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.
September 6, 2010
Although the cervix is supposed to hold a pregnancy until term things sometime go wrong. Women can lose an otherwise healthy baby because of a weak or short cervix. When cervical tissue becomes weak, this condition is known as Cervical Insufficiency (CI) and affects approximately 0.1 to 2% of all pregnancies. Women who have a history of painless bleeding in the second trimester or complain of pelvic pressure followed by the delivery of a fetus most likely have CI. Also, women who have had three or more pregnancy losses in the second trimester have CI as well. Patients with these types of histories have traditionally been treated with a procedure called a cerclage. Think of a cerclage as a stitch in the cervix that keeps it closed so that the baby can continue to grow.
There are many reasons why women develop CI and include women who have a short cervix, collagen disorders, uterine abnormalities and cervical lacerations. Some women are born with a short cervix while others acquire it because of surgical procedures such as a cone biopsy, LEEP (loop electrosurgical excision procedure) or laser ablation. Voluntary pregnancy terminations can also shorten the cervix and increase the risk for a preterm birth. The collagen disorder such as Ehlers-Danlos syndrome can so as well.
Can cervical insufficiency be diagnosed before pregnancy? Unfortunately not, however, the use of a patient’s history, physical exam and ultrasound can help tremendously. Visualization of membranes seen during a speculum exam is extremely suspicious for CI and requires a cerclage if the patient is less than 24 weeks. Any cervical length of less than 15 mm is diagnostic of CI and requires a cerclage.
The average length of the cervix at 20 and 22 weeks is 40 mm; at 32 weeks it’s 35 mm. A woman who has a cervical length of less than 25 mm will most likely get a cerclage if she has a history of a three previous second trimester miscarriages. A woman less than 23 weeks with a cervical length of less than 25 mm might be offered a cerclage or progesterone treatment.
Part 2 of this article will discuss what happens if a woman without symptoms of preterm labor is found to have a cervical length less than 25 mm and when and where should the cerclage be removed? What lifestyle changes should be made with a cerclage?
Do you know how to anticipate and manage the unexpected events that could occur during your pregnancy? You will if you purchase The Smart Mother’s Guide to a Better Pregnancy available on Amazon.com or wherever books are sold.
January 6, 2010
You’ve had an ideal pregnancy without major issues, developed a custom birth plan and life appears to be good. You’re finally admitted in labor, cruising along but then your contractions suddenly became abnormal. After some help with Pitocin, you reach ten centimeters and then push for over two hours. There is now a growing concern that your baby might be too large. Your physician is contacted, reviews your fetal tracing, examines you and decides to perform a c/section. The labor room nurses breathe a sigh of relief. Was the physician correct?
The patient, who experienced the scenario just described, gave a resounding “yes!” and was extremely grateful that her 8-½ pound baby arrived safely albeit via a C-Section. Most obstetrical textbooks would also agree; this patient had an Arrest of Labor.
An Arrest of Labor occurs when the contractions of the uterus does not allow the baby to come down the birth canal or is not powerful enough to open (or dilate) the cervix. The labor has been “arrested” or stopped. This can happen for a number of reasons including having a large baby, inadequate contractions, abnormal pelvic bones or uterine cavity. An accurate diagnosis of an Arrest of Labor is important to avoid birth complications. The most common (and dreadful) birth complication is a Shoulder Dystocia, meaning that a baby’s head has been delivered but the rest of its body is stuck, especially at the shoulders. Several maneuvers are made in attempt to deliver the baby including pushing on the top of the uterus (aka fundal pressure), using a suction cup excessively (called a vacuum extractor) or tugging and pulling on the poor baby to no avail. ALL these maneuvers are inappropriate and could cause serious harm. If caught off-guard there ARE appropriate maneuvers that can be done but a better strategy would be to avoid the issue altogether. This is exactly what occurred with the patient described above. Her physician had the good sense to take the path of least resistance.
How do you know if you have an Arrest of Labor? If you dilate to a certain number of centimeters and remain at that same number for over two hours despite several interventions. Your lack of progress in labor suggests that your baby might need some help. The victory is not in having a vaginal delivery; it’s bringing home a healthy baby.
For additional information I invite you to obtain a copy of The Smart Mother’s Guide® to a Better Pregnancy. Remember, a healthy pregnancy doesn’t just happen; it takes a smart mother who knows what to do.
December 14, 2009
An IVF patient posted a blog complaining about the possibility of only receiving two ultrasounds during her pregnancy and I could feel her pain. Quite recently I had a protracted discussion with an imaging center that kept denying my patients an ultrasound based on Medicaid’s rule of only one ultrasound per pregnancy.
Medicine has become a BUSINESS and many clinical decisions are now based on whether or not someone will be paid. Those who know me or read The Smart Mother’s Guide to a Better Pregnancy know that I abhor “keepsake” ultrasounds that are done for gender determination and entertainment. However, I value legitimate fetal ultrasounds that are reviewed by radiologists because they have saved lives. The earlier the fetal ultrasound is done, the more accurate the fetal dates. This could become an issue if you unexpectedly need an induction of labor.
An ultrasound done at 20 weeks provides information regarding the anatomy of the baby. Is there a 4-chambered heart? Are the baby’s intestines normal? Has the brain developed properly? Everything’s okay? Great, but what happens at the end of the pregnancy? The real-time information that ultrasounds provide to determine fetal well being is priceless. This year alone at least seven of my patients’ were spared stillbirths because we detected poor fetal growth, abnormal placentas, low amniotic fluid and umbilical cords wrapped around their babies necks, thanks to a third-trimester ultrasound.
So how do you get around the only-one-ultrasound-per-pregnancy rule? Your physician must write an order as a “follow-up” of a condition previously detected or diagnosed. Did you have previous abdominal pain or bleeding? Was there a suspicion that your baby wasn’t growing properly? Was the placenta in the correct position? These conditions justify obtaining a follow-up ultrasound. If you have a high-risk condition, don’t hesitate to request a referral to a high-risk specialist who can monitor your baby using 3-D ultrasounds.
Visual access of your baby is extremely important. The one-ultrasound-per pregnancy rule is total nonsense.