Expecting Better by Emily Oster

How strongly I recommend this book: 8 / 10

Date read: March 30, 2025

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Summary

As a new dad, I found this book incredibly useful. There are so many variables when it comes to being a new parent, and this book provides a fantastic, evidence-based approach to navigating it all. I love the structure; it’s clearly laid out and very easy to read through. My wife and I implemented many of the tips, and they really helped us prepare during the nine months of pregnancy, as well as in the months before and after. I’ve also read her follow-up book, Cribsheet, and I highly recommend this book for any new parent.

Favorite Quotes and Chapter Notes

I went through my notes and captured key quotes from all chapters below.

P.S. – Highly recommend Readwise if you want to get the most out of your reading.

Highlights and Notes

Introduction

• Pregnancy seemed to be treated as a one- size- fits- all affair. The way I was used to making decisions— thinking about my personal preferences, combined with the data— was barely used at all. This was frustrating enough. Making it worse, the recommendations I read in books or heard from friends often contradicted what I heard from my doctor.

• And they found that, in fact, television has no impact on children’s test scores. Zero. Zilch. It’s very precise, which is a statistical way of saying they are actually quite sure that it doesn’t matter. All that research in public health about the dangers of SpongeBob? Wrong. It seems very likely that the reason SpongeBob gets a bad rap is that the kinds of parents who let their kids watch a lot of television are different. Correlation, yes. Causation, no. Pregnancy, like SpongeBob, suffers from a lot of misinformation.

PART 1: In the Beginning: Conception

• Researchers in France studied a group of around 2,000 women who were undergoing insemination with donor sperm. One nice aspect of this study is that they didn’t have to worry that older people had sex less frequently because everyone in the study was trying to get knocked up at the right time of the month in a controlled environment. After 12 cycles, the pregnancy rate was around 75 percent for women under 30, 62 percent for women 31 to 35, and 54 percent for women over 35. In this oldest group things were similar for women 36 to 40 and over 40. More than half of the over- 40 women in the sample got pregnant within a year.

• Obese women have more pregnancy complications, as the graph on the next page illustrates. One example: 23 percent of normal- weight women have a C- section, versus almost 40 percent of obese women. The risk of preeclampsia, a serious pregnancy complication, is more than three times as high if you are obese.

• But, in fact, the majority of the time it is not possible to get pregnant. The key issue is timing: you need sperm to be around at the exact moment that the egg is ready. When is that? The average woman has a menstrual cycle of 28 days, counting from the beginning of one period to the beginning of the next. The first day of your period is considered day 1. The week of your period and the week after it are preparation for ovulation. About 14 days after your period starts the egg is released(this is ovulation) and begins to travel down toward the uterus. The egg is available for fertilization during this journey, which lasts a couple of days. If the egg meets a sperm on its way to the uterus and the sperm gets lucky, fertilization occurs. If you happen to release two eggs and they both meet sperm, you get twins; twins can also happen if the fertilized egg divides right at the beginning. When the fertilized egg(or eggs) reaches the uterus, implantation occurs and pregnancy actually begins. The process from egg release to implantation lasts 6 to 12 days. For most successful pregnancies, implantation occurs 22 to 24 days after the first day of your last period.

• The key to pregnancy is that when the egg starts making its way down the tube, the sperm has to be waiting for it. This means the best time for sex or insemination is the day before or the day of ovulation. It takes some time for sperm to swim into the fallopian tubes, so the day after ovulation is generally too late. Sperm are, however, a bit more robust than the egg. They can typically live up to 5 days in the fallopian tube, waiting. This means the window is actually a bit longer. Sex 4 or 5 days before ovulation can lead to a baby, although it’s less likely.

• For most of the month, pregnancy is impossible(at least based on these data). No one conceived by having sex after ovulation— by the time the sperm gets up into the fallopian tubes, the egg is long gone. In addition, no one conceived by having sex more than 5 days before ovulation. The window of possible conception is short: from 5 days before ovulation through the day of ovulation. But note that if you time it right, the chances of pregnancy are good. Conception rates are more than 30 percent for the day before and the day of ovulation! These odds are really not bad. If you had to pick just one day in the month for sex, you’d want to pick the day you ovulate(or the day before: the pregnancy rates are similar).

• In other words, there seems to be no benefit to alternating sex days, having sex more frequently, or having sex less frequently. The crucial thing is to hit the day of ovulation or the day before.

• Researchers in the United States studying women who had gone off the pill in the last 3 months found they had longer cycles(by a couple of days), more variable cycle length, and later ovulation in some cycles than those who had been off the pill longer. 5 In addition, when researchers measured their cervical mucus, the women who had been off the pill longer had cervical mucus that was more“welcoming” to the sperm. The very good news, however, is that these effects are relatively short- lived. In the German study, virtually everyone had a normal cycle by 9 months after going off the pill. For some women it is much faster: 60 percent of women in that study had a normal cycle the first month off the pill.

• Timing matters! Pregnancy rates are high if you have sex on the day of ovulation or the day before, but fall rapidly away from that. It’s possible to get pregnant by having sex as many as 5 days before you ovulate, but it’s a lot less likely. After you ovulate, forget it until next month(you can still have sex, you know, for fun).

• It can take up to 9 months to resume your normal menstrual cycle after going off the pill, but there are no long- term effects on fertility.

• Low- tech ways of detecting ovulation(temperature charting, cervical mucus) are informative, but not 100 percent accurate.• Higher- tech methods, such as ovulation pee sticks, are pricier but very accurate.

• It is worth noting that false negatives(that is, tests that say you are not pregnant but you actually are) are possible, especially if you are testing very early. Even the marketing materials for the most sensitive tests suggest that only about half of pregnancies are detected four days prior to a missed period. False positives, however, are very rare. If there are two lines, even if the second one is faint, you are pregnant.

• These researchers found that almost a quarter(22 percent) of pregnancies ended in miscarriage before pregnancy would have been detected using methods that were standard at the time.

• In addition, these early pregnancy losses, far from being harbingers of future fertility problems, actually are a good sign about fertility. In the same study, 95 percent of women who had a very early loss went on to have a recognized pregnancy. This was higher than for women who didn’t have an early pregnancy loss. Given this, it’s worth thinking about whether those expensive early pregnancy tests are really worth it. You might be the kind of person who wants to know everything that is going on. But you also might rather wait and see.

• Very bad behavior during the 2- week wait could affect your chance of conception, but won’t affect the baby if you do conceive.

• Early pregnancy tests can detect a pregnancy 4 or even 5 days before your missed period, but pregnancy loss is common in this period.

PART 2: The First Trimester

• For alcohol, this means up to 1 drink a day in the second and third trimesters, and a couple of drinks a week in the first. In fact, for the most part studies fail to show negative effects on babies even at levels higher than this. By a drink here I mean a standard drink— 4 ounces of wine, 1 ounce of hard liquor, 12 ounces of beer. No yard- long margaritas! Caffeine is actually a little more complicated. I ultimately concluded that 3 to 4 8- ounce cups of coffee per day(more than many people drink, although actually not more than I drink) are fine.

• Although I will immediately contradict myself and make one recommendation(and back it up with evidence): do not smoke. This is the official line, and the data are squarely behind it. Smoking puts both you and your baby at risk.

• When you drink, alcohol enters your digestive system and is passed into your bloodstream. Your liver processes the alcohol into a chemical called acetaldehyde and then into acetate. The acetaldehyde is toxic to other cells, and depending on how quickly you drink, it can remain in your bloodstream. You share your blood with your baby through the placenta; acetaldehyde, which remains in your bloodstream, is therefore shared with the fetus. Your baby actually can process some alcohol, but not as much as an adult(obviously). If too much acetaldehyde is passed to the baby, it can get into his tissues and impact development. When you drink slowly, you metabolize much of the alcohol before it would get to the fetus. If you drink quickly, your liver cannot keep up and toxins are passed to the fetus. This is why binge drinking is so bad, but it also illustrates why negative effects of light drinking do not follow directly from negative effects of heavy drinking.

• The bottom line is that the evidence overwhelmingly shows that light drinking is fine. In fact, there is virtually no evidence that drinking a glass of wine a day has negative impacts on pregnancy or child outcomes. Of course, this is a little sensitive to timing— 7 drinks a week does not mean 7 shots of vodka in an hour on a Saturday night. Both the data and the science suggest that speed of drinking, and whether you are eating at the same time, matters. It’s not that complicated: drink like a European adult, not like a fraternity brother.

• We know that nausea is a sign of a healthy pregnancy. At the same time, it also causes women to avoid coffee. But this means that women who drink a lot of coffee are probably those who are not experiencing nausea. These women are more likely to miscarry. But you might be wrong to conclude that coffee causes miscarriage; it may well be that lack of nausea causes both miscarriage and coffee drinking. This problem is pervasive throughout the studies we talk about here. Researchers try to“adjust” for this— asking women whether they experienced any nausea, for example— but this is hard to do. Nausea isn’t a yes- or- no thing— some people are a little nauseated and some are a lot. The more sick you are, the better the sign about the pregnancy. Really, fully adjusting for this is basically impossible.

• I also found one clever study that showed that decaffeinated coffee was as strongly linked to miscarriage as caffeinated coffee. Decaf coffee has the same nausea problem, but no caffeine. If the real problem was caffeine, why would decaf coffee matter? It didn’t prove the case, but it was pretty suggestive.

• The Bottom Line• In moderation, coffee is fine.• All evidence supports having up to 2 cups.• Much of the evidence supports having 3 to 4 cups.• Evidence on more than 4 cups a day is mixed; some links are seen with miscarriage, but it is possible that they are all due to the effects of nausea.

