The Third Trimester: Weeks 25 - Term

December 14, 2007

Fetal Surveillance (Antenatal Testing...or, Peek-a-boo, we see you!)

A generation ago, women were seen by obstetricians as just sort of getting pregnant and just sort of having a baby nine months later. Most of them, anyway. Occasionally a disaster would strike, and due to the lack of meaningful ways to observe the baby, these disasters would often come as a complete surprise. Certainly an astute obstetrician of the time could pick up on some warning signals, such as questionable growth (assessed by means of the size of the prospective mother's abdomen), irregular fetal heart beat (heard with that very strange-looking horn device), or abnormal position (determined by grasping and feeling the abdomen according to certain described maneuvers). The mother's condition was easier to check, but the baby's evaluation was a hide-and-seek affair, the obstetrician getting only insightful glances through the non-invasive techniques of the time.

Fast forward to the present. The cost of a doctor's diligent care has increased tenfold, but the modern obstetrical abilities have multiplied exponentially into the priceless range. After all, how much is a good baby worth? Today we actually see the baby by ultrasound. Guesses at appropriate growth are eliminated and replaced by exact measurements. Also, the baby's position, still most frequently determined by physical exam, is confirmed. Amniotic fluid, a normal amount being one of the most crucial determinations of fetal well-being, can be measured. Fetal movement, tone, and even "breathing-like" movements can be directly observed, statistically assuring a mother-to-be of her baby's good health.

Another test, the non-stress test (NST)--also called Fetal Activity Determination (FAD)--makes use of the valuable relationship between fetal movement and fetal heart rate. When you run around the block, your own heart begins to race. This is your body's way of speeding up the whole process of delivering more oxygenated blood to areas of increased need, our muscles. It's a good thing everything works together like this, or many of us would drop dead just chasing after that dog that got out again. In the same way, when a baby moves, which the mother marks on a fetal monitor, we should also see a corresponding rise in the fetal heart rate. This tells us that everything is pretty much working right in the baby, too.

The combined results of the ultrasound exam and the NST are referred to as a Biophysical Profile. Scores are assigned by adding up all of the criteria met (observed). Over the years many researchers have exhaustively tabulated what all of these results mean. When all of the normal ultrasound items are found, and the non-stress test is normal, their statistics have demonstrated that a baby has a 99% or better chance of another week's worth of fetal well-being ahead. So doing these evaluations once or twice a week on high-risk mothers have immeasurably ("priceless") increased the value of prenatal care as compared to a generation ago. We get the earliest of warning signals that allow us to intervene if necessary, and all of this information comes without a single needle, drug, or tear. The price of steak has gone up just as much as the rise in the cost of prenatal care. But a generation later we're still getting the same steak.    ©1998 GERARD M. DiLEO, M.D., F.A.C.O.G.

See also, Biophysical Profile and Amniotic Fluid

Isn't There Someone More Qualified? Finding an OBGYN

"Isn't there someone more qualified to do that?"

That was comedian Bobcat Goldthwait's question to the doctor when he was asked whether he wanted to cut the umbilical cord at the birth of his child. You really need to hear him tell the story to appreciate the panic he experienced when he was unexpectedly asked to do it. Actually, cutting the cord is not really a big deal, medically, at least. (Except that it really should be cut by someone!) The point is that there are many things in modern labor and delivery that aren't medically important, like who cuts the cord, whether areas are shaved, or who's in the room.

Modern marketing for today's hospitals that are competing for obstetrical business have come a long way, and it works out fine for the patient. She is doted over and served, and Dad is part of the big event. Video and photography are welcome, as are friends and other relatives. In the background, masked by all of the good cheer and warmth that makes good marketing sense, is the real reason for having babies in a hospital--anesthesia if and when needed, a blood bank and surgery suite should complications arise, and a high-risk nursery for babies in jeopardy.

But it's the foreground that is marketed. And if a patient never needs any of the real hospital safeguards, then she and her husband come away with a very nice experience in the birth of their child. Hopefully, they will never know what emergency preparedness lurked in the shadows, waiting to spring into action should the need have arisen. And if Dad wants to cut the cord, that's O.K. If Mom wants to listen to New Age music during her pushing, it's not medically risky. Hopefully, all that the expectant parents need to know is that the working end of the hospital is there immediately when needed; and that their obstetrician will judge what is medically necessary. All of the rest should be up to the patient and her husband. After all, it's their experience.

If there are little extras the couple wants and that are important to them and these extras pose no medical hazards, then we as obstetricians should be happy to comply. After all, I and many other doctors have been there ourselves. We'd want the same consideration. Different techniques of labor--Lamaze, Bradley, and others-- should be welcomed. An epidural anesthetic is also a comforting way to have a baby. All of these varieties shouldn't matter to the doctor or hospital as long as they don't affect the medical outcomes.

The obstetrician should want three things: a good mother, a good baby, and a good experience. And all of the marketing and hoopla have in fact helped for the good experience. The hospital delivers by offering comfortable rooms a woman can labor, deliver, and recover in. Striving for a good mother and a good baby is where the doctor comes in, and backed by the modern hospital, this goal is sought discreetly in the background, with the parents loving, without hindrance, a most important and cherished moment in their lives.

For more information on fetal development check out our pregnancy videos.

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