Self-Care-Program for pregnant women

Prof. Erich Saling MD FRCOG, Jürgen Lüthje MD
and Monika Schreiber MD
Institute for Perinatal Medicine, Berlin, Germany
(Translation into English: Amos Grunebaum MD FACOG, Cornell University, New York)

Introduction

Pregnancy is a time of happy anticipation and planning, but it’s also a time of doubts and concern. The biggest worry which future parents have is naturally the concern whether their baby develops normally and arrives in a healthy condition. The chances of having a healthy baby are optimized because early recognition of abnormal developments in the course of pregnancy can be achieved by modern regular prenatal care.

However despite good prenatal care the rate of prematures (<37 gestational weeks) in Germany has increased from 7.1% in 2001 to 9,4% in 2004 and e.g. in the USA from 11,9% in 2001 to 12,3% in 2003. Despite the progress of neonatal intensive care medicine, babies born very early, especially those before 32 weeks of pregnancy often have severe problems during the early neonatal period as infants and possibly throughout their lives. It is therefore important to do everything possible to prevent the child and the whole family from having to cope with such a heavy burden.

There are some observations and examinations which you can do yourself at home to prevent a threatened preterm birth. That’s why we developed a Self-Care-Program for pregnant women in addition to our Prematurity-Prevention-Program for physicians. The explanation is simple: During regular prenatal care the physician sees a pregnant woman usually only once every 4 weeks. But within the framework of the Self-Care Program the pregnant woman can examine herself much more frequently, every 3-4 days. Chances are therefore improved to diagnose and solve potential problems much earlier.

Since it’s introduction in 1993 approximately 10.000 pregnant women have participated in our Self-Care-Program. About 3000 mothers returned the questionnaire after the end of the pregnancy. 1,120 of them have been multiparous. The rate of extreme prematurity (birthweight under 1,500 grams) among the multiparous was significantly lowered from 7.8% in the immediate prior pregnancy to 1.3%.

After this study two large campaigns with our program were performed by U. Hoyme and coworkers. These campaigns led to a significant decrease of prematurity rates:

The first was carried out in Erfurt (the capital of Thuringia, Germany), where pregnant women have been offered to perform self-measurements of their vaginal pH by means of test gloves. Patients who were not interested in participating served as a control group. In this study, the prematurity rate was 8.1% in the self-measurement/intervention group and 12.3% in the control group. Likewise, 0.3% versus 3.3% of the neonates belonged to the group of very early prematures with a gestational age of < 32+0.

Encouraged by these results, in 2000 a similar pH screening campaign was initiated in the whole state of Thuringia, in order to reduce prematurity. A significant reduction of early prematurity from 1.58% to 0.99%, and a significant reduction of low birth weight cases in all groups was achieved.

After this campaign had been finished, the prematurity rates monitored in 2002 were as high as they had been prior to the introduction of the activities. That’s why the new Thuringia prematurity prevention campaign 2004/2005 started on September 1st 2004.

The success rates are inasmuch a breakthrough, as for decades no other simple approach has been successful in significantly and permanentely reducing prematurity rates on a large country-wide level. One important factor is that no other measure has been able to identify such an early stage of the prematurity process and to intervene so early with successful countermeasures.

Please note that the Self-Care-Program for pregnant women is an additional step to regular obstetric prenatal care visits.

How can you prevent premature births?

Ascending vaginal infections are responsible for a large percentage of premature births. These infections can spread into the uterus and may be responsible for changes of the cervix and early contractions, premature rupture of membranes, and ultimately premature delivery. They may also lead to infections of the unborn child. Infections can also be responsible for late miscarriages (miscarriages after the 12th pregnancy week).

Therefore every pregnant woman should self-examine and observe herself at home to find possible clues which may help her identify a threatened early or late miscarriage.

How can you identify a risk of vaginal infections earlier than before?

In the vagina there is a normal flora of organisms with an equilibrium between the large numbers of normal lactobacilli and the smaller numbers of other possibly harmful organisms (other bacteria, viruses, yeast). Your body’s own immune defenses make sure that there are not too many of the other organisms. This defense system is supported by the lactobacilli. They produce lactic acid which creates an acid environment in the vagina which keeps most of the critical organisms at bay.