• turns out that it is not just Mom’s smoking that matters. Secondhand smoke exposure(for example, from fathers or grandparents) also leads to many of the same negative outcomes. A 2010 review article found that babies of mothers who were exposed to secondhand smoke during pregnancy were about 2 ounces lighter at birth than babies who were not. 35 It’s worth saying that the women in these studies were exposed to a lot of smoke, like the amount that would come from living with a husband who smokes. Very occasional contact(a night in a restaurant with smokers, or walking by someone smoking on the street) is not a big deal.

• There’s no evidence that smoking before pregnancy creates problems. Even quitting partway through is better than continuing. 38 A final note: the best option is to quit smoking cold turkey as soon as you find out you are pregnant, or, ideally, before.

• In my seventh week I went to the doctor(already my third visit) for an early ultrasound. Early ultrasounds like this can be used for very accurate pregnancy dating. Because the fetal growth is so fast early on in pregnancy, a good ultrasound can detect the difference between a pregnancy that is, for example, 6 weeks and 4 days along versus 6 weeks and 6 days. If things are developing normally, this ultrasound can be pretty amazing. You will almost certainly see some evidence of a baby by this point— an actual embryo, or at least evidence that the egg is implanted. If you are far enough along, you may actually hear(or, more likely,“see”) evidence of a heartbeat on the ultrasound.

• study in England showed that the chance of first- trimester miscarriage was around 4 to 5 percent for first pregnancies or women with a previous successful pregnancy. But for those with a previous miscarriage, it was around 25 percent. 2 This may seem scary, but it is important to remember that most women who miscarry— the vast majority— go on to have successful pregnancies.

• You might wonder if there is something you can do(other than getting pregnant at 20 rather than at 35!). The answer is probably not. As most pregnancy losses at this point are due to chromosomal problems and those are determined at fertilization, it is out of your control. 6 For a small number of women, low levels of progesterone may contribute to early miscarriage; this can sometimes be corrected with a progesterone supplement. How important this is and the right solution are of some debate in the medical literature. If you have had several miscarriages, it is something your doctor might consider.

• Around 10 to 15 percent of pregnancies that are developing normally at 6 weeks will end in miscarriage. This rate declines quickly over the first trimester, and falls to around 1 to 2 percent by 11 or 12 weeks.• Older age and previous miscarriage increase your risk.

• The vast majority of pregnancy food restrictions arise from concerns about food contamination. If you undercook a burger, and the meat comes from a meat processing plant that is also home to a bacteria like E. coli, you will very likely be sorry the next day. If you use a raw egg in your Caesar dressing and the chicken that laid it had salmonella, you’re exposed to the bacteria and run the risk of illness. I will stop here, but I’ll say that I don’t recommend immersing yourself in food safety issues unless you want to spend a week as a paranoid germaphobe.

• Pregnancy Off- limits Food List• Raw eggs(salmonella)• Raw fish(salmonella, campylobacter)• Raw shellfish(salmonella, campylobacter, toxoplasmosis)• Unwashed vegetables and fruits(toxoplasmosis, E. coli)• Raw/ rare meat and poultry(salmonella, toxoplasmosis, campylobacter, E. coli)• Smoked fish(Listeria)• Pâté(Listeria)• Unpasteurized(raw) milk(Listeria, campylobacter)• Raw milk soft cheese(Listeria)• Deli meats(Listeria)

• Toxoplasmosis: Harmful but largely avoidable. If you have heard of this in the context of pregnancy, it was almost certainly related to cat litter, not food. Toxoplasmosis is caused by a parasite— toxoplasma gondii— and concerns about this parasite are the reason pregnant women are told to avoid cleaning the litter box. However, you are quite a bit more likely to get this from raw meat or unwashed vegetables than from cat litter

• Listeria: Harmful and hard to avoid. Listeria in pregnancy is very dangerous. Listeria infection begins with standard stomach- flu symptoms but typically gets worse, including chills and muscle aches. It can be fatal even in healthy adults, and pregnant women are much more susceptible: up to a third of all Listeria infections are in pregnant women. Thankfully, Listeria is not that common: about one in eight thousand pregnancies a year are affected.

• One general rule: Listeria grows well at refrigerator temperatures, so any food that has been sitting around a long time in the fridge should probably be avoided. Ultimately, this is something you need to decide for yourself. The question is not whether Listeria infection is scary: it is. The question is what decisions you can make to avoid it. It would be difficult or impossible to avoid all foods that have caused a Listeria outbreak— not just deli turkey, but cantaloupes, sprouts, celery, taco salad, grilled chicken, and on and on. Even if you did avoid all these foods, Listeria could well show up in apples next, or pork chops. There’s just no way to know. The link with Mexican- style cheese seems especially strong to me, and I avoided it

• I also mostly avoided turkey, although I didn’t extend the restriction to other deli meats. It seemed unfair to tar them with the same brush. My best estimate, based on the data, was that avoiding ham sandwiches would have lowered my risk of Listeria infection from 1 in 8,333 to 1 in 8,255. Would you want to do this? Maybe. Someone certainly could make a case for doing so. However, this change is really, really small. For me, it wasn’t worth it.

• Oster Updated Off- limits Food List• Raw/ rare meat and poultry(toxoplasmosis)• Unwashed vegetables and fruits(toxoplasmosis)• Queso fresco and other raw- milk cheeses(Listeria)• Deli turkey(Listeria)

• Don’t worry too much about sushi and raw eggs— they might carry bacteria, but these bacteria are no worse when you are pregnant than when you are not.

• Toxoplasmosis infection during pregnancy can be damaging to your baby. The risks are small, and you can cut your risk in half by thoroughly washing your vegetables and by not eating raw or rare meat.

• The most dangerous food- borne bacteria is Listeria. Unfortunately, a lot of sources of outbreaks are random: cantaloupes, celery, sprouts. Avoiding Listeria is very desirable, but may be difficult due to the random nature of the outbreaks. Based on past outbreaks, you would do well to avoid queso fresco and, probably, turkey sandwiches.

• The CDC has a very helpful general source for information about food outbreaks: https://www.cdc.gov/foodborneburden/index.html. If there is another cantaloupe- related outbreak, you’ll probably hear about it there first!• If you do get sick, call your doctor.

• Why are only large fish a problem? Two reasons. First, big fish eat little fish, and mercury gets concentrated as you move up the food chain. Little fish absorb mercury only from seawater, and therefore typically have low levels of it. Big fish absorb more mercury from the little fish they eat. The bigger the fish, the higher the level of mercury(on average). The second reason is longevity. Bigger fish typically live longer, and the longer they live, the more time they have to accumulate mercury. Sharks can live to be very old, and are therefore chock- full of mercury. The main concern with eating high- mercury fish is the possible impact on your fetus’s developing brain. Mercury is poisonous, and in high doses can cause neurologic damage even in children and adults. For a fetus, even a small dose may matter.

• Averaging across a few studies, researchers found that a 1 microgram/ gram increase in mercury level led to a decrease of 0.7 IQ points. This effect is fairly small, at least relative to normal mercury levels in the United States. The difference in mercury levels between the average American woman and the most mercury- exposed woman is enough to produce a 3.5- IQ- point difference in their children. Or think about it like this: if you start at the average mercury level and manage to somehow drop your exposure level to zero, this would buy your child, on average, about 1 IQ point.

• Fish— specifically, fish oils— contain very high rates of omega- 3 fatty acids. These are great for your baby. In particular, they are great for brain development, exactly the thing that mercury is bad for. Published right alongside that study of mercury was a similar study of omega- 3 fatty acids, sometimes called DHA. Using evidence from randomized controlled trials of various types of DHA supplementation, the same researchers concluded that increasing your DHA intake by 1 gram per day would increase your child’s IQ by, on average, 1.3 points.

• Several studies have demonstrated that women who consume more fish tend to have children with higher IQs. 10, 11 This means that even with prenatal vitamins and other supplements, more fish is at least correlated with smarter kids.

• The fish in the top right quadrant are the best: these are fish that are high in omega- 3s but low in mercury, such as herring and sardines(small, oily fish) and salmon. Eating more of these fish can be nothing but good. Three ounces of sardines a day would have a huge impact on your omega- 3 intake, but virtually no effect on mercury level.

• The Bottom Line• Mercury is bad for your baby. Omega- 3 fatty acids are good for your baby. Fish contain both. Your best option is to try to pick fish with a lot of omega- 3s and not a lot of mercury.• The worst thing you can take from the mercury advice is the idea that you should avoid fish. Fish are great! People who eat a lot of fish have smarter kids on average, even with the greater mercury exposure. Try to pick smart, and learn to love sardines!

• Almost 90 percent of women report some symptoms of nausea and more than half report some vomiting as well. 1 This tends to peak at around 8 or 9 weeks of pregnancy and fall off after that.

• If you’ve been very sick for the first few weeks, you shouldn’t expect to feel great as soon as you hit week 13 or 14, although things should be gradually improving at that point.

• To answer this, we can get a little more detailed. In one study of 2,500 women, at the worst point in her pregnancy, the average person was throwing up at least once a day, and about 13 percent of them were throwing up at least 3 times a day. 3 And as for the name“morning” sickness, it’s a serious misnomer: in another study with detailed data of the timing of nausea over the course of the day, more than 80 percent of the women reported that they felt sick all day, not just in the morning. 4 But the number of days of actual vomiting for women in these studies was actually small: only an average of 6 bad days over the course of the pregnancy.

