Welcome to the kick Your Expert led podcast, helping you explore and learn everything about getting pregnancy, birth, and becoming a parent.

On the podcast and our online pregnancy program grow My Baby, we share my experience of helping more than four thousand babies to be born.

And our experience of running a women's health clinic and parenting for boys.

We're here to help everyone to feel empowered in pregnancy and birth with real life, practical information.

Welcome everyone.

I'm Bridgid Maloney.

And I'm obstetrician doctor Patrick Maloney, and today we've.

Got a Q and A.

Yes, we're getting up in Q and A numbers like I think this might be the twenty third.

Really, is that right?

Tellia, yep, that's.

The twenty third.

Wow, that's a lot.

Good.

That's good.

I enjoyed this and I just love the questions that you guys send in, So keep sending them in because it just gives us a feel on where people's knowledge base is and what's missing in the I don't know the media environment where you can't get the answers anywhere else.

So yeah, we love it.

All right, let's get straight into it.

Hepato Hi, doctor Pattern bridget.

My name's Tegan, and I have a question about antipatum hemorrhages and their impact on future pregnancies.

So as a background, my first pregnancy was a partial moler pregnancy found at thirteen weeks, which the baby had passed at eight weeks.

I required a DNC and then also needed a second d and C two months later for ongoing bleeding and complications to do with retained products.

I then had a very uncomplicated second pregnancy, and when I first went into labor, about two hours after my first contraction, which was still very irregular and twenty minutes apart.

At that point, I had some frank bleeding.

It was just a couple of tea spoons and it was dripping on the floor.

It definitely wasn't my mucus plug.

So I went to the local maternal Fetal Assessment unit and had a speculum and they confirmed that it was coming from inside my cervix.

A CTG showed bub was all okay, but they said I had to remain there in the hospital and have continuous CTG monitoring.

I didn't have any further bleeding for a few more hours until I probably twelve hours later, I was in I was ten centimeas dilated and beginning my pushing phase where I had some more bleeding again, probably three teaspoons worth.

So my question is, how does this, because we never found out what the cause was, how does this impact any future pregnancies?

From what I can see online, antipartum hemorrhage is can be quite severe serious, but yet mine was very, very small.

So I was just wondering if I have to do anything differently?

Thank you?

All right, So I think obviously we need a definition of what anti partom hemorrhage is.

But she described a molar pregnancy at the start.

Yeah, which involved bleeding, right, but it was not strictly relevant to what happened next.

Okay, Yeah, so the molar pregnancy, you know, doubtless was was disappointing and and and upsetting, but it was managed according to to routine guidelines and that you know, those abnormal pregnancies will often come to light in the setting of bleeding.

So that was unrelated with what happened in the second pregnancy, which was some some bleeding term and an a pH or anti partum heammage.

Bleeding before the baby comes has a big number of different causes.

But if we look at the bleeding that happens at full term, sometimes it's because the labor is actually starting and we just don't know.

Okay, So it's interesting that after that bleed she was she had the baby that day.

Eventually, what we don't know is whether that was part of an induction or part of a or part of a spontaneous labor.

One thing that is of interest to people is there is that sometimes one of the first signs of labor is something called a show where the cervix is opening to a point where I bleed a little bit, and in small volumes, that's a normal thing to happen, and on other occasions the someone at term might have a larger bleed of fresh blood that seems to be too much just to think it's an entirely benign thing, like a show from the cervix, And in that situation, we really need to watch closely to make sure that that bleeding is nothing to do with a placenta that's lower than we thought it was, or that there's some other more significant problem.

We tend to observe quite closely, and sometimes the appropriate manager management of an aph at term, an anti patter hemorrhage at term.

If we don't know what happened and why the bleeding happened, but we're otherwise very close to the do date, Occasionally induction of flavor is an appropriate management strategy for that, because if we're in the darkness or exactly why that bleeding happened, and it was enough of a volume to make us concerned, then the risks of inducing the labor may be significantly less than the risks of doing nothing.

And she's mentioned three teaspoons twice of fresh blood.

Is that a significant amount?

No, these are small volumes.

It's just that the amount of blood that's revealed vaginally doesn't necessarily to present the entire amount of abnormal bleeding that might have happened.

