Have you ever wondered how guidelines are set for the care that you should receive by your doctor during your pregnancy, at childbirth, and then after you deliver your child? The American College of Obstetricians and Gynecologists, otherwise known as ACOG, do set those guidelines, and they recently updated the information on their seventh edition book that you can find on Amazon, Your Pregnancy and Childbirth.
I interviewed Dr. Holly Cummings, who is an OB GYN, and she answers some of the questions around some of the surprising guidelines and how they came about and the role that women should play to ensure that they have a successful and healthy pregnancy, childbirth and postpartum care.
What we Discuss:
Updates to when your first postpartum visit should be
Supplementation required when breastfeeding
Pitocin versus natural ways to induce
How to avoid prolapse and incontinence
Folic acid vs. methylated folate
Healthcare disparities
Transcript
Georgie Kovacs: There has been a long overdue, but welcomed change to guidelines, where previously the recommendation has been that your first postpartum visit to your OB GYN is six weeks after delivery. Now, it is recommended that you can do it three to four weeks after delivery.
Dr Holly Cummings: I think that, historically, I wasn't around decades ago, when somebody decided that we could just see people at six weeks after delivery and everything would be okay. But there is a historic basis for the idea that most people have completed their physical recovery by six weeks. Certainly people will talk about that maybe that has some tradition, from even very few centuries ago in the Catholic Church, and antiquated ideas around when somebody could resume physical activity, including intercourse after delivery.
And it does hold true that a lot of people are physically, if they've had a childbirth, tear. Most people have healed by six weeks, but not everybody. And there's a lot more to the postpartum time period than just having your tear healed and having your stitches dissolve.
And so I think over the last few years, we've really realized that there's a lot of care that still needs to happen in the postpartum time period. And we're sort of calling it now the fourth trimester of pregnancy.
So the 12 weeks after delivery. And there's been increasing recognition that people still need a lot of assistance. There can be problems such as high blood pressure that can arise even after a baby is born. If somebody has had diabetes during pregnancy, that can still be a concern for everybody, we really worry about their emotions and their mood postpartum.
And as well as the physical recovery, plenty of people aren't physically healed by six weeks. And if you wait till six weeks to have your first contact with someone after delivery, then you may have missed opportunities to help them heal from all these different aspects.
And then certainly breastfeeding as well. If you've waited till six weeks to ask someone how breastfeeding is going, if someone's having trouble, you've lost the opportunity to help. In the last few years, we as a group of physicians, obstetrician gynecologists, along with other medical providers who help take care of pregnant patients have really increased our emphasis on the postpartum time period, and this emphasis on the fourth trimester, and tried to improve the care. And so I do think it's really great that ACOG has come out, we've actually come out with guidance in writing that we should touch base with our patients at those time periods that you mentioned.
The trimester is a 12 week time period, and you should have at least two checkouts in there.
I would love to be able to spend hours with every single one of my patients, and sometimes the practice setting doesn't allow for it. But when it's important, we should be able to take that time.
Georgie Kovacs: When these guidelines are put in place, how do all the OB GYN know about them? It's one thing for it to be written, and then there's another thing to change mindset.
Dr Holly Cummings: OB GYN is an interesting field. Most OB GYN’s in this country do belong to ACOG, the American College of Obstetricians and Gynecologists, In order to be board certified in obstetrics and gynecology, we undergo annual board certification updates, and some of that process involves making sure that we're up to date with ACOG’s guidance.
So ACOG publishes two different types of written guidance called practice bulletins and committee opinions. And those are available on their website, also through medical publications, and it's our responsibility as board certified OB GYN is to stay up to date with those recommendations.
Georgie Kovacs: I assume getting board certified involves answering many questions. How can the system ensure OB GYN’s know about this change to guidelines? It is an important one.
Dr Holly Cummings: Absolutely. I think there's a wide variety of practice settings in this country. Some some physicians are based at tertiary care academic centers. Other people are in community practice or solo practice. Some people practice in very rural settings, with very low resources. And so there is going to be a variety of practice patterns and practice settings.
However, sort of the commitment we've all made as OB GYN, as women's health providers, is that we are trying to do the right thing by our patients at all times. And so I do think it's reasonable for a patient to come to her care provider and say,” Look, this is what I understand the recommendations to be. Is this what I should expect from my experience with you, and if not, why?”
ACOG has done a lot with really taking into consideration all those different practice patterns. So for instance, it's very hard to mandate that you must be seen by your provider three weeks after childbirth. It might not be possible for that medical practice. And it actually might not even be possible for the patient to get to the office, but allowing for the opportunity of a telephone contact telemedicine visit that broadens the opportunities.
