The Washington Post recently published a story about mammoth retailer Wal-mart’s new policy that allows pregnant women more options so that they can continue to work even late into their pregnancy. While this change of policy is a moral and economic victory for pregnant Wal-mart employees, it did not come without a fight.
In 2011, the Equal Employment Opportunity Commission received 5,797 pregnancy-related complaints from women who represented all walks of life from a cashier to corporate executives who felt that they were discriminated against by their employers solely on the grounds of being pregnant. According to the National Women’s Law Center, almost 9 out of 10 women worked into their last two months of pregnancy which carries an increased risk of complications. Rather than allow the pregnant employees to change positions, work less hours or sit in a chair, many find themselves terminated or asked to take a temporary leave of absence that often times becomes permanent. Many are forced to use their Family Medical Leave time before having the baby and must rush back because they’ve run out of time.
Tiffany Beroid’s blood pressure started to rise as her pregnancy advanced. Her doctor gave her a light duty note but Wal-Mart told her they didn’t have light duty work, forcing her to take her pregnancy leave sooner than anticipated. Through social media efforts, pregnant employees of Wal-Mart with problems similar to Beroid’s began networking and an organization called Our Wal-Mart that is a labor union supported group began to advocate on Beroid’s behalf. She was also assisted by a work advocacy group called A Better Balance as well as the National Women’s Law Center.
March 5, 2014 became a day of victory for the thousands of pregnant employees of Wal-Mart when the company issued a new policy that allows its pregnant employees to perform less demanding work if they’re having difficulty fulfilling their duties.
All pregnant women are encouraged to become familiar with The Pregnancy Discrimination Act of 1978 in order to protect their rights. The policy changes of Wal-Mart are to be commended. Let’s hope other industries will follow suit.
Most women look forward to having a baby but no one wants to feel pain. In recent years, having a baby in a pool of water has become a popular trend because it allegedly reduces the need for pain meds and anesthesia however not so fast, says both obstetricians and pediatricians. The American College of Obstetricians and Gynecologists (ACOG) and the American Academy of Pediatrics (AAP) have issued a formal opinion (Committee Opinion #594 April 2014) that does not support “immersion” (aka underwater) births because of its associated complications while a mother is pushing to deliver her baby. The “pushing” part of childbirth is also known as “second stage labor.”
Why is this important? Because there are presently 143 birthing centers in the U.S. that offer underwater births to pregnant women. In fact, 1% of all births in the United Kingdom are immersion. While some research claims that these births are safe, experts think otherwise and state that the number of women studied was too small to detect rare but potentially harmful outcomes.
While some women may experience a feeling of well being and control, decreased stress and less vaginal tears during an immersion birth, according to the Committee Opinion, there is no scientific evidence that an underwater or immersion birth helps the baby. In fact, there is evidence of increased complications such as
• increased infections to both the mother and newborn, especially after the membranes are ruptured (aka “water broke”)
• difficulty in regulated the newborn’s temperature
• increased risk of the umbilical cord tearing from the placenta
• infant drowning and near drowning
• infant seizures and suffocation
• severe infant breathing problems
Should women give up immersion births completely? Probably not. The experts think that a woman may stay in these tubs during labor but should NOT push or deliver the baby underwater. They also recommend stricter protocols, patient selection and infection control.
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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.
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.
A few years ago, a 20-something year old pregnant woman presented to her physician with complaints of a skin bump that was red and painful. She was told it was a spider bit and given antibiotics. The patient ultimately went in labor but required an emergency cesarean which went well without any complications. Four days later she developed skin lesions and 3 months later she expired after a very stormy hospital course. What did she die of? MRSA, which stands for Methicillin Resistant Staph Aureus.
Staph Aureus (Staph) is a bacteria that can be found on the skin and doesn’t usually cause problems as long as there are no breaks or cuts in the skin. However, if there are cuts and Staph gains entry into the skin, an infection can develop that if often not serious. However, Staph has a very dangerous form that is resistant to the medications that will normally treat it. The resistant form of Staph can cause havoc if unrecognized which can lead to several complications including death. In fact, 20% of people who have (MRSA) dies from this infection because the diagnosis is made too late. One of the most common complaints patients have when there is a MRSA infection is a bump or red lesion on the skin that is misdiagnosed as a spider bite. How do you avoid the misdiagnosis? By knowing who is at risk and what to look for.