So someone might get a few spots vaginally, come in to be assessed, have an ultrasound that shows a much larger amount of blood that's bleeding behind the placenter, between the placenter and the uterie, more called an abruption, and that's actually a much bigger deal.

You mentioned a CTG, but she didn't mention an ultrasound.

Did she.

Typically the assessment of an aph would include an ultrasound in particular if the woman didn't seem to be laboring.

So if the labor was up and going and there was some bleeding, you might just say, fine, let's just watch the baby, make sure the labor's progressing well, and have our baby today.

Yeah, if there's no labor and no apparent benign cause for the bleeding, then you've got to go looking for it, and an ultrasound would be part of that assessment.

You've mentioned lots of times, and it might be in our program.

I can't remember, but that pregnancy is kind of bleedy, like you know, everything quite vascular and yew.

The placenta's kind of made of blood vessels.

It's not that unusual that it bleeds.

But also that any fresh blood needs to be investigated.

Well.

Yes, so we don't just decide things a normal We investigate, exclude the dangerous causes, and if we can't find any dangerous cause, say okay, that's fine, that bled has happened, let's up our level of surveillance.

But otherwise carry on.

And do you think there'd be any difference in management of this woman's second pregnancy and labor.

Yeah, that's what she asked, and I don't think so I just think that that a note should be made that anti partmwhich occurred in this pregnancy, but ultimately didn't have a highly pathological cause, and and I should be kept on that.

And I figure when she said that she's done research on antipatam hemorrhage, Google has shown her some pretty serious things.

Yeah, all the serious nasty things that she didn't have.

No, Yeah, but that's why we check.

Some people have got those things.

And so you know, bleeding at terms, it needs to be investigated.

And can we just very briefly just list potential causes of bleeding A term that is serious.

Bleeding from a low placenter could affect the function of the placenta, something called an abruption, where there's bleeding behind the placenta between the placenta and the uterine wall.

A problem with the cervix itself that like, for example, if it was coming open too soon, that could involve bleeding.

So a thorough investigation is to be done with clinical examination, take a careful history, and do some appropriate tests.

All right, listener, I really hope you have a great labor and pregnancy for your next time.

You keep listening.

Absolutely, I mean, it's not clear from the call.

But let's say, for example, and she wanted to get into ten sentiments.

So let's assume that baby is born vaginally, then quite quite apart from any any risk to the future pregnancy from bleeding complications, which would be low.

Actually having had a previous vaginal birth, she would be she would be in most other regards a low risk situation.

Hi, my name is Alice.

I am nineteen weeks pregnant.

This is my second child.

I am actually going through the public system this time.

I went through private for my first.

Private health isn't going to kick in in time as we just returned from living overseas.

I just had an AMERGA three test one because on advice, that's new testing and it's good to know those levels.

However, I did have a second trimester screening test one at the same time, and I didn't know that that was being done, and I don't think needed did my GP because she did apologize that she didn't unticket, So I think that's sort of part of the testing.

And I know from being in the public costable system now that it is something that they're finding is happening if they're bit so I just think it's something that I should raise for other people as well.

My NIPT test was great, low results.

My scans have all been perfect and really good and normal, but that second timester screening test came back as high risk, which I understand it to be a statistical test.

You know, there's numbers involved, like here they take markers in your blood and then like you know, multiplied by age, and you know factors other factors, and there's like a high degree of error in it.

However, it has positive bit of stress.

And although I've been often and AMNIO, it's not a risk that I really want to take, but I just thought i'd raise that because I think it's a good one to maybe cover.

Firstly, Ellis, I love the name Alice.

That's the name of our son's girlfriend.

Hi, Ellis.

If you're listening, that would be so distressing, wouldn't it.

I think it is so so it is distressing.

So let's just recap for people.

There used to be a test that was done more commonly where we would take some blood around the ten week mark and an ultrasound around the twelve week mark and use those pieces of information to calculate an estimate of the risk of down syndrome in a baby, and it was a test that had some problems, not the least of which was that it required a fair bit of interpretation.

It's still done and requires interpretation.

If someone says that your risk of having a baby with Down syndrome is one thing three hundred, then some people will think that's good news, and other people will think that's bad news to basically depending on how they look at those numbers.