It does sometimes take more time in our conversations with the patient, but that's not a bad thing in itself. I would love to be able to spend hours with every single one of my patients, and sometimes the practice setting doesn't allow for it. But when it's important, we should be able to take that time.
Georgie Kovacs: When ACOG creates these guidelines, how does that translate into what is covered as a benefit with insurance companies?
Dr Holly Cummings: It's certainly a reality in this country, insurance coverage sometimes dictates what we're able to do. Part of the benefit of having recommendations like this in writing as an official stance of ACOG is so that we can, on the flip side, come back to the insurance companies and say, “Look, this is the right thing to do for our patients, and so you should cover it.”
We've seen since, the recommendations for that three week check-in postpartum have come out from ACOG, there are more insurance companies covering it. Historically, as part of the pregnancy care in the United States for a few decades now has been covered under what we call a global package. And so there's a single payment that the insurance company makes to the OB GYN for our delivery provider after delivery. And so that covers all nine months of prenatal care, and the delivery and six weeks of postpartum care.
And because of those historic guidelines, the six weeks of postpartum care was listed as a single office visit, which tied our hands as providers. We can't see everybody in extra time, if we're not going to get paid for it. That's not fair to us, as well. And so by having this recommendation in writing, we've been able to come back to the insurance companies and say, This is the right thing to do for our patients, therefore, you should also cover it. And so we're starting to see that with some of the payers now. That they are covering that additional visit, which is great. And that's how we slowly move the needle for everybody.
Georgie Kovacs: The next question is about vitamin D supplementation. I was surprised to learn that if you are breastfeeding, the milk does not necessarily produce all of what the baby needs. Thus, if you're breastfeeding, it's important to supplement the baby with vitamin D, but if you are using formula, you don't have to. The same goes for iron. Can you talk a bit more about this, especially since we are often told breast milk produces everything the baby needs.
Dr Holly Cummings: Breast milk is absolutely a complete form of nutrition for human babies, and we support exclusive breastfeeding and meeting everybody's breastfeeding goals. But we do know from breast milk analysis that vitamin D is the one thing that breast milk does not contain enough of under our normal diet.
Now, what's interesting is I don't know that we know if this is a product of the modern, 21st century industrial diet or is this something that, evolutionarily, was always a problem.
It is true that formula has been supplemented with enough vitamin D, but breast milk does not contain enough vitamin D, generally. And so we do recommend breastfeeding patients to either supplement the baby with vitamin D.
Alternatively, the adult breastfeeding person can take extra vitamin D supplementation. And that is what allows enough vitamin D to get into the breast milk into the baby.
Georgie Kovacs: The next question is related to kegels. I've had the fortune of interviewing a few folks who do pelvic floor physical therapy and pelvic floor rehabilitation. And one of the aha’s that I had is around the right kegels. What I learned is that it depends on what is happening with the pelvic floor because if you do what most people think of as the kegels, and that's not why you're having the issue, it can actually make things worse.
So I was curious about your thoughts and perhaps if there's some considerations for potential revisions of what's described here?
Dr Holly Cummings: The kegel exercises, as described here, are correct, .and that's generally how we counsel people, but I do agree that they're not necessarily for everyone.
So one of the things to talk about with your provider at your postpartum visit is:
Have I healed physically
Do I have any ongoing pain
Would I benefit from pelvic floor physical therapy
And I know the pelvic floor physical therapist would say everybody would benefit from physical therapy.
I'm aware that in other countries, it's sort of a routine postpartum follow up. And I do think there's a growing awareness that getting people in early after childbirth can help with so much of the physical recovery, the muscular spasms that can happen and the long term pain.
And I agree that if some people have sort of, depending on what their concerns are, are doing kegels in this way might not be the right thing. And so certainly, if you're trying to kegels at home and you're having more pain, then you know, don't keep doing that and seek help. Ask for a referral to pelvic floor PT.
Georgie Kovacs: With respect to prolapse, I interviewed a woman who recently wrote a book about urinary incontinence. And there's just all these things that can happen. When we live in our own body, we become very used to what is. We may not always know, until something really bad happens that it probably could have been caught earlier.
Outside of the luxury of being able to go to a pelvic floor physical therapist, in all cases, are there things people should look for outside of just pain that maybe should be a warning sign of probably not a grin and bear it kind of moment, this is a go see your doctor kind of moment?
