Women have been doing it for millennia, but pregnancy and childbirth remain riddled with questions and insecurities for first-time mothers and their families. With options expanding, populations aging and mosquitoes at the door, area professionals explain how to plan a healthy pregnancy for all.


How do you define the scope of your purview—when does the patient enter your care and when do they leave? Kyle L. Garner (Sarasota Memorial Hospital Chief of OB/GYN, and Gulf Coast Obstetrics and Gynecology): Typically, we’ll see patients from the time when they’re starting to think about having a family. We’ll even do preconception counseling for those patients who have health issues. It really starts before they conceive, but then carries through all the way until about six weeks after they deliver, managing other health issues that may arise even after the baby is born—things like breast-feeding support, depression support and general care.


What is the advantage to bringing an obstetrician on board early in the process? Garner: It’s helping to identify certain health issues that may be present in the mother, both medical and genetic, that the parents may want to address prior to undertaking conception. It’s making sure conditions such as high blood pressure, diabetes and weight are under control, making sure they have a well-balanced diet and good exercise—folic acid supplementation is really key before they conceive because that helps reduce the risk of spina bifida. That counseling helps ensure that moms put their best foot forward to conceive and have a healthy pregnancy. Pam Beitlich (SMH Director of Women and Children’s Services): And if they have alcohol consumption or they’re smoking and they’re really starting to plan, you counsel them that they might want to stop. John Abu (SMH Vice-Chair of OB/GYN): The preconception counseling is very important and the key is to make sure that nutritionally they are well-balanced. Folic acid is very important. Most of us don’t eat as well as we should. Obesity is a big problem right now and it could play a role in infertility in some of these patients, in the sense that it changes the hormonal process resulting in irregular periods. And if you don’t have periods, how are you going to get pregnant? Increased weight gain can contribute to that significantly.


Can obesity in the parent negatively affect an already forming fetus? Abu: To some degree it will, though not genetically. We now know that obese patients tend to have obese children, but it also has to do with the environment. The type of food and diet that this person eats will be passed on to the offspring. So if you have poor nutrition as a parent, you’ll end up giving that to your children and that can lead to obesity. Beitlich: More than you might think, Sarasota does have a population of moms that might be on some prescribed medication or illicit medication, even before they know they’re pregnant. A lot of counseling goes into that and making sure they really know what that can do to a baby. Garner: Narcotics are a big problem. It’s the big issue for many of us here and it does have a dramatic effect on babies once they’re born because they go through withdrawal just like adults. The neurological system is developing and it’s an immature system that results in some significant vital sign instabilities and difficulty feeding at this crucial time. There’s a lot of intervention that has to go into making sure those babies survive that early process.


What are the most common lifestyle habits that you find you have to tell patients to pick up or avoid when trying to start a family? Garner: One of the most important is folic acid, along with having a well-balanced diet with fresh fruits and vegetables and a good source of protein. Then the simple things like quitting smoking, a significant risk factor in pregnancy for preterm birth. What I constantly hammer home is that the health of the mother prior to conception directly reflects the health of the pregnancy and the baby when they’re born. 


Through the course of the pregnancy, how often do you prefer to see the mother or expectant family? What do you keep an eye on? Abu: Very often, patients are not sure if they’re pregnant and by the time they see us they’re almost three months along. Up to 50 percent of pregnancies are not planned. We do some typical blood work, confirm the gestational age and how far along they are and then run an ultrasound. Once they’re confirmed, we see them every four weeks until they’re about 28 weeks in, then every two weeks until week 36 and then every week until they deliver. Initially there are things we have to do, like basic blood testing and other tests to rule out things like Down Syndrome and other neurological defects. There are many genetic abnormalities we look for—not typically on everybody, but if you’re at high risk.

Garner: We typically see the patients once a month and divide the testing into three big categories. The first category is testing the mom for any medical conditions. Is she anemic? Does she have high blood pressure, diabetes or any infections that may affect the pregnancy? A few weeks later, we start testing the baby to see if anything is wrong. We start genetic screening, offering early ultrasounds to look at the structure of the baby and make sure that the baby is developing normally. The big ultrasound where you find out what you’re having is usually around 18 to 20 weeks. We can see not only if it’s a boy or a girl, but the internal structure of the baby to make sure [the baby is] developing the right way, because that may translate into needing additional evaluation and consultants to manage those issues or to being delivered in a hospital that can deal with those kinds of anomalies. The final phase of testing usually happens around the 28- to 30-week mark to look if the pregnancy has caused any health issues in the mother.