It's somewhat been replaced by NIPT testing, which is a much more precise system of very different type of test picks up on DNA in the maternal circulation at ten weeks and can basically tell us a yes and yes no answer to those major syndromes with a very very high degree of accuracy.

The reason why you might have both tests might come down to the fact that the NPT was organized by GP in the private sector and the other test was inadvertently ordered for you in a public hospital.

The NRPT testing is still reasonably expensive, and some public hospital patients who don't want to go to the extra expensive having the NPT test organized outside the hospital will have the one that the hospital is prepared to pay for, which is the combined second trimester screen.

So what if the economics of that has ever been sort of looked at, because if you get a high risk second trimester screen, which then means that you go on to have an amniosantisises, surely that's way more expensive than having an NPT.

Yes, And I think that this is it's an excellent question.

It's some of the some of us on the inside of the system surprise that some of the funded tests continue to be funded when they when there are alternatives that that might work out better economically.

And it sounded like she said that the GP ordered the test but perhaps forgot to uncheck a tick box thing.

So I suppose it's just the patient sort of knowing that make it.

Could just be a systems problem.

Yeah.

Yeah.

Pape is one of the is one of the tests, one of the one of the blood levels that's ordered on the second tests, and there are other there are some other reasons why you might want to know someone's PAPE level, not just to do with down syndrome risk.

And so I think if someone orders an independent PAPE level, it should not really be done as part of a full tech and trimester screen for somebody who's already had a normal NPAs see if the it doesn't really matter if you look specifically at down syndrome screening whether it comes out saying the risk is one one hundred, one fifty or whatever, when you already know the risk is essentially zero because you've had an appropriate in IPS test.

Yeah, yeah, all right.

I think it's just being aware of that.

But also this, Alice, is perfectly okay for her to ignore the second trimester screening test.

It depends what it's said.

So if it's said that there was an that the problem was with the pape level, then that can actually be predictive of other issues later in pregnancy, such such as preclam serious and third trimester growth restriction, and so it may have some relevance to that, but it's not relevant to her in terms of the down syndrome misk for the baby that's already been established.

Yeah, good, okay, all right, Well good luck with that, Alice, And I thank you for raising that as an issue.

And yeah, it is the difference between the different say protocols or systematized tests within different systems.

And we're going to have an episode on that soon about the differences between public and private, So yeah, that'll be interesting.

Stay tuned.

All right, let's go on to our next caller.

Hi.

My name is Paris and I am pregnant, currently seven weeks pregnant and waiting for my first scan, which is in a week for my dating scan.

I started taking a pregnancy multi vitamin when I found out that I was pregnant in week four.

I wasn't expecting to get pregnant, so I wasn't taking it Prior when I found out, I did start taking an Elevate multi vitamin and it actually started making me feel really sick in the stomach, so I stopped taking it.

My doctor recommended that I do take prenatles, but they're just not making me feel good.

What should I be taking.

That's not going to upset my stomach?

And what is the effects of not taking it?

Like I understand the whole spinal cord defects and things like that, but if I'm this late into the pregnancy already and I haven't been taking vitamins, is this going to really affect my pregnancy?

And should I stick it out and have the tummy pains and the bad poos for the vitamins or should I try something else.

Thank you great.

Questions, such a great question, and it does impact problem, yeah, come on problem, and it impacts your enjoyment of that first time if yeah.

So, I think the main thing to remember is that is that the most important thing to be taking in the first trimester is filight supplementation.

And you can get folid as a standalone pill that is very easy to take and doesn't call the problems that you're getting.

So you can get the benefit of folate supplementation, the protection against your tube defects in a pill that you will be able to tolerate.

And that's what I would recommend to anyone who can't take a multivite.

So what's causing the problems?

It's something else in the multivite.

It's usually the iron, And so you don't just take nothing.

You just don't worry about the multivite for a while.

Take the plane folate.

You can get a huge jar of plain folate from Pharmaciess, not expensive, very well tolerated.

Get the benefit of that, and then all the other things rely on your healthy diet and then try and reintroduce a multivite later on if you can.

But folate's the one that you really can't get enough off no matter how healthy your diet is.

But you can't get enough most of the other things by eating meat, fresh fruit and vegetables.

And if you want to be on a male t there are plenty of different ones.

Try a different brand, try a different iron dose, try a liquid instead.

Of a talent any particular time of day.

