September 10, 2012
In today’s tough U.S. economy, healthcare is in the forefront because of the three trillion dollars spent each year. Patients are not seeing their money’s worth and neither is the U.S. government who writes the check for a large percentage of it. The cost of women having babies too early or prematurely costs our society $26 billion dollars each year. Something has to give.
Women’s health is the topic of great political debate as you may well be aware if you listen to the news or watched both political parties’ national conventions during the past two weeks. Do women control their destinies? Do we and will we continue to have control over our bodies? These are the questions at hand. While there’s great chatter about this topic as the U.S. election nears, there’s also a quiet revolution occurring in our healthcare system that will directly affect pregnant women.
Prenatal care as we know it will begin to change, especially if you receive Medicaid or government sponsored insurance. The current trend is to visit your healthcare provider’s office individually and wait to be seen. In the future, you will be seen by your healthcare provider as a member of a group, not as an individual. This is called enhanced prenatal care with group appointments and will be the wave of the future.
Groups of 10 pregnant women will be seen at the same time for approximately 10 prenatal visits that will last approximately 90 minutes. It is anticipated that 2 healthcare providers will not only take your vital signs, listen to your baby’s heartbeat, but will also allow you to interact with the other patients in this group setting to discuss prenatal issues, receive health education information and any concerns that you may have. Believe it or not, this model of care is not new. The concept was called Centering Pregnancy and was developed by nurse midwife Sharon Shindler-Rising in 1989.
In the future, doulas and social workers along with midwives will become more prominent in terms of prenatal care as things continue to evolve. Are you ready for group prenatal visits?
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 5, 2012
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.
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 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 24, 2011
Infertility or the inability to have a baby can be devastating and affects approximately 10 percent of the female population. There are many conditions that prevent women from having children including and Mayer Rokitansky Kuster Hauser syndrome (or MKHS). MKHS is a rare disorder that affects a woman’s ability to conceive. At present, for every 10,000 women, only 1 to 2 will be affected. Both Sara Ottoson of Sweden and Melina Arnold of Australia have this condition. MKHS is characterized by the absence of a vagina and part of the cervix. Patients with this condition have normal breast development and functioning ovaries. Genetically, they also have female or double X-chromosomes and look like normal women. The problem comes to light during adolescence when a teen fails to have a period. The condition is also known as Vaginal Agenesis because they are born without a true vagina, a problem that can be corrected through surgical and non-surgical procedures. Unfortunately, they are unable to have children and usually adopt or use a surrogate mother. Those options, however, might soon change.
Both Ottoson and Arnold plan to have biological children using those mothers’ transplanted wombs next year. The wombs that these women resided in prior to their birth will potentially be used to nurture their unborn babies. Ottoson and Arnold will be making history in the same manner as Louise Brown did in 1978 when she became the first successful “test tube” or In Vitro Fertilization (IVF) baby. Has a womb transplant been attempted before? Yes, about 10 years ago in Saudi Arabia but it was an unsuccessful procedure. After four months, the 25-year-old patient’s body rejected the transplanted uterus of a 46-year old woman. Ottoson will receive the uterus of her 56 year old mother but will not be able to conceive through IVF until she has waited a full year to make certain that her body will not reject the donated organ.
If womb transplant becomes successful, it will also be a powder keg regarding ethical and legal issues. It would also provide an option to women who are cancer survivors and desire fertility. All eyes will be on Ottoson and Arnold next year. It will be history in the making.
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.
October 5, 2011
It’s a sad commentary when human beings have to be reminded how to act like human beings, especially when they’re in the helping profession. Loni Hildebrandt was a 29 year old certified nursing assistant who was pregnant with her first baby. Make that two babies because she was pregnant with twins. Hildebrandt considered her pregnancy miraculous because she had infertility and was a diabetic since the age of one. Together, she and her boyfriend saved their money and obtained fertility treatments. Her mother, Jo Novtny, a nurse of 30 years was ecstatic when she saw the ultrasound of her two grandbabies but her happiness was short-lived. One day after the procedure, Hildebrandt began to bleed so they went to Sarasota Memorial Hospital in Florida.
Sarasota Memorial Hospital has an excellent maternal fetal medicine (aka high-risk obstetrics) department but Hildebrandt never made it there. She got as far as the hospital’s emergency room where she was attended to by one of its physicians. Despite repeated requests to have her blood sugar checked, Hidebrandt had to wait six hours before it was done. An ultrasound at the hospital revealed a blood clot that was causing the contractions and the ER doctor told her that he could probably save one by “suctioning the clot so the labor would stop.” According to The Herald Tribune, the physician suctioned the clot and one of the twins as well. Hildebrandt allegedly began bleeding more, passing bright red blood clots. They called for help but no one came. According to the newspaper report, a nurse put the afterbirth in a bedpan and left it near Hildebrandt’s head where she was lying. Her mother moved it and placed it under her daughter’s bed. Novtny ultimately delivered the second twin because no one else was around. The ER doctor returned to the room saw the fetus in Novotny’s hand took it from her and put it in a bucket.
Novtny states her daughter did not receive proper treatment until her personal physician arrived and remained in a pool of blood for over 10 hours. Hildebrandt’s iron count was dangerously low because of the bleeding. Her mother’s request to speak with the hospital administrator was met with no response so she wrote a letter to the governor instead. An investigation was done, gross negligence was found, the ER doctor resigned and Hildenbrandt’s nurse was cited for “lack of critical thinking skills.” The hospital will now have unannounced federal inspections in order to keep their Medicare payments. The hospital administrator issued a public apology.
Perhaps one day hospitals will do the right thing, even when no one is watching. Hopefully, Hildebrandt will become pregnant again and have a better outcome.