July 18, 2012
“Convenience” in not a Reason to do an “Early” Induction or C/Section
In Native American culture there is a premise that Nature thrives on order but it is man who creates the disorder. That thought came to mind last month when I presented yet another malpractice case for review with a panel of colleagues. A patient wanted to be induced at 39 weeks and inevitably had significant complications with a poor birth outcome. In my expert opinion, I suggested that the physician should have waited until the patient was 41 weeks before she attempted an induction and one of my colleagues thought that I was vehemently wrong. “She was full-term and entitled to an induction” he practically shouted in my ear. “That’s not the point,” I countered. There was no reason to do the induction except for physician and maternal convenience. I reminded him that most high-risks specialists will start fetal monitoring and nonstress tests (NSTs) at 40 weeks to document fetal well being and then induce labor at 41 weeks if it has not started spontaneously.
At 39 weeks, the cervix is usually thick which means it has to be softened with medication before Pitocin (the medicine that starts contractions) can be given. Anytime an induction goes beyond 48 hours, there is a strong possibility that it will end in a C-section. At 41 weeks, the cervix is usually soft and if an induction must be started, it has a much greater success rate for a vaginal delivery.
Very few physicians will allow a patient to deliver beyond 42 weeks because the baby gets too big and the placenta becomes old. An “old” placenta, aka “grade 3” means the baby could possibly receive inadequate oxygen and inevitably there will be meconium which is an internal bowel movement that sometimes indicates fetal distress.
According to the Bloomberg News, “Aetna has renegotiated maternity payments with 10 hospitals around the country so far, bringing rates for cesareans and vaginal births closer together.” This will inevitably decrease my colleagues’ checking accounts but please do not look for sympathy from me. The standards of medical care were written for a reason. Performing inductions of labor for the sake of “convenience” is certainly not one of them.
July 2, 2012
Do You Know How to Avoid a Homebirth Disaster?
A Maryland jury made history by awarding Enso Martinez and Rebecca Fielding $55 million dollars but there are no winners in this tragedy. Enso Martinez Jr. has irreversible brain damage and Johns Hopkins Hospital will spend resources that could be used for research for direct patient care, to defend their care of Fielding.
Home birth in the U.S. has increased by 20% in part, because of Ricki Lake’s documentary, The Business of Being Born. Women want to have their babies at home despite the admonishment and warnings from the American College of Obstetricians and Gynecologists. To all pregnant moms who want to have their babies at home, I get it. I truly do. You want a comfortable intimate environment to have what you deem is a “natural event” without “unnecessary intervention.” You want to be like the celebrities who have had successful home deliveries. But here’s the problem: your home is not equipped to deal with emergencies and they DO occur. Just ask celebrity mom Christine Turlington Burns, who experienced a postpartum hemorrhage and had to be rushed to the hospital in order to save her life. Obstetrics is a specialty of the unexpected. You MUST be prepared for emergencies.
Fielding entered Johns Hopkins Hospital because the baby was “stuck.” The midwife couldn’t deliver the baby because it was either too large or she couldn’t manage a shoulder dystocia. According a blogger, Dr. Amy Tuteur, Midwife Evelyn Muhlhan’s license was suspended by the State of Maryland because of five homebirth disasters including Fielding’s delivery.
An ambulance brought Fielding to a hospital where she allegedly waits for over 2 hours for blood test results. A c. section is delayed. A baby has brain damage. Take home message?
- Know your midwife’s professional record. Does she have malpractice suits? Has she been sanctioned by the state medical board for negligence?
- Meet your midwife’s ob-gyn back-up. The Smart Mother’s Guide to a Better Pregnancy discusses this in detail. At the first sign of trouble, Muhlhan should have contacted her ob backup. If she didn’t have one, she was begging for trouble.
- Have a PERSONAL copy of your prenatal chart with you and your back-up hospital or birthing center should have a copy as well. This is standard prenatal procedures. Having a homebirth doesn’t change that. Your prenatal record contains all of the important information including blood type and blood count. No one, I repeat NO ONE, is going to bring you into the operating room without knowing your blood type unless you are hemorrhaging to death. Had Fielding had a copy of her prenatal record, she might not have encountered the delay.
If you’re going to have a homebirth, then please take the necessary precautions. An ounce of prevention is always worth more than a pound of cure.
