In this episode I am excited to welcome Nicole Phelps! Nicole is a philanthropist who spends the majority of her volunteering with the Michael Phelps Foundation, which promotes water-safety, healthy living, and the pursuit of dreams. In addition to her efforts with the Foundation, she also supports events and programs with Make-A-Wish and Operation Shower among others. A mother of three boys, Phelps is a “Mommy Advocate” and works to bring awareness to the challenges of motherhood by sharing her personal experiences through content campaigns, social media platforms and speaking engagements. A former marketing professional with YP, Phelps graduated with honors from the University of Southern California’s Annenberg School of Communications and Journalism and also cultivated a successful career in pageantry, being named Miss California USA 2010. She currently resides in Paradise Valley, AZ with her husband, Michael, their three sons (Boomer, Beckett, and Maverick) and two French bulldogs (Juno and Legend).
Hear Nicole share her pregnancy and birth stories, and particularly her experience with cholestasis during pregnancy – a liver condition that can cause severe itching and other symptoms, and carries the risk for serious complications including stillbirth. We discuss the evidence on cholestasis, and the vital members of Nicole’s birth team who helped her along the way.
Connect with Nicole Phelps on Instagram and Twitter.
Follow the Michael Phelps Foundation here.
For more information surrounding ICP, visit ICP Care, a nonprofit resource dedicated to help pregnant mothers who experience Intrahepatic Cholestasis of Pregnancy.
For more information and news about Evidence Based Birth®, visit www.ebbirth.com. Find us on Facebook, Instagram, and Pinterest. Ready to get involved? Check out our Professional membership (including scholarship options) and our Instructor program. Find an EBB Instructor here, and click here to learn more about the Evidence Based Birth® Childbirth Class.
Research on Cholestasis during Pregnancy
Listen to the pronunciation here
Chole = bile, stasis = not moving around much
Bile is what the liver produces and stores in the gallbladder, and it helps break down and aid in the digestion of fats.
Cholestasis during pregnancy is also sometimes called:
- Intrahepatic (within the liver) cholestasis of pregnancy
- Obstetric cholestasis
- Pregnancy-related cholestasis
- Recurrent intrahepatic cholestasis of pregnancy (when the conditions returns in future pregnancies)
What is cholestasis during pregnancy?
- It is a liver disorder that occurs in pregnant people
- The liver makes a digestive fluid called bile that helps your body break down fats and helps the liver get rid of toxins and waste. With this condition, the bile isn’t flowing properly. Instead of being released from liver cells, bile builds up in the liver and impairs liver function. In Greek, cholestasis actually means the “standing still of bile.”
- The problem usually starts in the third trimester of pregnancy (around 30 weeks of pregnancy), but some people experience severe itching as early as 8 weeks of pregnancy
- A few days after the birth, bile flow usually returns to normal and the condition goes away (although it can return in future pregnancies). You can talk to your provider about blood tests 2 to 6 weeks after birth to check your liver function.
- Breastfeeding is not contraindicated with a diagnosis of cholestasis during pregnancy
What are the signs and symptoms of cholestasis during pregnancy?
- The most common symptom is severe itchiness (the medical term is pruritus) without a rash that usually begins on the palms of the hands and soles of the feet and then spreads to other body parts. It tends to be worse at night and can disturb sleep. Some people find that the itching is improved with cold temperatures. The severe itching is caused by chemicals called bile acids that have built up and spilled into blood and tissues. Not everyone with elevated bile acids have itching and, in those that do, bile acid levels do not correlate with itching severity.
- Note: Cholestasis of pregnancy should not to be confused with the mild itchiness that accompanies 20% of pregnancies, due to changing hormones and stretching skin.
- Cholestasis of pregnancy should also not be confused PUPPPs (Pruritic urticarial papules and plaques of pregnancy (PUPPP), which is an itchy rash that starts on the abdomen and has no effect on the risk of stillbirth.
- Other symptoms of cholestasis of pregnancy include:
- Darker urine
- Pale and/or oily stool
- Loss of appetite
- Nausea or pain in the upper right belly
- About 10 to 15% pregnant people have yellowing of the skin and whites of the eyes (called jaundice) that typically appears within 4 weeks of onset of itching
How many people are affected by cholestasis during pregnancy?
- Cholestasis during pregnancy affects about 1 to 2 in 1,000 pregnant people in the U.S. and about 1 in 140 pregnant people in the U.K.
- It’s estimated that the condition affects about 5% of Latina women in the U.S. and about 1% of women who have Northern European ancestry
- The condition is more common in certain populations, such as pregnant people with south Asian origin, Scandinavian ancestry, or some indigenous Chileans (where it is reported to complicate >27% of pregnancies)
- Chile, Bolivia, Finland, Sweden, and Portugal are among the most affected countries in the world
What causes cholestasis during pregnancy?
- Scientists have identified genetic changes (mutations) to two genes (the ABCB11 or ABCB4 genes) that cause cholestasis during pregnancy; however, most people with cholestasis during pregnancy do not have genetic changes in these genes
- The increase in the pregnancy hormones estrogen and progesterone may make some people susceptible to developing the condition. Being pregnant with multiples means higher estrogen levels, which increases the risk of cholestasis during pregnancy. High dose oral contraceptive pills can also trigger cholestasis during pregnancy.
- People are more likely to get the condition if their mother or sister had it
- Another risk factor is having a history of liver disease, like hepatitis C
- Studies have found increased risk of the condition among pregnant people who have had in vitro fertilization pregnancies and among those over the age of 35 years
- Decreased levels of selenium (an essential mineral) may play a role
- Interestingly, more people are diagnosed with cholestasis during pregnancy during the winter than other times of year, and researchers aren’t sure why but think it might have to do with vitamin D
How does cholestasis during pregnancy affect birth outcomes?
