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.
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 16, 2011
A recent medical study by Dr. Ira J. Chasnoff of the Children’s Research Triangle asserts that Hispanic women who have assimilated to American culture have a greater risk of having children born with fetal alcohol syndrome. According to Chasnoff , pregnant Hispanic women in San Antonio had the second highest drinking rate of 29 cities in the states that were studied. I find that rather hard to believe based on my twenty-one year history of taking care of Hispanic pregnant women. I have seen first, second and third generation Hispanic women and never encountered alcoholism among any of them. However, Chasnoff brings up an interesting point about alcohol and pregnancy. There are two schools of thought. According to Good Morning America, there are physicians such as Dr. Jacques Moritz, who think an occasional glass of wine is okay to consume during pregnancy however the U.S. Surgeon General and the American College of Obstetrician-Gynecologists advocate strict abstinence from alcohol while pregnancy.
According to medical literature, more than one-half of women of childbearing age report drinking alcohol and 1 out of 8 women report binge drinking. Alcohol appears to have negative effects throughout the entire pregnancy, not just during the first-trimester. At present, it is not known how many drinks consumed would affect the fetus, therefore strict abstinence is recommended before conception and during the pregnancy.
What happens if a pregnant woman is alcohol dependent? She will need close monitoring because of the adverse effect on the fetus including support from a multidisciplinary team of healthcare and social work providers. Women who consume three or more drinks per day are encouraged to enter an alcohol treatment program. Women who drink less than 3 drinks per day are encouraged to receive counseling. The pediatrician should be present at the birth of a woman who is alcohol dependent in the event the baby has alcohol withdrawal. Women who continue to drink should be discouraged from breastfeeding.
Dr. Chasnoff is to be commended for studying substance abuse and pregnant women but please don’t stereotype ethnic groups in the process. Pregnant women should abstain from drinking alcohol if at all possible. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
November 7, 2011
A recent article about the shameful infant mortality rate in the U.S. caught my attention. Certainly the statistics quoted are nothing new but still remains alarming. However, the Op Ed by CNN contributor Deborah Klein Walker gave the subject matter a new spin. Walker wrote “This is one of the greatest injustices in our country: that a baby’s chance of having a healthy life is largely dependent on where he or she is born. States and local communities vary widely in what care their leaders choose to provide to women and children.” If Dr. Walker were present, I’d give her a great big hug for her courage to say what no one else dared. A baby can die based on a hospital zip code.
Every pregnant mother needs to take a mini course in hospital politics because they are directly affected. A hospital is no longer a place of healing. It is a business and at times, ruthless. I have witnessed a colleague forced out of business because she said no when a hospital wanted to buy her practice so they withdrew her admitting privileges instead. I recall bitter battles with my former employer because I would not encourage my patients to deliver at a hospital that was notorious for being under staffed, overworked and a haven for medical errors, simply because of a business relationship that my employer had with thatehospital.
I commend our federal government for initiating programs such as Healthy Start and the new home visiting program, but dependence on government assistance alone cannot guarantee a healthy baby. A pregnant mom must do her due diligence. She must investigate the credentials of the provider and hospital where she intends to give birth. What should a pregnant mom do if she lives in a community or state that has a high infant mortality rate? Give birth at a teaching hospital that’s affiliated with a university or medical school. Most of these institutions receive federal and state financial support and are obligated to provide care to patients.
Can a baby die based on the zip code where it’s born? Unfortunately, yes unless the mother is willing to do her homework and take the necessary precautions to avoid that from happening. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
October 10, 2011
The story of Tanya* is compelling. She was 24 weeks pregnant with her third child and the hospital was threatening to send her home. Two years ago, she faced similar circumstances and delivered a baby at 23 weeks. Luckily, the baby is now two years old but the one before that was not so lucky. Tanya presented to a local hospital during her first pregnancy because of complaints of abdominal pain. She was sent home because her contractions “weren’t regular.” Ten hours later, Tanya returned to the hospital because of a “nagging feeling that something was wrong” although her contractions were still not regular. Unfortunately, her cervix was dilated and the contractions could not be stopped. Her son was born alive but died one hour later because the hospital was not equipped to deal with premature newborns. Tanya’s second pregnancy was similar to her first because she developed premature contractions again, at 23 weeks. As with the first pregnancy, her contractions were not strong and regular so she was discharged home from the hospital with a monitor that was supposed to help. It didn’t. Luckily, she had an appointment with her high risk physician the next day who informed her that she was dilated although she did not have regular contractions. Her preterm labor could not be stopped but this time, her baby did not die.
