July 4, 2012
How to Avoid a Homebirth Disaster, Part 2
When I wrote How to Avoid a Home Birth Disaster, I didn’t plan on writing a “Part 2” but the more research I did about Rebecca Fielding’s case, it became obvious that writing a Part 2 would be necessary.
I want to preface my comments by revealing that I’m the granddaughter (3 generations removed) of two 19th century midwives. One delivered babies on a Virginia plantation and the other delivered half of her community until her death in 1936. I have the utmost respect for midwives because it was a midwife from Belize and not my colleagues who taught me the art of delivering my first baby. The record of Evelyn Muhlhan is unfortunately a cautionary tale for pregnant moms who opt to deliver at home.
In the Matter of Evelyn D. Muhlhan, License No. R060032, between July 2008 and September 2011, several complaints were brought before the Maryland Board of Nursing. The law (Code of Maryland Regulations 10.27.05.01(6)states that midwives must have a collaborating physician to cover them documented in a collaborative plan also known as an “Agreement.” Each year the agreement must be updated and submitted to the Board. The Board invoked an emergency suspension for Mulhan’s license for the following reasons:
- On June 7, 2008, she performed a vaginal home delivery on a patient who had a previous c-section, Factor V-Leiden deficiency and maternal obesity. Factor V deficiency predisposes patients to blood clots. The baby had to be brought to the emergency room because it was unresponsive, had meconium and was blue. The patient weighed 295 pounds. A physician was not consulted. Fortunately, the baby lived.
- On April 14, 2010, she used Pitocin in the patient’s muscle although it’s only supposed to be given in the vein. She used an antiseptic solution to treat Group B Strep as opposed to Penicillin which is the standard of care. The patient pushed for 3 hours, Muhlhan did an episiotomy, the baby did not deliver, so she repaired the episiotomy and then sent the patient to the hospital where an emergency c-section was done. The baby was born with brain injuries.
Muhlhan also attempted to deliver an 11-pound baby at home, had a patient who ultimately ruptured her uterus and manually removed another patient’s placenta that ended in a life-threatening postpartum hemorrhage.
So what’s the message? You must, I repeat, you must investigate people in whose hands you place your life. And this applies to physicians as well. Hospitals are imperfect institutions. It is the provider who will and should protect you from those imperfections based on their skill and advocacy. Homebirths will not be for everyone. There are health conditions that simply prevent this from happening.
We are moving towards promoting quality within healthcare as opposed to procedures and money. But we are far from getting there as yet. Each one of us must do our part to protect the integrity of our lives, our babies’ lives and heal our fractured healthcare system.
July 2, 2012
Do You Know How to Avoid a Homebirth Disaster?
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.
May 23, 2012
Should All Pregnant Women be Tested for STDs?
While the topic of sexually transmitted diseases (STD) is not pleasant, it certainly is essential, especially for pregnant women. A recent medical study reports that only 59% of pregnant women are tested for Chlamydia and Gonorrhea. That is absurd. Both the Center for Disease Control (CDC) and the American Congress for Obstetrician/Gynecologists (ACOG) recommend that all pregnant women be screened for STDs during their first prenatal visit.
Untreated STDs can cause havoc during pregnancy. From preterm labor to newborn blindness, STDs are not a nice thing to have. But the good news is, they’re curable provided you know that you have one. One of my former patients complained about “breaking her water” although she was only 26 weeks pregnant. When I checked her, she did indeed rupture her membranes but also had an STD called Trichomonas which I ultimately treated. Had I not checked her, we would never have known about the premature rupture of membranes as well as the STD. The patient was sent to a specialty hospital where she remained for the next 11 weeks until she had her baby.
In our present healthcare climate, time equals money. The more patients a provider sees the more money he or she makes so there is the temptation to cut corners. Every pregnant woman should have an initial PAP smear at her first prenatal visit. Most PAP smears have the ability to detect cervical cancer as well as the Human Papilloma Virus (HPV) in addition to Trichomonas and Bacterial Vaginosis. Both of these infections need to be treated in order to reduce the risk of developing preterm labor and your partner needs to be treated for Trichomonas as well. If your partner is not treated and you have sex, consider yourself reinfected.