For babies:
- There is an increased risk of stillbirth (fetal death after 20 weeks of pregnancy) when bile acids levels are high
- A recent systematic review assessed 109 articles and combined data from 23 studies into a meta-analysis. Altogether, it included over 5,000 cholestasis cases and over 165,000 controls. They looked at risk of stillbirth by total bile acid level. For singleton pregnancies, the risk of stillbirth was 0.13% at levels less than 40 mmol/L, 0.28% at levels of 40 to 99 mmol/L, and 3.44% for bile acids of 100 mmol/L or more. They interpreted these results to mean that mothers with cholestasis and singleton pregnancies are only at increased risk of stillbirth when levels are 100 mmol/L or more (a higher threshold than previously thought). They say that most women with cholestasis during pregnancy can be reassured that risk of stillbirth is similar to that of pregnant women in the general population when levels are below this concentration.
- There is an increased risk of premature birth (birth before 37 weeks of pregnancy) both from inductions recommended to prevent stillbirth AND from spontaneous preterm birth
- There is also an increased risk of fetal distress (slow heart rate and lack of oxygen); signs of fetal distress include reduced fetal movement, changes in the baby’s heart rate, and passing meconium before or during childbirth
- Babies are at increased risk of breathing problems from aspirating meconium or from being premature with lungs that have not fully developed
For mothers:
- Studies have found increased risk of gestational diabetes, large-for-gestational-age infants, and preeclampsia
- Mothers may be at increased risk of heavy bleeding after birth (PPH), but there is conflicting evidence from studies
How is cholestasis during pregnancy diagnosed?
- Few professional guidelines agree on the diagnostic criteria, which makes it difficult to interpret studies and the data on how often the condition occurs. Most guidelines agree on the requirement of severe itching and abnormal liver function tests.
- If you experience severe itching during pregnancy or other symptoms of cholestasis, your care provider may give you a physical exam and blood test to check your liver function (LFT)
- Another test can measure your bile acid levels (BA).
- A professional guideline from Australia described bile acid concentrations >15 mmol/L as diagnostic
- Bile acid levels are lower in the fasting state and rise after a meal, but very few studies and guidelines specify whether the test should be done in a fasting state
- Most studies use an upper limit of normal between 10 and 14 mmol/L, but this may be reduced to between 6 and 10 mmol/L in people who are fasting
- Bile acid levels > 10 mmol/L have been reported in up to 40% of asymptomatic women, supporting the theory that normal pregnancy is a cholestatic state
- While total serum bile acids (TSBA) are the most used biomarkers for the condition, a Cochrane review and meta-analysis that included 16 studies did not find any evidence to recommend or refute the routine use of these tests in clinical practice. They think the diagnostic accuracy of TSBA for the condition might be overestimated and they recommend that providers not base their diagnosis only on TSBA levels (they should consider all possible differential diagnoses and tests, consulting a hepatologist if needed).
What is the treatment for cholestasis during pregnancy?
- There is a lot of variation between practice guidelines, but all six practice guidelines summarized in a recent review article recommend Ursodeoxycholic acid (UDCA) as first-line treatment. It is also called ursodiol (brand names Actigall® and Urso®). UDCA is a naturally occurring bile acid that is formed in the gastrointestinal tract as a result of bacterial metabolism of other bile acids. This prescription medication has been shown to lower the amount of bile acids in your blood and decrease itching. UDCA administration results in improvement in itching in ~60% of women and complete cessation in ~40%. Symptom improvement is usually observed within 1 to 2 weeks after initiation and a decrease in serum bile acids 2 weeks later.
- A multicenter, randomized placebo-controlled trial called the PITCHES trial included 605 women in the U.K. with cholestasis. They assessed whether treatment with UDCA reduced the risk of a composite outcome of perinatal death, preterm birth, or NICU admission. They did not find a difference between groups, suggesting treatment may not reduce poor outcomes for babies.
- A 2013 Cochrane Review concluded that there was insufficient evidence to indicate that the following medications: S-adenosylmethionine, guar gum, activated charcoal, dexamethasone, cholestyramine, Salvia, Yin- chenghao decoction, Danxioling and Yiganling, or Yiganling alone are effective in treating people with cholestasis during pregnancy
- Care providers may use regular liver function tests to monitor the condition (at least six professional guidelines recommend weekly tests—twice weekly for severe bile acid concentrations). If the tests are normal but severe itching continues, the tests should be repeated every week or two.
- Care providers may use additional fetal monitoring, such as amniocentesis, fetal heart rate monitoring, and biophysical profile; however, the role of antenatal testing in cholestasis remains controversial. SMFM states that while antepartum fetal testing is recommended, there are no evidence based recommendations for the appropriate type, duration, and frequency of testing. Other practice guidelines do not consider cholestasis during pregnancy to be an indication for antenatal testing, as it has not been proven to be effective in predicting pregnancies at risk of stillbirth. For example, ACOG does not include cholestasis during pregnancy among its indications for antenatal testing.
- Some providers give vitamin K supplements to mothers because cholestasis can affect the mother’s absorption of vitamin K. Sometimes it is only recommended if the condition is very severe and starts in early pregnancy, and/or if pale stools indicate a blood clotting problem. Several professional guidelines recommend checking coagulation tests and making other preparations for the possibility of PPH, depending on the severity of the cholestasis. There is very limited evidence to support giving mothers with the condition vitamin K during pregnancy to prevent severe bleeding.
What is the evidence for inducing labor for cholestasis during pregnancy?
- Some care providers recommend planned early birth (induction) to prevent stillbirth and other complications. All six professional practice guidelines that were reviewed by Bicocca et al. (2018) recommend induction between 36 and 38 weeks for cholestasis during pregnancy.
- In the U.S., ACOG (2019) recommends induction between 36 weeks, 0 days and 37 weeks, 0 days or at the time of diagnosis if diagnosed later. They add that planned birth before 36 weeks of pregnancy may be indicated depending on laboratory and clinical circumstances. You can discuss your bile acid levels and other tests with your care provider when considering the timing of induction. The SMFM recommends considering whether there is documented pulmonary maturity before inducing prior to 37 weeks.
- A 2014 decision-analytic model study concluded that giving birth at 36 weeks would prevent the most stillbirth events. These finding were supported by a 2015 retrospective study that found 36 weeks to be the optimal time to give birth to reduce risk of perinatal death. https://www.ncbi.nlm.nih.gov/pubmed/25687562 However these researchers did not measure the severity of cholestasis.