Dr Holly Cummings: Any sort of incontinence, and by that we mean leaking, leaking anything that you don't want to be leaking, which can include leaking urine, stool, or gas. So if you don't have control of those bodily functions, you should absolutely seek medical attention. It can be a sign that the muscles haven't healed properly after delivery, or maybe if you had stitches, additional healing needs to take place. And these are things that the earlier they can be identified, the better the outcomes are at fixing them. And sometimes, it's a combination of physical therapy, sometimes it involves surgical procedures, but you really want to have that very detailed evaluation either by your childbirth provider or OB GYN provider, or there are specialists within the field of gynecology, often referred to as urogynecologists who specialize specifically in the pelvic floor musculature.
Georgie Kovacs: When is incontinence a concern given that birth already impacts a woman’s body.
Dr Holly Cummings: I agree that it's very common to see leaking, particularly urinary leaking for the first few weeks after delivery. And that can be whether somebody has a vaginal birth or cesarean delivery, because the pelvis and the pelvic muscles have just gone through a lot. And so it takes some time for strength and sensation to recover.
But if by the time of a six week or certainly 12 week check-in, you're still having that leaking, you should mention it. I would say even sooner if you're having any fecal incontinence, of stool incontinence, or fleetest, or what we call gas incontinence. So if you're leaking stool or gas, you should let your provider know sooner.
The other symptoms I think about are in addition to pain or leaking, I think about a pressure sensation, or people will describe a heaviness in the vagina. or certainly if you feel any tissue bulging out that didn't used to bulge out, that's a classic symptom. That's the definition of prolapse, and so that deserves a dedicated exam as well. Oftentimes, over the first few weeks to months after delivery, it all resolves, but sometimes it doesn't. And so you want to be proactive.
Georgie Kovacs Let’s talk about induction and why someone may need to be induced.
Dr Holly Cummings: We think about pregnancy as a natural process, and eventually at some point, your body will go into labor on its own. The issue arises if there are reasons that it would be better to deliver to not wait for the body to do it on its own.
Historically, it was done for three major reasons, it was to identify three big problems.
Preeclampsia (blood pressure problems). What people knew, even hundreds of years ago, could be what was termed toxemia of pregnancy. So you know, everything seemed to be fine. And then somebody got really puffy. They couldn't measure blood pressure centuries ago, but horrible things like seizures could happen, you know, obviously, not good outcomes. And we now know that that's a process called preeclampsia.
Diabetes. So hundreds of years ago, you couldn't check your, you know, prick your finger and check the sugar in your blood. But people knew that if somebody had sweet tasting or sweet smelling urine, it was a sign that there was too much sugar in the system, and that could cause pregnancy problems.
Stillbirth. This is not something that obviously, it's sort of the most tragic thing that can happen. And it's something that we want to prevent if we can. We know that if somebody stays pregnant on their own, for as long as possible, yes, eventually the body will go into labor, but bad things could happen along the way.
Georgie Kovacs: When should medical intervention occur in pregnancy to get the baby out? Tell us about the concerns in being overdue.
Dr. Holly Cummings: And so we want to be judicious about making sure that those bad things don't happen without intervening too much. And so, you know, in the absence of a medical problem in either the pregnant patient or the fetus, we generally don't necessarily recommend induction without, you know, a good reason or conversation with your care provider.
One of those reasons is being overdue. Yes, eventually your body will go into labor, but the longer you stay pregnant past your due date, unfortunately, the risk of stillbirth can go up. And so that's probably the most common reason that people may be having the conversation with their care providers about should I be induced and why and when?
There is an increasing frequency to induce patients at 39 weeks, or at least talk about inducing people at 39 weeks sort of what we call electively. And this came out of a study that was done here in the United States a few years ago at multiple medical centers called the ARRIVE Trial. And what it showed was that if you induce patients who otherwise didn't have medical problems, if you induce them at 39 weeks, they had lower rates of C-section and lower rates of a few other outcomes like preeclampsia and stillbirth. Then if you let the patient stay pregnant and wait till they went into labor on their own, historically, we tried not to induce people, again, if there wasn't a good reason, because we worried that the process of inducing them could increase the C-section rate. And so what this study showed is that that's not true. So it did not increase the C-section rate if you were induced. And so it has sort of given us the permission to say, if you would like to be induced, we know that this is probably not harmful to you.
I can't speak for all OB GYN in the country, but I can say that when I talk to my own patients, I don't talk to them about induction at 39 weeks as a way of decreasing C-section rates or decreasing preeclampsia rates. But I say if it's something you're interested in, I feel like it's safe. Whereas before, you know, 5-10 years ago, I would say, I think you might be setting yourself up for a C-section unnecessarily. And so it just allows one more option for my patients and I to discuss.
