Brain Dead and Pregnant: A Moral Dilemma

Courtesy of politix.topix.com

Courtesy of politix.topix.com

The contradictions of life can be maddening. On one hand, we have the case of Jahi McMath, a 13-yearold girl who is brain dead on a mechanical ventilator that her family fought to maintain and on the other hand, there is Marlise Munoz, a 33 year-old mother of a 15 month old son, who collapsed on her kitchen floor from what appeared to be a blood clot to the lungs back in November. Munoz, according to her husband and family, never wanted to be on life support but the state of Texas ordered it when they discovered that she was 14-weeks pregnant. Should state law override the wishes of a patient because of her pregnancy?

The family of Munoz is concerned and angry about the state of Texas’s decision for a number of reasons. Munoz was without oxygen for over an hour before her husband found her on the floor which meant that the fetus was without oxygen as well. Medical experts believe this could cause serious problems for the unborn baby. Munoz’s father describes his daughter has having “rubbery arms that feel like a mannequin” which makes it difficult for him to visit her in the hospital. Munoz was very early in her second trimester (14 weeks), remote from delivering a baby, yet forced to be, as her father states, “a host for the fetus.” Who will have the ultimate responsibility of raising the child once the physicians intervene and deliver it via C. Section?

When John Peter Smith Hospital was confronted regarding their decision, they emphatically state that they are merely following the rule of law; however some medical ethics experts disagree and state that the hospital is misinterpreting the law. According to the New York Times, at least 31 states have adopted restrictive laws prohibiting physicians for ending life support for “terminally-ill pregnant women regardless of the patient’s wishes or her family’s.”

Should a brain dead pregnant woman lose her rights under the United States Constitution in order for the benefit of her unborn baby? I’d love to know what you think.

How can we prevent a Teen Mom from Carrying a Dead Fetus in a Shopping Bag?

Fetus in a shopping bag

Tiona Rodriguez, a 17 year old teen mom was arrested in a New York City Victoria Secrets store on suspicion of shoplifting and accompanied by 17 year-old Francis Estevez, who was also arrested. The security guard looked in the shopping bag and found a foul-smelling dead fetus wrapped in a black plastic bag along with underwear and clothes. Rodriguez informed him that she was 6 months pregnant, had a miscarriage and didn’t know what to do with the baby. She was then taken to Bellevue Hospital, most likely for a psychiatric evaluation. The dead baby was taken to the morgue where it was reported that he weighed 8 ½ pounds and died from suffocation. It is alleged that Rodriguez gave birth at Estevez’s house and from a recent picture on Facebook® where she is wearing camouflage pants and a tee-shirt; it is quite possible that she was concealing the pregnancy. She was allegedly excited about an upcoming interview at a popular restaurant.

There will be those who despise Rodriguez and others who will sympathize with her. Could this tragedy have been prevented? Absolutely and here’s how:

• Rodriguez should have received a long-acting birth control method before leaving the hospital after having her first baby 2 years ago

• All pregnant teens should have at least one home visit during their pregnancy by The Healthy Start Program or the Pregnant Home Visit Program

• Messages about the Safe Haven Infant Protection Law should be plastered in doctors’ offices, prenatal clinics, billboards, text-messages, buses, subways and even on MTV to let families know that they can anonymously leave their baby at a hospital, fire and police departments for three days without getting in trouble

• Adoption IS an option. There are loving parents desperately waiting to adopt newborns and give them a decent home.

A newborn baby took his first breath and then ended up dead in a shopping bag. Who ever thought we’d see this in the 21st century?

What Will Prenatal Care Look Like in the Future?

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?

Do You Know How to Avoid a Homebirth Disaster?

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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?

  1. Know your midwife’s professional record. Does she have malpractice suits? Has she been sanctioned by the state medical board for negligence?
  2. 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.
  3. 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.

You’re Pregnant and Your Local Hospital Closed. Now What?

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.

Should We Delay Clamping the Cord At Birth?

Should we?

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.

Should Life Begin in an Airport Bathroom?

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:

  1. Obtain a copy of your prenatal record prior to traveling in the event of an emergency
  2. Find out the name of the nearest Level 3 hospital where you will be staying
  3. Do not sit for more than 2 hours without standing for a few minutes to stretch your legs to prevent blood clots.
  4. 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.