Title: Best Practices for Safest Pregnancy | overlaid on image of street art in San Francisco (Miranda Hernandez)
(Miranda Hernandez)

***Disclaimer: please understand I am not a physician or medical practitioner of any kind. Information contained herein is a summary or direct quotation of information provided by reputable medical sources. Should you have questions about information presented here, it is best to discuss with your medical provider.***

The following list has been compiled from recommendations put forth by the American College of Obstetricians and Gynecologists (ACOG), the Center for Disease Control (CDC), and several international organizations committed to stillbirth prevention. While no single recommendation can guarantee stillbirth prevention, these five pieces represent the latest recommendations from the combined community.

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1. Fetal movement tracking

Recommendation: Fetal Movement Tracking

  • Starting between 24-28 weeks, become familiar with your baby’s individual pattern of movement. Do not compare your baby to other babies or other pregnancies
  • Report noticeably higher or lower patterns of movement to your provider. Always go to your provider’s office or L&D if you notice a significant change in pattern in movement
  • DO NOT rely on home dopplers for reassurance that your baby is okay

What’s the Reason?

How Successful is This?

  • Various studies have found reduced rates of stillbirth after implementation of programs promoting fetal movement tracking (Kicks CountSaving Babies Lives Care Bundle Element 3)
    • Note: Stillbirth CRE noted in the the Safer Baby Bundle Element 3 that some studies have not found evidence of either benefit or harm, but that others have indicated success in reduction of stillbirth rates. Further research is coming in this area
    • Note: the AFFIRM study found a small difference in rates of stillbirth when patients and providers were educated on the importance of fetal movements as compared to a control group, but they classified the difference as not significant. Further studies are in progress (AFFIRM)
  • Anecdotally, you can read success stories of babies born safely after problems were identified following reported reduced fetal movement (Kicks Count; Movements Matter; Still Aware)

 

2. Recommended Vaccinations

Recommendation: Vaccinations

  • Get the Tetanus Diphtheria and Pertussis (TDAP) vaccine between 27-36 weeks of pregnancy, even if you have gotten the shot previously or in previous pregnancies.
    • If you can’t get it in this time frame, some organizations recommend getting it after birth, but some do not
  • Get the flu vaccine during flu season, between October and May each year
  • Require all friends and family who will be spending time with your newborn to get both vaccines at least two weeks before seeing the baby in person

What’s the Reason?

  • Pertussis (whooping couch) and influenza (distinct from the common cold or stomach flu) are especially dangerous to pregnant women and young children, and can result in complications, including death (CDC; see specific references below)
  • Administration of the TDAP vaccine during pregnancy stimulates development of antibodies against pertussis which will protect the child for the early months after birth (ACOG/ACOG; CDC; ACNM; March of Dimes)
  • Because the TDAP vaccine requires two weeks to be fully effective, friends and family should avoid contact with the newborn until they are fully vaccinated (ACOG; CDC; ACNM; March of Dimes)
  • Administration of the flu shot during pregnancy reduces a pregnant parent’s risk of hospitalization from flu, and passes immunity to her child (CDC; ACOG)

How Common is This?

  • The United States sees between 10,000-50,000 cases of whooping cough each year (down from 200,000 cases per year prior to the vaccine), and of those, as many as 20 deaths (CDC)
  • CDC estimates that influenza has resulted in between 9 million – 45 million illnesses, between 140,000 – 810,000 hospitalizations and between 12,000 – 61,000 deaths annually since 2010 (CDC)
  • Each year, between 7,000-26,000 children are hospitalized due to complications of influenza, resulting in between 37-187 deaths (CDC)

 

3. Recommended Prenatal Testing

Recommendation: Prenatal Testing

  • Get tested for GBS between 35-37 weeks of pregnancy
    • If you test positive, you will require IV antibiotics during labor
    • If you test positive or you have risk factors of a history of GBS, it recommended you not have your membranes stripped and not have your water broken without 4 hours of IV antibiotics
  • Get tested for gestational diabetes between 24-28 weeks of pregnancy, or earlier if your provider recommends
  • Test regardless of personal health and history of past pregnancies (note: recommendations on wide-scale testing may vary by region, but my personal recommendation is to default to testing)
  • If you have pre-gestational diabetes (diabetes prior to pregnancy), follow provider recommendations for a healthy pregnancy

What’s the Risk?

  • GBS can put the pregnant parent at risk for preterm labor and premature rupture of membranes, or for diseases like bacteremia, sepsis, or pneumonia. GBS can put the baby at risk for premature birth, lifelong handicap, or death (CDC; Group B Strep International; Tommy’s; ACNM; ACOG)
  • Babies can be affected by GBS both during pregnancy and up to 6 months after birth (Group B Strep International; Tommy’s)
  • Gestational diabetes may put the pregnant parent at risk for low blood sugar, need for C-section delivery, or high blood pressure, potentially leading to preeclampsia. It may put the baby at risk for excessive birth weight and/or stillbirth, and a propensity to develop diabetes later in life (CDC; Tommy’s; ACOG)
  • Pre-gestational diabetes may result in birth defects or problems with the pregnancy (ACOG)

How Common is This?