Yeah, some people find that it makes their morning sickness worse, so you can take it another time of day.

Some people prefer ones that have got two daily doses so that they're not such a big hit at once, but so you get to shop around a little bit.

One of the problems is it's pretty.

Dear, Yeah, and.

To turn around by another ninety dollars.

Exactly, And then if you can't tolerate that one, you're sort of stuck with that job.

But you can certainly get follow it standalone.

And that's what I say to people.

If you if you honestly can't take a multi FIGHTE don't healthy diet, but you still need to follow get that as a standalone.

I also have to say that I can't remember the number of episode, but we'll put it in the show notes.

We had Steph Vlakis from the dietologist who is a whiz on all of this.

So she talked to us about prenatal and pre pregnancy vitamins and minerals, how to take your supplements, how to make sure that you're taking the supplements that you need and you're not just taking in a big bucket of supplements that perhaps you don't need most of them.

So and she offers a consult and I'm pretty sure she still probably has a code for us.

So she offers a consult for people who want to have a personalized nutrition or supplementation plan, and she'll look at your diet and see what's missing.

And yeah, I think that's probably a good way to go.

And you know, in the long run, might actually be more cost efficient have someone tell you what exactly you should be taking.

All right, thanks so much for calling in about that question.

Let's move on to the next caller.

Hi, doctor Paton Bridget.

My name is Rachel.

I am currently six weeks and six days pregnant per the LMP date.

I do know that I ovulated on cycle Dane nineteen, other than the standardized SACLE day fourteen.

I presented to emergency earlier in the week with some bleeding.

They drew my blood and did an ultrasound.

The ultrasound showed a mean nine millimeter gestational sack with a yolk sack present.

However, no feel pole and the HGG was consistent with a six week pregnancy.

The doctors are concerned that my sack is not the size in line with a six week pregnancy, and I guess I would like to understand.

Can it be normal that your hCG levels can be higher than the gestational sack is presenting without it meaning a miscarriage.

I have seen the ranges for HGG and they are very big with some overlapping.

The doctors have told me I have a threatened miscarriage.

At this stage, I'm just trying to understand a little bit more about the data that informs that.

I'm currently waiting for some more blood tests to show hopefully an increasing hCG with an ultrasound scheduled for next week.

Thank you.

Now, this caller left this call two weeks ago, so she'll know the answer.

She'll know the answer by now, and I hope it's gone.

Well.

Look, it's a terrific question because it highlights a problem that we've got of the management of people's anxiety about early pregnancy.

You can image before ultrasounding was invented with someone in this situation, you would we would have gone, I don't know, let's let's just wait and see and either they would continue to bleed and the cervix would open.

That was a miscarriage, or they wouldn't that garry on, They'll still be pregnant months later, and that and that was you know.

So, so by having all this fancy technology, we've created a problem, which is that we we look at pregnancies very very early and people it can create a deal of anxiety.

And I overlay that when you can get onto the internet and see what hCG levels might be.

And yeah, so the call is quite quite correct that there are wide ranges of normal range for BETAHCG.

And that's why we tend to use the BEHCG testing in quite specific scenarios, typically to follow progress.

So healthy pregnancy should go up, miscarriage is likely to go down.

E topics that can stay about the same.

That's extra information.

It's very important to understand that in Australia in twenty twenty five, the management of this problem is an ultrasound diagnosis okay, and the guidelines for doing that properly are there for everyone to see.

Anyone can look them up.

It's called the Australian Society of Ultrasound in Mersine or ASUM, and if you google ASUM building Early Pregnancy DIAG guidelines, there they are.

We'll put them in the show notes to you.

Absolutely, so it says if you've got this exact scenario and a scan that shows this, there are some rules that mean this is a definite miscarriage.

So a sack that's so big without a fetal pole in it, or a fetal pole that's so big without a heartbeat in it, then those things are miscarriages.

You can't have a sack that's so big if there's no baby inside.

If there's no baby inside there, it must be a miscarriage.

They are not with reference to better HG levels, so it doesn't say if the better OTG is this number, then you should be this bregiant no wide.

The normal range is too wide, and you can't use better CG to make a diagnosis in this setting.

You're gonna use ultrasound.

So it'll say that if you're supposed to be if you had a sack of this diameter and they saw a yolk sack, which is a good start, but no fetal pole yet.

