Self-Care-Program for pregnant women

Erich Saling MD FRCOG, Jürgen Lüthje MD and Monika Schreiber MD
(Translation into English: Amos Grunebaum MD FACOG, Cornell University, New York) 		 
Introduction
Prevent preterm births
Identify vaginal infections
How to determine vaginal pH
pH too high
When to measure vaginal pH
Increased risk of prematurity
Warning signals
Prevent vaginal infections
Protection against strong pressure
Obtain test gloves

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 preterm babies (< 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, 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 more than 9000 pregnant women have participated in our Self-Care-Program. More than 2000 mothers returned the questionnaire after the end of the pregnancy. 1120 of them have been multiparous. The rate of newborns with very low birth weight (under 1500 g) 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 preterm birth 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 preterm babies 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 preterm births. A significant reduction of preterm births < 32 weeks 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 preterm birth 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 permanently reducing preterm birth 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.
 Top of page

How can you prevent preterm births?

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

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.
 Top of page

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 4.0 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 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 (i.e. a normal pH) does not guarantee complete safety, but a normal vaginal milieu provides a good protection against most organisms associated with preterm births. Also fungi can grow in an acidic environment. Although they are not usually responsible for preterm births, they can support vaginal dysbalances, therefore countermeasures are indicated.

If you 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.
 Top of page

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 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.

Insertion of the test glove

Fig. 1: 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.

Test glove with color scale

Fig. 2: Test glove with color scale

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 lactobacilli preparations after you completed the antibiotic therapy. For both therapies it is necessary to talk to your doctor, though.
 Top of page

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 on 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.
 Top of page

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 preterm baby, it makes sense to test more often than twice a week.
 Top of page

When is there an increased risk of preterm birth?

In some women the risk of preterm birth 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 preterm delivery or stillbirth please read our information about the “Early Total Cervix Occlusion (ETCO)”

Table 1: Risk factors

a. Prior events
  • One or more preterm birth or stillbirth
  • Two or more pregnancy terminations
  • A prior cervical conization (removal of tissue in external cervical os)
  • Prior vaginal infections
  • After infertility treatment

b. Events in the present pregnancy
  • Multiples (twins, triplets, etc.)
  • Increased amniotic fluid (polyhydramnios)
  • Certain pressure situations (professional or private, physical or emotional)
  • Smoking
  • Regular alcohol consumption or use of other drugs (also excessive consumption of stimulants, such as coffee)
  • if you have inflammation of the gums (parodontitis)
 Top of page

What are the warning signals of a threatened preterm 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)
  • Preterm 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.
 Top of page

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, that can be washed at 60 °C. Do not use any vaginal douches and don’t introduce foreign substances into the vagina (sprays, gels etc.) unless they are prescribed by your doctor.

A well-balanced diet which provides your baby with the best nutrition is also best for your own body’s defense system.

  
 Top of page

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.
 Top of page

Where can you obtain the test gloves?

Unfortunately, due to delivery difficulties of the manufacturer, the CarePlan VpH test gloves for pregnant women's self-care are not available at the moment. more ...