November 14, 2011
Oh, No! Michelle Duggar is Pregnant Again
OMG, Michelle Duggar is pregnant again. Is she competing with the wife of Feodor Vassilyev? Vassilyev was pregnant 27 times between 1725 and 1765 and gave birth to 16 pairs of twins, 7 sets of triplets and four sets of quadruplets. 67 children survived infancy making her the woman who had the most documented number of children in the world. Vassilyev had a history of multiple births. What’s Duggar’s excuse?
I’ve written about Duggar before out of genuine concern and received over 2,000 comments on the Basil and Spice website. Many were unkind. People like Duggar because of her affable personality but want to ignore the facts: with each subsequent pregnancy, her life becomes fraught with danger. Her last pregnancy was extremely high-risk, complicated by pre-eclampsia and the emergency premature delivery of her daughter who only weighed 1.3 pounds at birth. It was a very close call. According to Answers.com, the Duggar family gets paid an estimated $25,000 to $75,000 per episode on the reality television show on Channel TLC. So, is it perhaps the show’s ratings that have prompted this 45 year old mother of 19 children to have yet another child? Is it the Baby-Doll syndrome where women have multiple children because they like the baby doll effect of having a newborn? I’m still scratching my head. However, I would be remiss if I did not, as an obstetrician offer some advice (albeit unsolicited) regarding the dangers of extreme parity (aka a great number of pregnancies). It was the same advice I offered almost 2 years ago.
- Mrs. Duggar, you are 45 years old and have what’s known in obstetrics as Advanced Maternal Age. This condition predisposes you to several high-risk conditions including pre-eclampsia, preterm labor and a host of other issues.
- You’ve carried 19 children in your uterus and its muscles are stretched to the max. Post-partum hemorrhage lies high on the list as a future complication and is the most common cause of maternal death in the industrialized world.
- You’ve also had a cesarean section and now have the potential to have a placental abruption (early placenta separation from the uterus) as well as a placenta accreta (the placenta sticks to the uterine incision and is extremely difficult to remove).
The Bible says to go forth and multiply and you’ve followed directions well. Now pat yourself on the back and give your body a well deserved rest. You escaped serious harm because of Divine Intervention and a skilled medical staff. Please, do not push the envelope.
June 8, 2011
Life Should Not Begin in a Toilet Bowl
She was well past age 35 when she showed up in the emergency room inebriated, confused and complaining of a swollen stomach. One might ask shouldn’t she be able to tell whether she was pregnant after giving birth to so many children? Perhaps she was in denial because pregnancy had not served her well. Each child she brought into the world eventually became the ward of social service.
An ultrasound was done and the baby was in plain view. There could be no more denial. It was a third trimester pregnancy. An emergency room physician listened to the fetal heart rate and declared it normal. She requested that social service be contacted as the alcohol began to wear off. Perhaps she was mandated to do so if she ever became pregnant again. When social service was contacted they advised the hospital staff to call the police who in turn, deemed she should go to jail because of an outstanding warrant.
It was not known how long the fetus had been exposed to alcohol but no one bothered to contact an obstetrician. Or place her on a fetal monitor. Instead, the ER doc wrote on her discharge summary to contact an obstetrician in the event that she was incarcerated for more than three days. She refused to allow the ER doc to do a pelvic exam but the nurse did one instead. However, the pelvic exam was not documented on her chart.
It’s not clear what happen when she arrived at the jail. There were no patient records available for review and an obstetrician was not consulted or called. 48 hours after her hospital discharge, while sitting in her cell, she felt like she had to move her bowels, screamed for help and then pushed as hard as she could, and her baby landed into the toilet like a projectile. Its umbilical cord was severed from the traumatic birth and it nearly bled to death. By the time the ambulance arrived, the baby was lifeless but CPR brought it back to life. If only this story had a happy ending. The baby has severe brain damage and required life-saving surgery on its heart because it was born with an anomaly. Had the hospital kept the patient or obtained an OB consult prior to her discharge, the results of her delivery might have been more favorable.
Did she need to wear a neon sign to alert the hospital staff that she was a high-risk patient? No prenatal care. Alcohol abuse. Advanced maternal age. Need I go on?
Life should not begin in a toilet bowl. Its effects can be indelible, far-reaching and devastating.
[i] This is an actual medical malpractice case that I was asked to review and given permission to discuss.
March 30, 2011
10 Rules of Engagement Every Pregnant Woman Needs to Know
I read an article in my local newspaper the other day that gave me reason to pause. The State of Florida intends to hand over 3 million Medicaid patients to managed care companies who will reduce payments to physicians and hospitals. In exchange for accepting these low payments for professional services, doctors are guaranteed through pending legislation that no matter what egregious errors they make, the patient will only receive a maximum of $250,000 in a medical malpractice lawsuit. This is definitely a “lose-lose” situation for patients.