The amount of acidity in the vagina is indicated by the ”pH value”. The more acidic a fluid, the lower the pH value. Normal pH values at the entrance of the vagina are between 4 and 4.4.

Sometimes the number of lactobacilli decreases due to a weakening of the immune system, due to unfavorable external conditions or they are decreased by the invasion of other organisms. Most of these cases can be recognized by the increased pH-value at the entrance of the vagina: It rises above 4.4.

A pH level of over 4.4 can be an indication of a a significant decrease of lactobacilli (so-called vaginal milieu impairment or vaginal dysbalance) which is often a precursor or already the actual stage of an infection. Therefore there is an opportunity to identify and treat such disturbances or vaginal infections, before they lead to complications.

Please note that some organisms are able to multiply even in an acid environment. And that an acidic vaginal environment (e.i. a normal pH) does not guarantee complete safety, but a normal vaginal milieu provides a good protection against most organisms associated with premature births. Also fungi, can grow in an acidic environment. Although they are not usually responsible for premature births, they can support vaginal dysbalances, therefore countermeasures are indicated.

If you self-examine yourself, you can do it at much shorter intervals than is possible within the usual prenatal care visits and thus identify the initial changes of the vaginal pH much earlier.

How do you determine your own vaginal pH?

The CarePlan®VpH test glove has been developed with our collaboration to measure the vaginal pH. A test strip whose color changes according to the pH is located on the index finger of the CarePlan®VpH test glove. You can perform this measurement at any time of the day and it is simple to use.

Put the glove on your right hand (even if you are left-handed) so that the test strip is on the inner side of your index finger. You should not touch the strip with wet fingers as this may give you a false result. Introduce the index finger about 2-3 cm (about one inch) into your vagina (no more than 3 cm as this may give you false information because the pH value is normally higher deep in the vagina) and then turn your index finger several times back and forth to make sure it gets well moistened inside the vagina. You can try different positions to make this easier such as standing, with one foot raised on a chair.

Illustration: Insertion of the test glove

Remove your finger from the vagina and immediately compare the color of the test strip while it’s still moist with the color-scale (see illustration) and identify the correct color and the corresponding pH. The value is normal if it corresponds to the yellow color of the pH values 4.0 or 4.4.

Throw the used glove away, it consists of biologically self-destructing polyethylene (PE). To prevent loss of information we suggest that, immediately after you read the results, you write down all pH values and the date of measurement on the accompanying sheet. Take the information with you to each prenatal care visit.

Please notice that you should continue to measure your vaginal pH even when you take antibiotics (even vaginally applied antibiotics). Don’t be alarmed if the vaginal pH rises. The reason is that antibiotics not only destroy ”bad” organisms but they can also destroy the “good” lactobacilli. If the pH is rising you may want to start a vaginal acidifying therapy. You may also want to get treated with lacobailli preparations after you completed the antibiotic therapy. For both therapies it is necessary to talk to your doctor, though.

What should you do if the pH is too high?

Don’t be alarmed just because the vaginal pH value rises above the normal value. For example, the vaginal pH can normally change after intercourse because of the alkaline ejaculate. You should therefore wait for at least 12 hours after intercourse before you measure the vaginal pH, unless condoms have been used. Another reason for a high pH could be a possible contamination with urine (urine can have different pH values).

If you get a high pH value you should repeat the test several hours later or wait until the next day. If the vaginal pH continues to be higher than the norm, you should make an appointment to see your doctor to evaluate the possible cause of the elevated pH.

In the presence of elevated pH values we suggest to use condoms during intercourse to keep the risk of an ascending infection as low as possible.

When and how often should you measure the vaginal pH?

It’s suggested that you measure the vaginal pH starting from the beginning of the pregnancy until at least the end of 34 weeks gestational age, but optimally until delivery, because even a mature baby may have infection risks. Even if you hear about our program for the first time late in pregnancy, it may be worthwhile to start testing late.