• you are throwing up every day for a month, that is unusual: in these studies, only about 5 percent of women report nausea that severe.

• Good news here: if you eventually gain an appropriate amount of weight after the nausea resolves, there do not seem to be adverse effects on baby size.

• As unpleasant as it is, nausea is a sign of a healthy pregnancy. Miscarriage rates are much lower for women who are nauseated than for those who are not. In early pregnancy the differences can be quite large: one study showed that the overall risk of first- trimester miscarriage was 30 percent for women without nausea, versus just 8 percent for those who were nauseated.

• Usually the first step is the simple stuff you are doing anyway: eat only what you can tolerate and don’t eat much at once, have some crackers before you get out of bed, and so on.

• One thing that does seem to work is vitamin B6: randomized trials suggest a reduction in nausea from relatively high doses. B6 is safe; it’s actually found in your prenatal vitamins, although at doses lower than you’d need to combat sickness. In the trials, it seemed to be most effective against mild nausea and had no impact on actual vomiting.

• In 1983, Bendectin was taken off the market in the United States. To understand why, we need to understand that some babies are born with birth defects even if their mothers take no drugs during pregnancy and do everything perfectly. There is just some baseline risk of birth defects in the population. Bendectin was prescribed to many, many women. And some of their babies had birth defects. Perhaps because of the thalidomide experience in the 1950s, some women who took Bendectin and had babies with birth defects found their way to lawyers. In the early 1980s, those lawyers brought a suit against the makers of Bendectin, claiming that the drug caused the birth defects. The makers of the drug, facing millions of dollars in legal fees even if they ultimately won the suit, pulled the drug from the market. This actually gives us another source of information on the effectiveness of the drug, and supports it. When it was pulled from the market, hospitalizations for severe nausea doubled. 12 The FDA was naturally worried. They had approved the drug in the first place; had they made a mistake? As it turns out, no. In response to the lawsuit, several papers collated the studies on Bendectin. A 1994 review included twenty- seven studies comparing women who did and did not take Bendectin. 13 They found that women who had exposure to Bendectin in the first trimester had children with slightly fewer birth defects, and statistically, they couldn’t prove that there was any difference between the two groups. In light of this extremely reassuring evidence, the drug retained its FDA approval in the United States. However, the threat of lawsuits loomed, and Bendectin never came back on the market in the United States. This is particularly ridiculous because the drug is actually just a combination of two over the counter items— vitamin B6 and Unisom— both of which are considered safe in pregnancy. In the absence of a single pill solution, doctors and women have made use of this“roll- your- own” Bendectin option for years.

• Sure, it’s possible that your doctor will be reluctant to prescribe you medication, or may first suggest you try eating smaller meals. But it increasingly seems to me that it’s the women who are reluctant to ask, who think they should suffer in silence. That’s not always a great idea: serious dehydration and weight loss during pregnancy can lead to complications. Why risk it when there are good, safe treatment options?

• Treatment(in order):(1) small meals,(2) vitamin B6 + ginger ale,(3) Vitamin B6 + Unisom(or Diclegis, with a prescription),(4) Zofran.

• The goal of all prenatal screening and testing is the same: to learn whether your baby has a chromosomal abnormality. Human DNA has twenty- three pairs of chromosomes. The vast majority of chromosomal problems are caused by having three copies of a chromosome rather than the normal amount of just two. For most of the chromosomes, a fetus with three copies will not survive— you’ll have an early miscarriage, or you’ll never know you were pregnant at all. In a few cases, however, survival is possible or likely. By far, the most common of these is Down syndrome, which is caused by having three copies of chromosome 21. Down syndrome is characterized by some degree of mental retardation and distinctive facial features, among other things. The two other common ones are Edwards syndrome(three copies of chromosome 18) and Patau syndrome(three copies of chromosome 13). These are more severe than Down syndrome; babies born with these conditions rarely survive their first year.

• The risk to your baby of any of these conditions depends on your age. I’ve included a quick reference table, along with some comparisons to probabilities you might be more familiar with. 1 I was 31 when Penelope was born. This put my risk around 1 in 700. This means that of 700 women my age who get pregnant, on average 1 of them will carry a baby with Down syndrome. By the time my son, Finn, was born I was thirty- five. That put my risk up to 1 in 374.

• It has been known for decades that some fetal cells circulate in the maternal blood stream during pregnancy. If it were possible to isolate those cells— to separate them from Mom’s— this would enable fetal genetic sequencing without any invasive testing. The key to the accuracy of amniocentesis or CVS testing is that these procedures access and test actual fetal cells. If that were possible without invasive testing, it would deliver the best of both worlds. Progress in this area was, however, impeded by the fact that the concentration of fetal cells in maternal blood is extremely low. This made it difficult or impossible to get enough blood to isolate a sufficient concentration of fetal cells. In the late 1990s, however, researchers discovered that cell- free fetal DNA— fetal DNA that exists outside of cells— mixes at much higher concentrations with maternal cell- free DNA. When cell- free DNA is isolated in maternal plasma, 10 to 20 percent of it is fetal in origin. 3 This higher concentration has made it possible to improve prenatal screening. In principle, if it were possible to simply separate the maternal and fetal DNA, it would be possible to sequence the full fetal DNA using this procedure. The technology is still not quite there on that— although it is improving. Instead, this procedure works by looking for things in the cell- free DNA that wouldn’t be there if it were just the mom.

• The cell- free fetal DNA technology described above has become increasingly common, but for many women it will still not be covered by insurance. In my case, it was covered only because by the time I got around to having Finn I was over 35 and, therefore, considered“high risk.” If this is not accessible to you, you are likely to be offered an older technology that involves an ultrasound and a blood test for hormone levels. The most useful measurement taken in these tests is an ultrasound measure of the amount of fluid behind the baby’s neck(called the nuchal translucency, or NT). Fetuses who have Down syndrome are much more likely to have a lot of fluid behind the neck. Doctors also measure two hormones in Mom’s blood(PAPP- A and hCG). Women who are carrying fetuses with Down syndrome also tend to have different hormone levels from those whose babies have normal chromosomes. By comparing your measurements and hormone levels to those of fetuses with and without Down syndrome, your doctor can learn about your baby’s health.

• It is also worth noting that the performance of this test differs significantly by age. Detection rates are much lower for younger women(only about 85 percent for women in their late twenties), and false positive rates are extremely high for older women(close to 50 percent for women in their early forties).* If you do go with this option rather than the newer testing, some doctors will offer further screening in the second trimester, around 15 to 18 weeks of pregnancy.

• Cell- free fetal DNA testing(MaterniT21, Harmony, and others) are very accurate and can detect about 99 percent of Down syndrome cases.• False positives are rare, but they do happen.• If these tests are not available, first- trimester screening with ultrasound and blood tests can detect about 90 percent of Down syndrome cases but with higher false positive rates.

• CVS is performed much earlier in the pregnancy, typically between 10 and 12 weeks, before the end of the first trimester.

• These tests are accurate. Either one will tell you with an extremely high degree of confidence whether or not your baby is healthy. False negatives or false positives are vanishingly rare.

• The most significant risk of these tests is that you accidentally hit the fetus with the needle; a related risk is the needle going through the placenta, which can also cause problems. It used to be that doctors would do an ultrasound before starting and then make a guess about the best way to go in. If the baby moved, they might have guessed wrong. Today, doctors typically watch what they are doing the entire time on the ultrasound. This means there is basically no risk of either hitting the baby or going through the placenta. Adding to those improvements, the quality of ultrasound technology has dramatically increased in the last decades. The better picture makes it easier for the doctor to see what she is doing and lowers the risks. Fortunately, there are some newer studies of amniocentesis. And, not surprisingly, they show much lower risks. One good one is the FASTER trial. 13 This was a study originally designed to evaluate the noninvasive screening options, but some women in the study chose to undergo invasive screening as well.

• Miscarriage rates from both amniocentesis and CVS are small.• A reasonable estimate of procedure- related miscarriage risk from amniocentesis is about 1 in 800, although most studies are not large enough to allow us to reject the claim that there is no increased risk from this procedure.• Most data suggest miscarriage risks from CVS and amniocentesis are indistinguishable, but because CVS has become less common over time, it is important to look for a provider who still does many of these.

• Historically, genetic testing recommendations depended only on age. Women over 35 were offered invasive screening and those under 35 were not. This is based very loosely on comparing probabilities. A woman at age 35 has about a 1 in 200 risk of conceiving a baby with any chromosomal problem. The(historical) estimate of the risk of miscarriage from an amniocentesis was 1 in 200. So someone decided the right way to make this decision was to compare probabilities. Over 35, the risk of a chromosomal problem is higher than the risk of miscarriage, so you should test. Under 35, the miscarriage risk is higher, so you should not. From a decision perspective— heck, from a basic logic perspective— this is insane. One reason, of course, is that those risks are all wrong. The invasive- testing risks are currently a lot less than 1 in 200. With the noninvasive- screening option people can learn a lot more about their risk than is possible just based on age. So neither side of this“equation” is correct.

• Let’s say you are 31 and you undergo the cell- free fetal DNA screening. With a good result on this, the baby’s risk of having Down syndrome is around 1 in 100,000. The risk of miscarriage from the amniocentesis or CVS test is around 1 in 800. What you need to decide for yourself is whether having a baby with Down syndrome unexpectedly would be more than 125 times worse than having a miscarriage(that is, 100,000 divided by 800). If yes, then skip right to the invasive test— probably CVS given the timing. If no, then stick with the noninvasive screen. Of course, it’s not easy to answer this question, but it is the question you need to answer.