Unlike men, women rarely have symptoms so it is important to be tested for Chlamydia because if untreated, there is a risk of going blind. All pregnant women should be tested for Chlamydia and then retested after receiving treatment to make certain the infection is gone. The same principle holds true for Gonorrhea.
All foul-smelling vaginal discharges need to be checked by your provider. No exceptions. Some providers will not examine the patient but give her a prescription for a “yeast” infection. All vaginal discharges cannot be attributed to a yeast infection and needs further evaluation.
All pregnant women need to be tested for STDs, not a mere 59%. Remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
December 28, 2011
An OB Nightmare: Mom Dies after Giving Birth to Twins
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…
June 27, 2011
Dr. Linda Cares: Exercise and Pregnancy An Update
Exercise while pregnant has always been a controversial issue. The days of of “eating for two” to justify inappropriate eating habits is passé. Nine years ago, The American Congress of Obstetrician-Gynecologists published guidelines regarding exercise and pregnancy. Essentially they recommended 30 minutes or more of moderate exercise each day for pregnant women in the absence of medical or obstetrical complications. The Center for Disease Control’s (CDC) recommendations for an “active lifestyle” does not exclude pregnancy.
In the June 2011 issue of Obstetrics and Gynecology, Gerald Zavorsky, Ph.D and Lawrence D. Longo, MD, wrote an excellent article on exercise and pregnancy. They recommend exercise intensity that increases the heart rate to at least 60% of its maximum capacity during pregnancy to reduce the risk of gestational diabetes. Other recommendations for pregnant women are as follows:
• Pregnant women aged 18 to 45 may do 8 to 10 muscular strength exercises for one to two sessions per week on nonconsecutive days. One aerobic training session can be replaced by a muscle strengthening session in the weight room or at home
• Use lighter weights and more repetitions. If you usually perform leg presses with 35 lb for 8 to 12 repetitions, try 20lb for 15 to 20 reps.
• Avoid walking lunges because they may rise the risk of injury to connective tissue in the pelvic area
• Be careful with free weights because they may involve the risk of hitting the abdomen. Use resistance bands instead that offer different amounts of resistance and varied ways o do weight training and should pose minimal risk to the abdomen
• Try not to lift while flat on your back. In the second and third trimesters, lying on your back may cause the uterus to compress a major vein that could limit oxygen received by the fetus
• Zavorsky and Longo recommend that you listen to your body. If you feel muscle strain or excessive fatigue, modify the moves and reduce the frequency of the workouts. “Pregnancy is not the time to perform heavy weight lifting.” Instead, they should do muscle strengthening exercises according to the prescribed guidelines because it will burn calories and increase the resting metabolic rate.”
As always, please consult your physician or healthcare provider prior to starting an exercise program and remember, a healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
March 14, 2011
The Hijacking of Pregnant Women
So, here we go again. Yet another slap in the face by big Pharma. Something is fundamentally wrong when a company charges $1,500.00 for a $10.00 drug that will not only save the lives of human beings but also reduce the annual $26 billion dollar cost of premature births.
Hydroxy progesterone caproate, marketed as Makena, has been around since 1956 and has been used for the past 15 to 20 years to help reduce premature births. It was originally manufactured by Squibb Pharmaceuticals but was removed from the market for reasons unknown. However, physicians were able to continue prescribing the drug by having it made in compound pharmacies for $10 to $15 per injection. The FDA subsequently gave KY Pharmaceuticals the exclusive right to produce the drug. Well, that was a glaring mistake. Why would the FDA want to give a company EXCLUSIVE rights to produce the drug? In a free market, competition is critical in keeping prices down. Twelve percent of births in the U.S. occur prematurely and a disproportionate number are African American women and teens. The drug has to be given between the 16 to 20th week of pregnancy and continued up until 36 weeks. Let’s do the math. The medicine has to be injected weekly. A patient taking the drug beginning at 16 weeks will have to continue taking it for approximately 20 weeks and 20 x $1500 =’s $30,000. So what originally costs $200 to $300 to prevent preterm pregnancy has now spiked to $30,000. How many different ways can we spell the word, GREED?
The prevention of premature births is paramount to the well-being of a newborn. Makena is not an optional drug. It will benefit many unborn babies and especially those whose mothers have a short cervix. Because Makena is now an FDA approved drug, the off-label brand previously made by compound pharmacists is not an option because of liability issues. Do you really think the insurance companies are going to pay $1500 for this drug?