Managed care is bad news for pregnant women. Extremely bad news. Every ultrasound, lab test and hospital admission that your physician or midwife orders on your behalf will have to be pre-approved by a gatekeeper who is on a mission to increase the profits of their company by reducing the amount of money that is spent on you. So you must therefore be on a mission to keep both you and your unborn baby out of harm’s way. How do you do that? Here are a few suggestions that are taken from The Smart Mothers Guide to a Better Pregnancy:
- Research your prospective healthcare provider through your State Board of Medicine’s licensing department to make certain they do not have any 7-figure malpractice suits settled or pending
- If you’ve had a previous high-risk pregnancy, request a referral to a Maternal Fetal Medicine high-risk specialist for your prenatal care
- If you delivered a preterm baby in the past, chances are likely you will do it again. Ask to have your cervix measured when you have an ultrasound and if it’s short , request a referral to a high-risk specialist
- If you have vaginal bleeding and are pregnant, do not leave a doctor’s office or an emergency room without someone doing an ultrasound to confirm that (a) the fetus is alive and (b) the pregnancy is not in the fallopian tubes (aka) ectopic pregnancy. An undiagnosed ectopic pregnancy could rupture and cause havoc.
- If you complain of a vaginal discharge, do not leave your healthcare provider until someone gives you a diagnosis and treatment. Untreated vaginal infections can lead to preterm labor. Bacteria is not your friend when you’re pregnant
- Back and lower abdominal pain should not be ignored, especially if you are less than 36 weeks. It could represent signs of premature labor
- Become familiar with fetal tracings. Flat lines and “u-shaped” curves during labor could mean your baby is in trouble and needs to be delivered quickly
- Try to deliver in a hospital that has a level 3 nursery and/or a NICU (neonatal intensive care unit)
- If a hospital mistreats you, contact its administrator. If you’re still not satisfied, file a complaint with the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
http://www.jointcommission.org/
- Trust your instincts. I can’t emphasize this enough.
Prevention is the key to reducing medical injury, not taking away someone’s right to sue.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do. Check out the video below for my information and pick up a copy of The Smart Mother’s Guide
March 21, 2011
NICUs Do Not Need Gatekeepers! Shame on the State of Texas
What is wrong with the state of Texas? Have they no heart? Why is it that at the time of fiscal crisis, it’s always the “little” people whose services are eliminated first? The “little” people in this case would be babies who are either born sick or premature. The New York Times article, In Search of Cuts, Health Officials Question NICU Overuse, by Emily Ramshaw was shocking. The Texas state officials have set their sights on looking at “inappropriate admissions” to the neonatal intensive care units as a way of cutting costs. Allegedly, they have “data” that demonstrates that $36 million dollars could be saved every two years if they curtail “over-utilization” of NICU admissions. Admittedly, some of my ob-gyn colleagues brought this level of scrutiny upon themselves when they performed “elective” inductions and cesarean sections based on “maternal requests.” That was clearly a faux pas. Any medical school and residency training program worth their salt instilled in their students the necessity to have a clinical reason as justification before performing a medical or surgical procedure.
However, these elective procedures only represent a small percentage of NICU admissions. The main reason for NICU admissions are based upon premature births that represent 12 percent of the annual 4 million U.S. births. The Texas Commissioner of Health and Human Services thinks the Texas NICUs are “over-utilized.”It’s a pity he didn’t provide any examples. The NICU typically takes care of babies with very specific high risk conditions such as hyperbilirubinemia that causes jaundice and potential death, hemolytic disease of the newborn that, if untreated in an emergent manner could lead to death from the baby hemorrhaging, very low birth weight babies, respiratory distress syndrome, congenital heart disease and a myriad of other life-threatening problems. Without having medical training, it is mind-boggling how The Texas commissioner or anyone else can determine if a NICU admission is appropriate or not.
In today’s litigious climate of medical malpractice and lawsuits abound, it is not unreasonable for a baby to be admitted to the NICU for observation if its APGAR scores are low. Better safe than sorry. Does the state of Texas propose to ration healthcare to newborns in the same manner that insurance companies ration healthcare to adults? Will you now become gatekeepers regarding life and death decisions?