Tanya contacted her Bedrest Coach, DarlineTurner-Lee, owner of Mamas On Bedrest that provides support to high risk pregnant moms and Lee contacted me. She asked for advice regarding Tanya who was 24 weeks and about to be inappropriately discharged home from a specialized teaching hospital. I offered strategies on Tanya’s behalf but there weren’t necessary. One of the physicians at the hospital convinced the staff to allow Tanya to remain in the hospital until 28 weeks. There are lessons to be learned from her case
- Trust your instincts. Tanya was correct in not wanting to be discharged home because of her previous history. Women who delivery preterm babies (especially at 23 weeks) are bound to do it again. The chances of survival are far greater at 28 weeks than at 24 weeks
- She obtained an advocate and sought a second opinion. 2 heads are always better than 1 especially when there is doubt about a diagnosis or treatment
- If you have a high risk problem, always attempt to be admitted to a Level 3 hospital where they have specialized care for newborns
Tanya expressed her gratitude by saying “. . . I thank God for people like you and the staff who fight for our little miracles.”
1 out of 8 pregnant women will deliver a premature baby in the US each year. Hopefully, this time, Tanya will not be one of them.
September 26, 2011
Three young mothers under the age of 40 are dead because they wanted to be beautiful. Kellee Lee-Howard wanted a slimmer body. Ditto Maria Shortall and Rohie Kah-Orukatan. Shortall worked as a housekeeper; Lee-Howard was the mother of six kids and Kah-Orukotan died at the same place where she received manicures. What do these women have in common besides being minorities? They had liposuction procedures performed by men who offered a discounted price for an elective surgical procedure. These men professed to be competent in performing the procedures but never had accredited training.
I knew this day was coming. I saw the storm long before the clouds emerged. As the insurance payments for professional medical services decreased and declined, physicians began to look for alternative ways to earn money. But was it ethical? Gynecologists began to do liposuctions. General surgeons did breast augmentations. Some primary care physicians abandoned seeing patients altogether and opted to do chemical peels and weight loss treatments. Medical spas were added to traditional medical practices. Everyone wanted to cash in on a woman’s desire to be beautiful. Physicians were now business owners and entrepreneurs. However, could they attend a weekend seminar and returns to their offices on Monday ready to do the procedures? Were they really as competent as a plastic surgeon who had five years of training?
Jayne O’Donnell recently published an expose about these doctors in USA Today entitled Lack of Training in Cosmetic Surgery Can Be Deadly. It reads like a litany of horror. The physician who performed Kah-Orukotan’s liposuction was an Occupational Health physician. He didn’t have the proper equipment in his office nor was the procedure approved for office surgery. Shortall and Lee-Howard’s physician did an internship in pediatrics, another internship and residency in general surgery but never got board certified in the 27 years that he has practiced medicine. Had these ladies accessed the Florida Board of Medicine website and looked up their physician, they would have noted the $350,000 settlement in 2004. They would have also noted the absence of board certification, the absence of plastic surgical training and the absence of privileges to admit to a hospital.
All three women died from complications of anesthesia. They had received too much lidocaine which is a numbing medicine given by injection prior to a surgical procedure. Too much lidocaine can also stop the heart. These deaths should have never happened.
In Part 2 of this blog, you will learn what can be done to avoid becoming a victim of a preventable medical mistake. The life you save could be your own.
September 5, 2011
It seems that Matthew Scheidt, had a summer job working part-time for a surgical supply company. He allegedly went to the Human Resources Department of the Osceola Regional Medical Center (ORMC) and convinced them that he was a Physician Assistant student at Nova Southeastern University and lost his identification badge. This is the hospital where many of my former patients were forced to go for medical care because they were either uninsured or received Medicaid. My former employer had a fiscal relationship with them. The use of the word “forced” is quite appropriate because my uninsured patients had no options. When those who had Medicaid requested to deliver at a women’s hospital in another county they were discouraged to do so by the powers that be. I recall with great pain the memos, reprimands and threats I received from my former employer because I wanted to give my patients the freedom of choice. Oh, the stories I could tell about the numerous altercations I had with certain staff members regarding patient management issues. So the fact that this hospital is now on local and national radar screen does not surprise me at all. The hospital was formerly owned by the organization that Florida’s incumbent governor once worked for and eventually paid fines because of fiscal improprieties. The hospital’s long-standing former administrator resigned once the governor ran for office. Yes, politics indeed can affect patient management. But let us return to the story of Scheidt.