So if somebody says, Look, I'm so tired of being pregnant, I just, I want this baby out. Or if they say, like, my husband's being deployed, and I want him to be able to meet the baby before he ships out. It gives us that extra bit of reassurance that this is a safe thing to do. So that's sort of how I approached induction with patients.
And then there's going to be a lot of people who do have medical reasons to be induced: things like preeclampsia, diabetes, and again, that's because we have evidence that says if you stay pregnant for too long with those conditions, you're increasing your risk of stillbirth. And stillbirth is a tough thing to talk about because it's not, you know, that's not the stick I want to be beating people over their heads with during pregnancy, to be thinking about stillbirth all the time. But unfortunately, it can happen. And so that's in the back of my mind. I don't want everybody else to be worried about it.
Georgie Kovacs Pitocin is often used for induction, but I also learned raspberry leaf tea and dates. There is actually an abstract on taking four dates per day leading up to childbirth. What is your perspective on pitocin versus these other treatments?
Dr. Holly Cummings: There's a whole wide range. So I talk to patients about at home methods in the office methods and then in the hospital methods. So at home, you're right, we have the evidence about dates. The data showed that the people who eat that number of dates daily, toward the end of pregnancy did go into labor on their own slightly earlier than people who didn't eat the dates.
We don't have good evidence like that for evening primrose oil, but the reason is that or red raspberry leaf tea is the other thing that often gets talked about. The reason that these natural or food based methods have come around is because for centuries, we had an oral tradition where people noticed that maybe these foods made a difference in triggering labor.
The scientific basis behind it is that some of the chemicals in those plants have a category of hormone called prostaglandins, which is similar to some of your own human labor hormones. By ingesting the prostaglandins in food form, maybe we can help soften the cervix or ripen the cervix.
You don't want to start anything like that too early. We know that there are risks of being induced or triggering labor if your body wasn't ready before 39 weeks, but certainly at 39 weeks, I think it's safe to try those food based methods.
We don't have evidence for the evening primrose oil or the red raspberry leaf tea. But I think it's safe to do.
In the office, you can talk to your prenatal provider about doing something called sweeping your cervical membranes, we call it sweeping the membranes or stripping the membranes. And that involves checking the cervix to see if it's dilated. And if it is sort of sweeping the finger around the inside of the cervix to release some of your own natural prostaglandins. So we all have prostaglandin hormones in the cervix and in our bodies. And so by releasing those manually with that sweep, the idea is that you can trigger labor. It's only about 50-50 if it's going to work, but if it works, it tends to work in the next day or so.
Georgie Kovacs: What about intercourse? Does that help with induction?
Dr Holly Cummings: Intercourse can certainly. The idea there is that semen also has prostaglandins. And so it's sort of two things. Physically, having an orgasm is the uterus having a contraction as you're giving the uterus a contraction and hopefully telling it to keep contracting and get things going. You're exposing those prostaglandins in the semen to the cervix, and maybe it'll help.
Georgie Kovacs: Let’s talk about C-section rates in the United States. Many speak about astronomical rates in the United States, but in the latest data, the US was ranked sixth or eighth based on 2018/2019 data.
Dr Holly Cummings: Context and frame of reference is always the most important thing for everything we think about in life. There are countries in the world that have much higher C-section rates, and that's generally driven, sort of from two categories. One would be the cesarean delivery done on patient request, and one would be the cesarean delivery that maybe wasn't medically indicated, but suggested by the OB GYN provider.
I can't speak to culture or society about why that happens in all these different countries. But it's certainly true that there are countries in the world with much higher C-section rates.
There are pros and cons to delivery both ways. There are pros and cons to having a vaginal delivery, there are pros and cons to having a cesarean delivery. And for most people, they would prefer to have a vaginal birth. And we totally support them in doing that. And we talk about the benefits of vaginal birth for both pregnant patients and the baby.
There are definitely times when a cesarean delivery is indicated safer for the adult patient or the baby. And there are times that the pregnant patient might say, look, I hear what you're saying, but I would like to have a cesarean delivery and we should support that as well. After discussion, you know, there's always going to be risks and benefits. And the important thing is that somebody understands the decision that they're making.
Georgie Kovacs: Let’s talk about folic acid. About two years ago, I spoke with the head of American Society for Reproductive Medicine, and I asked him about methylated folate. It is my understanding that a lot of the population has MTHFR one or both of the genes. As a result, they don't process folic acid properly, so it's much better to take methylated folate. This is probably more a question for you specifically, rather than necessarily the ACOG representation, because I did not see it in the book. What should women be aware of?