- A systematic review published on February 14, 2019, in the journal Lancet (Ovadia et al), reviewed 109 studies of cholestasis of pregnancy and determined that the risk of stillbirth is higher when bile acid concentrations are 100 micromoles per liter or higher. For women with levels lower than that, their risk of stillbirth is probably closer to that of someone from the general population. However, levels of bile acids can change and the levels would need to be measured repeatedly to make sure that the risk level has not changed. https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31877-4/fulltext
- The evidence for induction is not very strong, although it’s widely accepted in clinical practice. There are no randomized trials evaluating induction and thus optimal timing of birth remains unknown for pregnancies complicated by cholestasis. A review author wrote that a large, multicenter, prospective cohort study evaluating the link between bile acid levels and poor health outcomes at different gestational ages is needed.
Are pregnant people who experience cholestasis during pregnancy at increased risk of other health problems?
- It’s estimated that 50-60% of people who have had cholestasis during pregnancy before will have it again in a future pregnancy, but recurrence rates may be as high as 92% with a family history of the condition
- People who have had the condition may be more likely to develop liver and gallbladder disease, disorders of the immune system, or cardiovascular diseases later in life, especially with a family history of cholestasis during pregnancy
- Researchers in Finland conducted a 44-year follow-up study of 571 women who had cholestasis during at least one pregnancy compared with 1,333 women who did not have cholestasis during pregnancy.
- Half (50.4%) of the women with a history of the condition were diagnosed with at least one disease of the digestive system compared with a third (34.4%) in the reference group. The risk of cholelithiasis (forming gallstones), cholecystitis (inflammation of the gallbladder), diseases of the pancreas and hypothyroidism was increased compared with the reference group.
Final Thoughts
- Cholestasis during pregnancy is a poorly understood condition and we need more research!
- Pregnant people should alert their care providers if they experience severe itching.
- Prescription treatment for cholestasis can reduce or stop the itching but has not been shown to improve fetal outcomes.
- The diagnostic value of bile acid level tests is controversial (and there is no agreement about thresholds for ‘normal’ versus ‘abnormal’ levels)
- However, high levels (especially above 100 mmol/L) are linked to increased risk of fetal death. This test can be one of several factors you consider before deciding on induction.
Research References on Cholestasis during Pregnancy
ACOG (2019). Committee Opinion No. 764: Medically Indicated Late-Preterm and Early-Term Deliveries. Obstet Gynecol. 133(2), e151–e155. Click here.
Bicocca, M. J., Sperling, J. D. and Chauhan, S. P. (2018). Intrahepatic cholestasis of pregnancy: Review of six national and regional guidelines. Eur J Obstet Gynecol Reprod Biol. 231, 180–187. Click here.
Gurung, V., Middleton, P., Milan, S. J., et al. (2013). Interventions for treating cholestasis in pregnancy. Cochrane Database of Systematic Reviews, Issue 6. Art. No.: CD000493. Click here.
Hämäläinen, S. T., Turunen, K., Mattila, K. J., et al. (2019). Intrahepatic cholestasis of pregnancy and comorbidity: A 44-year follow-up study. Acta Obstet Gynecol Scand. 98(12), 1534–1539. Click here.
Manzotti, C., Casazza, G., Stimac, T., et al. (2019). Total serum bile acids or serum bile acid profile, or both, for the diagnosis of intrahepatic cholestasis of pregnancy. Cochrane Database of Systematic Reviews, Issue 7. Art. No.: CD012546. Click here.
March of Dimes (2018). Accessed online February 19, 2020. Available at: https://www.marchofdimes.org/complications/intrahepatic-cholestasis-of-pregnancy.aspx
National Health Service (2019). Accessed online February 19, 2020. Available at: https://www.nhs.uk/conditions/pregnancy-and-baby/itching-obstetric-cholestasis-pregnant/
National Institutes of Health (2020). Accessed online February 19, 2020. Available at: https://ghr.nlm.nih.gov/condition/intrahepatic-cholestasis-of-pregnancy
Ovadia, C., Seed, P. T., Sklavounos, A., et al. (2019). Association of adverse perinatal outcomes of intrahepatic cholestasis of pregnancy with biochemical markers: results of aggregate and individual patient data meta-analyses [published correction appears in Lancet. 2019 Mar 16;393(10176), 1100]. Lancet. 393(10174), 899–909. Click here. Free full text!
Smith, D. D., Rood, K. M. (2020). Intrahepatic Cholestasis of Pregnancy. Clin Obstet Gynecol. 63(1), 134–151. Click here.
View the transcript
Note: This transcript may be revised.
Rebecca Dekker:
Welcome to the Evidence Based Birth Podcast. My name is Rebecca Dekker and I’m a nurse with my PhD and the founder of Evidence Based Birth. Join me each week as we work together to get evidence based information into the hands of families and professionals around the world. As a reminder, this information is not medical advice. See ebbirth.com/disclaimer for more details.
Rebecca Dekker:
Hi everyone, and welcome to the Evidence Based Birth Podcast. Today. I am so excited to speak with Nicole Phelps about her birth experiences and about cholestasis of pregnancy. Nicole Phelps is the proud mom of three young boys and supportive wife to World Champion Michael Phelps. Nicole is a philanthropist who volunteers her time with the Michael Phelps Foundation, which promotes water safety, healthy living, and the pursuit of dreams. She’s also a former marketing professional and was crowned Miss California USA in 2010. Nicole and her family, including two French bulldogs, live in Paradise Valley, Arizona. You can follow Nicole on Instagram @mrs.nicolephelps and Twitter at @mrsnicolephelps. Here at Evidence Based Birth, we’ve been following Nicole for a while now, and we are so excited she’s come on the podcast to share her story. Welcome, Nicole, to the Evidence Based Birth Podcast.
Nicole Phelps:
Thank you so much for having me, Rebecca. I appreciate it.
Rebecca Dekker:
I’m so excited that you were willing to come talk with our listeners about your pregnancy and birth experiences and especially about your experiences with cholestasis during pregnancy. I was wondering if you could take us to your first pregnancy, and kind of tell us what was going on in your life at that time.
Nicole Phelps:
So let’s see here. 2016, I don’t even know where to begin. That was a crazy year. Michael was competing in the Olympics. I was pregnant with our first child. We had just moved into a brand new home, and I was planning a wedding. So if you could pile everything you could possibly do into one year while having a baby, we did it. Clearly we succeeded and had a blast doing it, but it definitely made pregnancy more fun, I think.