I leave you with a profound quote from one of my readers, Dorice Arden:
“. . . a shocking reminder of just how low the value for humanity has sunk. The notion that patients are considered a commodity has far-reaching consequences. The very thread that ties us to our humanity is the value we place on life and life-sustaining measures. The attention and care we share with each other sets the tempo for the future.
Well said, Dorice. Well said.
March 9, 2011
Sacrificing Patient Care in Order to Make a Living Part 2
Did you ever love something or someone so much that you had to walk away because it hurt too much to stay? That’s how I feel about medicine. From the moment I saw my first delivery, I was hooked and there was no turning back. Perhaps I’m highly offended at our present state of affairs because I had to work so hard to gain acceptance into med school. I spent countless nights in the library at Columbia School of Physicians and Surgeons studying for the MCATs. Endured physiology, histology, biochemistry, gross anatomy (included the dreaded head and neck) and microbiology so that I could eventually diagnose clinical problems. I walked through the fire of residency training and came out whole on the other side. Yet, despite all of these humble achievements, I couldn’t see the destruction of healthcare coming. And neither did many of my colleagues. However, instead of banning together to save our profession, some of us allowed ourselves to be fiscally co-opted giving rise to the birth of “volume oriented medicine.”
Healthcare is now a business and quality of patient care has flown out the window. Billable procedures with diagnostic codes are the order of the day. “Productivity” is a buzz word, a euphemism for volume. The insurance companies are paying less, yet the healthcare providers are expected to do more. The number of patients on schedules increases and it has become “normal” for some of my colleagues to see 48 pregnant women in a day. A former medical director decided that he wanted to increase “productivity” even more so he paid physicians on a per-patient-basis and of course, his theory worked. When one of his cronies had 80 pregnant women scheduled in 5 minute intervals for one day, I had seen enough. I wrote a letter of complaint to the Florida Board of Medicine and was informed that there was no law that prohibited the number of patients a healthcare provider could see in a day. I then contacted the American College of Obstetrician-Gynecologists (ACOG) and they too, had no protocol or rule about volume. So, it was the wild, wild, west regarding patient care. No rules. No boundaries. And certainly no patient protection. Regime changes occurred, but the “numbers” game continued. I had had enough. So after 15 years of attempting to administer quality care in the midst of chaos and strife, I have tendered my resignation. There is nothing more that I can do except put it in the hands of God.
February 16, 2011
Life Should Not Begin at the Bottom of a Toilet
Here we go again. Jessica Blackham was at a circus performance and suddenly became ill. She went to the bathroom, started bleeding, ended up at a hospital and then developed amnesia when questioned about what happened. Simultaneously, a cleaning crew at the South Carolina arena found a newborn baby with his feet in the water and his head resting on the toilet rim. He was barely breathing and if Eder Serrano and his co-worker, Marco Calle had not pulled the six pound baby boy out of the water and resuscitated him, his 24-year-old mother, would be facing murder charges as opposed to unlawful neglect towards a child and felony child abuse.
How many different ways must we say Safe Haven Law so that families will finally receive the message? I had blogged about newborn abandonment less than a year ago when a baby was found in an airport trashcan (Trash Cans Were Not Meant to Hold Babies). A parent or agent of a parent can remain anonymous and surrender the baby to a “safe haven” which is usually a hospital, a healthcare facility, a fire or police station. Relinquishing the baby to a safe haven protects the parent from prosecution for abandonment or neglect if it is done within 72-hours of the baby’s birth and some states such as New York, Florida, Michigan allow longer periods of times. North Dakota and Missouri along the longest time and will accept an abandoned baby one year after its birth under the Safe Haven Law.
No one is exempt from crisis and such was probably the case with Blackham. She was the mother of a 4-year-old, married and allegedly estranged from her husband. Another man has come forward claiming paternity and accusing Blackham of feigning amnesia. Jason Jones alleges she complained about morning sickness on a social media website early in her pregnancy. A judge and a jury will have to sort out the sordid details and had she brought her newborn to a safe haven as opposed to allowing him to remain in a public toilet, the prosecutor would not be involved.