Then the appropriate time to re scan this woman is blah blah blah.

Unfortunately to know the answer for sure.

Sometimes that says you should be rescanned in two weeks.

Yeah, it's a long time.

The way it is, it's a long time.

But they've had to put the guidelines at that level to make sure that nobody's diagnosed with a miscarriage who in fact has an early viable pregnancy.

And the reason why we think it's a miscarriages we're just looking too early.

So things to remember, it's trans vaginal scanning and you've got to follow the guidelines.

A s u M.

How you've answered that, it assumes a lot of prior knowledge.

I just want to pick up on a couple of well things, just really quickly seeken to find transferginal probe.

Just yeah, that's that's a probe that's inserted inside your Vagina's.

The ultrasound guidelines are saying it's for trans vaginal scanning.

Yep, feed a pole.

Yeah that's the star little baby.

So you can actually see that on the scan, and that's a bit that's going to have the heartbeat and grown to the baby be hCG.

That's the pregnancy hormone that the Pianistick test works on.

So I expect all my oh our listeners to know all this stuff.

I might pick this up for the first time.

You said they wouldn't be medical jargon.

Yeah, so it's really important that these are ultrasound dignos yep.

Yeah.

And there's a system in place to make sure that we don't tell anybody you've had a miscage.

You should have a creator if they if they haven't.

But also that we don't that we get to a point where we say nap.

If this was a viable pregnancy, it'd have turned up on ultrasound by now.

Yeah.

So for example, in this situation, if they say, right, well, according to these guidelines, you should be scanned to get in twelve days, then at least it won't take longer than that.

Yeah, because in twelve days you'll either have a fetal pole with a heartbeat or you won't.

And there's your answer.

Best of luck.

I hope everything is still positive for you.

Hello.

My name is Teresa and I'm thirty seven and twenty seven weeks pregnant with my first I've been listening to your podcast.

I'm really enjoying learning about all things pregnancy.

I've just got two questions.

One is about placenta encapsulation, the process involved, and if the promoted benefits postpartum are really true.

And my second question is I'm still surfing only about once a week.

It's all I can manage in very small waves.

I guess my biggest concern is am I doing any damage to the baby by lying down on my tummy?

Thanks?

Well, there was a big surge of everyone wanting to have placenta encapsulation around about the time Kim Kardashian said that it all this amazing.

So we haven't had this question for ages, but I think, you know, it's good to talk about.

It might be back out of fashion again.

Yeah, well, you know cycles that'll come back in.

So I did some digging and in twenty six sixteen there was a good research study done, small numbers, but it sort of showed that the tablet from the placenta did have a little bit of iron in it.

Yeah, some micro nutrients, but the.

No what else says iron in?

Yeah?

Just stay yeah?

Yeah?

Yeah.

So the cohort that took the placenta tablet was compared to a cohort that just took a plus ebo, And even though that the placenta tablet had a little bit more iron in it, there was no difference in levels in the in the two groups.

So yeah, it's you know, I think that is My opinion is that this is something that you should do if you want to.

And for some people, doubtless it has a metaphysical benefit, the spiritual benefit, but I think there's zero evidence that has a a health benefit as we understand it.

So, yeah, it's tissue from your body.

It's bound to have some elements in it.

It's probably it's got some iron in this, that and the other Those are things that you can get from the rest of your diet.

And you absolutely do not need to eat the placenta encapsulated or otherwise to be healthy.

The encapsulation process turns a great big percent of the size of a dinner plate into a little pill, and what most of what's in it is going to be lost in that process anyway, and there it's possible that it's not well enough controlled for infection.

And in fact, in America, the CDC.

What's that stand for?

Again?

The Center for Disease Control has put.

Out a warning saying that there's an increased risk of infection from the process of the encapsulation.

Yeah.

I think that like that, when the placenta comes out has to be stored somewhere.

That's not going to be a sterile event.

The encapsulation process may take care of that, but it doesn't.

I think it just comes back to if someone can can is sure that they're getting a spiritual, emotionally emotional, metaphysical benefit from from taking a pill made out of the placenter than sure, but looking for a traditional Western medical benefit, it's not there.

And maybe that spiritual benefit might be from taking it home and planning it under a trait and giving it a little ritual.

