Preventing another preterm birth

I mentioned last week that in preparation to conceive another baby I intend to do everything I can to best prepare my body to carry our next baby to term. Most importantly I want to have a healthy baby.  Also important, I want to avoid a stay in the NICU and I want to have the opportunity to experience another birth at home.

I trust midwives and believe in the midwifery model of care. There is one freestanding birth center in Richmond and I was excited to learn that I could go there for my annual exams and for other women's health issues not in the context of pregnancy or postpartum care. I don't plan to give birth at the birthing center, but I am grateful to have the option to work with women who share my values and beliefs around well-woman care.

I brought in a list of questions I had been gathering related to preventing premature rupture of membranes (PROM) and preterm birth and we chatted at length about what exists in the literature and their experience and observations around these topics.  For much of the conversation there were two midwives in the room and we had a little pow-wow reviewing my birth histories, and discussing a plan of action moving forward.

My midwives are collaborating with me, not dictating, and I'm driving my care. There's no telling the course of my next pregnancy, but I do feel like I can use the evidence that exists as a guide to facilitate a better outcome.

There are many known risk factors for preterm birth and I only detail here the ones that are personally relevant, but you can read a comprehensive list at the March of Dimes website.  Having had one preterm birth puts me in the greatest risk category for having another preterm birth, so I'm taking this seriously.

My research is still evolving, but there are definitely some things that we know:
Child Spacing: pregnancy spacing of less than or equal to 12 months is associated with higher incidence of PROM and premature birth. 
Testing Positive for GBS: women who are GBS+ are more likely to experience PROM
Circulating autoantibodies: women who have circulating antibodies in their bloodstream (thyroid related) are less likely to carry to term and more likely to miscarry.
Bacterial Vaginosis and other infections: highly correlated with PROM

Nutrition also plays an important role in healthy pregnancies and healthy babies.

Possible nutritional preventive measures include: fish oil, iron, magnesium, and zinc, as well as folic acid, bioflavonoids (orange pith!), selenium, vitamin C, and higher protein intake. Some of these vitamins and minerals are associated with strengthening the amniotic sac, which is protective against infection and PROM, while others boost the immune system. I doubt that the exact mechanism for each of these is clear, but the greater body of literature shows significant positive associations, even if small.

With Roscoe, my first sign of labor was when my water broke around 1:00 in the afternoon at 38 weeks and 2 days. Still considered term, but on the early side, especially for a first baby.  My labor was very fast at 5 hours and 23 minutes. Similarly, my water broke around 1:00 pm with Merritt, although much earlier in the pregnancy. A midwife adage that mine relayed is: A water that breaks at night is labor. A water that breaks in the day is something else (infection, a malpositioned baby, etc.). That is not to say that labor won't proceed as a result of the PROM but that labor wasn't the primary cause of the water breaking.  Eight to ten percent of women experience PROM as the first sign of labor, so while common it is not normal.

Here is my plan:
1. I am giving my body more rest time between pregnancies. The spacing will probably be around 24 months.
2. I will wean Merritt before I conceive again. I know that many momma's nurse older siblings through pregnancy with no problem. I nursed Roscoe through my pregnancy with Merritt, and I will never know what affect it may have had, but since my amniotic sacs may be weaker, and nipple stimulation can induce uterine contractions, it's something that I am choosing not to do this time.
3. My practitioners will be aggressive from the start to screen for potential vaginal infections
4. I will follow the Brewer Diet advocated by Dr. Bradley. My midwife did note that she doesn't typically suggest 100 grams of protein for her momma's but that given my risk factors she definitely would.
5. As we always have I will be working closely with my endocrinologist to ensure that my tsh levels are in the normal range.  This is the best protection against high levels of circulating autoantibodies.
6. I'm going to be more diligent about flossing my teeth, and gum health in general, including visiting the dentist more regularly. Periodontal disease is highly linked to preterm birth.

In addition to a prenatal vitamin, I will take supplements for vitamin c, fish oil, iron, and folic acid. I want to investigate further selenium, magnesium, zinc, and maybe bioflavonoids (an herbal supplement), especially optimal dosing. My preference is to take in the necessary vitamins and minerals through food rather than supplements, and bioflavonoids aren't regulated.

I will continue to exercise through this next pregnancy, as I did with the other two. I will also do my best to reduce unnecessary emotional stresses (no plan yet for how to accomplish this!).

Are you aware of any other evidence-based steps that I can take?  If you experienced PROM or premature birth with one of your babies did you have a similar experience in subsequent pregnancies?  Did you do anything differently?