Years ago, the subject of domestic violence was not discussed in mixed company. Today, every health care professional must be proficient in its recognition in order to obtain credentials and licensure. The same principal should apply regarding the Safe Haven law and I challenge the American Congress of Obstetrician-Gynecologists to be at the forefront of this initiative. “Babies are born to live; not to die.” Life should not begin at the bottom of a toilet.
September 15, 2010
Why Pregnant Women in Labor Need Not Suffer in Pain
Whenever a pregnant woman lists “no pain medication” in her birth plan, I cringe and then urge her not to be stoic. Women who are not in pain tend to progress better in labor, contrary to myths and fabrications. According to medical studies, labor can cause pain similar to an amputated finger. The American Congress of Obstetrician-Gynecologists states that it is unacceptable for “an individual to experience untreated severe pain” that can be corrected with anesthesia while under the treatment of a physician. As long as there are no medical reasons prohibiting medication, pregnant women should ask and receive pain relief while in labor.
Untreated labor pain has been associated with the development of post-traumatic stress disorder. Post partum depression is more common in women who did not receive pain relief during labor and men are also affected when their laboring partners are in pain. A discussion of pain relief should be done by OB care providers prior to the patient’s hospital admission including whether the anesthesia services will be covered by her insurance plan, including Medicaid.
Not all pregnant women need to receive an epidural although it should definitely be an option. There are many options for pain relief in early labor including IV medications, acupuncture, assistance from a doula, and water therapy in showers or whirlpool baths. As the labor progresses, an epidural may be requested.
An anesthesia evaluation should be done by an anesthetist or anesthesiologist prior to the placement of an epidural, including informed consent for the procedure. Information such as bleeding disorders, low blood pressure and the use of blood thinners should always be obtained. The most common side effect of an epidural is low blood pressure which can be corrected provided that emergency equipment is readily available. Fetal monitoring should be continuous while the patient is receiving an epidural as well as monitoring of her blood pressure. Many hospitals now offer a patient-controlled epidural pump that allows the patient to sit up or walk while in labor.
Contrary to popular belief, epidural anesthesia does not increase the rate of cesarean sections but it can increase the second stage (time that the patient is pushing) by 15 to 30 minutes as well as the use of forceps or a vacuum extractor. It’s equally important to make certain that the anesthesia has not eliminated the patient’s ability to feel the urge to push.
Giving birth is one of the most pivotal moments in a women’s life. Please do everything in your power to make it enjoyable.
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.
August 30, 2010
Is Shackling Pregnant Inmates During Labor Justified?
The article by Carolyn Sufrin, End practice of shackling pregnant inmates brings back memories of my own encounters caring for incarcerated pregnant women while working in a public health arena. Although the patients violated the law, many of their crimes were self-inflicted involving drug use, violations of parole and at times, petty or grand larceny. None were violent offenders. The type of care they received often depended on the correction officer who was responsible for them. Some were better than others.
The American Civil Liberties Union and the National Advocates for Pregnant Women celebrated a moral and legal victory last year in the case of Nelson v. Norris. In this case, Shawanna Nelson was forced to be shackled and reshackled to her bed during her final stages of labor by her correction officer. Nelson was incarcerated for credit card fraud and passing “hot checks.” Nelson sued the correction officer stated he inflicted cruel and unusual punishment by forcing her to be shackled during her labor in violation of her civil rights under the 8th Amendment to the Constitution. Anyone who has ever witnessed the birth of a baby knows that women need movement in order to withstand painful contractions. Sometimes they grasped someone’s hand or a bedrail or their knees in order to push or sustain the pain.
Although three judges from the 8th Circuit Court of Appeal initially decided that Nelson could not sue the prison warden or corrections officer, that decision was ultimately reversed and is deemed “historic.” Many states have now passed a law prohibiting shackling of pregnant women, the most recent being Pennsylvania on July 2nd of this year.
Everyone makes mistakes and some of them are costly however, no one deserves to bring life into the world shackled to a bed. Renowned medical groups such as the American Medical Association and the American Congress of Obstetricians and Gynecologists strongly advised against using restraints on women who are in labor. Has YOUR state passed a bill prohibiting the shackling of pregnant women?
A healthy pregnancy doesn’t just happen. It takes a smart mother who knows what to do.