I strongly urge the Commissioner to rethink this issue. Budget cuts to NICU admissions will have a ripple effect. Not paying for life-saving NICU admissions will lead to an increase in the cost of paying for chronic debilitating illnesses that could have been avoid. Every baby that’s born deserves to live. Please don’t set the stage for them to die.
March 9, 2011
Sacrificing Patient Care in Order to Make a Living Part 2
Did you ever love something or someone so much that you had to walk away because it hurt too much to stay? That’s how I feel about medicine. From the moment I saw my first delivery, I was hooked and there was no turning back. Perhaps I’m highly offended at our present state of affairs because I had to work so hard to gain acceptance into med school. I spent countless nights in the library at Columbia School of Physicians and Surgeons studying for the MCATs. Endured physiology, histology, biochemistry, gross anatomy (included the dreaded head and neck) and microbiology so that I could eventually diagnose clinical problems. I walked through the fire of residency training and came out whole on the other side. Yet, despite all of these humble achievements, I couldn’t see the destruction of healthcare coming. And neither did many of my colleagues. However, instead of banning together to save our profession, some of us allowed ourselves to be fiscally co-opted giving rise to the birth of “volume oriented medicine.”
Healthcare is now a business and quality of patient care has flown out the window. Billable procedures with diagnostic codes are the order of the day. “Productivity” is a buzz word, a euphemism for volume. The insurance companies are paying less, yet the healthcare providers are expected to do more. The number of patients on schedules increases and it has become “normal” for some of my colleagues to see 48 pregnant women in a day. A former medical director decided that he wanted to increase “productivity” even more so he paid physicians on a per-patient-basis and of course, his theory worked. When one of his cronies had 80 pregnant women scheduled in 5 minute intervals for one day, I had seen enough. I wrote a letter of complaint to the Florida Board of Medicine and was informed that there was no law that prohibited the number of patients a healthcare provider could see in a day. I then contacted the American College of Obstetrician-Gynecologists (ACOG) and they too, had no protocol or rule about volume. So, it was the wild, wild, west regarding patient care. No rules. No boundaries. And certainly no patient protection. Regime changes occurred, but the “numbers” game continued. I had had enough. So after 15 years of attempting to administer quality care in the midst of chaos and strife, I have tendered my resignation. There is nothing more that I can do except put it in the hands of God.
February 10, 2011
Why the Story of Mareena Silva is Important: Playing it Safe During the First Trimester
The story of Mareena Silva, a 19 year old pregnant woman who was mistakenly given a medication that could have caused a miscarriage is a precautionary tale of why it’s so important to be vigilant during pregnancy.
Silva was prescribed an antibiotic at six weeks gestation. Although the name of the antibiotic was not given, she ultimately received Methotextrate, an anticancer drug that is sometimes used to treat ectopic or tubal pregnancies and could have caused a spontaneous abortion. Silva unknowingly took one pill before realizing that the pharmacy had made an error. Of course, she is now concerned that her unborn child might be adversely affected as a result of the error. However there’s a deeper story regarding Silva. Her physician prescribed an antibiotic at a critical time of the first trimester called organogenesis which occurs between 6 to 10 weeks gestation. During organogenesis the brain and central nervous system of the baby develop. This is an extremely important time of fetal development and most physicians use a hands off approach regarding prescribing medicine unless the patient is critically ill and compromised. As a patient safety measure, here are some suggestions to avoid incurring a similar or repeat episode of Silva’s near-fiasco:
- If you are given a medication during the first trimester, ask your healthcare provider if you can wait until after your 10th week to take it.
- When receiving a prescription, look up the generic name of the medication as well as the trade name so that you will familiar with both names in order to detect potential errors.
- Make certain that everyone knows you’re pregnant. If you’ve missed your period but haven’t had an official pregnancy test, please request it.
- When picking up medicines from the pharmacy, confirm the name of the medication, including the correct spelling, the strength, the dose of the medicine and number of times it should be taken in a day.
- Ask your healthcare provider about the category of the medicine and potential side effects. A category “A” and “B” are safe during pregnancy but again, it should be deferred if possible until the second trimester.
Never take medication during pregnancy without knowing the risks as well as the benefits. If the risk outweighs the benefit, buyers beware.