Beitlich: At that point, you start talking about your birth plan. We try to do a lot of work around that with moms in the community so they know we’re very active with vaginal births. We went through a phase in Sarasota of higher C-sections and we’re trying to do a lot around low-intervention. Whatever you want it to be is what we’d like it to turn into. Garner: And people are taking more ownership. There’s more knowledge out there about the experience that they want and that discussion starts happening. Patients may have the perception at the beginning of “I want an all-natural birth,” but through those evaluations finds out there’s a serious medical condition or fetal condition that’s going to preclude this perception. That’s a lot of what we do as obstetricians—help guide those mothers through that expectation of what they want when they start off excited and then find out halfway through that there’s something wrong with the pregnancy. We negotiate that to make sure she knows what’s going on and still ends up with our final goal of a healthy mom and a healthy baby.

Beitlich: We have a Level-3 neonatal intensive care unit and we have high-risk maternal fetal medicine here so we can handle those high-risk things, but we also then do a lot of collaboration if we’re going to deliver that baby. Not a lot of hospitals are able to do that. Garner: It takes a lot of coordination and that’s the obstetrician’s job. The vast majority of moms are healthy and end up having a healthy baby with no intervention at all. We’re here to identify that small percentage of moms who have major complications and end up with significant issues in the pregnancy. Beitlich: About 10 percent of our births go to the NICU [Neonatal Intensive Care Unit]. It’s not high. Abu: The coordination is very important and that’s something patients don’t see. There is a lot of effort behind the scenes. When someone has a high-risk pregnancy, specialists are involved, following the baby on a routine basis and communicating with the physician. At the same time, we communicate with a neonatologist that we may have a baby with these problems coming. Then before the baby is born they speak with the mother. And once the baby is about to be delivered, all these specialists are available. There’s a lot of coordination.


When it comes to the delivery, options range from hospital birth to home birth to water birth to who knows what. What are the pros and cons of each and are there any you particularly recommend or discourage? Garner: Everybody has their own opinion on that and there has also been fomented an inherent distrust in the establishment medical community. For whatever reason, we’ve become an anti-establishment culture. We see it in our politics and we see it in our hospitals. People are looking towards alternative care as a viable model for providing health advice and care in the community. That’s broken down here in Sarasota basically as having the home birth option, a birthing center option and a hospital birth. The home birth option is literally “I have no resources other than maybe a few I’ve brought and I’ve had my attendant, doula or midwife come and help me do this.” You have very few resources to deal with any complication. You hear the stories like, “I was in labor for 45 hours and pushing for five.” These moms are at huge risk for having postpartum bleeding. Do you have the resources to manage a mother bleeding to death in your own home? You don’t have access to huge amounts of IV fluids and medications and a blood bank and the surgical intervention that may become necessary. Beitlich: We’re all in this for the same reason—to have a healthy mom and a healthy baby. You have two patients that you have to be aware of. And with that prevalence of people looking at home births and birthing centers, we’ve done a lot to collaborate with providers in the community. Our goal is to ensure that they’re seeing low-risk moms.

Garner: The birthing center is an intermediary. They have a few additional resources but the problem in our minds is that you are still faced with the small percentage of moms who need some more drastic intervention and don’t have those resources available to address them. And then you have the hospital, which is the greatest of interventions. The problem has been that hospital intervention tends to be very sterile from an emotional standpoint and patients tend to feel like they come into the institution and they’re treated like a number—treated like cattle—and basically lose all control of the experience they want. We created that model over the last decade because we’ve seen higher and higher Cesarean section rates and more intervention from an obstetrician standpoint without seeing if it improved our outcomes. We thought it did, but over the past few years we’ve realized that’s not true. That kind of high intervention really isn’t resulting in better outcomes for moms and babies and that’s led people to say “I don’t want that.” Beitlich: We’ve done a lot to accommodate the environment. We moved from the oldest part of the hospital and now have three floors in the new courtyard tower. And we worked really hard with our staff and got input from patients about what they wanted those rooms to look like.

Garner: It’s become an important process for the hospitals to try and strike that magical balance between the experience the mom wants and being a less- intervention institute. But with regards to the home birth and birthing center births, it’s clear to me that, if you can strike that balance of lowering your intervention and giving mom the experience they want, the hospital is the ideal place. You have all the resources so that when you have a complication you have a better outcome. Looking at the risks associated with the alternatives, babies born outside of a hospital have almost a two-and-a-half-fold increase risk of death in the first three to four months of life and you have a ten-fold higher rate of having an Apgar score of zero, which is the initial score of how a baby is breathing and stuff like that. You’re four times more likely to have neonatal seizures if you deliver outside of a hospital. The hospital is a great place, we just have to strike that balance and meld those other two experiences to give that positive experience in the hospital. Beitlich: We want to give [patients] the things they want. They can get up and walk around the unit the whole time, we have birthing balls, we have several rooms with tubs for pain control—we’ll do whatever. But should something happen, we are right down the hall and able to get that baby out in an emergency. Abu: To clarify, we have tubs and the patient can labor in them if they want, but we don’t do water delivery. The American College of Obstetrics completely discourages that and is not in favor at all. We don’t do that and it’s not encouraged or recommended.