Dr Holly Cummings: I certainly have patients who take one or the other and feel there may be benefits. We don't have robust data. It's tough, because it's hard to do women's health studies and pregnancy and preconception studies for a variety of reasons. But as a result, we have very poor data for what to do around pregnancy and childbirth, on a lot of topics. And this is one of them.
I don't think there's any harm in taking methylated folate. At most, you might be spending money on something that maybe you didn't need.
Georgie Kovacs: Now let’s discuss disparate populations. This is a hard one because the answer is not easy, but I find each guest provides interesting information and insights.
Dr Holly Cummings: It's very important to discuss healthcare disparities, health equity, racism and systemic racism and how it affects healthcare in general and absolutely very much prenatal care and pregnancy and childbirth. OB GYN as a field has a long history of unfortunately being on the backs of people who are not able to give consent who were in slavery, and as a specialty, we have long known that and are starting to really acknowledge it and and recognize that we have a lot to owe to women who are never able to give consent, or have a shared decision making conversation with their providers.
Even up until the last few years, there have been numerous studies on any number of topics in medicine, where it was pointed out that being of a particular race, or being of a particular socioeconomic status, was a risk factor for some sort of outcome.
Simultaneously, we know that race is a social construct. So genetically, from a DNA perspective, there's very little difference in someone of one race or another, you know, between black and white, or Asian, or ethnicities, Hispanic or not Hispanic, genetically, we are all so similar. And so how can we say that being of a particular race puts you at a higher risk of high blood pressure? When on the other hand, we say genetically, we're all the same?
The answer is systemic racism. So you know, it is unfortunate, but the system has created a system in which people get disparate care and unequal care. And it's not right.
There's a lot of groups looking at this and trying to figure out how we can level the playing field. And some of it is everyday resources, like having access to food, food security, safe, and affordable housing, having a job that, you know, doesn't create too much stress, because all of those things play into how healthy somebody can be as they prepare for pregnancy or are pregnant, and how they experience pregnancy and childbirth. So that's all really important.
And I think leveling the playing field with information, as you said, is great. And so that's why this book is amazing. You know, it's not free, it's fairly inexpensive. But it's also available from your local public library, I've definitely seen it there. And so that's a resource. This is a personal plug, but I love public library systems. And so you can get lots of good information there.
The wonderful thing about the internet is it has really leveled the playing field, from an information standpoint, and in a lot of ways as well. And so you know, a lot of information is available on the ACOG website, ACOG.org. And up at the top, there's an area that is specifically for patients, and you can go there and get free information based on the same, you know, ACOG recommendations. And so you know, as much as possible, and I also acknowledge that not everybody has access to the internet, or reliable access to the internet. And so all these things are true. And we just have to do everything we can to make sure that people are getting equal and appropriate care and the best care for them.
Georgie Kovacs: What is your greatest hope for women's health?
Dr Holly Cummings: I've been thinking about this a lot. My greatest hope is that every patient has the opportunity to work with a health care provider who meets them where they are, and meshes with them. Ultimately, we're all individual people with individual personalities, and I pride myself on trying to get along with everybody, and giving them the care that they are looking for.
Georgie Kovacs: Beautifully said. Thank you so much for your time. I really appreciate it.
Resources
Trial about induction: ARRIVE Trial
Check out all of Fempower Health’s resources on Pregnancy and Motherhood and Pelvic Health.
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About ACOG
ACOG is the nation’s leading group of physicians providing health care for women, with over 60,000 members. For more than 60 years, ACOG has written the medical guidelines that obstetricians-gynecologists and other medical professionals use when caring for women. “Your Pregnancy and Childbirth” is unlike anything else on the market, with recommendations supported by ACOG’s clinical guidance and the everyday experiences of obstetricians-gynecologists who have cared for millions of pregnant women.
About Fempower Health and the Founder
Georgie Kovacs, is the founder of Fempower Health, the go-to resource for all things women health serving women, their providers, and companies looking to build/improve on products for women. She also hosts the Fempower Health Podcast, where she interviews experts to help women better understand how to navigate their health both day-to-day and in partnership with their providers. Her mission is to minimize the years many take to seek proper diagnosis and treatment.
Georgie founded Fempower Health after her first-hand experience with infertility and endometriosis. Leveraging this experience along with her 20+ year tenure in the biopharmaceutical industry and consulting, she leads this movement to empower women. With limited research dollars and women’s “training” to grin and bear it, both women and doctors are in the impossible position to diagnose and treat conditions with little information. Women deserve more and better information, insight and innovative health solutions.
**The information shared by Fempower Health is not medical advice but for information purposes to enable you to have more effective conversations with your doctor. Always talk to your doctor before making health-related decisions.
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