Nicole Phelps:
So with Boom’s totally easy pregnancy, I had a little bit of back pain, so I had to go get PT work done. I had hired a doula solely knowing that Michael would be away in Colorado Springs for training camp leading up to Olympic trials, and we kind of had somewhat a birth plan in place, but knew more than anything things would kind of be moving targets with Michael being gone.
Nicole Phelps:
So about 37 weeks I go in, I know I have a regular appointment. On Friday I would have been 37 weeks. The Tuesday prior I knew I was going in to see my doctor, the Monday night before Tuesday, I started to get really bad itching on my feet and my hands, and I just remember laying in bed like, “What is wrong with me? This is horrible.” And so I started researching it, and sure enough there was a condition called cholestasis, and it could cause stillborns. So obviously when you read stillborn, you kind of freak out as a mom, first time pregnancy, and I’m like, “Okay, well I’m going to tell my doctor about this.”
Nicole Phelps:
So I went in on Tuesday morning and I told my doctor what was happening and going on. She was like, “Okay, let’s get a blood test done. I’m glad you looked at it,” because I personally probably would have ignored it just because I hadn’t had any kind of complication, and it just seemed weird to me. So we tested for it, which blood tests still to this day take … I believe it’s four days. I don’t know if you’ve found different research, Rebecca?
Rebecca Dekker:
Yeah, I think that has been common in the past. That’s hard to monitor the severity, but I think some facilities can do a test in the normal one day, and then others take longer. Probably depends on where you’re located.
Nicole Phelps:
Okay. So where I am, that was the quickest that we could get results back. So I was looking at about Thursday or Friday. Wednesday night, I started having pain, and I was just kind of off. So I went to dinner. My dad was with me because Michael was traveling, and we had kind of made sure that I had somebody with me at all times so I wasn’t alone, and I told my dad, “I’m going to go to bed. I’m not feeling right, and take a bath.” So in the meantime I had texted my doula and said, “Hey, I’m feeling this way. Is everything okay?” And she’s like, “Take a bath. Tell me how you feel after.” So I did that, and everything was still there. And so what I’ve learned and what she was encouraging me to do is when you take a bath, and you’re potentially in labor or not in labor, the cramps that you’re feeling will go away with the bath. That didn’t go away for me.
Nicole Phelps:
So I kind of labored pretty much through the night by myself, in and out of the shower, kind of on and off with her, because again, first birth, I’m 36 and five days at that point. There’s no reason for me to be going into labor of any kind.
Rebecca Dekker:
Right.
Nicole Phelps:
So it probably was about 4:00 in the morning. I call my doula and I’m like, “Hey, still going on.” She tells me to call my doctor. I call my doctor, and by that time I’m having contractions and they’re definitely close enough to get me into the hospital. So I go into the hospital, and I check in, and that’s probably around 8:00 AM, and I’m four centimeters dilated. So clearly had labored most of the night, and now here I am in the hospital, going to have my baby, when we were waiting to figure out if she was going to induce me Friday, because if my results came back positive on Thursday, she would have had to induce me just out of fear of what cholestasis could do to my baby.
Rebecca Dekker:
So you ended up having basically an early term birth spontaneously.
Nicole Phelps:
I did. Yes.
Rebecca Dekker:
Yeah. Which is something we know can happen with cholestasis as well.
Nicole Phelps:
Very much so. And Rebecca, do you want to touch anything on cholestasis as I go through this process, or do you want to come back to it?
Rebecca Dekker:
Yeah. Sure. No, we should probably talk about it so our listeners know what we’re talking about. So chole stands for bile, and stasis is a medical term for not moving around much, and bile is what the liver produces and stores in the gallbladder. It helps break down and it aids in the digestion of fats. So cholestasis is when the bile slows down its movement in the liver and just kind of becomes static there. It doesn’t move, and then it starts spilling out.
Rebecca Dekker:
So what Nicole was talking about, what she experienced was increased bile acid levels throughout her body, which does create a risk in the pregnancy, and there’s a lot we don’t understand about it, but we do know that the classic symptom is where you have itching that starts in the palm of the hands or the soles of the feet and then starts spreading to areas of the other parts of your body with no rash. And so this is a lot different than other types of itching conditions that might happen in pregnancy.
Rebecca Dekker:
So you had the itching. Did you have any other symptoms besides itching and then contractions that were a little bit early?
Nicole Phelps:
No, not at all. I just had the itching. And funny enough, my doctor had experience with cholestasis while she was in residency, and unfortunately that mom’s baby ended up being a stillborn. So for whatever reason my doctor had gone through that experience, and knew that she needed to take it seriously and not brush it off like I know some moms have experienced.
Rebecca Dekker:
So you’ve heard from other moms whose symptoms have been dismissed or kind of, “Oh, you’re exaggerating”?
Nicole Phelps:
Yeah, and it’s sad because I think we see that a lot. When you’re pregnant, there’s a lot of ailments that we can experience, right? And what is reality, and what’s not reality, and it can be hard to wade those waters too. Especially when it’s your first time being pregnant, or third time, you don’t know what you’re experiencing always.
Rebecca Dekker:
Yeah. And it is somewhat rare. I think it happens about one in 500 to one in 1,000 pregnancies.
Nicole Phelps:
And I know it’s even rarer here in the US.
Rebecca Dekker:
Right. It’s more common in some parts of Scandinavia, Chile, Bolivia, Finland. So there’s some parts of the world where rates are much higher than they are here.
Nicole Phelps:
And it seems in the, you can correct me if I’m wrong, but I believe in the UK they’re doing some amazing research around cholestasis and getting moms screened for it and making sure that it’s handled properly.
Rebecca Dekker:
Yeah, I did see it’s more common in the United Kingdom than it is here. It affects about one in 100 or so people there.
Nicole Phelps:
And as I’ve gone through this path, more and more moms, if I posted something on Instagram or I did a previous podcast, we’ve had people that have come up to and been like, “I went to the doctor because I had your symptoms, and sure enough I had cholestasis.”
Rebecca Dekker:
Wow.