In general, it’s sufficient to test twice a week if you have an uncomplicated pregnancy. For your own peace of mind there is no contraindication to test more frequently. This is usually recommended if you had vaginal infections in a prior pregnancy. If you are at increased risk of delivering a premature baby, it makes sense to test more often than twice a week.

When is there an increased risk of prematurity?

In some women the risk of prematurity is increased because of events in the past or present pregnancy (see table 1). In those cases increased vigilance is necessary.

If you previously had one or more premature delivery or stillbirth please read our information about the “Early Total Cervix Occlusion (ETCO)”

Table 1: Risk factors

What are the warning signals of a threatened premature birth?

You should contact your obstetrician immediately if you notice any of the following:

• Repeated measurement of a vaginal pH of 4.7 or higher. Especially high pH values can be caused by amniotic fluid in the presence of premature rupture of the membranes. (If you suspect that your water has broken you should contact your doctor immediately or go to the hospital).
  
• Vaginal spotting or bleeding
  
• Increased or foul smelling vaginal discharge ( a small increase is normal in pregnancy)
  
• Frequent urination ( a moderate increase may be normal in pregnancy) or a burning sensation during urination
  
• Itching or burning in the vagina or genitalia
  
• Fever and/or diarrhea (with these you may often have increased activities of the uterus)
  
• Premature contractions:
  • menstrual-like pains
  • pulling in the groin or sacral area
  • intermittent hardening of the lower abdomen

More than normal contractions include those which occur more frequently than twice per hour or more frequently than 10 times per day.

What can you do to prevent vaginal infections?

The likelihood of infections in general as well as infections of the vagina is often increased in pregnancy because of hormonal changes. But there are precautionary measures:

A warm environment without much exposure to air supports the growth of candida. Therefore don’t wear too tight clothing, and don’t use plastic covered panty liners. You should preferably wear natural clothing, like cotton. Do not use any vaginal douches and don’t introduce foreign substances into the vagina (e.g. no sprays or gels) unless they are prescribed by your doctor.

Concerning your nutrition: Healthy food which provides your baby with the best nutrition is also best for your own body’s defense system. Preferably you should drink milk and eat milkproducts, whole wheat products, vegetables, potatoes, low-fat meat, fish, and foods rich in unsaturated fatty acids. You shouldn’t feel too guilty about each piece of chocolate or cake that you eat. But you should consider that both sugar and white flour products can benefit yeast. For your convenience we have listed some web pages concerning nutrition in pregnancy, but we can’t take any legal responsibilities for their content.

Pregnancy nutrition frequently asked questions
http://www.fensende.com/Users/swnymph/Nutrition.html

The labor of love
http://www.thelaboroflove.com/websearch/Pregnancy/Nutrition/

Amerikan College of Obstetrics and Gynecology
http://sales.acog.com/acb/stores/1/product1.cfm?SID=1&Product_ID=84
(booklet costs $ 20)

How can you protect yourself against strong pressure?

Pregnancy is a natural event. But the growing small human being in you requires a lot from your body and soul. Try to prevent exposure to strong physical work and emotional stress. As long as you feel fine there is no need to protect yourself too much.

Your work and which work you can do is usually regulated by pregnancy guidelines. When in doubt ask you insurance company.

Emotional stress can often not be easily prevented, but you should get help from family members, friends or see a counselor. Moderate physical exercise such as walking and swimming can often be a good stress reducer after a stressful day. You should discuss with your doctor who knows your medical history best which sports activities are recommended for you.

Where can you obtain the test gloves?

You can buy the test gloves in most pharmacies (chemist shops) in:

• Germany
• Chile

Careplan VpH Test Gloves are also available internationally via distributors. For further information, please visit www.clearview.com or email service@invmed.de

If you understand German and live in Europe, you can take part in our Self-Care Program and order the gloves and information material at our institute at a reduced rate (please visit our German page for further information).

In all other cases, please contact service@invmed.de.

www.saling-institut.de
© 2005 Erich Saling-Institut of Perinatal Medicine, registered company
Content is copyright protected. All rights reserved.
The information obtained from our internet homepage does not in any way provide a replacement for the personal advice and care given by your own physician.
Please read our legal information and the notice about making quotations. Imprint

This page was last edited on 24.09.2009