• Jesse and I spent a lot of time on this question(some of it even in person, not over e- mail). With Penelope, I ultimately decided to undergo the ultrasound screening and skip the invasive testing. The test went well, we stopped there, and Penelope was born healthy. In the end, I am not sure this was the right choice from a decision standpoint, and at some point later in the pregnancy I panicked that we should have done more accurate testing. When I got pregnant with Finn I was sure the CVS testing was the right thing to do— I knew I had to know for sure with this pregnancy. In the language of the decision- theory above, relative to when I was expecting Penelope, our preferences had changed. The risk of a miscarriage seemed less important now that we already had one child. And the costs associated with a special- needs child seemed much higher. But, in the end, the genetic counselor convinced me that the risks of CVS might have increased a lot given that they were so rarely performed. She pointed out that the cell- free fetal DNA testing was excellent— with a good test result, my risk was more like 1 in 35,000— and suggested this should be enough. We thought long and hard about it but decided— and I emphasize that this is a pretty unusual decision— that it still wasn’t enough for us given our preferences. In the end, I followed up the cell- free testing with an amniocentesis in the second trimester. We reasoned this was very low risk, and if we did it early there was still time to consider our options in the very unlikely event that the results showed something different from the cell- free testing. This worked well for us, although the genetic counselor(and my mother) thought it was very unusual. That’s the thing about preferences, though: not everyone has the same ones.

• The worry about cat litter is toxoplasmosis. If that sounds familiar, it should: it comes up in the context of food restrictions, as the most common source of toxoplasmosis is uncooked meat. Recalling the discussion there: if you have been exposed to toxoplasmosis before pregnancy, there is no cause for concern, but if you are exposed for the first time during pregnancy, it can be dangerous for the baby, causing low IQ, vision problems, or death. Although uncooked meat is the primary source of toxoplasmosis, it is also possible to get it from cat feces. If your cat has been eating uncooked meat, that is.

• One question you might be asking yourself: What about really hot days? Is that the same thing? I wasn’t able to unearth any studies about hot days and birth defects, but there is some evidence from Spain on the effect of heat on birth. The authors found that very hot days seemed to prompt women to go into labor earlier(by about 5 days).

• Two warnings, though. The cervix is a bit more sensitive during pregnancy, and if your partner hits it during intercourse you might bleed a bit; this is normal and not something to worry about at all. Second, as you get into later pregnancy, the good old missionary position isn’t going to work as well. Creativity will be necessary!

• In general, there is a recommended limit on radiation exposure over the course of your pregnancy(technically, it’s 1 mSv, but that probably has no more meaning for you than it does for me).

• Unless you travel very frequently you are unlikely to reach even the most conservative limit for radiation exposure. One flight from Chicago to Boston would deliver about 1 percent of the limit. Long- haul international flights are worse: the longest available flight delivers about 15 percent of the limit. This might seem like a lot(if you take more than three round trips from New York to Tokyo you’re over the limit), but it is worth noting that this is less than 1 percent of the level at which there is any actual demonstrated risk of birth defects or miscarriage. 11 Consistent with this, at least one study that compared infant outcomes for women who did and did not fly during their pregnancies found no difference in preterm birth, fetal loss, or neonatal intensive care unit(NICU) admission.

• In practice, at least for the moment, most airports have normal metal detectors as well as the full body scan, and pregnant women are generally pointed toward the non- X- ray option. If you are worried, you can always opt for the pat down. It’s not enjoyable, but it is radiation- free.

• The Bottom Line• Changing the cat litter is fine(make sure you wash your hands after)…•… but gardening is associated with an increased risk of toxoplasmosis. It should be avoided.• Dye away! Concerns about hair dye are overblown.• Getting too hot during your first trimester— be it from a fever, a hot tub, or some type of superhot yoga— can lead to an increased risk of neural tube defects like spina bifida.• Some airplane travel is completely fine. If you work on an airplane you might consider a modified schedule.

PART 3: The Second Trimester

• Impacts of weight gain on child weight later are extremely small if they are there at all.

• On average, the complications associated with a very small baby are much more serious than those associated with a very large baby. If you had to choose, most women would prefer to face the increased risk of a C- section rather than an increased risk of breathing problems or neurological complications for their baby. On its own, this probably means that you should be more concerned about gaining too little weight than too much weight.

• The Bottom Line on Weight• On average, if you gain more weight, your baby will be larger. If you gain less weight, your baby will be smaller.• Both very large and very small babies face additional risks, although too- small babies face greater risks. If anything, you should probably be more concerned about gaining too little weight than too much.• But, mostly, chill out.

• If you do a CVS test in the first trimester(or an amniocentesis later), you can learn the baby’s sex at that point. Because chromosomes differ for boys and girls(an XY for a boy versus two Xs for a girl), this is part of the genetic mapping. If you forgo this test you can still learn your baby’s sex on an ultrasound. For many people(us included) this happened around 20 weeks. It’s at this point that many doctors will do a“midtrimester” ultrasound. The baby is sufficiently developed at this point that you can look at all kinds of things— how well the blood is flowing through the heart, the number of fingers and toes, location of organs, and so on— and, of course, genitals. Although the 20- week ultrasound is common, it’s actually possible to see fetal sex on an ultrasound as early as 12 weeks, especially if it is a boy.

• The Bottom Line• If you want to learn your baby’s sex before birth, you can do so through CVS, amniocentesis, or ultrasound.• There’s no affirmative evidence that fetal heart rate or other old wives’ tales do a good job of predicting gender.• You cannot increase your chances of a particular gender by changing the timing of sex before conception.

• So there is no reason not to start even before you are pregnant, although these studies show you can get the benefits of the exercise even if you start midway through the pregnancy. This study shows results similar to a number of others. A review article from 2009 suggests that women who are encouraged to do these exercises are less than half as likely as control women to experience any urinary incontinence during late pregnancy or in the postpartum period. 7 This is especially true for women having their first baby. And there might be more: at least one small randomized study8 focused on the birth experience of women encouraged to do Kegels and those who were not. Women in the Kegels group spent a slightly shorter time pushing(40 minutes versus 45 minutes, on average), and only 22 percent of the Kegels group pushed for more than an hour, versus 37 percent of the no- Kegels group.

• The Bottom Line• General exercise during pregnancy is fine. Not exercising during pregnancy is also fine. By and large, you should feel comfortable continuing to do what you are already doing.• Kegels prevent urinary incontinence and quite possibly improve your pushing ability in labor. Do them.• Prenatal yoga is definitely worth trying. Although the studies are not large, they do show some large effects. If nothing else, perhaps you will improve your self- actualization.

• Sleep Position: You’re not supposed to sleep on your back. The theory is that as the uterus gets larger(beyond 20 weeks or so), it can compress an important blood vessel. This decreases Mom’s blood pressure, and can reduce blood flow to the placenta and the baby. That this occurs is something we know from physiology. What is the more relevant question for you is whether there is any evidence that this actually has risks for the baby. If you wake up on your back, should you worry? As it turns out, very likely not.

• The Bottom Line• Unisom is safe to take. Ambien is also probably safe, but the evidence is a bit more mixed.• Most evidence suggests that restrictions on back sleeping are overblown, although one recent study disagrees. Concrete guidance is limited.

• When I looked a bit further, it seemed that basically everything was Category C in the United States(it turns out to be about 70 percent), meaning the FDA’s attitude toward most drugs is equivocal. Further, the drugs that the FDA recommends avoiding aren’t always the ones you’d expect. My intuition was that the stronger the drug, the more dangerous it would be for the fetus. But there are strong recommendations against taking Advil, and much less strong ones about Vicodin. Of course, ideally you would never have to take any drugs during your pregnancy, but for most of us this is not realistic. For one thing, if you have something like a kidney infection, it’s actually quite dangerous to leave it untreated. Even in cases where a drug might seem optional— back pain, chronic migraines, or even antidepressants— not taking medication can cause its own problems. Before making a choice one way or the other, it’s important to understand a bit more about the possible downsides.

• Your baby develops in your uterus and is connected to you through the placenta. The placenta is actually an incredibly unusual organ, which scientists are still working to fully understand. Among its neat properties is that it contains both Mom’s and baby’s blood and manages to keep them separate while at the same time transferring nutrients from Mom to baby and waste products from baby back out to Mom(for disposal). Not too long ago doctors thought the placenta was an impenetrable barrier. It didn’t matter what drugs or other substances pregnant women ingested, because nothing could affect the baby. One does wonder how, under this theory, the baby got any nourishment! We now understand that this is very wrong. Pretty much whatever drug you are taking— over the counter, prescription, or illegal— the baby is getting exposed to it. Most drugs pass through by a process called passive diffusion, a fancy way of saying they just kind of soak through. If a drug doesn’t get through the placenta, and therefore doesn’t get to the baby, we can pretty much rule out the possibility that it’s a problem. There are two types of drugs that either do not soak through or do so at only very minimal amounts: drugs that are too“large” and drugs that the placenta stores or processes. Drugs with really big molecules do not pass through the placenta to the fetus. An example of this is heparin, a blood thinner. The heparin drug molecule is just so large and heavy that it literally cannot“fit” through the placenta. Think of the placenta as a sieve and heparin as a slightly- too- large piece of sand.

• Historically, the FDA splits the drugs pregnant women might take into five categories: A, B, C, D, and X. Category A drugs are the safest, and Category X drugs are the most dangerous.