MRSA tends to be found in places where there are many people living close to each other such as nursing homes, but of late, several cases are also associated with
People who are either in a prison or an athletic facility.
Athletes who share towels or razors
People who either work in prisons or visit relatives or friends incarcerated should always wash their hands after a visit.
If you are given a diagnosis of a “spider bite,” request that it be cultured, meaning a Q-tip is used to take a sample from the bump. Sometimes people can have the infection without having any symptoms. This is known as being a “carrier.” Again, if you are given the diagnosis of having a spider bite, ask that a culture be obtained from inside of your nose to make certain you don’t have MRSA.
MRSA can be treated appropriately with the right antibiotics. Medicines that are associated with Penicillin such as Amoxicillin and cephaplosporins will not work.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
Today will be a day of mourning for pregnant women who are uninsured and receiving Medicaid in Houma, Louisiana. Their local hospital closed its maternity and neonatal units because of a $2.9 million dollar budget cut. Over 100 employees will lose their jobs, many whom have held their positions for over 20 years. This closing will have a ripple effect and is an increasing phenomenon that has besieged many hospitals across our nation. Over thirteen hospitals in Philadelphia closed their labor and delivery departments and in my own backyard, South Seminole Hospital in Florida did the same. What’s going on? Hospitals claim they’re losing money and government insured and non-insured pregnant women are feeling the aftermath. These are some very scary times.
The options for Houma’s uninsured pregnant women or women who receive Medicaid are quite limited. A few years ago, they could have gone to Lafayette Hospital in Lafayette; or Earl K. Long in Baton Rouge or Charity Hospital in New Orleans. Sadly, all of those hospitals have closed their labor and delivery department. I know those hospitals well, having worked and lived in Louisiana for almost four years as a community health physician.
Although Houma is a small, close-knit community, its hospital provided hundreds of prenatal visits for pregnant women in nearby parishes. They interacted like family. The nurses at Leonard J. Chabert Medical Center are devastated and apprehensive about the future of the pregnant women knowing that most cannot afford to go to private physicians and many have high risk problems. Consequently, many of these patients will be forced to travel over 300 miles on a 5-hour trip to Shreveport, Louisiana to receive prenatal care at its charity hospital.
I strongly encourage the State of Louisiana to brace itself for an increase in infant and perhaps even maternal deaths. Many high risk patients are simply not going to be able to make that 300-mile trek to Shreveport without adverse consequences. Any perceived benefit from that $2.5 million dollar budget cut will quickly dissipate based on the spike of NICU admissions that are sure to come.
The women and their unborn babies deserve better. Shame on the State of Louisiana.
A lie unchallenged becomes the truth. While I admire GOP candidate Rick Santorum’s decision to raise a special needs child, I certainly wish he would keep his political agendas out of my exam room. Yes, it takes love and courage to raise a child with Trisomy 18, a genetic disorder that’s associated with severe physical and mental challenges. However, this does not make Santorum an expert on prenatal tests and to say anything to the contrary, is both reckless and immoral.
Prenatal tests, especially those that tests for chromosomal abnormalities, are optional. A woman can decline the tests if she chooses to do so and I’ve had patients who have exercised that perogative in the past. But first, let me tell you why these genetic tests are so important. If a woman discovers that she has a baby with Trisomy 21, commonly known as Down’s syndrome, both she and her pediatrician will have time to prepare for possible complications. Many genetic disorders are associated with heart conditions and require immediate surgery after birth. There are instances where the baby is born with a pediatric cardiologist in the delivery room who then whisks the baby away to have a life-saving cardiac procedure. This cannot happen if you don’t have the prenatal test.
In my 25-year career as a physician, I’ve only had 2 confirmed cases of Trisomy 21 and both mothers decided to keep their pregnancies. However, please be aware that there are some genetic disorders that are incompatible with life and the baby expires shortly birth. Most mothers do not want to experience that type of emotional trauma.
Mr. Santorum, please stop using Women’s Health as a stepping stone to gain entrance into the White House. If you can’t campaign for President based on truth and merit, then perhaps you’re not cut out for the job.