Man, it's done a good job.

Yes, So that makes more sense to me.

Actually, I don't think if it's mostly about metaphysics, then we're going to honor it somehow without eating it.

Yeah.

Good and surfing surfing as a twenty seven week Yeah.

So kudos to you for that's fantastic.

I don't see a problem with lying on your front as part of your exercise.

I think that you may not be able to do that comfortably for much longer.

But I don't think it's dangerous.

I think that what you the recommendations about exercise in pregnancy come down to contact sports and the likelihood of you being hit in your belly, and people make decisions at an appropriate part of their pregnancy to reduce the intensity of the exercise accordingly.

Now, there must be some danger in surfing.

If you really got out and the waves are smaller than your chances of being totally wiped out and knocked over is probably low.

But there must be some dangers, and a less expert person might give up surfing a lot earlier in favor of something that has less risk of direct trauma, such as the gym.

More.

Yeah, me, as an inexperienced boogie boarder, I do love booger boarding, but I'm not very good at it.

But you come up to the wave and sometimes the wave as you're trying to get out there, and the wave can catch the board and jam that into you tummy.

Yeah, so this person sounds better out than that, So you know, an individual decision.

Yeah, And you know, living a healthy lifestyle out there in the surf, well that I love that and perhaps yeah, just to reveleks back on your need for the placenta.

So you're already living in a healthy life.

Good, good point.

Yeah, even if the encapsulated placenter had a ton of benefits popes, you don't need them anyway.

Yeah, already, I've got one more for today, pat Let's listen.

Hi, doctor Patton Bridget, thank you so much for your incredible podcast.

I am twenty one weeks pregnant with my second baby.

I had my first one two and a half years ago.

Both pregnancies I have had low pap A.

This didn't seem to impact my first one too much until right at the end, at thirty nine and six, I went in for a standard midwife checkop and my blood pressure was very high.

It definitely wasn't pretty clemsier, but doctors did feel that I needed to be induced due to the high blood pressure in the fact I was at terms, so we were induced and that resulted in an emergency CAESAR due to obstruction of labor at four centimeters.

I guess we'll never know if that was because of his positioning, or his huge head size, or my pelvis.

We will never know.

However, it does make me curious to know if there is any correlation between feedback outcomes when the prior cesarean has been due to obstruction of labor.

I guess I'm just a little bit nervous that the same thing could happen again.

So that's my first question, and my second one is in terms of going post dates.

As I said, I'd love to give my boy the opportunity to go into spontaneous labor and attempt to be back.

However, I also want to keep bub safe and with the low pap A obviously there's that risk of plasenter failure.

So I guess I'm a little bit nervous going over, but curious to hear your thoughts.

I'm curious to hear your thoughts to patterns.

I'm curious to hear my thoughts as well.

That's a lot, Yeah, it's a lot, that's right.

So sorry, I don't mean to downplay that.

That's a lot for this person to be thinking.

That must be just all consuming, I think.

Yeah.

So I think that that raises an important point that we want our listeners to have a high level of pregnancy knowledge, but we don't want those people to think that they have to deal with these decisions on their own.

Okay, there these are discussions to have as a motivated patient, but also with an expert care.

Yeah, so just don't don't have to n all this out for yourself.

No, but you can take the right questions back to your care.

Absolutely, that's the key to Yeah.

So let's talk about the the v back success rates.

I tend this is an unofficial sort of system, but I tend to think about feedback people in terms of good or poor candidates.

And for example, if somebody's first baby was born by cesarean section without labor for say breach or a percent of preview or twins, and there was no labor, then for all we know that person labor is like a complete champion, and we you know they given the opportunity to labor, they might labor great and have a baby Vatinally, there are some people whose firstian section was was performed for obstruct to the labors or non progressive labors in a setting that might be likely to happen again, So a very big baby born to somebody who has another baby with the same partner, for example, And for those people, it's not true to say that v back is necessarily off the table.

It's just going to reduce the chances that the VBAK is going to win in vaginal birth.

And they would have to go very well to achieve that.

And I've talked about that before.

Be super motivated and you know, yeah, I know all the points where other decisions might be made.

Yeah and so, and it really, in my experience, it really does affect someone's decision making that if you say that, look, for all we know this will go, you would go absolutely fine.