• Categories A, B, and C are all drugs for which there is no strong evidence of harm to human babies. The difference is in the quality of the evidence in people and the results of experiments in animals. Categories D and X are drugs that are contraindicated in pregnant women because studies have shown evidence of harm to babies from taking them. Category D includes drugs for which, although there is evidence of harm to babies, there might be a case for taking them, depending on the benefit to the mother. Class X drugs are those that absolutely should not be taken during pregnancy under any circumstances.

• Category A:“Adequate, well- controlled studies in pregnant women have failed to demonstrate a risk to the fetus in any trimester of pregnancy.” It was almost impossible to find an example of a Category A drug. The FDA obviously has a very high(read: insane) standard for a well- controlled study. Most of the vitamins in my prenatal vitamins are not even Category A! The one example I could find was folic acid. The safety of folic acid has been supported in a large number of randomized studies of folic acid supplementation. But more than this, folic acid actually prevents birth defects.

• A review article published in 2010 summarized the evidence on this from randomized trials: women who took folic acid supplements were about 70 percent less likely to have a child with a neural tube birth defect(like spina bifida). 2 It may not only be birth defects: a large recent study in Norway suggested women who took folic acid before conception and during early pregnancy had children with much lower rates of autism. 3 In other words, this is not just safe, it’s very highly recommended.

• most of the things in your prenatal vitamins are Category B: many millions of women have taken them for years and there is no evidence of adverse effects. However, as there are no randomized trials(because randomly taking away prenatal vitamins would be unethical), these substances cannot technically be in the Category A bucket. Other than prenatal vitamins, probably the most common Category B drug is Tylenol(or, more accurately, the active ingredient, acetaminophen). This is the most commonly used pain reliever during pregnancy; it seems likely that the majority of pregnant woman take it at some point.

• In layman’s terms, drugs are characterized as Category C if there is no actual evidence of risk, but there is also no large- scale human data. This includes drugs where there is evidence of harm in animal studies, and those with no animal studies. It includes drugs with some small human studies, and those with no human studies. One drug could have some small studies in people that show that things are fine, and also some nonrandomized studies in animals that show that things are fine. A second drug could have no human studies and animal studies that have shown fetal damage. And they’d both be in Category C! When I had my UTI, I couldn’t figure out where Cipro fell in the Category C spectrum. It’s an important difference: evidence of harm versus no evidence at all. People smarter than me have noticed that Category C is less helpful than it might be, and there has been some push for the FDA to change this categorization. But for now, this is what we are stuck with. If your doctor wants to prescribe you a Category C drug, you have to push her on the evidence quality or look it up yourself. One Category C drug frequently prescribed during pregnancy is hydrocodone, the active ingredient in both Vicodin and Norco. You’ll probably get these prescribed if Tylenol isn’t a significant enough painkiller.

• Nevertheless, this provides new evidence on the(possible) dangers of hydrocodone, evidence that will eventually be incorporated into the FDA classification system(my guess is that hydrocodone will stay Category C until more evidence comes in one way or the other). This is part of what is tricky about Category C: as the evidence evolves, drugs might seem more or less risky but remain in the same class. Given that you are pregnant now, and not sometime in the future, you’ll have to make these decisions as best as you can with limited evidence.

• One caveat to keep in mind: drugs can also be Category X just because they have no purpose during pregnancy. Oral contraceptives are a Category X drug, but not because they are damaging to the baby. 10 This has relevance for a response to accidental exposure. After accidental exposure to Accutane, many women choose to terminate a pregnancy, knowing that the risk of life- threatening birth defects is very high. A similar response to accidental birth control pill exposure is not warranted. Although you should stop taking them after becoming pregnant(what’s the point?), they are not implicated in birth defects.

• The Bottom Line• You should feel comfortable taking anything in pregnancy categories A and B.• You should avoid anything in categories D and X(exceptions would be made for Category D drugs that treat very serious illnesses; this is doctor territory).• For drugs in Category C, try to get a better idea of the safety evidence

PART 4: The Third Trimester

• And, maybe paradoxically, for me this fear was made worse by knowing that by 25 or 26 weeks there is a better than 50 percent chance of survival outside the womb.

• On the other hand, I was also worried about Penelope coming too early. Preterm birth(defined as before 37 weeks) is actually fairly common in the United States, occurring in about 12 percent of pregnancies.

• A premature birth is one that occurs between 22 and 36 weeks of pregnancy. The fact that this starts at 22 weeks is pretty incredible. As late as the 1960s, babies born even a few weeks premature frequently died. Among the most famous examples of this is John F. Kennedy’s son, Patrick, who was born at about 34 ½ weeks, weighing almost 5 pounds, yet died two days later from respiratory disease. At the time, this wasn’t a surprise. How things have changed: in 2005, 98.9 percent of babies born at that gestational age and weight survived their first year.

• Prematurity, especially extreme prematurity, does have some long- term impacts. Babies born prematurely are more likely to get illnesses as children, on average have lower IQs, and often have vision or hearing problems. In one study of 5- year- olds born before 30 weeks of gestation, 75 percent of them had at least one disability(versus 27 percent among children born after 37 weeks). Their IQs were also 5 to 14 points lower, on average. 2 Moderate prematurity(32 to 36 weeks of gestation) also has had an impact on IQ in some studies, but these tend to be smaller and serious disabilities are less common.

• Second, although survival rates are low for babies born early, they are not as low as you might have expected. More than half of babies born at 24 weeks will survive the first year— 24 weeks are just 5 ½ months pregnant. By the time you get to 28 weeks, still only 6 ½ months into pregnancy, the survival rate is almost 95 percent. These statistics have improved a lot even since the early 1980s, when survival at 28 weeks was only about 80 percent.

• What doctors can do is give you one of a set of several tocolytic drugs(a common one is magnesium sulfate). These drugs will lessen contractions and can usually delay birth for a day or two(sometimes longer). What’s the point in delaying just a couple of days? Two things: location and steroids. A hugely important determinant of survival among very preterm infants is the quality of care they receive and the types of interventions that are available to them. This, in turn, depends on the“level” of the NICU in the hospital in which you give birth. NICU levels range from 1(which is basically just a nursery for healthy babies) to 4(the highest level; in some states this is denoted 3C). The most advanced NICUs have the ability to do all types of neonatal surgery. They have ventilators and can often hook babies up to a heart- lung machine, which replicates the function of those two organs while they continue to develop. Very premature babies are unlikely to survive without these interventions. Babies who are born very prematurely in hospitals without these capacities are typically transferred to more advanced hospitals once they are stable, but, if possible, it’s better to be born in one of these in the first place.

• In addition to location, the other intervention that makes a very large difference in survival is administering steroids. Steroid shots given to Mom speed up fetal lung development. 5 Even 24 hours of this treatment can make a huge difference: a recent review of randomized trials shows that steroids resulted in a 30 percent decrease in fetal death. Delaying birth for even a day or two lets doctors administer these drugs for long enough to make a difference. 6 Babies are considered early- term at 37 weeks and full- term at 39 weeks of pregnancy. After 37 weeks most infants do not need any extra care after birth. Of course, the sharp distinction between preterm at 36- 1/ 2 weeks and term at 37 weeks is artificial, and it is better for your baby to be born at 39 or 40 weeks rather than 37. But these differences are all small; infant mortality in the United States for nonpremature babies is just 2 in 1,000 births.

• This wouldn’t be such a big deal, except that bed rest actually has some significant negative consequences. Full bed rest is defined as one to two hours of activity per day, with the rest of the time spent in bed. No work, no running after your toddler, no setting up the baby’s room, no making dinner, no exercise, no nothing. This has serious downsides for the rest of the family, and, for women who work, for their jobs. Studies cite financial strain on families when women are put on bed rest, even if they don’t work, because of the need to get someone else to help around the house. And even if you ignore these factors, there are actually medical risks to bed rest— bone loss, muscle atrophy, weight loss, and, in some studies, decreased infant birth weight. 11 There is some suggestion that it increases the risk of blood clots

• It would seem that this is one of those issues where the conventional recommendation has hung on despite evidence suggesting it’s not just ineffective but damaging. There may be unusual situations in which bed rest is a good idea, but the medical literature hasn’t found any of them. If your doctor suggests it you should almost certainly question her. Does she really think it will help despite all the evidence to the contrary?

• The Bottom Line• Survival outside the womb is possible(although not likely) as early as 22 weeks. Survival dramatically increases with continued gestation after this point. By 28 weeks, more than 90 percent of babies survive, and by 34 weeks it’s 99 percent.• Delaying birth after the onset of labor is difficult, but usually can be done for a few days. Delaying even just a day or two can have large impacts on survival by allowing you to be moved to a more advanced hospital, and giving time for steroid shots to improve the baby’s lung function.• There is no evidence that bed rest will prevent preterm labor. Avoid it.

• You are most likely to have your baby in your 39th week of pregnancy: close to 30 percent of babies are born in this week. The next most common week is week 38(18 percent), followed by the 40th week(17 percent). About 70 percent of babies are born before their due date. This includes all births; first births and those that are not induced tend to be a bit later.

• If you get to your due date without a baby, there is a 60 percent chance you’ll have the baby in the next 7 days. If you haven’t had the baby by 41 weeks, there is about a 60 percent chance you’ll go into labor spontaneously. At 42 weeks the vast majority of doctors will induce labor.

• In practice, although your doctor is more likely to tell you about dilation, cervical length(effacement) is probably a better predictor of labor onset. 3 Your doctor is measuring this at the same time that she is measuring whether you are dilated, so it’s reasonable to ask her about it if she is doing a cervical check. It’s usually reported as a percent(“ You are 50 percent effaced,” for example), which captures how far you have gone between the normal nonpregnant situation(0 percent effaced) and what will happen at delivery(100 percent effaced).