Scheidt allegedly performed CPR, changed IVs, cleaned wounds, performed interviews and physical exams on male patients who were disrobed. He was also in the operating room. He only got caught when he asked permission to go to “restrictive areas” of the hospital and I pray it wasn’t the labor and delivery suite. How did this happen? Because our healthcare system is presently on automatic pilot. There are no checks and balances. No accountability. A 17 year old can show up in the human resources department of the hospital and no one does a background check to verify his credentials. Pity the poor patients. This is one of many reasons why The Smart Mother’s Guide to a Better Pregnancy (TSMG) was written. Patients need to be protected.
Could this happen to you? In a heartbeat if you’re not astute and aware. There is a chapter in TSMG, called Investigating the Places Where You Will Receive Care. I strongly encourage everyone to read it.
May 16, 2011
“But for the grace of God go I.” My late aunt drilled that value into my six-year old head and it has never left. An article regarding a New York politician recently caught my attention. When New York State enacted a bill to ban the shackling of pregnant prisoners, a New York State Assemblywoman objected. The article goes on to discuss the case of Jeanna M. Graves, who, in 2002 was arrested on a drug charge and began a three year sentence. Graves was pregnant with twins and while in labor, was handcuffed during her entire C. Section. How utterly ridiculous.
Before a C. Section begins, a patient is usually given either an epidural or spinal anesthesia. On rare occasions, she is put to sleep with general anesthesia if the baby must be delivered emergently. On all accounts, the patient’s legs will either be numb from anesthesia or she will be sleeping. Why then does she need shackles? She’s certainly not in a position to run. Although I addressed this issue last August, it needs to be revisited again.
Women’s health and pregnancy should not be political agendas. I recently tweeted about another controversial article that blamed the reduced workforce in Memphis on teen pregnancy. Yes, it’s true that 49% of teen pregnancies are unplanned and unwanted but somehow the teens eventually mature and become productive human beings for the sake of their children. Our workforce problems stems from the outsourcing of U.S. jobs overseas, not teenage pregnancy.
Jeanna Graves was not perfect but neither did she commit a heinous crime. She used drugs and had a self-inflicted disease. In the course of my professional career, I have witnessed the most egregious acts corruption, fraud, deception and medical negligence, all under the rouse of helping the poor yet not one administrator ever left the building in shackles or seen the inside of a county jail.
Here’s a question for New Yorkers: Would you really elect someone who approves of shackles on pregnant to be your congressional representative?
May 11, 2011
At one time, a hospital would be called a 24-hour institution but now it’s a business. Within this business are shift workers that include nurses, technicians, clerical staff and even hospital employed doctors who are now called hospitalists. In a teaching hospital resident physicians also work in shifts so the responsibility of patient care is always being transferred from one group of healthcare providers to another. Do they always communicate effectively? Regrettably, “no.”
Sign-outs, handoffs, shift changes, nurses’ report. These are the multiple names for the process where a departing provider is responsible for letting the arriving provider know what’s going on with the patient. According to statistics, 80% of medical mistakes occur during shift changes and 50 to 60% of them are preventable. Listed below is an excerpt from The Smart Mother’s Guide to a Better Pregnancy that teaches pregnant moms what things should be known during a shift change.
“While in labor, there will most likely be a change of shift and a transfer of information should occur. However, it is not always successful. Information is sometimes lost, incomplete, misunderstood or inaccurate. Your doula or a family member should make a list of all tests that have been ordered since your admission. He or she should also know your most recent vital signs, including your blood pressure and whether your baby’s fetal tracing was reassuring. Other important include:
- The length of time since your membranes ruptured: the longer your membranes have been ruptured, the greater your chances of developing an infection in the amniotic sac around the baby called Chorioamnionitis
- A positive group B strep that must be treated with antibiotics to prevent your baby from contracting the infection
- The length of time you have been receiving Pitocin. The status of your fetal tracing should be noted to make certain that the baby can tolerate the contractions caused by Pitocin.
- Any other significant clinical issue that might have been discussed that could adversely affect your labor
Before the end of a shift, your family member or doula might ask the departing nurse or provider to review his or her notes regarding your care and ask “Is this correct?” When the new shift takes over, your doula or family member would show them the notes and ask whether they received the same information that was verified by the previous shift.
The path to a successful delivery becomes much straighter when everyone marches in the same direction. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.