here so you can see the gamut of tests that providers routinely bill your insurance for now days and how I made my decision to do or decline them. I am not a medical provider – please make sure to discuss any questions you have with your own provider! I was just thinking that some of you would find it helpful to have all of my research in one place. (here is a pretty comprehensive list of what is available to have done at standard prenatal visits)

At Every Visit: (my midwife does all of these)

First Trimester:

Second Trimester: (I declined almost all of these – I’ll expand on this further below)

Third Trimester:

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During the late 1st trimester / early 2nd trimester, there are a lot of genetic screening tests that one can opt to do. I didn’t do a whole lot of research on these because Charlie and I wouldn’t have chosen to terminate the pregnancy for any reason, and (in our opinion!) that would be the only reason we would have done the tests anyway. There is a lot of room for error on those early test results, and many of them just give you a percentage risk factor – not a yes/no if the fetus actually has the disorder, and for us, we didn’t feel like it was necessary to pay more to worry more – potentially needlessly! If the child was born with a trisomy or something, we would have figured it out from there. If there had been an issue that was incompatible with life, we figured we would find out about that at the 20w anatomy scan and make decisions then.

Regarding the rest of the tests that can be done in 2nd tri / 3rd tri that I did research on:

Anatomy Ultrasound

I wrote about this a few months ago, as I was torn about what to do. Ultimately, we decided that since I’m hopefully going to have a home birth experience about 30 minutes from the hospital this time around, we wanted to make sure that there was nothing physically abnormal development-wise with the baby that would require immediate medical attention at birth. For the $400 price tag, the peace of mind was definitely worth it, especially considering how much money we’re saving by doing a home birth. Most people call this the “gender scan” — but the real reason for this ultrasound is to measure the fetus’ organs and bones to make sure everything is developing correctly!

Gestational Diabetes Test

ACOG screening exemption criteria: Age less than 25, not a member of an ethnic group with an increased risk, BMI <= 25, no history of abnormal glucose tolerance or macrosomia, and no known diabetes in a first-degree relative.

Because I’m > 25 years old, I’m not automatically exempt from this screening, but this is still a test we’re going to decline anyway. My reasons? There’s no real proof that this test is being done at the right time of the pregnancy or actually changes anything at all in outcomes. The treatment for it is basically eating healthy and moving your body and delivering the baby — all of which I am doing / intend to do anyway! Here’s my research:

  • Evidence Based Birth: Gestational Diabetes and the Glucola Test
    • To this day, researchers still don’t know the answers to a lot of questions about screening for gestational diabetes. This is what I gathered from reading the most up-to-date literature:
      • We don’t know the best screening test for gestational diabetes.
      • We don’t know the best time during pregnancy to screen for gestational diabetes.
      • We don’t know if you need to fast beforehand.
      • We don’t know if the best cut-off point for the test.
      • We don’t know if screening the entire population results in improved outcomes. (Researchers theorize that screening can improve outcomes such as large birth weight, but nobody has done a randomized, controlled trial to test this theory)
  • Cochrane Summaries: Screening for gestational diabetes and subsequent management for improving maternal and infant health
    • This review of four trials involving 3972 women found that there is little high-quality evidence on the effects of screening for GDM on health outcomes for mothers and their babies.
  • Cochrane Summaries: Treatments for gestational diabetes
    • The review of eight studies (1418 women) suggests that offering specific treatment for gestational diabetes may be associated with better baby and mother outcomes, but has not found robust evidence on the best choice of treatment which provides the better outcomes for these women and their babies, even if identified correctly.
  • Cochrane Summaries: Different types of dietary advice for women with gestational diabetes mellitus
    • Based on the current available data, we did not find that any one type of dietary advice was more effective than others in reducing the number of births that required instrumental delivery or the number of babies who were large for gestational age or had a birthweight of 4000 grams or more. The included trials had various levels of risk of bias and it remains unclear which diet is the most suitable diet for women with GDM for improving the health of women and their babies in the short and longer term. 

Group B Strep

This test I wasn’t as sure about skipping because the complications for a GBS infected (not just colonized) baby are seroius, but the more I read, the more confident I am about declining it. Risk factors for GBS include:

Based on my research below, I’m comfortable going with the “risk-based approach” (which the CDC used to recommend in the US and which the UK still follows). A positive GBS test would require me transferring to a hospital setting for antibiotics, and I’m not willing to do that at this point. However, if I do end up with any of the risk factors outlined below, I will definitely head to the hospital and get myself hooked up to an IV!

  • Evidence Based Birth: Group B Strep in Pregnancy: Evidence for Antibiotics and Alternatives
    • Based on information from these 3 studies, in 1996, the CDC recommended 2 ways to prevent early GBS infections:
      • The “universal approach.” Screen all pregnant women at 35-37 weeks and treat everyone who is positive with antibiotics during labor (this is the method that is currently used in the U.S.)
      • The“risk-based approach.” Treat laboring women with antibiotics if they have one or more of these risk factors: GBS in the urine at any point in pregnancy, previously gave birth to an infant with early GBS infection, goes into labor at less than 37 weeks, has a fever during labor, or water has been broken for more than 18 hours (this is the method that is currently used in the United Kingdom)
  • Cochrane Summaries: Intrapartum antibiotics for known maternal Group B streptococcal colonization
    • Very few of the women in labor who are GBS positive give birth to babies who are infected with GBS and antibiotics can have harmful effects such as severe maternal allergic reactions, increase in drug-resistant organisms and exposure of newborn infants to resistant bacteria, and postnatal maternal and neonatal yeast infections.
    • This review finds that giving antibiotics is not supported by conclusive evidence.

Rh Negative Mother / Possible Rh Positive Baby

This has to do with blood Incompatibility Issues (& automatic administration of Anti-D during and after pregnancy). Most women won’t have to deal with this. I’m A neg Rh- (which apparently 7% of the world’s population is), so I do need to address it. Because I have had no uterine trauma or vaginal bleeding during this pregnancy, and I had a negative antibody screen post-delivery with Stella, I’m comfortable skipping the 28w RhoGAM shot. I will, however, be getting the shot post-delivery. During my pregnancy with Stella I got it both at 28w (for $250) and post-delivery, but only because I had never actually researched the issue! If I had any sort of uterine trauma during the remainder of this pregnancy for any reason, there is a 72 hour window in which you can get the shot to still have it effectively block the antibodies from being formed. This makes me 100% comfortable with skipping the routine intrapartum administration of it and only getting it if necessary (as well as postpartum within 72 hours).

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So there ya go. There is obviously a ton that I have not researched, but for a standard, uncomplicated, low-risk pregnancy, that is the basic run down of the tests that are usually done – often without your approval, and simply because “it’s routine.” Don’t be afraid to educate yourself, ask questions, and make the decisions that are best for you and for your pregnancy!

If you have questions about other specific tests that I didn’t go into detail about here, I highly recommend the websites Evidence Based Birth and The Cochrane Summaries for really through, unbiased, research based information!

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