Why is that? Abu: Because there’s no research for it and there are a lot of complications that can come with it. You can stay in the tub while you’re laboring, but once you start to deliver we get you out. Garner: The thought is that a water birth is more gentle for the baby and that the babies have an easier transition. Abu: But there’s no evidence for that. Garner: No evidence whatsoever. Abu: They could drown. Garner: As a matter of fact, there’s concern that you’re exposing the baby to aspiration because they might try to take their first breath underwater. You may have contamination because of bacteria, blood and fecal material in the tub increasing the risk of pneumonia. There’s limited evidence that it’s good and there’s some evidence that it’s harmful. 


Many women are also becoming mothers later in life. Is this something you’ve noticed and does that present challenges? Beitlich: Absolutely. Garner: They’re getting older. You’re seeing moms who are 30, 40 and 50 years old having babies. Abu: I just had a patient this week—51 years old. The challenge is that the older you are, the more likely you are to have medical issues compounding your life. We’re not meant to have babies at the age of 50. Anemia, hypertension, diabetes, heart disease, connective tissue diseases like lupus—those things have an effect. Beitlich: It’s a bigger physical strain on your body. Garner: There’s a huge metabolic expenditure to grow a human being and, just like when you’re 20 you can run five miles, drink all night and then do it again, at 50 years old you can’t do that. Beitlich: Although I have met some 50-year-old women that are in fabulous shape. It just depends on the woman and her health. You can still have a baby if you can conceive. Garner: But there are other factors. There’s the genetic risk. As you get older, babies are more likely to be genetically anomalous, more likely to have Down Syndrome or trisomy. When you’re 20, your risk is one in 300 or 400; when you’re 35, your risk is one in 200; but when you’re 50, your risk is one in eight. That rate dramatically increases. Plus you have things like peripheral vascular disease that happen in our bodies as we all age and our eyes go bad, fingers go numb, joints start hurting. That same aging process happens in the uterus and the uterus isn’t as able to withstand a pregnancy and because of that the babies don’t grow quite the same. Older mothers have increased risks of intrauterine growth restriction, preeclampsia, high blood pressure and the pregnancy itself is far more complicated. I may have a 50-year-old triathlete; it doesn’t matter—she’s still at increased risk because her uterus is 50 and not 20.


In the past, there have been questions and mistrust surrounding anesthesia and pain medication during labor, typically over concerns on the effect on the baby. Is this still an issue and is it something expectant mothers should be worried about? Abu: They are good questions, but they are not serious issues. When a patient comes in we also have an anesthesiologist see the patient, interview them, look at risk and determine what they want. We have IV medication for those who want it. Some don’t want anything and that’s great and others say they want an epidural and that’s great. If you don’t want that, we have nitrous oxide. That’s something we started about a year ago and it’s worked very well.


There’s no issue with transference to the baby or anything like that? Garner: There are some risks with IV medications. It goes through the mother’s veins and gets transferred to the baby. If you give those too close to the delivery, those babies may come out sedated and they have a difficult time breathing sometimes. We’re trying to find alternatives and that’s where the nitrous oxide has come in. The nice thing is that it’s rapid onset but out of your system in a minute or two so there is really no effect to the fetus. Regional or epidural is only in the nerves of the spine, so it doesn’t get transferred to the baby. They affect the baby in that they affect the mom’s circulatory system and can cause the mom to have issues with low blood pressure that can translate to the baby not getting as much oxygen or liquids that it needs. There are signs that we can see and then fix that. Beitlich: We like to have different options. Some moms come in and don’t want anything but if they’ve never been through labor before they may change their minds. Being the only woman in the room, I’m all about women A) being listened to about what they want and B) having options. I want them to have as many options as they need. We’re there to provide.


Are obstetricians in the area or Florida in general worried about the Zika Virus? Abu: Yes, to some degree, but not that much. It’s not going to affect us like it does South America. Garner: The Zika Virus definitely has the potential to be affecting a lot of women in our community, as we are a subtropical climate. At this point, there is no evidence of Zika being here in the mosquitoes. The cases that have been here in the US have all been from people who traveled abroad and brought it back. Eventually we do believe it will make its way here and when that happens it’s going to be concerning for moms who are either pre-conceptual or trying to conceive. However, it’s relatively easy to prevent—you just wear long sleeves and use DEET-containing insect repellant outside and just inherently many of us tend to be inside most of the time. If you’re not out there exposed to the mosquitos, you’re not going to get it bad. In places like Brazil, mothers are often outside. They don’t have windows on their cars or home; they don’t have air conditioning. They live in a different culture that more rapidly allows these viruses to promulgate. Abu: You have to ask patients if they’ve traveled over the last two weeks because the effect will be felt within the first two weeks. If you go six months ago and then have a cold, I don’t suspect that you have Zika. But if you’ve been there two or three weeks ago, then I would be suspicious. Garner: We’re aware, but not concerned.