And in that situation we estimate that around eighty percent of those babies will be born vaginally.

If we set out to do that, then that's good odds.

People like that the sound of that, and off they go.

If you start to saying to somebody, well it's much in your case, it's much less likely to work.

It's difficult to quantify precisely, but let's say it's so many percent.

Then sometimes they go, well, you know, now I don't like the sound of it that much, because you know, Winno Vbeck's got some rarebit serious risks and I've got to go through that labor and if it's still unlikely to work, perhaps I'm not so Okay, so that's one thing.

It's difficult to quantify, but there are a couple of red flags in this caller's first labor which suggests things that might happen again.

And then the second issue is that of the pape.

Remember having a pape test in early pregnancy has an increasing role in trying to predict who might be at risk of a poor placental performance towards term.

That has to be stacked up against the problem of the fact that the best way to have a vaginal birth from a feback is to come into spontaneous laborate term, and you may need to wait, however long until that happens.

And in your keenness to wait for a spontaneous birth, we may be giving a placenta with a question mark over it more of an opportunity to play up.

So one thing has to be somewhat weighed up against another, remembering that with low pape situation, it's not a simple matter of saying your placenta is going to pack up there should they're sure you should have a section or an induction before that has a dance step, But no, it's just a matter of surveillance, and it may be quite possible to enter into some surveillance to us to establish that the placenter is actually going fine and by yourself the time necessary to come into spontaneous laborate term and give your VBA the highest chance of success.

How do you go, Like, I mean, gosh, there's so much there and obviously she's got to weigh up all those pros and cons.

Yeah, this is obstetric Yeah, but as.

The obstetrician that is telling someone like you can they come in and you can see that in their life what they want most is a vaginal birth and they're so like heartbroken when it is that you sort of laydies facts and figures down and sort of talk to them about it.

Yeah, you get as a people pleaser, you get better at it, you do.

You get better at it, you get I think you get better at sussing out the true motivations of people and the things that are the most important to them.

And it's one of the problems in the public system where you don't see the same care on multiple occasions, is that that level of finesse is probably lost.

Yeah, and you hear words that perhaps if say you got to know somebody wouldn't be using like, you know, this is failure or this is incompetent, or this is yeah, yeah, no, you shouldn't be using those words anyway.

But yeah.

For example, if we get this wrong with some people.

Let's say someone had a cesarian section for their first birth and they are mightily unhappy about that and deeply disappointed and deeply committed to having a vaginal birth on a second time around.

If we lay it on too thick with that person about them being a poor candidate or high risk or so and so forth, without any sort of understanding of their of their internal thoughts on the matter related to their dissatisfaction with the first birth, then sometimes that person might say to the to the hospital system, don't want you at all, and try and have the second baby vaginally at home.

And sometimes some of this is our fault.

We can create dissatisfaction to the point where people make some risky decisions, and that person may have been way better off kept in the camp and said, Okay, have your birth in the hospital.

We will offer you high levels of placental surveillance frequently throughout those last few weeks and help you, to the best of our ability, keep your confidence that the percenta is working properly long enough for you to come into spontaneous labor.

And sometimes it's a bit of a compromise because we're not talking about someone's call better, we're talking about their pregnancy.

It's different.

And especially you know, as we know, there's a lot of people that are choosing to have only two children or only one child, only one, only one, and.

They want it to go.

Well, yeah, you know, if you turn up to public hospital and you've got gallstones, watch gold bladder out, you don't get a say in how that's done.

But this is not that nice different.

Well, best of luck.

I hope you have a pregnancy and birth your second time of your dreams.

I hope, so, I hope.

So all right everyone, that's us for this week.

If you like this type of information, firstly, we have a free newsletter that you can sign up to.

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So I highly recommend everybody getting onto that free newsletter.

We put a lot of effort into it, a lot of thought, and I think it's been really helpful so many people that have already done it.

All right, and until next week, Thanks for listening everybody, bye for now.

Yes.

Hey, even though doctor Pat is well a doctor and we get lots of other doctors and other experts on our podcast, I just need to remind you that this podcast is for informational purposes only.

We share lots of medical insights and experience, but everything we talk about is general in nature and may not apply to your specific situation.

Please always consult with your own healthcare provider for your individual medical advice.

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