Linda Burke-Galloway, MD, MS, FACOG, is the author of The Smart Mother’s Guide to a Better Pregnancy (Red Flags Publishing). Her book is available on Amazon.com and other bookstores. For author requests, please contact Ms. Zanade, L. Mann of Online and Off Marketing and PR Agency, 347-968-8067. All Rights Reserved
February 7, 2011
“Beat Her Until She Has a Miscarriage”
In less than six months after writing Seven Reasons Why Pregnancy Becomes a Deadly Affair , the public outrage is faint and inaudible regarding domestic violence committed against pregnant women. The subject therefore has to be revisited again.
On a college campus, less than 90 minutes away from my home, a 17 year old woman was kicked and punched in her abdomen for no apparent reason other than she carried life within her womb. The alleged father of her baby, Devin Nickels, a college student at Florida State University was apparently not happy about his new prospective role. He purportedly contacted a high school buddy, Andres Luis Marrero, who now attended the University of Tampa and asked him to beat his girlfriend until she had a miscarriage for $200.00. Marrero, instead, offered to assault the girl for free.
According to the University of Tampa’s newspaper, The Minaret, Nickels drove his girlfriend to a secluded wooded area near an apartment complex and Marrero allegedly assaulted her despite her pleas that she was pregnant. The woman was treated at a local hospital and her pregnancy was still viable. Hours later, Marrero allegedly wrote about the attack on his Facebook® wall describing it as “fun”. He was subsequently arrested for armed kidnapping and aggravated assault on a pregnant woman. His father made a statement that his son was an “outstanding kid all his life” and he had no idea “where this was coming from.”Nickels was also arrested on the FSU campus.
Unfortunately these travesties continued. A Comcast.com online newsletter reported the story of a 17- year- old Ypsilanti high school that allegedly stabbed a classmate 12 times in the back of the head, with whom he had sex because she told him she “might be pregnant.” She ultimately had surgery that resulted in an intensive care unit admission. The classmate lived because she “played dead.”
A few facts are in order for those misguided individuals who look at violence as a means of ending a pregnancy. According to a medical study, violence does not influence pregnancy loss. A 45 year old pregnant woman has an 80% chance of having a miscarriage. A 17 year old girl, despite being kicked in the stomach does not. One of the consequences of having sex is procreation. According to CDC, 49 % of all pregnancies in this country are unplanned. Teens need to be aware of the awkward fact that if they have sex, there is a near 50% chance that they will become pregnant and if their partner is not happy, they are at a greater risk of experiencing domestic violence even to the point of death.
Violence against pregnant women is becoming unparalleled in its viciousness. How many dead bodies will it take before we start doing something about it?
October 11, 2010
What Every Pregnant Cashier Needs to Know in Order to Protect Her Baby
courtesy of ghonie.blogspot.com
Is your job hazardous to your pregnancy? It might be if you work as a cashier. One more thing has now been added to a pregnant woman’s list of concerns. Recent articles have reported that pregnant women who work as cashiers have an increased risk of exposure to a hazardous chemical called bisphenol A or BPA.
BPA is a chemical that is found in plastic products including drink containers, plastic utensils, the lining of canned foods and in cash register receipts. It has caused prostate and breast tumors in animals and has been associated with heart disease and diabetes in humans. According to medical reports, more than 90 percent of pregnant women had BPA detected in their urine and 87 percent was found in the urine of their babies at birth. High levels of BPA in pregnancy have been linked to an increased risk of obese children and aggressive behavior in girls. A few years ago, concerned mothers successfully advocated for BPA-free baby bottles out of concern for their babies. However, the exposure that the unborn baby receives during pregnancy appears to pose an even greater threat.
Who is at risk for BPA exposure? Pregnant women who work as cashiers and handle cash register receipts as well as pregnant women who eat canned foods on a daily basis. Pregnant women, who are exposed to cigarette smoke, handle vinyl flooring and plastic containers are also at risk. The Occupational Safety and Health Administration (OSHA) is mandated to protect workers from a hazardous work environment by setting standards that employers must follow. Every employer is required to have a Material Safety Data Sheet (MSDS) that contains important information on the chemical properties and health effects of materials used in the work place. It would not be unreasonable to ask your employer for a copy.
Ideally, BPA should be banned from consumer products but until that happens here are some helpful tips for pregnant working moms:
- Ask permission from your supervisor or Human Resource department to wear gloves if you are a cashier, if they give you a difficult time; show them this link and then mention the regulatory agencies such as OSHA and the EPA
- Eliminate or reduce eating canned foods
- Microwave food in glass only
- Lobby your local politicians to have BPA removed from cash register receipts and cans
By being proactive, you are improving your chances of having a healthy baby. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