• For women who were more than 60 percent effaced(that means shortened about halfway) at 37 weeks, almost all of them(something like 98 percent) went into labor before their due date. On the other hand, for women who were less than 40 percent effaced, almost none of them(less than 10 percent) went into labor before their due date.

• You may decide(some women do) that you want to skip the cervical checks. Some people figure that the baby is eventually coming out one way or another, so how valuable is this information, anyway? But it can be pretty useful. When my friend Heather was expecting her second baby, her plan was to fly her mother in to take care of baby number one while she and her husband were at the hospital. At 37 weeks she was 1 centimeter dilated and 80 percent effaced. She took a look at this graph, and moved her mother’s flight up by ten days. Not a moment too soon: her mother arrived on a Thursday afternoon, and baby boy followed on Saturday night. Evidence in action!

• A high Bishop score implies that you are further along. It also indicates an increased chance of a vaginal delivery; usually a score of 6 or above is seen as fairly advanced.

• A final note. Both the Bishop score and cervical length alone are very predictive of the outcome of induced labor: the more ready you are, the more likely the induction will lead to a vaginal delivery(versus a C- section). 7 This is another reason to pay attention to them. If you do end up considering a medical induction but you want to avoid a C- section, they can give you a good sense of the risks.

• The Bottom Line• No one has ever been pregnant forever.• The majority of babies arrive within a week on either side of your due date.• Cervical checks are predictive of coming labor(although not perfectly); ask about effacement in addition to dilation to get a more complete picture.

• Medical induction is increasingly routine, but it wasn’t always like this. Not that long ago, doctors were actually somewhat reluctant to induce labor until quite late. In 1990(the first year in which this is recorded in the national data), fewer than 10 percent of births followed medical induction of labor. By 2008 the number had grown to 25 percent. Inductions done before the due date have actually changed the length of pregnancy in the United States. In 1980, 55 percent of births occurred on or after the stated due date, and by 2008 this figure had dropped to just 33 percent.

• The advantage of either(over Pitocin alone) is that the induction is less likely to lead to a C- section. 1 Regardless of how you do it, medical induction is very likely to be successful in the sense that after it is done, you have a baby.

• What my doctor was offering me was, in essence, an elective induction. I could choose to have the baby at 40 weeks rather than wait for her to arrive on her own. And by 39 weeks I was definitely tired of being pregnant and Penelope was plenty big. And yet I wanted nothing to do with this. There were basically two reasons. First, use of Pitocin may increase pain in labor. For anecdotal evidence on this all you have to do is go to the Internet: chat boards are full of women who have had both spontaneous labor and an induction and report that the latter was more unpleasant. My mother had three children, all without an epidural, and reported that the labor she had with my youngest brother after she was induced was the worst, despite the fact that he was the third kid. Going beyond anecdotes, researchers find that women who are induced with Pitocin are more likely to use an epidural; increased use of pain relief probably points to increased pain(at least before the epidural was administered!). 2 Second, there is some evidence that induction can increase the risk of a C- section, mostly when Pitocin is used alone. 3 Of course, C- sections are safe and common, but recovery from them still tends to be harder than recovery from a vaginal delivery.

• Among induced births, those at 37 weeks do worse than those at 40. Some babies are ready at 37 weeks, but that does not mean they all are. Recognizing this, in 2014 the American Congress of Obstetricians and Gynecologists reclassified 37 to 38 weeks of pregnancy as“early term” rather than“full term” and argued that inductions in this period should only be done if medically necessary.

• Increasingly, inductions are done because of a worry that the baby isn’t tolerating pregnancy well. There are two main monitoring technologies doctors use for this: amniotic fluid levels, and something called a non- stress test. There are good reasons to use these. Knowing more about how the baby is doing inside the womb can literally save lives. For the high- risk pregnancy conditions I talked about a few chapters ago, continual monitoring is extremely helpful and we are lucky to have it.

• Inside your uterus your baby swims around in a large pool of amniotic fluid. If the pool gets too low, you can develop a condition called oligohydraminos(catchy!), which just means low amniotic fluid. The danger is that if the fluid level gets too low, the umbilical cord can get compressed. Think about it like a pool: as the water gets lower, you are more likely to be pressed up against the side rather than floating. If the cord is caught between the baby and the side of the uterus, it’s harder for blood to flow through it. Low fluid can also indicate that the placenta isn’t doing its job correctly, which could point to other problems. This is a real and significant concern. Babies born to mothers with consistently low fluid readings are more likely to need time in the NICU, and their mortality rates are higher.

• If you have a low fluid reading there is good reason to do other tests(like the non- stress test described below) to make sure nothing else is going on with the baby. If there are other signs that the baby is not doing well, especially at full term, inducing labor is generally recommended. But not all low fluid readings indicate a problem. Low fluid in the absence of any other problem is called isolated oligohydraminos. This would be a case where everything else about the baby looks normal— good size on the ultrasound; moving well in a non- stress test— and the only issue is a low fluid level. It is common for doctors to induce labor in this case, especially if you are full term or close to full term. 6 This is what happened with my various friends— low fluid at term equals induction.

• And yet despite this common practice there is little evidence suggesting that these isolated low- fluid readings warrant induction. 7 To the extent that there is evidence, it suggests that babies do as well with“expectant management”(jargon for leaving you alone). One small(54 women) randomized study compared women induced for an isolated low- fluid reading versus those who were not induced and found no difference in what happened with their babies.

• The first is to make sure your doctor is measuring the fluid in the most reliable way. Fluid levels are measured on an ultrasound. The ultrasound tech takes a few measurements and uses them to calculate how much fluid there is. They can report the amount of fluid in two ways: total fluid volume(also called AFI) or the depth of the“deepest vertical pocket.” Once again, imagine your uterus as a pool, this time with a deep end and a shallow end. The total fluid volume measures the amount of water in the pool; the deepest vertical pocket measures the depth of water in the deepest part of the deep end. As measurements go, the deepest- vertical- pocket measure is much better. It captures the same number of truly problematic situations but is much better at not identifying cases where there is nothing wrong. 11 It leads to fewer inductions and fewer C- sections. It’s easy to see why: your baby has a choice of where to hang out in the uterus, so as long as there is an area of the deep end of the pool with enough water, it’s really not that important how high the water is in the shallow end. Although it is more common to use the total amount of fluid, it makes sense to push them to take both measurements. The second solution, even easier, is hydration. In several randomized trials it has been shown that having women drink two liters of water before their ultrasound dramatically increases their fluid levels. 12 This is a lot of water, and you’re really going to have to pee afterward, but it’s not a complicated intervention! Finally, if your readings are borderline, you may want to push for a repeat measurement rather than agreeing to an immediate induction. When my friend Jane went in on her due date, she had a borderline low reading, followed by another one the next day. The doctor scheduled an induction, but Jane pushed for one more measurement the day before the induction— at which point the level was higher, so they canceled the induction and let her go another week. By this time we joked that perhaps she shouldn’t have listened to me. But in the end she was glad to have waited, especially because her son was on the smaller side.

• Given that such a large percentage of babies fail these tests due to sleeping, doctors will usually do a number of things to try to wake up the baby before they start to worry. Among the most effective of these interventions is a very simple one: clapping. 13 In one study, 485 women were given these tests and initially 143 of them failed. For these women, the researcher then clapped loudly 3 to 5 times right on top of the abdomen. This got the attention of most babies: 92 percent of the babies who were previously asleep had a normal test result after the clapping.

• The Bottom Line• Best option: go into labor on your own.• Prebirth fetal monitoring is a good idea, but beware of false positives.• Fluid monitoring. Two easy ways to avoid false positives:(1) stay hydrated, and(2) ask your doctor to measure the deepest vertical pocket rather than total fluid volume.• Non- stress test. Advice: just keep clapping.

• Of the breast stimulation group, 37 percent were in labor by 3 days, versus only 6 percent of those without breast stimulation! This is a large effect, and was very consistent across all studies. There was also some reduction in the risk of postpartum hemorrhage, a significant postbirth complication. It sounds great: no needles, you can do it at home, it has other benefits, and it works to induce labor! The only downside is that it is awfully time consuming. The women in these studies were asked to massage their breasts for at least an hour a day for 3 days; in two cases, it was an hour 3 times a day. That’s a lot of time. In some cases the women used a breast pump. Less work, still a lot of time. On the other hand, for me at least, the last few days of pregnancy were spent mostly on the couch watching television. Perhaps I could have put the time to better use.

• The Bottom Line• Tea, oil, sex— all duds at starting labor.• Acupuncture evidence is mixed.• Nipple stimulation works, and so does membrane stripping(but don’t do this last one at home).

PART 5: Labor and Delivery

• The first part of labor(the 0 to 3ish centimeters) can take a very long time. There is really no predicting it. Many women dilate to this level over a period of weeks, often without noticing. There’s no sense worrying about timing here.

• This speeds up as you go forward: the average woman will take almost 6 hours to go from 3 to 7 centimeters, but will go from 7 to 10 centimeters in 90 minutes or less(this is that transition period). The newer data also shows that before 7 centimeters, it would not be uncommon for women to go 2 or even 3 hours without any apparent change in dilation. This may be helpful to know because going for long periods with no progress can be frustrating and cause women(and sometimes their doctors) to question whether the process will ever progress.

