July 18, 2012
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
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.
March 19, 2012
Is it wrong to be born? That question was asked in front of an Oregon jury who responded in a resounding yes with a guilty verdict of 12 to 0 against Legacy Center for Maternal Fetal Medicine and the Legacy Lab. The jury awarded nearly 3 million dollars to Ariel and Deborah Levy for the wrongful birth of their daughter, Kalanit who was born with Down syndrome although the prenatal tests said that she was normal. Levy was 34 years old at the time of her pregnancy with Kalanit and requested genetic tests. She had two previous deliveries of healthy boys and thought she had completed childbearing. Her pregnancy with Kalanit was a total surprise and she wanted to make sure the baby was normal. A chorionic villus sampling (CVS) was done at 13 weeks and the results were good. Levy breathed a sigh of relief, but not for long.
Although the CVS result was normal, Levy’s two ultrasounds weren’t. They were suspicious for Down syndrome but her physician assured her that she had a normal baby and did not bother to do an amniocentesis. When Kalanit was born, a hospital worker informed Levy that she appeared to have Down syndrome. One week later, the diagnosis was confirmed. Levy and her husband were devastated. How could this happen? Kalanit has a rare form of Down syndrome called Mosaic Down syndrome meaning some of her cells do not have abnormal chromosomes.
The Levys initiated a lawsuit in 2007 for a wrongful birth. They contend that although they love their daughter, had they known she had Down syndrome, they would have terminated the pregnancy. The trial languished for 10 days. The Levys received death threats. The Pro-Life and the Pro-Choice supporters squared off in predictable fashion and I shake my head in frustration. The ultrasound didn’t lie. An amniocentesis was warranted. The Levys did not make an informed decision regarding the birth of their daughter because they were not given the correct data.
Physicians don’t walk on water. On some regretful occasions, we will make mistakes. If for any reason you’re not comfortable with your physician or the diagnosis given, please get a second opinion; or even a third. And above all, trust your instincts.
Was it wrong for Kalanit Levy to be born? I’ll let you be the judge.
December 12, 2011
Sometimes Fate has to shout in order to be heard, especially when the voice of reason is ignored. Michelle Duggar was pregnant with her 20th child to the aghast of many including this author. We squirmed in our seats. We moaned. We groaned. We blogged. The combination of Duggar’s 19 children and her advanced maternal age of 45 is enough to make any obstetrician or midwife cry, especially when she becomes pregnant, yet again. Not surprisingly, Duggar experienced a miscarriage with pregnancy number 20. According to media reports, when the Duggars presented for their ultrasound, a fetal heart beat could not be obtained. What occurred in obstetrical vernacular was a missed abortion or an early fetal demise. Based on the Duggars’ press release, his wife probably had no symptoms prior to receiving the ultrasound. The cramping, spotting, abdominal and back pain was probably absent. An early fetal demise without symptoms or missed abortion means the baby stopped growing because there was a condition present that was incompatible with life. Did Duggar’s age increase her chances of having a miscarriage? Absolutely. 93.4% of woman who are over 45 will have a miscarriage. Or put another way, only 6% of pregnant women over age 45 will deliver a baby. 7% of all women Duggar’s age will have an ectopic (tubal) pregnancy and 8.2% will have a stillbirth. One out of 19 pregnant women who are age 45 will have a baby with Trisomy 21 or Down’s syndrome. So should we be surprised that Duggar had a miscarriage? No. And no one is gloating over her misfortune. A miscarriage for any family, even those with 19 children is lamentable. However, most pregnant women who have experienced a miscarriage will attempt to conceive again. In the case of Duggar, this would be a profound tragedy. Mrs. Duggar, you have our condolences regarding your miscarriage. Millions of people enjoy coming into your home each week and think you are delightful. However it is out of our profound concern for your well-being that prompts us to implore you. Please don’t push the envelope any further. Please give your uterus a well-deserved rest.
December 5, 2011
The umbilical cord of the fetus is the lifeline to its mother. Not only does it carry nutrients from the mother, but it also removes waste products from the fetus. The cord, as it is referred to, plays a very important role in obstetrics. At birth, a sample of blood from the cord is obtained and tested to identify its blood type and make certain the baby has enough oxygen. Traditionally, the cord is clamped immediately after birth or within the first 15 seconds of life to reduce the incidence of jaundice. However, this no longer holds true. A recent article in the New York Times discussed a Swedish medical study that demonstrated waiting 3 minutes or more before clamping the cord reduced the chances of getting iron deficiency in the newborn four months later. The blood of a newborn is unique because it is in its most primitive state and has stem cells. Stem cells are important because they have the potential to grow into many different cells in the body. When clamping of the cord is delayed, the baby essentially receives a blood transfusion of its own blood.