Word with a Doula

Speaking with Cheryl Kindred, labor and postpartum doula and founder of Sarasota Mother Care and Maiden to Mother.


How do you envision the role of the doula through the course of a pregnancy? What is the primary responsibility? Kindred: A doula’s role is to support the birthing family. She does that during the pregnancy with education, resources and comfort measures through both in-person and remote support. In labor, she is on call and available to support the family and help them work together to create a team environment with whoever their care providers are and in whatever birth setting they are most comfortable. She’s one person who’s unbiased, who doesn’t have any agenda and is just there to support the mother and make her feel safe, comfortable, heard and in control. After the birth, the doula can step into a role of postpartum doula as opposed to labor doula. And that’s another place where doula support really shines because a postpartum doula comes in when everybody else leaves and can help a woman transform that postpartum experience from what the modern media tells us it is, which is scary and sleep-deprived, into a transition where she feels confident and capable as a parent and her family is able to find their new normal.


It seems like very personalized care. Kindred: One of the biggest things that we do is individualized care. It’s important that the doula’s care to each family is centered around their needs. So if the client is a VBAC—vaginal birth after a Caesarean—our care is going to focus on avoiding a Caesarean and what happens if a Caesarean becomes necessary and how to make that a positive experience. If it’s her first child, it’s going to focus a lot on describing and helping her understand what this process is going to be like and what the variations of normal are.

Is nutrition something that the doula works with? Kindred: Absolutely. We talk about normal weight gain and body image because that’s a huge thing. Pregnancy is usually the first time someone is really experiencing their body being out of their control. We talk a lot about making healthy choices, when indulging is good and normalizing the whole pregnancy experience. 


What role does the doula play on the big day? Kindred: The doula is never in place of a medical care provider. A doula is there to provide non-medical support. The woman still has a doctor, nurse midwife or licensed midwife depending on what her choices have been. The doula is a complimentary role. She’s there to provide support, which can be very physical. We can do counter-pressure, support her belly and help her get through those contractions and rest in the breaks in between. The doula works right alongside the mother’s partner to help them be a great support person too, because labor is a huge opportunity for connection between a couple.


How do you work to bring the whole family together on this? Kindred: That’s something really important—it’s not just the woman becoming a mother; it’s the family becoming a closer unity. Often partners are nervous about how they can best support the birthing woman. We are there to help them know what to say, when to say it and when to be close and give her a hand to hold and your eyes to focus on. We facilitate all those moments of connection so that the father or grandmother or second mother can go into being a parent more comfortable and confident.


What is the best way to navigate the portpartum stage? Kindred: There is so much that’s new in the postpartum stage. Pretty much no one has a 24/7 job and we’re not used to that. When you become a parent, you now have a 24/7 job. It’s a lot of weight and can be overwhelming. The postpartum doula is there to provide practical support. She can help around the house and make sure that a recovering, nursing mother is eating well, staying hydrated and taking care of herself so that her body can recover from childbirth. She’s there to provide emotional support and listen to what’s going on in her life. The doula helps her navigate what is right for her unique family. We work alongside big siblings, extended family and partners so everyone can feel comfortable with baby care, comfortable with what postpartum depression symptoms are. They feel comfortable and confident going for additional support and the postpartum doula becomes the bridge. The postpartum doula is available throughout the first year to make that postpartum stage something that can be joyous and celebrated. 

About Our Participants

L. Garner, MD: A graduate of Davidson College, Dr. Garner earned his medical degree from Wake University/Bowman Gray School of Medicine before moving on to the University of Tennessee, Memphis for a residency in Family Medicine and a fellowship in Obstetrics. Garner currently serves as chief of Obstetrics and Gynecology at Sarasota Memorial Hospital and is a practicing physician with Gulf Coast Obstetrics and Gynecology. 

Pam Beitlich, RN: With more than 30 years experience in patient care and nursing administration, Beitlich serves as director of Women and Children’s Services at Sarasota Memorial Hospital. With nursing degrees from Hesston College, Goshen College and the University of South Florida, Beitlich was also one of the first coaches for the Studer Group healthcare coaching.

John Abu, MD: An obstetrics hospitalist with privileges at multiple area hospitals, Dr. Abu earned his medical degree from the Medical College of Ohio in Toledo before continuing on to Mt. Sinai Medical Center for both his internship and residency. Dr. Abu currently serves as vice-chair of the Obstetrics and Gynecology department at SMH.