I will never forget the patient or the day it happened. Assigned to my residency team, we had watched her vigilantly because she was 39 years old and pregnant with her first baby. Although she spoke no English the love that she had for the miracle growing inside of her could be understood in any language.
She had begun to have premature contractions at 33 weeks and we were trying to prolong her pregnancy for just a little bit longer to allow the lungs to develop. For approximately one week, we monitored her blood, her temperature and fetal movement. One of her tests ultimately indicated that she was developing an infection so we decided to induce her. We would then transfer the baby to the special care nursery where, under the watchful eyes of the neonatologists, he would continue to grow. My team was not on call that night although, in retrospect, I wished the heck that we were. We signed out the patient to the on-call team before we left. We gave them explicit instructions on how often to monitor the patient and discussed her complicated history. She was having, what we, in obstetrics called, a “precious baby” meaning that an older woman was having her first child. When we went home that evening, the baby was alive. When we returned the next morning, it was dead.
“What happened?” I asked as a volcano of anger started to mount. I received a litany of excuses, none of which made sense. Essentially, they missed an opportunity to intervene at the proper time and perform an emergency cesarean. By the time they got their act together, the baby was dead. There was a heated exchange of words between the male chief resident and myself. Another resident had to jump in between the two of us because at that moment, I was ready to swing.
Later that afternoon, the patient demanded to see her baby. We retrieved his body from the morgue in the basement, dressed him in a beautiful blanket and the social worker attempted to console her in her native language. I knew that I could never bring her baby back alive but from that moment on, I vowed to never allow a tragedy of that magnitude happen again.
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?
Malaysian shooter Nur Suryani Mohamed Taibi’s participation in the Olympics makes me nervous but I can understand her dilemma. It’s not every day that a woman receives the opportunity participate in such a renowned event, especially if she 35-weeks pregnant. At 36 weeks, most healthcare providers would strongly advise against traveling by air because the change in the barometric pressure has the potential of causing premature rupture of membranes, or quite simply, the “water” to break. Certainly no one wants that to happen while flying at 32,000 feet in the sky. Taibi not only has to worry about traveling safely from Malaysia to London and back, but hopefully the noise from the gun shooting during her competition will not produce any undesired effects of her unborn child such as hearing loss.
Taibi represents a new generation of women who have crossed over into unchartered waters based on their performance of untraditional roles. Auto mechanics, airplane pilots and astronauts are just a few of the many new occupational roles that women have assumed. In the case of Taibi, it was her father who put a gun in her hand and introduced her to the firing range at the age of 15. Fourteen years later at the age of 29, she has qualified for the Olympics which is a phenomenal achievement and will represent her country.
Hopefully, Taibi won’t develop preterm labor as a result of the sheer stress of Olympic competition. She is creating history and the medical community needs to do research on her for the next 10 to 20 years to determine if her late-pregnancy Olympic participation has any negative effects on her baby’s future development and health.
We know that the fetal ear develops from 8 weeks gestation to 28 weeks and the most common cause of children’s hearing loss is caused by abnormal development followed by infection and trauma. More than 10% of children aged 6 to 19 years loss suffer noise-induced hearing loss in one or both ears in the U.S. according to medical studies.
Taibi says participating in the Olympics is a chance of a lifetime. If you were 36 weeks pregnant, would you compete on a shooting range in the 2012 Olympics?
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 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.
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…
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.
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.
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.
The fact that Amber Miller did not fall or faint or develop complications while running in the Chicago Marathon is nothing short of a miracle. An ounce of prevention is worth a pound of cure. What on earth was her physician thinking when she was given the green light to half-run half-walk a 26.2 mile marathon? Miller was not your usual runner; she was approximately 39 weeks pregnant.
Although pregnant women are encouraged to maintain an active, healthy lifestyle that includes aerobic exercise, moderation is the order of the day. A woman’s body changes when she becomes pregnant. She has more fluid circulating in her body; hormones from the pregnancy make her ligaments more relaxed, thus she waddles. As the baby enlarges, the diaphragm (aka muscle of respiration) gets pushed up making it difficult for pregnant women to breathe. The heart rate increases and the center of gravity changes as the uterus becomes larger thus, increasing her risk of falling.
Miller participated in 8 previous marathons including one when she was pregnant with her first child. At that time she was 18 weeks. She says that she’s “crazy about running.” As the mother of two sons who were Junior Olympic Track and Field participants, I can relate. However, where is the voice of reason? Prolonged exercise means an increase in heat production which may or may not affect the fetus. Years ago, pregnant women were discouraged from running or performing any exercise that would increase their core temperature for fear it would adversely affect the fetus. Unborn babies cannot regulate temperature because their brains are not fully developed and it is a special part of the brain that controls temperature. In recent years, this rule has been relaxed because the medical studies are inconclusive. However, it is not recommended that pregnant women perform more than 45 minutes of continuous exercise and it should be in a temperature controlled environment. This was not the case with Miller. Although she ate frequently and drank water, she ran and walked for over 6 hours, developed contractions and subsequently went into labor. If her physician gave her permission to run at 39 weeks, then perhaps he or she should have accompanied MIller to monitor the process.
26.2 miles at 39 weeks is not a benign act and I certainly hope this will not become a trend among pregnant women. Can you imagine delivering a baby in the middle of a marathon? It would not be a pretty sight.