• The data on timing actually also answered part of my second question about labor problems. One of the major problems in labor is that the cervix opens too slowly or not at all. This can lead to a need for various interventions(Pitocin, for example) and can be an indication for a C- section if the baby is in distress(for example, if its heart rate is dropping). The second common labor problem is that women have trouble pushing the baby out in the second stage of labor. This can happen if the baby is very large or Mom’s pelvis is very small. It can also happen if Mom is having trouble with knowing how to push— as it turns out, it can be hard to figure out what it means to“push” the baby out. Depending on how far down the baby gets, doctors will sometimes respond to this by performing a C- section, and sometimes by using medical instruments(forceps or a vacuum extractor) to pull the baby out. A third possibility is that the baby might be facing the wrong way. It’s easier(not easy, just easier) to give birth if the baby is facing toward your back. If the baby is facing up(sometimes called sunny side), it can be harder to push her out. Which direction the baby is facing can(and often does) change during labor, so this is not something you can predict based on prebirth ultrasounds(although you can see what is going on in an ultrasound during labor). Often it won’t be clear that this is a concern until you are actually trying to do it. Again, this can increase the chance of a C- section.

• This is perhaps a good place for a word on C- sections. C- sections are generally safe, and they are common(about 30 percent of births in the United States). But OBs generally agree, for good reason, that they are not the preferred mode of delivery. A C- section is major abdominal surgery. Recovery varies across women, but is generally slower than after a vaginal delivery.

• Having the option to have a C- section if things go wrong is great; this has undoubtedly saved countless lives. But it shouldn’t be the first choice for mode of delivery. One exception to this, probably, is if your baby is breech. The majority of babies come out head first; this is the way that birth is designed. In order for this to happen, of course, they have to be head down at the start of labor. Saying a baby is breech means he is in some other position.

• Before 36 weeks, your baby being breech is absolutely nothing to worry about. Babies move around all the time. Even closer to your due date, it is usually not anything to worry about. Almost all babies will figure out the right positioning on their own and will rotate. At 28 weeks, perhaps 25 percent of babies are breech; by delivery, it’s only 3 to 4 percent. 3 Much of this rotation occurs before 32 weeks. In one study in Sweden only about 7 percent of babies were still breech by 32 weeks; half of those turned on their own by delivery. 4 If your baby still hasn’t turned around on its own by 37 weeks, there is an option to try to turn the baby manually. This is called an ECV: external cephalic version. The concept is simple. They give you some medicine to relax your uterus, and then try to muscle the baby around by pushing from the outside. Obviously this is all done with extensive monitoring to make sure the baby is handling it well, and at a hospital so that if something does go wrong they can deliver right away. This procedure is successful about half the time, and has limited complications, although it can be very uncomfortable(you might be offered an epidural). 5 If this doesn’t work and your baby is still breech when you get to labor, you will almost certainly have a scheduled C- section.

• The other common cause of a scheduled C- section is if you’ve had one before. Women who have given birth once by C- section are very often advised to have future babies the same way. Having a vaginal birth after a C- section is possible(it’s often called a VBAC, for vaginal birth after Cesarean) but not usually the default.

• The Bottom Line• Labor times vary a lot. Average dilation time is 1 to 2 centimeters an hour after active labor starts.• There are three major categories of labor problems:(1) dilation is too slow, or stops altogether;(2) baby gets stuck, and(3) baby is facing the wrong way, making it harder to push.• Emergency C- sections are a good option to have, but a C- section should not be your first choice…•… unless your baby is breech or(probably) if you’ve had a C- section before.

• Queen Victoria was among the first women to use anesthesia— in her case, inhaled chloroform— during the birth of her seventh child in 1853. She was a huge fan. The use of this type of pain relief spread, although mostly among upper- class women.

• Local pain relief— of which the epidural is one version— was first used in the early 1900s; it initially contained cocaine. Modern versions of the epidural(no cocaine) began to gain in popularity in the 1960s, and today the vast majority of labor pain relief is of this type.

• An epidural is administered during the first stage of labor— the part where the cervix is dilating. It is sometimes(but not always) turned off during the pushing, because pushing is often harder if you are completely numb.

• The epidural is extremely popular: it was used in about two- thirds of births in the United States in 2008. At the hospital where I had Penelope, the epidural rate is 90 percent.

• But, on the other hand, the evidence convinced me that there is no free lunch for Mom. I came to conclude that the use of an epidural complicates the process of birth, and probably makes the recovery a bit harder(on average). The risks were small, but they were there. To be clear, there are very good reasons to get the epidural. Well, there is one particularly good reason. It is really, really good pain relief.

• Epidural and Baby Positive Impacts: None identified(although that’s not the point!) Negative Impacts: Increased chance of unnecessary antibiotics No Differences: APGAR score, fetal distress, baby poop before birth, baby time in NICU

• The one negative consequence of an epidural for the baby is related to a maternal complication. For some reason(possibly due to the inability to sweat enough when nerves are blocked), women who get an epidural are much more likely to run a fever during labor. The fever is a known side effect of the epidural, but doctors can’t tell if it’s a real fever(due to an infection) or just a side effect. This leads them to react as if Mom has an infection, which often means treating the baby with antibiotics. In one study, 90 percent of babies born to women with a fever during labor were given antibiotics, versus only 7 percent of babies born to women without a fever. In the end, none of the babies in either group actually needed the drugs. 3 Unnecessary antibiotics are not ideal, but this is a fairly minor complication. The bigger risks of the epidural are for Mom.

• Epidural and Mom Positive Impacts: Better pain relief Negative Impacts: Greater use of instruments(forceps or vacuum in delivery), greater use of C- section for fetal distress, longer pushing time(15 minutes), higher chance of baby facing up at birth,* greater use of Pitocin in labor, greater chance of low maternal blood pressure, less able to walk after labor, greater chance of needing a catheter, increased chance of fever during labor No Differences: Overall C- section rate, length of dilation period of labor, vomiting during labor, long- term backache

• But instruments do increase the chance of vaginal tearing for Mom. They can also lead to some bruising around the baby’s head, which can look scary but heals quickly.

• The epidural seems to lengthen labor just a bit, mainly by lengthening the pushing stage. It also seems to increase the chance that the baby is born face up(the“wrong” way). This might be due to the fact that in most cases once you have the epidural you don’t move around much. Without an epidural, you want to move around during labor— your body is telling you to walk, to switch positions, etc. One theory is that this movement is what helps the baby get into the right position for birth. The lack of movement with the epidural makes this harder.

• There is one final issue that is not included in the preceding lists and that is the postdural puncture headache. Done correctly, the epidural needle goes into the membrane around your spine, not into the spinal fluid itself. Of course, these are right next to each other, and it’s possible to accidentally go into the spinal fluid. If this happens, it’s called a wet tap, and you have about a 40 percent chance of developing a postdural puncture headache in the few days after labor. Basically, it’s a really, really terrible headache lasting for several days. This wet tap is reasonably common: about 1 in 200 procedures, even at a good hospital. 4 It’s much more common if you have a doctor who hasn’t done many procedures before, so you definitely want to check that you are not getting some resident who’s trying his first epidural.

• The Bottom Line• Epidural is very effective pain relief.• But it increases the chance of some complications for the mother.

• But having thought about some of these decisions before labor actually starts is almost certainly a good idea. Writing them down gives you(or at least gave me) something concrete to discuss with the doctor. If you do this far enough in advance, you can ideally have that conversation in a quiet moment at 36 weeks pregnant, rather than between contractions.

• The other major reason for an induction(other than real risk to the mother or baby, for which I would of course have acquiesced immediately) is if your water breaks before labor. Television would have you believe that most women start labor with their water breaking. This is wrong. In fact, less than 10 percent of women have their water break before labor. For most women it doesn’t happen until quite late in the process. If your water does break first, you’ll often go into labor right away or within an hour or two.

• the vast majority of women are in labor within 12 hours of their water breaking. But if you’re not one of these women, standard practice is to induce labor. Most doctors will strongly encourage this. Their big concern is with infection. The water(the fluid in the amniotic sac) protects the baby from exposure to the outside world. Once that protection is gone, you and the baby are subject to infection.

• Oster Birth Plan, Bullet Point 1:• If water breaks before contractions start, our preference is to wait 12 hours and induce if labor has not started. Unless necessary, digital vaginal exams should be avoided during this period.

• To summarize: it’s unlikely that you’ll be under general anesthesia during labor, even if you have a C- section. And if that did happen, the risk of aspiration is vanishingly small. I certainly felt fine with the idea of eating during labor.

• I got myself an egg and cheese bagel, which I highly recommend as a prelabor meal. My mother recalls having a ham sandwich, which she also reports is a good option. It was good that I ate at home, because even my relatively lenient OB practice wasn’t into the idea of solid foods in the delivery room. This is common: birthing centers might be different, but most hospitals will not allow you to bring much in the way of snacks.

• It’s still worth talking this through with your doctor. If he subscribes to the ice- chips- only rule, there may be little you can do(short of switching hospitals or sneaking drinks in!).

• Oster Birth Plan, Bullet Point 2:• I will be drinking water and clear fluids during labor.

• After it was over, we both agreed that having Melina with us was by far the best decision we(I!) made.

• I’m not sure I can articulate quite why this was. I can, of course, say what she actually did— she arrived at our house as labor was getting more intense, stayed with us at home, and then came to the hospital with us and stayed until Penelope arrived. She did some back massage during early contractions, and encouraged me to switch positions when I was getting too comfortable(she actually used that phrase once—“ You are getting too comfortable on this birthing ball; you need to lie on your side so the contractions are more intense”). But I’m guessing the bigger benefit was just having someone who knew what was going on and who was calm and relaxed.