The story regarding Republican presidential candidate Rick Santorum’s daughter, brings the subject of genetics into the forefront. Santorum’s 3-year-old daughter, Bella, has Trisomy 18, which is an abnormal disorder where some cells do not contain 2 complete sets of 23 chromosomes. It is almost always fatal and most affected babies die at birth or shortly thereafter. Bella, by some schools of thought, might be considered a miracle.
The diagnosis of a genetic disorder such as Trisomy 18, usually begins with either a screening blood test such as quad screen, or a routine ultrasound after 17 to 18 weeks. The technician or physician might note a fetus that has a clenched fist or unusual feet called Rockerbottom feet. These signs are called the Edward’s syndrome. Other ultrasound findings that suggest genetic abnormalities include polyhydramnios or excessive amniotic fluid, a “double-bubble” sign indicating a condition called duodenal atresia that is associated with Down syndrome as well as heart problems. Also, most fetuses with Down syndrome also have congenital heart problems.
If a suspicious finding is detected on an ultrasound, the technician should report it to your physician immediately for further evaluation and consultation. These consultations should include a referral to a geneticist. The geneticist will take a complete family history from both you and the father of your baby and might suggest obtaining an amniocentesis procedure to obtain fetal cells for confirmation of the disorder. All amniocentesis procedures require written consent because there is a 1 percent risk of rupturing the membranes during the procedure. There are 2 schools of thought regarding genetic screening: one school says why bother? There’s nothing that can be done. The other says it is good to know in advance so that the mother can make critical decisions regarding the continuation of the pregnancy.
Genetic counselors can identify other potential problems such as hemophilia and color blindness which are called x-linked disorders. These conditions are carried on the genes of females but only expressed or affected by males.
Genetics is an evolving field that continues to play an important role in obstetrics and pediatrics. All pregnant women should be encouraged to fully utilize their services as needed.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
It’s an obstetrician’s worst nightmare and it continues to happen on a daily basis. The story of Michal Lura Friedman brings tears to my eyes. After 7 years of trying, the 44 year old songwriter finally became pregnant –with twins. Her husband, Jay Snyder, a free-lance voice-over artist, describes the 9 months of Friedman’s pregnancy as pure bliss. However towards the end, her blood pressure became elevated so she was scheduled to have a C. Section the day after Thanksgiving.
Snyder accompanied his wife to the hospital and witnessed the birth of his babies. Then Friedman began to bleed. And bleed. And bleed. At 9:30 p.m., she became yet another U.S. maternal mortality statistic.
At least 2 women die from complications of childbirth in the US daily. Some celebrities such as Christy Turlington Burns have become a Maternal Health Advocate as a result of first-hand experience. She had a near-miss childbirth experience but lived to tell the story. Many women, including Friedman, don’t. The American Congress and College of Obstetrician-Gynecologists (ACOG), will have both Burns and Tonya Lewis Lee, the wife of renowned director, Spike Lee as spokeswomen on the topic of maternal mortality at the 2012 Annual Conference in San Diego. However, we need much more. There are obstetricians who have worked on the front-lines managing high-risk patients for years who can’t get a seat on ACOG’s policy committees and it is frustrating. Here are a few questions that should be asked at the hospital where Friedman expired:
She had a short stature with a uterus stretched to the max with two babies. Was the possibility of hemorrhage considered?
When her blood pressure became elevated, was it controlled prior to doing the C. Section knowing the risk of possible HELPP Syndrome that is associated with pre-eclampsia?
Was there an OB Rapid Response Team?
Was a Bakri balloon used once the bleeding couldn’t be controlled with uterine massage or meds?
Was the prospect of a problem anticipated BEFORE it occurred or was there chaos trying to find appropriate meds and equipment as the tragedy unfolded?
Pregnancy is not a benign act contrary to what most people believe. Things can and do happen, most often when the hospital staff is unprepared and ill-equipped to handle an emergency. My heart bleeds for Jay Snyder. He is 41 years old, a new father and now a widow who must take care of two beautiful children, who will never know their mother. With all due respect ACOG, talk is cheap. More action must be taken to stop this.
Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do…
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.