Nicole Phelps:
And that’s incredible to me to know at least one or two, if not more, babies have maybe been saved. Maybe not. Maybe nothing would have happened, but I’m just thankful that we’re getting the message out there.
Rebecca Dekker:
Yeah. It’s so important for people to be in touch with their bodies and to be aware of things like this. So tell us what happened next. So you went into labor on your own at about 37 weeks, and was Michael around or was he still out of town?
Nicole Phelps:
So he was in Colorado Springs, and the night before, I called him and I was like, “Hey, keep your phone by you. Just be aware. I don’t know what’s going on. Maybe I’m in labor, maybe I’m not, but just be prepared,” you know? And he was kind of like, “Okay, yeah, sure. Whatever.” As your husband might do.
Rebecca Dekker:
Well, it’s three weeks before your estimated due date.
Nicole Phelps:
Exactly. Yeah. He’s like, “Whatever that means. I don’t know.” And his sister was getting married on the east coast that weekend too, so there’s other stuff that was going on in our lives that not necessarily took priority over me giving birth, but there were other plans in place other than me having Boomer on that day.
Nicole Phelps:
So the morning, I called him and I couldn’t get ahold of him, so I called our roommate Allison who lived with us here and was his roommate there at the training camp, and I was like, “Hey, I’m in the hospital and I’m probably giving birth today, so I need to talk to Michael.” And she was in the cafeteria and ran to their room, and got him on the phone, and all of that started turning, but we didn’t know how long things were going to take, when he could get back. So he had to go practice and do what he was doing that morning per his coach, as if nothing was happening. So once we kind of secured things in order for him to get back, he was back in the afternoon, and then it was kind of like, “Hurry up and wait.” For whatever reason, I held onto my water. There was no urgency in my body outside of the fact that I was having contractions and definitely in labor.
Rebecca Dekker:
Was your doula with you during this time then?
Nicole Phelps:
Yeah, she was. So she met me at the hospital a little bit after my dad and I had gone, and she helped me out tremendously. We were in and out of the bathtub. She was giving me back massages. She had me on a ball, and for anyone that has gone through birth without a doula, I would highly recommend hiring one, because I think she made a major difference in my birth experience.
Rebecca Dekker:
So you said you had to hurry up and wait. So did labor take a while for you then?
Nicole Phelps:
It did. Obviously I’m looking at my notes right here from my doula, and I had gone in in the morning, not until 6:52 at night was I completely dilated.
Rebecca Dekker:
So take us to that moment. What was the actual birth like?
Nicole Phelps:
So birth, when I actually started pushing, it went very quickly. Boomer was born at 7:21 PM, so the whole pushing process I feel like went faster than I know most moms experience, which I’m very grateful for, and I just remember doing everything I could to push Boomer out. I did have an epidural because he was pushing on my spine, so that had happened earlier in the day and I was in a lot of pain from that. I couldn’t come down and kind of just relax and breathe at all. So thankful for being able to have that type of pain management in that moment, and I was a little worried about having that and not being able to push or feel everything that was going on, and I had no issue with that. And literally my doctor was like, “Okay, he’s there. You need to push,” and I just remember Michael looking at me and me looking at him and looking at the doctor, and being like, “All right, this is it.” And I pushed, and Boomer was out. So I was like, “Okay, you tell me to do it, I got it. Let’s do this.”
Rebecca Dekker:
Then how did it feel to finally have your baby with you?
Nicole Phelps:
It was so incredible. She put him on my chest and he was able to kind of do that little crawl to the boob, and he latched right away, and I’m emotional right now as I talk about it, because it’s one of the most incredible feelings in the world.
Rebecca Dekker:
And what was Michael’s reaction at the birth of his first child?
Nicole Phelps:
Michael was excited. He was so excited. The doctor was kind of taking him through everything that had happened, cutting the umbilical cord, and he was just ecstatic. He was definitely on cloud nine, and it was probably better than having to go to practice again that afternoon.
Rebecca Dekker:
I bet. So tell us about the cholestasis then. Did the symptoms kind of go away on their own after your baby was born?
Nicole Phelps:
So crazy enough. Literally as Boomer’s born, lab results come back to my doctor and she tells me that I had tested positive for cholestasis. So the following day I would have been induced and had to have a totally different type of birth for my first birth experience, and pretty much once Boomer was born, no issue whatsoever. No itchy palms, no itchy feet, nothing. So it dissipated completely after birth.
Rebecca Dekker:
So did the doctor talk with you at all about risks of cholestasis happening in future pregnancies or anything like that?
Nicole Phelps:
She did. She let me know that the odds were higher. I don’t have the exact statistics that she gave me, but she did tell me, “Just want to let you know the odds are not in your favor for you to have a pregnancy without cholestasis, given that you just had cholestasis during this pregnancy.” And knowing that, I think because I have, still to this day, so much faith in my doctor, I don’t think it ever scared me. I know that that is a very scary thing to hear, and I know a lot of moms fear having another baby given that they had cholestasis in their prior pregnancy.
Rebecca Dekker:
Yeah. And when we were looking at the research in preparation for this interview, we found that it’s estimated that about 50% to 60% of people who have had cholestasis during pregnancy, have it again in a future pregnancy, but it can be as high as 92% if you have a family history of the condition.
Nicole Phelps:
Yeah. And I did ask my family. My mom comes from a large family. She’s got six other siblings, and none of them ever had it. Her mom didn’t have it, and nor on my dad’s side either. So I was the first to show cholestasis in our family.
Rebecca Dekker:
And so treatment for cholestasis, you weren’t diagnosed early enough in order to get treatment-
Nicole Phelps:
No.
Rebecca Dekker:
… because you weren’t diagnosed until after your baby was born. But there is one drug called ursodeoxycholic acid or it’s abbreviated UDSA, and it has brand names as well, and that has been shown to lower the amount of bile acids that collect in your blood, and help with itching in most people, but it takes about one to two weeks to get any relief from your symptoms. So cholestasis isn’t something that you can just take a Benadryl or anything to help with. It’s related to the bile acids building up.
Rebecca Dekker:
So Nicole, can you take us to your second pregnancy, because I know you have three birth stories to share with us.
Nicole Phelps:
I do.