  • Approximately 1 in 4 women carry or are “colonized” with Group B Strep. GBS is common, is not an STD, and personal cleanliness is not a preventative (CDC; Group B Strep International; ACNM; ACOG)
  • Approximately 4-6% of babies who develop GBS will die (CDC)
    • A pregnant woman with GBS who is not given antibiotics has a 1 in 200 chance of passing GBS on to her child. A pregnant woman with GBS who is given antibiotics during labor has a 1 in 4000 chance of passing GBS on to her child. (CDC)
  • Anecdotally, Group B Strep International shares stories of mothers and babies affected by GBS (Group B Strep International)
  • While certain risk factors may predispose a parent to gestational diabetes, the condition can affect anyone (American Diabetes Association; Tommy’s; ACOG)
  • Between 10-18% of pregnancies are affected by gestational diabetes (American Diabetes Association; Tommy’s)

 

4. Side Sleeping During 3rd Trimester

Recommendation: Side Sleeping

  • Starting at 28 weeks of pregnancy, go to sleep on your side (either side) instead of your back
  • If you wake up on your back, turn onto your side again

What’s the Reason?

How Successful is This?

 

5. Ideal Timing for Birth

Recommendation: Consider Induction of Labor between 39-42 weeks

  • Consider induction of labor at or after 39 weeks gestation, especially when one or more risk factors are present
    • Note: Some organizations recommend induction only in cases of maternal risk factors or conditions that have developed during pregnancy; some organizations also emphasize risks to induction
  • If you choose not to induce labor, continue monitoring fetal movement and consider other monitoring techniques on a regular basis (ACOG)
  • If you haven’t gone into labor naturally, consider induction of labor at 42 weeks gestation
  • Note: research in this area is currently in progress, and organizations cited elsewhere in this post may not have an official stance on this subject. In some places, I have cited specific studies instead of organizational opinions. I will keep updating this post as more information becomes available

Whats the Reason?

  • 39 weeks is considered full term, and induction can be recommended for healthy singleton pregnancies (ACOG)
  • Evidence shows rates of stillbirth rise for every day a pregnancy proceeds past 39 weeks (meta analysis by Grobman & Caughey)
  • Induction at term may reduce the risk of stillbirth, especially in patients with one or more risk factors or pregnancy-related conditions (Safer Baby Bundle Element 5; Cochrane)
  • 42 weeks is considered postterm. Postterm pregnancies have higher rates of stillbirths and other dangerous complications (ACOG; ACNM)
    • The Safer Baby Bundle Element 5 recommends induction at 41 weeks; the SWEPSIS trial was stopped because significantly more babies were dying in the expectant management group; the INDEX trial found a small but significant difference in outcomes when induced at 41 weeks vs. expectant management

How Successful is This?

  • Studies have demonstrated that induction at term leads to fewer stillbirths than expectant management (SWEPSIS; meta analysis by Grobman & Caughey)
  • For those worried about the cascade of interventions, studies have also demonstrated that induction at 39 weeks leads to fewer c-sections than induction at later weeks of pregnancy (ACOG; ARRIVE; Cochrane; meta analysis by Grobman & Caughey)
  • Further research is in progress

 

References:

ACOG Patient Resources; FAQs (ACOG)
American Diabetes Association
Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster-randomised trial (The Lancet)
Elective induction of labor at 39 weeks compared with expectant management: a meta-analysis of cohort studies (American Journal of Obstetrics & Gynecology) (paywall)
“Flu Information for Parents with Young Children” (CDC)
“Gestational Diabetes and Pregnancy” (CDC)
Group B Strep (CDC)
Group B Strep and Pregnancy (ACOG)
Group B Strep International
Induction of labour at 41 weeks versus expectant management and induction of labour at 42 weeks (SWEdish Post-term Induction Study, SWEPIS): multicentre, open label, randomised, superiority trial (BMJ)
Induction of labour at 41 weeks versus expectant management until 42 weeks (INDEX): multicentre, randomised non-inferiority trial (BMJ)
Induction of labour for improving birth outcomes for women at or beyond term (Cochrane Database of Systematic Reviews) (2018 version is open access; 2020 version is behind paywall)
Labor Induction versus Expectant Management in Low-Risk Nulliparous Women (New England Journal of Medicine)
Maternal Immunization: Understanding Safety and Efficacy, and Making a Strong Recommendation (ACOG)
Parenting in Pregnancy (Star Legacy Foundation)
Pertussis (Whooping Cough) (CDC)
Position Statement: Immunization in Pregnancy and Postpartum (American College of Nurse Midwives)
“Pregnancy” (CDC)
“Pregnancy and Whooping Cough” (CDC)
Safer Baby Bundle (Stillbirth CRE)
Saving Babies’ Lives Care Bundle (NHS)
Saving Babies’ Lives Care Bundle (Tommy’s page about the NHS bundle)
Share With Women (American College of Nurse Midwives)
Still Aware
Vaccinations and Pregnancy (March of Dimes)
Your Baby’s Movements (Kicks Count)

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