Iron, continuous fetal monitoring, and the value of midwifery care

Welcome to the weekly ZIP - your Zenith Informed Pregnancy!

Read on for a quick zip through 3 of the week’s most popular pregnancy questions, and the evidence behind them. Plus - bonus content on the latest & greatest in the world of pregnancy research. 

This week's top pregnancy questions:

1️⃣ Do I need more iron during pregnancy?

2️⃣ Travel tips, considerations, and what to avoid?

3️⃣ When does/doesn’t continuous fetal monitoring improve outcomes?

Do I need more iron during pregnancy?

Iron is quite important during pregnancy, yet gets less attention than other nutrients important in the prenatal period (like folate). So if the evidence on its benefit is there, how do you know if you’re getting too little, too much, or just the right amount?

📚The tl;dr from the evidence: Iron deficiency is fairly common in pregnancy, but isn’t actually obvious without testing. There are also factors that may increase your likelihood of being low on iron, like a history of anemia, heavy periods prior to pregnancy, or following a vegan/vegetarian diet. On top of that, your blood volume during pregnancy increases by up to ~30% – meaning extra iron is needed to make more red blood cells. During pregnancy, the recommended iron intake is ~27-30mg daily (higher than the 18 mg for people who are not pregnant). 

Since it can be hard to assess low iron from symptoms alone, your doctor should check your iron status at your initial prenatal appointment. Many prenatal vitamins do include iron in the recommended dose, but not all do, and iron from your diet typically isn’t enough to meet the needs of pregnancy. 

One caution from the data: more isn’t actually always better, so make sure you’re not adding extra iron beyond your prenatal without direction from your doctor. Evidence has shown excess intake (above ~45 mg/daily) can lead to unpleasant side effects like nausea, abdominal pain, and GI distress. Additionally, some research has suggested that iron overload may be associated with increased risk of pregnancy-specific complications like preeclampsia, gestational diabetes, or reduced fetal growth. This is why testing your iron status and double-checking what you’re getting through your diet and any existing vitamins/supplements before adding more is important! 

👀 Read Penny’s full summary of the evidence for more on iron during pregnancy

Travel tips, considerations, and what to avoid?

Somehow, the holiday season is almost upon us - which often comes with long road trips, train or air travel to visit family and celebrate together. We’ve seen many flavors of questions about travel safety come to Penny - whether how late in pregnancy air travel is safe, how soon to travel with a new baby, or preparing for long road trips with the added discomfort of pregnancy changes.

📚The tl;dr from the evidence: Travel doesn’t come with an inherent increased risk of pregnancy complications occurring; most guidelines are aimed towards staying comfortable, avoiding blood clots resulting from long periods of sitting, and ensuring that moms have proper access to emergency care if needed. 

Simple adjustments on road trips can increase comfort for longer drives (extra stretch breaks or compression socks to reduce the risk of blood clots, planning for extra bathroom breaks, and ensuring your seat belt sits properly - below your belly and across your hipbones). It’s recommended to avoid traveling alone if possible, particularly later in pregnancy as the risk of going into early-or-full-term labor increases the closer you get to your due date. 

The primary restriction is surrounding air travel, as many airlines actually restrict travel past 36-37 weeks (or even earlier, if you’re having twins) and may require a doctor’s note to board at/after 28 weeks. If you’re planning on flying, be sure to check your specific airline’s policy, and consider getting a doctor’s note just in case if you will be visibly pregnant at the time of your flight. 

Airline policies may feel overly restrictive or unnecessary for healthy pregnancies, but the airlines are largely trying to protect you against the risk of things like early labor, or even having to deliver your baby without the appropriate care team to support you, as it's impossible to accurately predict when labor will begin. And yes, while your health and safety is the top priority, airlines also aim to avoid liability and logistical issues that may arise from a medical emergency. 

👀 Read Penny’s full summary of the evidence for more on travel safety

When does/doesn’t continuous fetal monitoring improve outcomes?

Many of you have likely seen the New York Times article covering the practice of continuous fetal monitoring during labor, and the resulting high rate of C-section births that we see in the US. It’s sparked a lot of online discussion – does continuous fetal monitoring have any benefit, and why do we continue to do it if it so often leads to unnecessary C-sections?

📚The tl;dr from the evidence: Continuous fetal monitoring (CFM) is the practice of electronically monitoring the baby’s heart rate throughout labor (introduced in the 1970s, to replace manual intermittent monitoring with a stethoscope, and aiming to reduce neonatal deaths and increase the ability of understaffed hospitals to better monitor babies). The technology can be helpful, although isn’t perfect - it can have high false positive rates (flagging abnormality or fetal distress that isn’t actually present). 

In higher risk delivery scenarios, including women with preeclampsia, diabetes, IUGR, or carrying multiples, CFM is beneficial to detect fetal distress early, and as a result creating more time/opportunity for quick intervention if needed for mom and baby’s safety. 

In low risk pregnancies, however, evidence on CFM has not shown any improvement in outcomes - and has demonstrated higher levels of intervention (C-sections, as well as assisted births with forceps or vacuum). Intermittent monitoring is considered a safe and effective alternative. As with any procedure during pregnancy, you have the power to ask questions, have an honest conversation with your provider about your preferences or concerns, and provide your informed consent for CFM. 

Why, then, is it still so common in low risk pregnancies without evidence of benefit? The answer is complex, but the liability landscape can’t be ignored – obstetrics is amongst the most litigious specialties in healthcare, and so the “rather safe than sorry” approach can be pervasive (even when the ‘safe’ path can come with additional/different risks, such as performing a C-section). A provider (and the hospital they practice in) is less likely to face a lawsuit for safely performing an unnecessary C-section under the assumption that they are proactively intervening against fetal distress than they are for ignoring signs of distress that ultimately lead to a poor outcome for mom or baby.

👀 Read Penny’s full summary of the evidence for more on continuous fetal monitoring

🤓 Zenith's top read of the week

Bonus: what the Zenith team found interesting this week. Think cool pregnancy research or recently published studies, news in pregnancy health and policy, and more!

Over 30,000 Miles, a Midwife Navigates West Virginia’s Maternity Deserts (Kate Morgan & Maggie Shannon, The New York Times) - There’s been lots of buzz across social media on the NYT’s coverage of continuous fetal monitoring, but we haven’t seen as much buzz around this equally important article highlighting the importance of community care through avenues like midwifery. 

Home births, while still uncommon overall, are on the rise - and it’s great to see coverage of the critical support system that midwives provide to women, particularly in geographies and populations with less access to hospitals and obstetricians. This article shares a handful of powerful vignettes of the importance of community care to individual moms in West Virginia, as well as some background on the push to introduce state legislature for the licensing of certified midwives (which midwives are lobbying for in at least 7 of the states where nationally certified midwives cannot be licensed, unless they are nurses). 

Key excerpt:

“More than a quarter of the state’s hospitals have closed their delivery units since 2010. More than 60 percent have no obstetric care. In nearly half of the state’s counties, there are no birthing hospitals, and not a single practicing obstetrician. The state is also home to only one birth center, a childbirth facility typically run by midwives. Pregnant women spend hours driving to appointments. Babies are born on the side of highways and in emergency rooms. When due dates approach, women sleep on other people’s couches to be close to a hospital.”