Rebecca Dekker:
Yeah. So what was going on in your life when you had your second?
Nicole Phelps:
So during my second pregnancy, and actually what you just spoke on is a great segue, because during my second pregnancy, at 32 weeks, I was diagnosed with cholestasis, and my bile acids were actually really high, kind of scary high. And so I was on ursodiol through that pregnancy, and in conversations with my doctor, we decided that it was best that I would need to be induced at 37 weeks if nothing lowered and stuff didn’t show any better.
Nicole Phelps:
So with Beckett, life was a little bit calmer. There wasn’t all of the chaos that we had had, but I was having to go through the end of my pregnancy with cholestasis, and that in the back of my mind of how it could potentially affect my baby.
Rebecca Dekker:
Yeah. So you were diagnosed at 32 weeks, and then you were kind of waiting for that induction at 37 weeks then?
Nicole Phelps:
Yeah, and it was definitely a scarier end of pregnancy than Boomer was because I knew what I had and what it could cause, but again, I had full faith in my doctor and the way that she was handling everything, so I would go in for fetal heart monitoring twice a week, and get blood drawn once a week, and all the way up until 37 weeks.
Rebecca Dekker:
Yeah, and I think it’s important that you mentioned your bile acid levels, because there’s kind of a range of severity, and some of the milder forms of cholestasis, the stillbirth levels really aren’t that much more than a normal pregnancy, but it’s when you get the bile acid levels that are really elevated that you see the increased risks that you’re talking about.
Nicole Phelps:
Yeah. That was the hard part. It’s funny, because when I was pregnant with my second and taking ursodiol, and then I did research when I was pregnant with my third, I thought ursodiol was helping those bile acids, and come to find out that it’s only there as management for your symptoms, I believe. I don’t know if you’ve read different, Rebecca.
Rebecca Dekker:
Yes, and let me pull up the research. But yeah, it’s been shown to lower the amount of bile acids in your blood and decrease itching, but yeah, it’s really only used for symptom improvement. So they haven’t found yet that this medication improves outcomes for babies. It’s more of managing the symptoms until you can get to a point where it’s safe to induce labor.
Nicole Phelps:
Yeah. And so looking back on it, I don’t know if I would have done it differently, but I definitely think I would have taken it more into consideration of putting something else into my body while being pregnant.
Rebecca Dekker:
Yeah.
Nicole Phelps:
You know? Were my symptoms strong enough for me to actually need it? Just because I didn’t understand, and what you do is phenomenal for moms, is you do that research for them so they don’t have to sit around trying to figure it out.
Rebecca Dekker:
Yeah. And I’ll definitely list all of the research studies we found when we were prepping for this interview in the show notes, that people can look at the studies for themselves. So you were taking this medication to control the itching, and take us up to when you were getting closer to 37 weeks. Were you mentally prepared and physically prepared for that induction?
Nicole Phelps:
So I think I was mentally prepared. I mean, I had to be as much as possible, and physically I think I was as well. And I think part of that was knowing that Boomer came early, so odds were, I assumed, my body was just like, “This is how I do pregnancy, is I just have a baby that’s a little bit early.” So I think that that was my mentality going into all of it, and not fearing the fact that I had to be induced and I had to go through that process. On Monday, February 12, I went in at midnight into the hospital, and I actually was three centimeters dilated, and the baby was at station two.
Rebecca Dekker:
Your body was already preparing for the process.
Nicole Phelps:
It was preparing. Yeah. And so, I don’t know if part of me was just that mental preparation of knowing I was going in, and I was talking to my baby, and telling him, “We need to get through this, because I have to have you induced. You don’t get to do this on your own time.” So I was very thankful to hear that when I went in. And they gave me Cytotec. I think I had two doses of Cytotec. They did swipe my membranes, and she also did break my water.
Rebecca Dekker:
And did that get the process moving?
Nicole Phelps:
It did. So 12:30 she broke my water, and I was eight to nine centimeters dilated, and at 12:55 I was completely dilated, and at 1:12 I had a baby.
Rebecca Dekker:
Wait, so you went in right at midnight?
Nicole Phelps:
Yes.
Rebecca Dekker:
So you’re not talking about 12:00 the next afternoon?
Nicole Phelps:
Yeah. So I went in at midnight and I had a baby at 1:12 PM.
Rebecca Dekker:
At 1:12 AM?
Nicole Phelps:
- Not AM, PM.
Rebecca Dekker:
Okay. Okay, good.
Nicole Phelps:
Yeah. No, no, no. Cytotec did not do me that good.
Rebecca Dekker:
Okay. I was really … At first I was like, “Wow, that’s lightning fast.”
Nicole Phelps:
No.
Rebecca Dekker:
So it took about 12, a little more than 12 hours.
Nicole Phelps:
It did, yeah.
Rebecca Dekker:
And how was that labor experience then, with the induction?
Nicole Phelps:
It wasn’t bad. I think having the epidural and telling my doula prior, “I definitely want an epidural, because this is out of my control. I don’t get to control my pain, I don’t get to control any of this. This is something that I have to do for my baby,” and wanting to be as comfortable as I possibly could be outside of mentally knowing my bile acids were high, and all of the risks that were going along with everything that was happening. It definitely was a scarier birth than my first birth, but still an amazing experience, and I did everything the same way. I was still in and out of the bathtub. I was still on a birth ball. I was doing different positions that she would help me do, and the doula was still rubbing my back, and she was still there, and Michael happened to be there the entire time. So he got to experience birth for the first time.
Rebecca Dekker:
And did you use the same doula both times?
Nicole Phelps:
I did, yeah.
Rebecca Dekker:
How was that, being able to kind of redo birth again with the doula?
Nicole Phelps:
It’s amazing. Like I said before, I wouldn’t do it any other way. I absolutely love our doula, and I highly recommend women getting a doula, because I think they’re there in your corner, and even though I’m having to be induced and I’m having to go through the process in a hospital, she’s still there to fight for me or tell them, “No, I don’t think you should do this.” Or, “Can we try it this way instead of that?” And I think that’s really great, to have somebody that can advocate for you, that’s used to being in that setting, because your husband is not.