The practice of delayed clamping of the cord is not new but it is usually done after premature births to reduce complications. Delayed clamping of the cord of preemies by 30 to 120 seconds reduced the need for blood transfusions and reduced brain hemorrhages. These benefits were seen immediately. However, in the Swedish study, the benefits of delayed cord clamping were seen at a much later time interval of 4 months. This is was very significant and paves the way for further studies to determine if this benefit will still prevail months or even years later. Should all babies have delayed cord clamping? No not all. Newborns who had fetal distress during labor should not have delayed clamping because there is a greater transfer of blood from the placenta to the baby during this type of crisis. Also, babies who were growth restricted during pregnancy and babies of diabetic moms should not have delayed cord clamping as well.
Delayed cord clamping might play a significant role in the prevention of newborn and infant anemia. It certainly deserves a discussion with your healthcare provider at your next prenatal appointment.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
November 30, 2011
On a recent Sunday in the bathroom of the Baltimore-Washington International Thurgood Marshall Airport, a baby boy made his entrance to life. His mother was approximately 28 weeks and delivered prematurely, however both baby and mother were healthy according to the media. Although the details of the delivery are sketchy, anyone involved in obstetrics can predict what occurred.
The mother might have had a previous history of a urinary tract infection, or complained of back pain. Did her ultrasound reveal a short cervix? Or perhaps she had a history of a previous early delivery. If it was her first pregnancy, did she complain of mild abdominal pressure? Premature labor is one of the most common reasons for birth defects and has a price tag of approximately 26 billion dollars per year. The signs and symptoms of preterm labor often go unnoticed or diagnosed because healthcare providers aren’t paying attention. A urine analysis report showing bacteria in the urine will not be addressed. No inquiry will be made as to whether the patient made frequent trips to the bathroom or whether she drank soda. Soda predisposes patients to urinary tract infections because of the carbonation or bubbly component of the drink irritates the bladder. Untreated urinary tract infections can cause premature labor. A complaint of lower abdominal pressure will be attributed it to “round ligament pain” even though the patient is well beyond 20 weeks when it is most likely to occur. A complaint of back pain will be blamed on the changing shape of the uterus rather than sending the patient to the hospital for further evaluation. In essence, some healthcare professionals keep missing the diagnosis or intervening too late.
According to the American College of Obstetrician/Gynecologists (ACOG) pregnant women can travel up to 32 weeks by air provided they don’t have any complications or high risk conditions. The change in altitude can sometimes cause the “water to break” or the placenta to separate too soon. All pregnant women who plan to travel (especially by air) should consult with the OB provider for advice and instructions. For pregnant women who plan to travel, here are some suggestions:
- Obtain a copy of your prenatal record prior to traveling in the event of an emergency
- Find out the name of the nearest Level 3 hospital where you will be staying
- Do not sit for more than 2 hours without standing for a few minutes to stretch your legs to prevent blood clots.
- If you are complaining of back or abdominal pain before traveling, contact your provider immediately
Fortunately the baby born in the airport bathroom appears to be fine. However not all unexpected births have a happy ending. Pregnant moms, if you have to travel, please don’t push the envelope.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
November 14, 2011
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.
September 19, 2011
In 2007, Melanie Jaggard went to the hospital for a punctured ear drum and was given the shock of her life. She had cancer; a very rare form that was located at the base of her brain.
Adenoid cystic carcinoma (ACC) is the second most common cause of salivary gland cancer but can affect other areas of the body. Melanie is one of only 20 to 25 people in the United Kingdom to have ACC and had a 2-inch tumor was removed from her head following a delicate 10-hour operation. She was single at the time, cancer free and one year later met the love of her life, Charlie Jaggard, on an online dating site. Charlie proposed three months after their first date and life was good, until she received the news that the cancer had returned, this time metastasizing to her lungs. Surgery was not an option because the tumors were too numerous and radiation was too risky to the lungs. However the couple was not discouraged. They married in January 2009 and Melanie decided to be a victor rather than a victim. Although 89 % of people with ACC survive after 5 years only 40% survive after 15. Melanie has a life-span of 15 years and she and Charlie have both decided to look at the glass as half full rather than half empty. After careful consideration regarding Melanie’s condition and prognosis, they decided to start a family.
Melanie is now pregnant with twins and is very optimistic about her future. While there may be people who will criticize her for starting a family, the Jaggards are convinced that 10 to 15 years will give them time to raise money for a cure or at least discover medicines that can shrink the tumor. Approximately 1 in 1500 pregnancies is affected by cancer. Melanie holds the distinction of being the only pregnant woman to have ACC in the medical annals thus far. She is treading in unchartered water but optimism will be her guide.
Lucius Annaeus Seneca once said: “Sometimes even to live is an act of courage.” Hopefully one day her twins will thank her.
July 6, 2011
The drive through the streets of Addis was enlightening but not surprising. The streets were crowded with the movement of brown faces, cell phones, old women in layered clothes with shawl covered heads and teenage boys wearing hooded sweatshirts and urban culture. The poverty was glaring with tin-roofed shanty towns housing people who possessed the will to survive. Except for the rusted tin roofs and goat herders in the middle of the street, it could have been any urban city.