• Women with a doula were half as likely to have a C- section(13 percent versus 25 percent) and less likely to use an epidural(64 percent versus 76 percent). An older study, published in 1991, showed similar impacts. Women in this study were randomly assigned to have either a supportive doula or an observer in the room who did not help. Women with a doula were less than half as likely to have an epidural, had shorter labor, were about half as likely to have a C- section, and were half as likely to have forceps used in delivery.

• One interesting thing to note here: many people think a doula is helpful only for people who are trying to go without the epidural. These studies suggest that this is not the case. The C- section rates were lower even among women who used an epidural.

• She came by the house a few days later to check on us, another nice feature of many doula arrangements, and was able to confirm that Penelope was actually swallowing when she nursed

• Oster Birth Plan, Bullet Point 3:• Our doula, Melina, will be with us during labor.

• The natural childbirth books tell you that the time to go to the hospital is when you can’t smile in the picture you take on your way out the door. Sounds about right.

• This type of fetal monitoring has become close to universal in the United States: in 2002, 85 percent of women had this during labor. I have a lot of personal animosity about this monitoring. When we first arrived at the hospital, they left me immobile on this thing for about 40 minutes in triage. Laboring on your back has got to be among the least comfortable positions— my contractions slowed down, and I got cranky. Jesse was furious— he was about to, in his words,“Go Brooklyn” on them when they finally came in to move me upstairs. Once I was in the actual delivery room they gave me a portable monitor, which in principle allowed me to move around, but this wasn’t much better. When I moved around(presumably the point of the monitor being portable!), the straps moved around also. This meant that about every other contraction, the monitor stopped recording the baby. This caused two problems. First, I freaked out. Second, it meant that as I was trying to work through the contraction, the nurse was fiddling around with the straps. Melina finally told them they’d better turn the volume down or she was taking it off.

• Based on this evidence, both this review and the most commonly used OB textbook suggest that continuous monitoring isn’t necessary or even a very good idea for most women. It seems like what is happening is that doctors overreact to patterns they see in the heart rate when the baby is not actually in distress. It’s almost as if there is too much information. You might imagine that every baby, no matter how well the birth is going, has a few moments when her heart rate dips. If you aren’t watching all the time, you don’t see this, and that’s fine. If you are watching, you conclude something is wrong, and it’s off to the OR.

• It’s worth asking whether your OB is okay with intermittent monitoring, where you are hooked up to the machine for 10 or 20 minutes every hour but free to move around the rest of the time. This is a bit more invasive than listening to the baby with a Doppler, but it may give you more freedom and let you avoid some of the negative outcomes of continuous monitoring.

• Oster Birth Plan, Bullet Point 4:• Intermittent(ideal) or mobile fetal monitoring

• Something I didn’t realize before labor is that your doctor is actually not there most of the time. For hours it was just Jesse, me, Melina, and Nurse Tera. I’ve been told that if I had had the epidural, the nurse wouldn’t even have been there most of the time. The doctor swoops in when you are ready to push. She will basically take over at that point.

• Oster Birth Plan, Bullet Point 5:• If labor progression is slow during active labor, our preference for augmentation is(in this order):(1) amniotomy(breaking water) and(2) Pitocin.

• 72 percent of women in the“routine” group had an episiotomy, versus only 27 percent in the“only if absolutely necessary” group. Outcomes in these trials were worse for the routine episiotomy group. This group was more likely to have an injury to their perineum, more likely to need stitches, and(in one small study) had more blood loss. They also had more pain at the time of leaving the hospital and more complications with healing. One argument often made in favor of routine episiotomy is that it prevents really bad tearing. However, these studies showed no differences in the frequency of severe trauma in the two groups.

• Fortunately, likely as a result of this strong evidence against routine use of this procedure, episiotomies have dropped from around 60 percent in 1979 to only about 25 percent by 2004.12 We put this in the birth plan just as a precaution, but we also made sure to discuss it with the OB before labor. If she had said anything about doing this in a routine way, I would have run in the other direction. There is no reason for this to be done routinely, and if your OB feels differently, I might look for one who has read the medical literature in the last twenty years!

• Oster Birth Plan, Bullet Point 6:• No routine episiotomy

• This is perhaps not surprising, as Pitocin is the synthetic form of oxytocin, the hormone that is released when you start breast- feeding. Presumably, evolution designed the system this way for a reason: you have the baby, and when you start nursing you get a surge of hormones to help your uterus contract and prevent bleeding. The natural system is great, but the synthetic form of the hormone also helps.

• Oster Birth Plan, Bullet Point 7:• Pitocin in the third stage is fine if necessary/ recommended.

• There are just too many possibilities to have any real plan. The best you can do is have some idea of what’s coming, and think through the most likely scenarios. Be prepared, but don’t be committed. In the end, maybe something will happen you aren’t expecting, and you’ll have to go with that. You can’t prepare for everything.

• The Bottom Line• Broken water: Induce if labor doesn’t start on its own within 12 hours.• Eating and drinking during labor: Probably should be allowed, although most hospitals still will not let you have solid foods, and you probably aren’t going to want them anyway. Do bring some Gatorade to keep your energy up.• Doula: Having a doula decreases the chance of a C- section and of using an epidural. Recommended.• Continuous fetal monitoring: There’s no evidence it’s effective. If intermittent monitoring is available, do that.• Labor augmentation: Labor can progress slowly, and does for many women. The 1- centimeter- per- hour rule is probably a bit optimistic. But there are limited downsides to augmentation; both breaking the water and use of Pitocin tend to speed up labor without increasing C- section rates or other complications.• Episiotomy: Not a good idea.• Pitocin after birth: Useful in preventing postpartum hemorrhage. Recommended.

• When I looked into it a bit more, I found that whether this is a good idea depends on the baby’s prematurity, and the conditions into which he is born. For premature infants(those born before 37 weeks of pregnancy), delayed cord clamping seems to be a good idea. 1 It roughly halves the need for a blood transfusion for anemia, and has an even bigger effect on the need for blood transfusions for low blood pressure. Basically, it seems like preterm babies need more blood, and this is an easy, natural way to get it to them. For babies born full term, the evidence is more mixed, but increasingly it also seems to favor delayed clamping. 2 On the plus side, just as with preterm infants, delayed clamping is associated with higher iron levels(less anemia) that persist for at least 6 months. On the negative side, some studies(although not all) have shown that delayed clamping is associated with a 40 percent increase in the risk of somewhat serious jaundice. This all makes sense: jaundice happens when the baby is a little slow to get rid of bilirubin, a byproduct of red blood cells. When the baby gets more blood from the cord, this problem gets worse while the anemia problem improves. In the preterm infant, the need for blood is greater, so you get the positives without the negative. This is where the location of birth matters. Anemia is not very common in the United States because our nutrition is fairly good. This means that delayed clamping is perhaps less beneficial. In the developing world, anemia is much more common, and the benefits likely outweigh the risks. The ultimate question for you is whether you are worried more about anemia or more about jaundice. We are lucky that in the United States both conditions are extremely treatable, so you’re unlikely to make a big mistake either way.

• It is standard to give babies vitamin K supplementation within the first hours after birth. The purpose is to prevent bleeding disorders. A deficiency of vitamin K can cause unexpected bleeding in up to 1.5 percent of babies in the first week of life(the bleeding could come from the umbilical area, be prompted by a needle stick, or be internal). It can also cause bleeding later, between 2 and 12 weeks of age. Although it’s rare(perhaps 1 in 10,000 babies), this second manifestation is much worse: it often causes severe neurological damage or death. Supplementation with vitamin K is very good at preventing this. It’s typically given through a shot, although it can also be given orally. Evidence suggests that both are effective, but the oral dosing slightly less so. 3 Vitamin K supplementation has been standard since the 1960s. Unless you ask about it, you probably will not even know the doctor is doing it; it’ll just be one of the several things they do when they are cleaning up the baby.

• This treatment is obviously a good idea if you have(or might have) an untreated sexually transmitted infection. That is increasingly less common, in part because it’s routine to test for these during pregnancy, which makes it a bit less clear what the benefit is. Many countries in Europe have dropped this standard practice with no increase in blindness. Having said that, there are no apparent problems with this treatment and you probably won’t be given a choice. Most states in the United States mandate it. Although in principle you might be able to opt out, it’s not easy.

• The Bottom Line• Delayed cord clamping: a good idea if the baby is born before 37 weeks. If the baby is full term, it’s up to you to trade off the(possibly) higher risk of jaundice with the lower risk of anemia.• Vitamin K shots: effective at preventing bleeding, and the claims that they increase the risk of cancer are unsubstantiated.• Eye antibiotics: probably not necessary if you don’t have an untreated sexually transmitted infection, but legally mandated in most states and without any obvious downside.• Cord- blood banking: very unlikely to be useful for your family given current technology. Future technology is difficult to predict. Public cord- blood banking is worth considering.

• fewer than 1 percent of women in the United States have a home birth.

• The Bottom Line• If you don’t want any pain medication, there are some pros to home birth. There are fewer C- sections, less instrument delivery, easier recovery for Mom, and less tearing.• If you haven’t done this before, there is about a 30 percent chance you’ll end up in the hospital anyway.• Some studies suggest that mortality risks are higher with home birth, others do not. Risks are low in any case.• If you do decide to go this route, make sure you choose as experienced a midwife as possible, ideally a certified nurse- midwife, who has had nursing, midwifery, and infant resuscitation training.