Rebecca Dekker:
Oh yeah. I see what you’re saying. So you said it was a little bit scarier situation. Was that because of all the interventions you had to undergo for the induction, or because-
Nicole Phelps:
I think so. I think it was a combination of that, and I think you don’t know when you have cholestasis what the outcome is. Of course we monitored him the entire time, but you still are a little fearful.
Rebecca Dekker:
Have some anxiety until you actually have your baby in your arms.
Nicole Phelps:
Yeah. Yeah.
Rebecca Dekker:
So how long did you push for with this birth?
Nicole Phelps:
11 minutes.
Rebecca Dekker:
Wow.
Nicole Phelps:
Yeah.
Rebecca Dekker:
And did you get to have that same skin to skin moment with Beckett?
Nicole Phelps:
I did. Yeah. Yeah. Beckett was put on me, and same thing. He kind of crawled up and latched right away, and I held on to him dearly, and he was smaller. Boomer was six pounds, 12 ounces, and Beckett was six pounds, two ounces.
Rebecca Dekker:
Oh. That’s pretty good, though, for two 37-weekers.
Nicole Phelps:
Yeah. Yeah. Thankfully I didn’t go full term.
Rebecca Dekker:
So I know you’ve shared your first two birth stories on the Birth Hour podcast before.
Nicole Phelps:
I did.
Rebecca Dekker:
But since then you’ve had a third. So can you tell us a little bit about your pregnancy with Maverick?
Nicole Phelps:
My pregnancy with Maverick was pretty easy. I was at 32 weeks. We started testing for cholestasis because obviously I’ve already had two pregnancies prior with cholestasis, and with Maverick, we wanted to be on top of it and make sure that I wasn’t getting symptoms and wasn’t having any issue. And sure enough, we tested every single week leading up to his birth, and I never tested positive for cholestasis.
Rebecca Dekker:
Wow. What was that like?
Nicole Phelps:
That was weird. I’d go into the doctor and get my blood drawn, and sit and do my … I was still did all the fetal heart monitoring and everything, and it was a little bizarre, but for whatever reason Maverick was like, “Well, I need to have something so that you have to worry a little bit about me already,” and he just had a slow heart rate, and so we’d watch his heart rate, be like, “Okay, drink some apple juice. Here’s something cold. Let’s wake him up and make sure everything’s okay.” But Maverick kept me on my toes without me ever having cholestasis.
Rebecca Dekker:
With having that slow baseline heart rate?
Nicole Phelps:
Yes. Yeah.
Rebecca Dekker:
Was he like a little athlete already?
Nicole Phelps:
He must be. He must be already training. We’re not sure. But I was like, “Well, I guess my heart rate’s slow. Michael’s is obviously slow, so maybe he’s just taking after the family.”
Rebecca Dekker:
Yeah. So when did you go into labor then?
Nicole Phelps:
So with Maverick, I just had turned 36 weeks, and I swore I went through labor all night long, and in the morning I called my doula, called my doctor, they both said, “Go into the hospital, get checked,” and I was four centimeters dilated, but nowhere near giving birth. So they monitored me and made sure everything was okay and sent me home. And that was on Saturday morning, and on Sunday, we were having our baby shower, and I was like, I kept telling my baby, I was like, “You’re not coming until I have this baby shower, because I have to get through my shower before you’re allowed to come.” And sure enough, Monday morning, I was 36 weeks and two days, Maverick decided to enter the world.
Rebecca Dekker:
Wow. So even earlier than his brothers.
Nicole Phelps:
Yeah. Yes. He was earlier than his brothers, and he had me up all night long. So I labored at home. We’re pretty sure I transitioned in the car. I’ll never forget Michael, we get in the car, and he turned on some music, and I remember looking at him like, “What are you doing right now? I cannot process this.” And so I made him turn off the stereo, and we pulled up to the hospital, and my doula was there waiting for me. There were no wheelchairs, so I had a long walk through the hospital, to the elevator, to the birthing area, while construction men stared at me as I screamed down the hallways.
Rebecca Dekker:
Oh my. So it was really to that point, like it was really intense.
Nicole Phelps:
Yeah. It was very, very intense. And I pretty much, I think we got to the hospital around 6:00 and Maverick was born at 6:45, so my first medication-free birth.
Rebecca Dekker:
And how was that?
Nicole Phelps:
It was an incredible experience.
Rebecca Dekker:
What makes you say that?
Nicole Phelps:
Yeah. I still try to put it into words. I’m thankful that it was my last child that I was pushing out completely naturally, because it still hurt, and he was six pounds, six ounces, and I still don’t think I have fully been able to wrap my head around that birth process. There is something to be said about not having an epidural and not having any other interventions as you go through the birth process completely naturally.
Rebecca Dekker:
Did you get that kind of hormonal high after the baby was born?
Nicole Phelps:
I think so, yeah. I think I definitely did. I will say, though, I don’t think … I mean, outside of the excruciating pain, I don’t think there was a difference in my pushing. I couldn’t push as well my third time as I did my first and second time. It took me a little bit longer, and maybe that was just the pain I was in, but I know that there are people that have talked about it being a little bit harder when you have an epidural, and I think it was harder for me without it, to be honest.
Rebecca Dekker:
For the pushing phase?
Nicole Phelps:
Yeah.
Rebecca Dekker:
Yeah. And it sounds like you’ve had kind of three very different birth experiences, because your first was spontaneous labor with an epidural, second was an induction with an epidural, and then the third was spontaneous without an epidural.
Nicole Phelps:
Yeah. And even just the laboring process was different with all three of them. And they talk about you kind of go into a different realm, if you will, or mentality, but I’ll never forget waking my husband up and then going and sitting on my birthing ball, and just kind of going into a trance to get myself together before I got in the car to go to the hospital. And I don’t think, had we left a little bit later, I might have had a baby somewhere in between.
Rebecca Dekker:
Yeah. You might have had a car birth.
Nicole Phelps:
Yeah.
Rebecca Dekker:
Yeah. So tell us, did you have a doula at this third birth as well?
Nicole Phelps:
I did. Same doula. Kelly Sunshine. She’s amazing, and she helped me through all of that. I’ll never forget texting her in the morning, even before I got Michael up, and I was like, “Hey, so I want an epidural so I can sleep, because I haven’t slept the last three days.” And she’s like, “I think you might be too far along for that already.