The adoption agency and its guest house were smack in the middle of the Hood. The van turned down a very narrow dirt alley with shanty towns on each side and stopped at a gray tin gate that was encased with barbwire. The driver got out of the car, rang a buzzer and a security guard appeared along with the tiniest female toddler with the brightest wide eyes, long eyelashes and the color of caramel candy. Alert and beautiful, she was immediately swooped up into my arms as I said hello. The other toddlers ran forward and the gate was immediately closed. I could clearly understand the need for a security guard. The driver introduced us to the staff and showed us our room. Lunch was to be served at 1:00 p.m. so we had time to see our kids who were housed in a compound less than 300 feet away.
It was the moment of truth and we didn’t know what to expect. Armed with a digital camera, a camcorder, two toy cars purchased at a budget store along with two hearts filled with love, we approached another steel, barbed wired door, not knowing what to expect. The door swung open to a yard filled with screaming children in active play. Two young boys dressed in black tee shirts stopped for a moment and I immediately recognized Mamush. Both my husband and I called out his name simultaneously and he rushed to us, then gave each of us the tightest hug and sweetest kiss. Kayamo followed but was a bit shy. I pulled out the toy cars still encased n plastic and frantically attempted to open them quickly. Kayamo received his first and proceeded to handle it like a trophy with other children in hot pursuit. To my chagrin, Mamush’s car was screwed (of all things) into a case and it was a struggle to remove it. The nanny finally succeeded and Mamush was also displaying his gift from his new parents. Wanzo lifted both boys in his arms and the magic begun. We spoke to their nurse who gave me an update about their medical conditions. We saw their very humble beds and dorm room that was no bigger than a narrow hallway. There were four beds lined one behind the other in a room lit with a naked 40 watt light bulb. I couldn’t wait to get them home. My husband showed them a short video and their nurse translated. There were ooohs and aahs as they smiled with delight. Mamush mentioned Daddy’s car and the boys beamed with pride.
We walked back towards the courtyard, and then Mamush grabbed my husband’s hand pointing toward a building beckoning him to come. Kayamo followed closely behind as I remained, observing the new bonding. Kayamo then stopped, turned and looked at me as I waved to him. He walked towards me, held out his hand and beckoned me to follow as well. As it turned out, it was lunch time and the children were settling down to eat. Kayamo motioned for me to take a picture of him and his 2 buddies. Then Mamush stood before the children and said a passionate Amharic prayer that the children recited enthusiastically. We asked the nurse to tell Mamush and Kayamo that we were leaving to allow them to enjoy their lunch but we would return tomorrow. Both boys gave us the sweetest hugs and kisses. Kayamo held me so tight that I hated to let go. Any previous doubt or fear about the decision to adopt was eradicated completely. We were the proud parents of two precious gifts sent from Heaven above. These were our precious children with whom we are well pleased.
July 4, 2011
Independence Day always reminds me of my mother whose birthday fell two days prior to the holiday. My mom made her transition almost ten years ago but in her honor, I’d like to share a page or two from my journal that describes my own experience of becoming a mother.
I’m presently flying on Ethiopian Air across the Atlantic Ocean. The plane dropped 10 to 20 feet because of turbulence and my husband became embarrassed because I started calling on Jesus; loud and in living color. He tried to force me to listen to some Ethiopian music via red, antiquated looking head phones but I emphatically say no, I prefer to have a conversation with God instead. I’ve never been one who suffered in silence and when it appears like we’re headed straight for the ocean, of course I’m going to pray. I’m not a religious zealot but calling out God’s name in the time of trouble is like using a password to enter a safe haven in the midst of a chaotic world.
The pilot lowers the altitude and the plane is peaceful again. Back to the boys. I often wonder how did I arrive at this junction called international adoption? Twenty years from now when my sons are in their late twenties, I’ll be a three-quarter of a century. How will they respond to me when we finally meet? We appear to be getting closer to Ireland and Paris.
August 24, 2008. Seven whole days after my birthday and my life has changed dramatically. We stopped in Rome for fuel and a change of airline crew. The new crew was tougher, a little more no-nonsense but still professional and polite. I looked out the window and saw the demarcation between night and day; the dark, black sky giving way to a pale blue sky with orange hues. It was beautiful. I look at the flight monitor and watched our plane fly over exotic places such as Khartoum and Sudan. My former life seemed millions of miles away as the plane ventured towards my unknown future.
We finally approach Addis Ababa and as the plane was descending into the city, I observed the beautiful mountains and virgin landscape. It was breathtaking and of course, I cried. We had to obtain an entry visa that proved to be painless. They didn’t ask us to declare money nor the prerequisite pictures we were so careful to remember to bring. They only seemed concerned about the $40 visa fee and quickly snatched the two crisp $20 bills out of my hands and stuffed it into their pockets. Most of the immigration workers were 20-something year olds whose families probably bought their positions through backdoor deals and old political ties.
(To be continued. Please see Part 2 on Wednesday.)