Rebecca Dekker:
So she could already tell that it was time for you to get to the hospital and have the baby.
Nicole Phelps:
I think so. Yeah. Yeah, which is where I think a doula is just so amazing, because it kind of takes the guessing work out of you and off of you. I think it helps.
Rebecca Dekker:
Yeah. We teach a lot about that in our childbirth classes at Evidence Based Birth, just how it’s one of the benefits of a doula, is they can take a look at you or they can talk with you and they can kind of know where you are in the process, and give you some good ideas of when it might be a good time to head to the hospital.
Nicole Phelps:
Which she did, clearly.
Rebecca Dekker:
She’s like, “Go now.”
Nicole Phelps:
Exactly.
Rebecca Dekker:
I was going to say, one of the things we haven’t talked about yet in this interview is postpartum, and I was wondering if you would be willing to share your thoughts or experiences about going through that fourth trimester with your babies.
Nicole Phelps:
I would love to. I think there’s such a lack of discussion regarding postpartum, breastfeeding, and kind of the way that you need to care for your body, because we want to rush everything, and for whatever reason, all three of my children, I did my best to … It’s not feasible for everybody, but to lay around with each of my babies. Boomer did it when he was little, and then Beckett did it recently. They have all come, when other people start holding the baby, they always say, “That’s mommy’s baby. Give him back.” And of course, careful to have a time with each of them too, as I’m going through this process, but I just felt it’s so important to mend my body after each of these births, and so I was in bed for probably a week after with the baby. Thankfully my mom came in and helped out with the kids, and Michael obviously allowed it too, and just gave me that space to tend to me and to tend to the baby and to get breastfeeding done right. And you know, everything that I felt was important.
Nicole Phelps:
I will say I went from a doula to an IBCLC or lactation consultant, and I wouldn’t do it any other way. I’ve encouraged every mom that I’ve come across to get a lactation consultant, because if you choose that path, I think it’s one of the strongest things you can do.
Rebecca Dekker:
To set yourself up to have a better journey with breastfeeding?
Nicole Phelps:
Yeah. Yeah, and I still see mine. I mean, I think there was such a humbling experience having a third child, I don’t know if you went through that, Rebecca, but it was like, okay, I had my first, that was my first. I had my second, and I’ve already been there, done that, and now I’ve had my third and it’s kind of a re-centering of the experiences and being able to look at it in a different light.
Rebecca Dekker:
Yeah. My best friend’s husband used to say, he had four kids, that every time you have a kid, you write a manual, and then you kind of have to throw it out the next time and start over.
Nicole Phelps:
True.
Rebecca Dekker:
Which is kind of true and kind of not, because I feel like you do gain experience with each child that’s invaluable.
Nicole Phelps:
Agreed.
Rebecca Dekker:
But each baby is unique, and has unique needs. And so definitely I love your recommendation to have somebody lined up to help you with lactation, if that’s the way you’re going to be feeding your baby.
Nicole Phelps:
Yeah. I appreciate it so much, but there’s just so much that they can offer, too. Recently I went through tongue and lip tie with Maverick, and that whole process, and it can be scary, and there’s an unknown, and, “What’s right, what’s wrong?” And she helped me through that and she still helps me, you know? And here I am, he’s almost six months old, and I’m still going back to her and asking her questions. And so you just don’t know where they’re going to help you.
Rebecca Dekker:
So how is life now having three boys, including one of them being a baby still?
Nicole Phelps:
It’s fun. It’s chaotic, and we have a blast, and the oldest, Boomer, is three and a half. He’ll be four in May, so he definitely can take direction a little bit better. At times is not wanting to help, because that’s what they do best.
Rebecca Dekker:
That’s what they do at three. Yeah.
Nicole Phelps:
And then I have Beckett, who just turned two, who’s eager to help, but then he sees his older brother who says, “No, I’m not helping you.” And then he’s like, “Well, and then I’m not helping you.” So it’s a lot of fun, and all they do is love on Maverick, and it’s just really cool to watch, and there’s nothing like being a mom.
Rebecca Dekker:
Well, Nicole, thank you so much for sharing your stories. Is there anything I can help you with? Do you have any questions for me?
Nicole Phelps:
I don’t think so. I think I love what you’re doing, because you’re getting the word out there about so many topics that it can become so overwhelming as a mom, or as a first time mom, or pregnant. So I just think that’s incredible.
Rebecca Dekker:
Yeah, and I really appreciate you using this opportunity to help educate parents about cholestasis. And I’ll make sure in the show notes to link to all the research that we were able to collect on this topic, so that if you’re interested in this topic, you can read more for yourself.
Nicole Phelps:
I appreciate that.
Rebecca Dekker:
Thanks again for being here, Nicole.
Nicole Phelps:
Thank you for having me.
Rebecca Dekker:
All right, everyone. Thank you so much for joining us today to listen to Nicole tell her story and where we could all learn a little bit more about cholestasis of pregnancy, and I’m really appreciative to her for bringing this topic to light and helping educate other people about this condition. You can follow Nicole @mrs.nicolephelps on Instagram. Thanks everyone, and I’ll see you next week. Bye.
Rebecca Dekker:
This podcast episode was brought to you by the Evidence Based Birth Childbirth Class. This is Rebecca speaking. When I walked into the hospital to have my first baby, I had no idea what I was getting myself into. Since then, I’ve met countless parents who felt that they too were unprepared for the birth process and for dealing with a broken healthcare system. The next time I had a baby, I learned that in order to have the most empowering birth possible, I needed to learn the evidence on childbirth practices, find out how to stay comfortable during labor, and my partner needed to learn how to speak up for me.
Rebecca Dekker:
I’m excited to announce that we are now offering the Evidence Based Birth Childbirth Class in about 50 communities in the United States and around the world. In your class, you will work online and in person with an Evidence Based Birth instructor who will skillfully mentor you and your partner in evidence based care, comfort, measures, and advocacies, so that you can both embrace your birth and parenting experiences with courage and competence. Get empowered with a childbirth class you and your partner will love. Visit evidencebasedbirth.com/childbirthclass to find your class now.
Listening to this podcast is an Australian College of Midwives CPD Recognised Activity.
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